Should Alcohol Come With a Warning Label?

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Brian Lehrer: It's the Brian Lehrer show on WNYC. Good morning again, everyone. On Tuesday, we took a deep dive into the state of cancer in the United States after President Biden announced a so-called Cancer Moonshot program, remember that? We're going to follow up now with a closer look at one thing that came up briefly and that contributes to causing cancer in some people that most people don't realize, but that recent research seems to say we should be more aware of, and that is alcohol.

Alcohol has been classified as a Group 1 carcinogen and will explain what that designation means for decades by the International Agency for Research on Cancer and yet fewer than one in three Americans are aware that alcohol use is linked in some way to a higher risk of at least seven types of cancer. In widely-sided study published in Lancet Oncology in 2020, at least 4% of the world's newly diagnosed cases of esophageal, mouth, larynx, colon, rectum, liver, and breast cancers that year were set to be attributable to drinking alcohol. That's more than 740,000 people.

Joining me now on the link between alcohol and cancer and why better warning labels might be effective in helping consumers make better choices for their health is Marissa Hall, assistant professor in the Department of Health Behavior at the University of North Carolina, faculty fellow at the Carolina Population Center and a member of the Lineberger Comprehensive Cancer Center. Dr. Hall, we're so glad you could join us today. Welcome to WNYC.

Marissa Hall: Thank you so much for having me and I'm so glad you're covering this topic.

Brian Lehrer: Can we start with the definition of a Group 1 carcinogen? What does that mean?

Marissa Hall: Absolutely. The group one designation essentially means that the International Agency for Research on Cancer, which is the worldwide group responsible for these ratings concluded that there is sufficient evidence that a certain substance causes cancer in humans and so, like you said, alcohol has actually been in that category since the late '80s and it's the same category as things like cigarette smoking, so really things that we can conclude are known to cause cancer in humans.

Brian Lehrer: Cancer is such a complex disease though. In fact, throughout the years, the media people who aren't reading the science journals, medical journals, but just following the popular media on personal health, the media have reported that so many things cause cancer, grilled meats, non-stick cookware, soy products. It can sometimes seem like as Joe Jackson once saying, everything causes cancer so what do we actually know about the link between alcohol and cancer and how?

Marissa Hall: Yes, I guess I'll start by saying I relate to that feeling. It can be frustrating and hard to keep up with things that sometimes may cause cancer, sometimes may prevent cancer and so I understand that, especially with lots of scientific information coming at you, but I would say with alcohol, what I've noticed is just the consistency in the designation as a carcinogen. Also, we know that there are some things that are carcinogenic, but we don't have high exposure to them or we can't control our exposure to them.

The thing that makes alcohol different is that it's quite prevalent and so we know that exposure to it is quite high. In the US about 55% of Americans are current drinkers and we see some current trends with the pandemic that are pretty concerning in terms of those trends, maybe even worsening and so a Jama Network Open study found that alcohol use increased early in the pandemic compared to the year prior to the pandemic. Then another Jama study similarly found a 25% spike in alcohol-related deaths in the US from 2019 to 2020.

I think the main point here is just that unlike some potential risks of cancer, we know that this is really prevalent and we also know that really scientific consensus and the international agencies are really having consensus that there is this link between alcohol and certain types of cancers, which I think stands in contrast to other things thrown out there and found in some studies, but not perhaps consistently across a large body of evidence.

Brian Lehrer: Listeners, we are going to open up the phones right now for your calls in addition to what we're hearing from Dr. Hall from UNC. I wonder if oncologists are listening today, anyone want to call up and give the public maybe even anecdotes about individuals you've seen who you're pretty sure their cancer can be traced to alcohol use. 212-433-WNYC, 212-433-9692. Our first ever call in for oncologists specifically, but any doctor may call or nurse or anyone in the medical field who thinks you've seen alcohol-related cancers to help us report this story. 212-433-WNYC, 212-433-9692 or tweet @BrianLehrer.

Since part of our premise here is that considering the strength of the evidence that the public is largely unaware of this, how do you inform your patients about the associated risks? Is it one of the things if you're a primary care physician, for example, that you bring up in your screenings? Do you do this? Do you wear sunscreen when you're out in the sun because of skin cancer? Do you ask questions about alcohol use or the amount of alcohol use and mention the C word in conjunction with that ever?

