Millions of people begin the new year by doing a dry January challenge. That means they are learning about the benefits of reducing or quitting alcohol use, including health benefits, through their own experiences. But people are also engaging more with available information about alcohol, as they reflect about the role alcohol plays in their lives and if this benefits them, their families, and communities.
When I speak with people about their experiences and insights, very often one fact they learned stands out: alcohol causes cancer.
People didn’t know. But as they set out to do an alcohol-free challenge, such as during the month of January, they dive into the topic more, read about the harms alcohol is causing and what can be done about, and they get surprised, sometimes even shocked. Alcohol causes cancer and very few people know. When they find out, they think that everyone should know. And people have ideas about who should provide this information: public awareness campaigns from the government, specific information provided by doctors, information to cancer patients – are some of the ideas I hear from people in my conversations.
That is the context of the latest publication by colleagues from the World Health Organization (WHO) in the medical journal The Lancet. The WHO has published a statement in The Lancet Public Health: when it comes to alcohol consumption, there is no safe amount that does not affect health.
We know since 1988 that the alcohol (ethanol) in beer, wine, and liquor is a carcinogen, in the same risk group as tobacco and asbestos. Therefore, the question is valid: what is the added value of this latest WHO statement?
In my opinion, there are six reasons why the new Comment about the health and cancer risks caused by low dose alcohol use are a game changer.
We in Movendi International welcome any evidence-based contribution to the scientific and public discourse about alcohol harms in general and alcohol’s link to cancer in particular.
We are seeing that the evidence-based is getting ever stronger and the recognition is growing that alcohol causes cancer. For example, since 2009 we have published more than 200 policy and science stories about alcohol and cancer. And the frequency is accelerating in recent years.
In 2018, a landmark study showed that no level of alcohol consumption improves health or is good for health. The level of alcohol consumption that minimised harm across health outcomes was zero standard alcohol drinks per week,” wrote the researchers in the summary of their study.
Why the new WHO Comment matters
- Synthezising the latest knowledge
- Establishing clear key messages
- Establishing a WHO consensus
- Contextualizing the flawed concept of “harmful use of alcohol”
- Providing information on what low dose alcohol use is and the risks it carries, and
- Exemplifying the cancer burden due to alcohol in one WHO region
This systematic analysis from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 for 195 countries and territories, 1990–2016, was the most comprehensive estimate of the global burden of alcohol use that had ever been compiled and it sparked an acceleration of scientific and policy work to respond much better to alcohol’s cancer burden.
The new WHO Comment on the subject of the real harm from already small amounts of alcohol use is therefore another landmark. And I think there are six reasons why it changes the game in alcohol policy development, public discourse about alcohol harm, and scientific exploration of harm due to low-dose alcohol use.
1. Synthezising the latest knowledge
In its most basic added value, the WHO comment builds on decades of scientific research from leading scientists and scientific agencies, such as the International Agency for Research on Cancer.
For example, in the press release accompanying the Lancet publication, WHO writes that ethanol (alcohol) causes cancer through biological mechanisms as the compound breaks down in the body, which means that any beverage containing alcohol, regardless of its price and quality, poses a risk of developing cancer.
Alcohol is classified by the International Agency for Research on Cancer as Group 1 carcinogen that is causally linked to seven types of cancer, including oesophagus, liver, colorectal, and breast cancers. Alcohol use causes 740,000 new cancer cases each year globally.
2. Establishing clear key messages
Scientific language is often difficult to understand. But the new WHO statement on the harms of low dose alcohol use contains a number of clear key messages, both in the comment itself and in the press release that accompanied the scientific comment.
It is the alcohol that causes harm, not the beverage.
It is the ethanol in beer, wine, and liquor that causes cancer through biological mechanisms as the compound breaks down in the body. Any beverage that contains ethanol carries the cancer risk, no matter its its price, quality, or marketing.
Alcohol causes cancer.
Clarity from the World Health Organization matters greatly because it is the norm-setting agency for how we talk about and respond to health harms, including alcohol.
In the Comment, WHO clearly says that alcohol causes at least seven types of cancer, including the most common cancer types, such as bowel cancer and female breast cancer.
Risks start from the first drop.
The risk of developing cancer increases substantially the more alcohol is consumed.
Already small amounts of alcohol carry cancer risk.
Latest available data indicate that half of all alcohol-attributable cancers in the WHO European Region are caused by low dose alcohol consumption.
There is no safe or healthy amount of alcohol consumption.
No studies that would demonstrate the potential beneficial effects of low-dose alcohol use on cardiovascular diseases and type 2 diabetes outweigh the cancer risk associated with these same levels of alcohol consumption for individual consumers.
3. Establishing a WHO consensus
In September 2022, the WHO European Regional Committee adopted a new and groundbreaking Framework for Action on Alcohol by unanimous consent. But in the deliberations and negotiations among Member States the flawed concept of harmful use of alcohol* was the most controversial item: should it be done away with or should it be kept?
Ultimately, Member States agreed that the framework is better served without the flawed concept. But at the global level, in May 2022 the World Health Assembly adopted to new WHO Global Alcohol Action Plan (GAAP). The GAAP still contains the flawed concept of “harmful use of alcohol” despite criticism and protests from many Member States.
The decision of the WHO European region to do away with the flawed concept of “harmful use of alcohol” is the first signal of change towards a commitment to employ evidence-based language that does not play into harmful framings of the root causes of alcohol harm and what alcohol harm is about.
And the new WHO statement strengthens this consensus: it does not mention “harmful use of alcohol” but instead makes it very clear that there is no safe or healthy amount of alcohol use, and that even small amounts of alcohol consumption carry risks.
