The silent carcinogen: Europe's uneasy relationship with alcohol and cancer knowledge
25.10.2023 - In a study recently published in the European Journal of Public Health, Dr. Daša Kokole and her colleagues from the World Health Organization highlighted the public's understanding of the relationship between alcohol and cancer in the European Union and the UK. The research uncovers a notable gap in awareness, particularly in relation to specific cancers such as breast and colon cancer. As a key contributor to WHO Europe's EVID-ACTION project, Dr. Kokole emphasizes the need for initiatives like alcohol labelling and enhancing cancer awareness. We asked her about their findings to understand the broader implications for public health education.
Dr. Daša Kokole, Consultant at the World Health Organization, co-author of a study on public awareness of alcohol's link to cancer in the EU and UK, and contributor to WHO Europe's EVID-ACTION project.
AlcoholAndCancer: Your research focuses on public awareness of the link between alcohol and cancer in the EU and UK. Can you explain the significance of this study, given that alcohol is classified as a Group 1 carcinogen by IARC?
Daša Kokole: This is the first study that synthesised findings across Europe, looking at how many people are aware of the link between alcohol and cancer. We often hear that the awareness of this link tends to be “low”, but what does that actually mean? With this review, we thus aimed to look at existing quantifications of the awareness of alcohol’s relationship to different types of cancer. Alcohol has been classified as a Group 1 carcinogen by IARC already in 1988, and our findings underscore that this relationship has not fully trickled into public consciousness yet (as opposed to, for example, tobacco, which most people immediately associate with cancer).
Your findings indicate varying levels of awareness depending on the wording of questions and the specific type of cancer. Can you elaborate on some of the most surprising disparities you found?
First, in studies that asked question in an unprompted manner (e.g. “Which diseases are associated with alcohol?” Or “What are the risk factors for cancer?”), the percentages of people associating alcohol and cancer tended to be lower compared when the question was asked in more prompted manner (e.g. “Is alcohol a risk factor for cancer?”), showing this relationship is not yet salient in people’s minds.
Secondly, we also looked into awareness of the relationship between alcohol and specific cancers (e.g. oral, colon, breast cancer). Although there was lower number of studies examining these (at least among those surveying the general population), their findings indicated that awareness of alcohol’s link to specific cancers tended to be lower compared to cancer in general. Awareness of breast cancer’s link to alcohol was the lowest, ranging between 10-20%.
Finally, another manner the framing of the question potentially had some influence (although we did not systematically investigate this) was that asking about knowledge (e.g. with yes/no answers) led to lower percentages compared to questions where the participants had to indicate their level of agreement with the statement.
Based on your research, what do you believe are the main factors contributing to the general public's lack of awareness about the link between alcohol and specific cancers, such as breast and colon cancer?
Our study did not specifically focus on examining factors contributing to current awareness levels, but one reason might be that not enough (successful) efforts have been made yet by the governments or the public health community to communicate about this risk (although this is now rapidly changing, with increasing number of communication campaigns about alcohol as risk factor for cancer – e.g. Netherlands, Sweden and Denmark). Perhaps the public also has not been ready to hear the message yet, or has put the message of alcohol and cancer in the bucket of “everything causes cancer anyway”. For the latter, media can also hold responsibility with careless reports of dubious studies that make attractive headlines.
However, one documented factor possibly influencing the lack of awareness is misleading communication from alcohol producers and associated corporate social responsibility organization – for example, a 2018 analysis of information found on their websites showed that evidence on alcohol and cancer was often misrepresented, and the focus on this misrepresentation tended to be breast and colon cancer.
What do you believe are the implications of this study for future public health campaigns?
The findings in our study emphasise the pressing need for more comprehensive public health initiatives to communicate about link between alcohol and cancer – and not just cancer in general, but also specific cancers, especially breast cancer among women.
Some of the findings also indicate opportunity to inform and involve the health professionals, as they can be the one to communicate this risk (e.g. dentist with oral cancer, doctors and nurses at breast cancer clinics about breast cancer).
Another implication might be in terms of evaluation of any campaigns – that it’s very important to think through how to frame the knowledge questions to accurately capture any changes.
In the context of your findings, how do you think public awareness levels impact health behaviors and, consequently, cancer rates?
If you look broader at the theoretical behavioural models, it is clear that knowledge alone is not the main determinant of behaviour change – maybe for some individuals, but not on population level. However, providing information is often the first step – and in the context of alcohol, it has been shown that increased knowledge about alcohol related harms, especially cancer risk, is also associated with increased support for other alcohol policies, such as taxation, marketing and availability restrictions - which do achieve behaviour change in the shorter term. And given that alcohol consumption increases cancer risk, introduction of such policies is likely to reduce consumption on population level and in the longer term possibly cancer rates.
But this all happens over a long time scale, so impact of awareness on behaviour and health outcomes should not be the main criteria to influence the decision on whether to provide information to the public – ultimately, everyone has a right to know about what they are consuming, regardless of what they end up doing with this information.
Based on the insights from your study, what recommendations can you make to public health agencies or policymakers in the EU and UK to better inform the public about the risks associated with alcohol consumption and cancer?
Earlier we talked about communication campaigns informing about alcohol and cancer risk, but in order to reach the different segments of the population, the information should be conveyed through multiple channels and sources. Product labels are the key mean of communicating this information on the point of purchase and consumption, and would thus have high reach of the target audience – people who use alcohol. Ireland has legislated cancer warning on their label, so other countries can follow their example.
However, there should be further investigation about how to best communicate about alcohol and cancer, so that public will be willing to engage with the information, accurately understand it, and also know how to minimize the risk. We should also be careful to avoid stigmatization when communicating about this topic, as well as putting too much responsibility on the individual without acknowledging the environmental pressures and influences.