Or anyone else may call, 212-433-WNYC. Maybe you have an alcohol-related cancer and want to tell everybody else a cautionary tale, 212-433-WNYC, 212-433-9692, or tweet @BrianLehrer. Dr. Hall, breast cancer in that Lancet Oncology study that I cited in the intro, it says of the 172,000 alcohol-related cancer cases diagnosed in women, the vast majority, or more than 98,000 were breast cancer. Now, we focus in the media a lot on genetics when we talk about an increased risk of breast cancer, BRCA gene, things like that. Can you break down how alcohol factors into it and how commonly?

Marissa Hall: Absolutely. I'm glad you mentioned breast cancer because it's really a case where even light or moderate drinking can increase your cancer risk more so than potentially other alcohol-related cancers. The estimates from that same Lancet study, you mentioned estimate about 4.4% of breast cancer is attributable to alcohol, but some studies range up to the 4% to 10% range and so it may be even a bit higher. This is all to say, of course, there's a lot of other factors at play including genetics, but behavioral components really do factor into breast cancer risk.

There's a new campaign through the alcohol research group called Drink Less for Your Breath, which I think they do a really nice job of capturing some of these key facts and then actually allowing people to enter in the number of drinks they drink on average per week and really see how that affects their own personalized breast cancer risk, which I thought was a neat tool. I think with breast cancer and other cancers what we see is that there really is, as you alluded to earlier, pretty low awareness in the public among Americans and also globally in terms of this link between alcohol and cancer.

Just to put some numbers behind that, what we see is that in the US recent data from 2020 in a nationally representative survey finds that less than one third about 32% of Americans knew the link between alcohol and cancer and other studies similarly find a range in about the 30%. Really no matter how you look at the data, we see that a majority of Americans are not aware of this link between alcohol and cancer.

Brian Lehrer: How do they establish the link in something like breast cancer where we know there can be other factors like genetics? I think it might be useful to geek out a little bit on epidemiology because people might be skeptical and say, how do they know in an individual's case that alcohol contributed to it or how do they know in a population sense the big epidemiological studies that a certain amount of alcohol consumption increases your risk by 50% or by 500%. I've seen those numbers thrown around for different kinds of consumption and different kinds of cancers. How do they establish something like that?

Marissa Hall: I'm going to put in a call here for some epidemiologists to call in because I will just put the caveat that that's not my particular, I'm not a cancer or alcohol epidemiologist. My own area of expertise is really in prevention of cancer and changing health behaviors, and so I don't want to comment too much on this but I will say that I think that really it's modeling at the population level because I agree that it's tricky in any one person to know exactly what caused a specific cancer and of course, there's interactions between the environment and one's genetics as well as one's behaviors.

The key thing that I can comment on really is that we do know that there's a behavioral and preventable component to many kinds of cancers. I know you talked about this on your moonshot segment, which I was glad to hear. I think that's where we really can have a big bang for your buck in terms of investing in preventions and shifting behaviors. Of course, treatment is extremely important, but I think the more we can really target and focus on prevention, we could be better off, and that is for all kinds of preventable cancers due to tobacco and other things, but as well as alcohol.

Brian Lehrer: Here's a doctor calling in, she says, Miriam in Brooklyn, you're on WNYC. Thank you so much for calling.

Miriam: No, Brian. My name is [unintelligible 00:10:50], and I am a PhD. My doctorate is about human breast cancer; genomic alteration in human breast cancer. I wanted to talk about a personal experience with one of my dearest friends who we lost, our friend from university years back in France in Montpellier. He was a heavy drinker when he was in high school in Tangier, Morocco. Unfortunately, he's already gone. When I was studying in Montpellier, I would never have thought that I would lose [unintelligible 00:11:29] but unfortunately, this is a real thing. Alcohol is a very powerful carcinogenic, and not many people know about it.

I'm really glad that you are bringing this conversation today, Brian, and bringing your experts as well. Changing behaviors is, I think, one of the best things we can do because as your expert said, cancer as I presented it in my thesis, cancer is multiple factors and multiple steps that are taking place. There is nutrition, there's environment, there are viruses, there are many, many, many triggers.

Brian Lehrer: Miriam, thank you. Thank you very much. Betsy in Brooklyn, you're on WNYC. Hi, Betsy.

Betsy: Hi, Brian. Thanks for taking my call. I have a question and a comment, which is, what is the public health recommendation that's realistic? In a city where people are unwilling to even put on a mask to prevent a pandemic that has no cost savings to do that, how can you expect people to stop drinking or limit drinking when it would have a profound effect on the city's economy and people's lifestyle choices?