I also think it is encouraging to see the broad group of WHO colleagues who developed the Lancet Comment together: Hans Kluge, the WHO Europe Regional Director, and his colleagues at the regional office, Rüdiger Krech, the director of the health promotion department at WHO headquarters and his colleagues, Devora Kestel, the director of the mental health department at WHO and her colleagues, and Bente Mikkelsen, the director of NCDs at WHO, and her colleagues.
4. Contextualizing the flawed concept of “harmful use of alcohol”
The WHO Global Alcohol Strategy from 2010 and the WHO GAAP from 2022 are landmark decisions to accelerate action on alcohol as public health priority. But they both contain multiple flaws, among others the flawed concept of harmful use of alcohol*.
It’s a politically agreed term with ambiguity that benefits the alcohol industry because “harmful” use of alcohol let’s people think that there is also “harmless” alcohol use – and that resonates with the alcohol industry ploy to promote the concept of “responsible alcohol use”.
The WHO Global Alcohol Strategy contains a definition of what “harmful use of alcohol” means. But very few people know it, even fewer apply it properly, in the public discourse the definition is completely absent, and the alcohol industry exploits it for their benefit of misleading about the causes and consequences of alcohol harm.
That is why it is a game changer that the new Lancet Comment does not rely on the concept of “harmful use of alcohol” – with broad support from across the WHO. And the Comment emphasizes that there is no healthy or safe alcohol use. Already small amounts of alcohol intake carry health and cancer risks.
This new context should inform discussions about Europe’s Beating Cancer Plan, for example, where the alcohol industry is trying to exploit the concept of “harmful use of alcohol” to redefine what the alcohol-related elements of Europe’s Beating Cancer Plan are supposed to achieve.
The Comment says, for instance:
In the EU, light to moderate alcohol consumption was associated with almost 23,000 new cancer cases in 2017, accounting for 13.3% of all alcohol-attributable cancers and for 2.3% of all cases of the seven alcohol-related cancer types.
Almost half of these cancers (approximately 11 000 cases) were female breast cancers. Also, more than a third of the cancer cases attributed to light to moderate drinking (approximately 8500 cases) were associated with a light drinking level.”Anderson BO, Berdzuli N, Ilbawi A, Kestel D, Kluge HP, Krech R, Mikkelsen B, Neufeld M, Poznyak V, Rekve D, Slama S, Tello J, Ferreira-Borges C. Health and cancer risks associated with low levels of alcohol consumption. Lancet Public Health. 2023 Jan;8(1):e6-e7. doi: 10.1016/S2468-2667(22)00317-6. PMID: 36603913.
This clearly provides a frame for Europe’s Beating Cancer Plan and contextualizes what the concept of “harmful use of alcohol” means, how it should be understood, and why it should be done away with – because the term engenders the wrong associations about the harm due to alcohol.
5. Providing information on what low dose alcohol use is and the risks it carries
Another added value of the new Lancet Comment is that it outlines WHO’s view of how low dose alcohol use can be understood:
- 20 g of pure alcohol per day, which is equivalent to consumption of approximately
- <1.5 L of wine [12% alcohol by volume; ABV] per week,
- <3·5 L of beer [5% ABV] per week, or
- <450 mL of spirits [40% ABV] per week.
Many alcohol users are actually consuming small amounts of alcohol but they are not aware of the health risks, such as cancer. The Comment explains for example that in the EU, more than a third of the cancer cases linked to light to “moderate” alcohol use (approximately 8500 cases) were due to a light level of alcohol intake, below 10 g per day.
Many alcohol users consume more alcohol than those small amounts, but they do not reflect about their alcohol consumption in that way. They misidentify their alcohol intake even though they are consuming more than low-risk guidelines would outline.
A broader conversation and public discourse about the risks linked to low dose alcohol consumption and the prevalence of low dose and heavy alcohol use in society would help the public to increase recognition of their own alcohol intake and the risks linked with that.
6. Exemplifying the cancer burden due to alcohol in one WHO region
The WHO European region is the heaviest alcohol consuming region in the world with the biggest alcohol burden.
Increasing public recognition of the extent and severity of this alcohol burden is important. Therefore I think the Lancet Comment is a game changer. It provides a clear example of the cancer burden due to alcohol – driven by population-level alcohol use – for a larger audience.
- Alcohol use is linked with 740,000 new cancer cases each year globally.
- In the European Union alone, low dose alcohol use causes almost 23,000 new cancer cases per year.
- Almost half of these cancers (approximately 11,000 cases) were female breast cancers.
- And more than a third of the cancer cases caused by low-dose alcohol use are actually linked with a very small amounts of alcohol intake.
This type of overview of alcohol’s cancer burden in the European region is an important example for other WHO regions and other countries to better track how many cancer cases and deaths are due to alcohol.
These six points show that the scientific discourse is becoming more robust, that support for addressing alcohol harm is growing, and that the response is becoming more ambitious and evidence-based.
I’m looking forward to more conversations with people who wan to to reflect about the role alcohol plays in their lives, in our communities, and in our societies, to tell them about this new WHO consensus. And I’m excited to take this conversation forward with decision-makers at all levels because alcohol policy means cancer prevention. Alcohol policy means the chance to help protect people from harm and to promote health for millions more.
* Definition Harmful Use of Alcohol
The harmful use of alcohol has a serious effect on public health and is considered to be one of the main risk factors for poor health globally. In the context of this draft strategy, the concept of the harmful use of alcohol is broad and encompasses the drinking that causes detrimental health and social consequences for the drinker, the people around the drinker and society at large, as well as the patterns of drinking that are associated with increased risk of adverse health outcomes. The harmful use of alcohol compromises both individual and social development. It can ruin the lives of individuals, devastate families, and damage the fabric of communities.”World Health Organization Global Alcohol Strategy, 2010, page 5