Brian Lehrer: Betsy, thank you very much. Maybe you should clarify Dr. Hall, what you or other health behavior experts or people who study cancer risk, are recommending with respect to alcohol. Is it, "Don't ever have a drink" because people may think, "Well, that's too extreme. If I have a glass of wine once a week when I go out to dinner, that's not going to give me cancer." How do we put some particulars on those bones?

Marissa Hall: Great question. Thank you for calling in. What I would really first point to are the national guidelines. The Dietary Guidelines for Americans recommend limiting alcohol to no more than one drink a day for women and two drinks a day for men. Those can be updated based on the evidence, but it's interesting when it comes to cancer risk, and that the American Cancer Society also recently updated their guidelines to be a bit more strong in terms of cancer, saying that the best amount of alcohol for cancer risk is zero, but they also endorse this idea that among people who do drink to try to really limit it to one drink a day or less for women and two drinks a day for men or less.

Brian Lehrer: Which isn't actually that restrictive, right? For what we're talking about, you're saying that the experts say, you can have a drink every day, and you're not significantly elevating your risk for cancer, but is that really what they're saying?

Marissa Hall: Well, I would say there were definitely some public health groups that were not happy with those recommendations specifically based on this cancer link. It's true that for breast cancer that we have seen increased risk even at lower levels than those guidelines. Those guidelines are really meant to be limits and not recommendations like, "Everyone should be drinking one drink a day," for example. I think they're meant to acknowledge this realistic world that we live in that the caller just alluded to where we know we're not going to zero drinking, we're not talking about prohibition of alcohol, we're really living in a world where alcohol is really prevalent.

I think what we see with cancer is more research on this dose-response relationship where we do see benefits from cutting back, and we similarly on the flip side see increased risk with increased drinks. I think if you're not drinking, there's not a reason to start, but if you are a current drinker, I would say that the national agencies and guidelines are really basically that less is better on the population level. I agree that changing behavior is not easy, maybe in a bit, we can talk more about some policies and other intervention approaches for that.

Brian Lehrer: We will. We'll end with that in a minute. You mentioned dose-response, probably worth throwing in that there was a study just published in the JAMA Journal of the American Medical Association, Network Open, I think they call it at the end of August, so just a few weeks ago, that found the increased risk of cancer is proportional to the amount of alcohol consumed. This was a group of Korean researchers, who studied over four and a half million insured adults in Korea. Interesting that they pointed out insured, and found that the more people drink, the higher the risk, and the inverse is also true. The less you drink, the lower the risk. Jake in West Hempstead, you're on WNYC. Hi, Jake.

Jake: Hi. Thank you so much for taking my call. This was something you just spoke about just a second ago, but I'm wondering if you could just spend a little more time fleshing it out. I remember growing up, my great grandfather lived to 105, and he credited it to having a shot of whiskey every night with dinner, even when he was 100 years old. Even when he was 100 years old in the nursing home, and they wouldn't let him have his whiskey, and he got a doctor's note, saying that he should have whiskey every night with dinner.

My grandfather also lived until 93, always had whiskey with dinner. I remember learning that, or hearing just one shot of whiskey every day is good for you. I was even told that by my doctor when I asked. I was wondering if you could flesh out a little more spend time on really what should you not drink because they say that it's good for your heart or good for your blood to drink a little bit of alcohol every day. I'm wondering if you could just flesh that out a little more, please. Thank you very much.

Brian Lehrer: I'm glad you brought that up because one of the things that some of our listeners may be thinking about Dr. Hall is, "Well, wait, didn't we get a lot of press a few years ago about how a little bit of red wine is not only safe, it's good for you because the component called resveratrol."

Marissa Hall: Yes. I'm glad you brought this up, and thanks for your call. I would say it is true that there has been some limited research about potential cardiovascular benefits with red wine, but on the whole and again, this is not my own area of expertise, really I would say the consensus is moving to that any potential benefits are likely to help at least are outweighed by risks with cancer and other kinds of risks. Alcohol actually causes or contributes to over 200 different kinds of health problems, so it's of course not just cancer.

I would say with this red wine phenomenon gained a lot of traction in the media. Also, the alcohol industry was a big fan of this research, but I would say what we see especially with cancer risk is that there is not a safe alcohol when it comes to cancer. It's really all ethanol-containing drinks, which is all alcohol, and that the mechanisms don't appear to depend on the kind of alcohol. I think that's an important area where physicians and medical professionals can work with patients and also campaign to really inform consumers about that.

Brian Lehrer: Let's close by talking about informing consumers. I said in the intro, but listeners may have joined us along the way that your primary area of research at the University of North Carolina, Center for Health Behavior is warning labels. Right now on the side of alcohol containers, we already see government warning. According to the Surgeon General, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects, and consumption of alcoholic beverages impairs your ability to drive a car or operate machinery and may cause health problems.

You've been quoted as saying this warning is so vague that it borders on being misleading. What would you like to see as a standard warning label on alcoholic beverages?

Marissa Hall: I would say we have a lot of evidence from other domains like tobacco, as well as increasing alcohol warning research showing that there are key principles that make a warning effective. Unfortunately, this current warning does not adhere to these principles. One principle is that the warning should to be most effective be on the front, prominently displayed on the front of packaging, which is, of course, very intuitive. If you want a warning label to reach consumers and inform them, they need to be able to see it and read it.

If you all take a look at any alcohol containers you may have in your house, it's really very small print and on the side or the back of alcohol packages right now. A second thing that makes warning labels effective is including pictorial elements. Things like icon symbols, photographs, like you can imagine can help convey information. A picture does speak a thousand words in this case. Of course, the current alcohol warnings in the US are only including tech.

Then a third principle that makes warnings effective is using really clear and accessible language. The current warning really condenses three different kinds of health effects in one, and it would likely be more effective to separate those out and rotate them across packages so that consumers can really process the information better. Finally, again, this idea of rotating warnings, we do know that warning messages can wear out and lose their effectiveness over time.

It's important to refresh them not just for consumers' benefits, but also to reflect the current state of the evidence. This warning on alcohol packages hasn't changed in over 30 years. The things that are in the warning are fairly outdated, and they're still true, but there are more risks that we know about is that if you refresh the content could really speak to consumers and inform them about new risks they may not already be aware of. Then getting back the final point I'll make on this topic is this idea of being misleading.

The wording may cause health problems is pretty weakly worded, as well as vague. Consumer advocacy groups have picked up on this and said, really, ultimately consumers have a right to know about the risks of a product. This warning was a good first step back in 1988 but it's really time to improve them and strengthen them to match the strength of the evidence so that consumers can make informed decisions.

Brian Lehrer: Is that up to the FDA to do that?

Marissa Hall: Actually, a great question. FDA regulates tobacco warning labels, but alcohol is regulated at the Alcohol and Tobacco Tax and Trade Bureau or the TTB. The current regulation requiring warning labels was passed in 1988. It actually does recommend that the agency go to Congress when they think it's a good time to essentially revise warnings based on the evidence. I would argue that now is the time to do that and it's really time to think about these critically and think about strengthening them.

Brian Lehrer: As we run out of time. Since you're a warning label expert, can you give two great examples of warning labels that have been effective in changing behavior and improving public health? I asked for two because I have a feeling one of them is going to be cigarettes and that's obvious. Can you give me two?

Marissa Hall: Absolutely. Well, we'll start with cigarettes, like you mentioned. Really, with the strength of the evidence between cigarettes and all kinds of health problems, there's a lot of momentum around strong warnings. 127 countries globally, currently have graphic cigarette pack warnings, like the ones you may have seen from Europe, with strong photographs. We have lots of evidence from those countries as well as experimental trials and evidence showing that these warnings, not only lower smoking rates, and they do help people quit, they also really inform people and bring the risks to mind.

With smoking, most people really do already know that there are risks of smoking, but having the warning label on the actual product is a perfect way to bring those risks to the top of the mind right when consumers most need that information at the point of sale. Then a second example is in the area of food and nutrition, another area that I work in. We're seeing momentum as well with sugar-sweetened beverages as well as just generally the food supply.

There are 10 countries right now that requires nutrient labels on the front of food packaging, which say things like, "WARNING: HIGH IN ADDED SUGAR. WARNING: HIGH IN SODIUM." Initial evidence looks really promising for those kinds of labels to shift people potentially away from those nutrients as well as informing people about products. I think that's a emerging area. Also, we're seeing some momentum on the federal level in the US for food labeling as well.

Brian Lehrer: Marissa Hall, assistant professor in the Gillings School Department of Health Behavior at the University of North Carolina, faculty fellow at the Carolina Population Center, and a member of the Lineberger Comprehensive Cancer Center. Thank you so much.

Marissa Hall: Thank you for having me. I really appreciate it.

 

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