Outlook: Newsletter of the Society of Behavorial Medicine

Fall 2019

Cheers to Good Health? Challenges and Opportunities in Communicating Alcohol-related Cancer Risk

Courtney L. Scherr, PhD and Jennifer L. Hay, PhD; Health Decision Making SIG

Alcohol consumption can cause cancer. In the last five years, the evidence for this has become well-established (Rehm & Shield, 2014; U.S. Department of Health and Human Services National Toxicology Program, 2016). Heavy consumption is associated with liver cancer, whereas moderate to heavy consumption is associated with head, neck and colorectal cancers. Even light drinking is associated with increased risk for esophageal and breast cancer. A dose-response association exists - as alcohol consumption increases, so does cancer risk (Bagnardi et al., 2015).  Yet awareness of the link between alcohol consumption and cancer risk is modest, both internationally (Scheideler & Klein, 2018) and in the United States (Wiseman & Klein, 2019). Promoting public understanding of these risks present familiar communication challenges faced by behavioral scientists, public health professionals, and healthcare providers; we present some examples below.

Combatting positive associations with alcohol. Societal acceptance of drinking is deeply entrenched in culture. Positive associations and affect are intimately connected to the social and celebratory context of alcohol consumption as a way to unwind and connect with others. These associations may prevent message acceptance and behavior change motivation. In some respects, the relatively recent evidence for cancer risk associated with alcohol consumption harkens to the time when evidence was mounting for cancer risk associated with tobacco use, which traditionally had many similar positive affective associations. Similar to prior tobacco marketing, alcohol advertising works to deny, minimize or distract the consumer from associated cancer risks (Petticrew, Maani Hessari, Knai, & Weiderpass, 2018). Public health messages must consider affective implications and marketing messages in order to minimize message avoidance and/or reactance.

Addressing “mixed messages.” The belief that some drinking is healthy may complicate risk message acceptance. Over the past 30 years, messages regarding the cardiovascular health benefits of modest red wine consumption furthered this message (Lindberg & Amsterdam, 2008), in addition to more recent evidence of a protective effect for type 2 diabetes, and other cancers (e.g., renal cell carcinoma, multiple myeloma, non-Hodgkin lymphoma, and thyroid cancer) (Allen et al., 2009; Karami, Daugherty, & Purdue, 2015; Koppes, Dekker, Hendriks, Bouter, & Heine, 2005; Li, Yu, Zhou, & He, 2016; Santo, Liao, Andreotti, Purdue, & Hofmann, 2019). In a related way, messages about the health benefits of Vitamin D have complicated acceptance of cancer risk from sun exposure (Youl, Janda, & Kimlin, 2009).

Clarifying guideline changes. Current dietary guidelines for alcohol consumption do not yet stress the health risks of even light or modest consumption (U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2015). Yet, recent evidence suggests only zero alcohol consumption is considered safe (GBD 2016 Alcohol Collaborators, 2018). Given the evidence, we might anticipate changes to the dietary guidelines[CL3] [CELS4]  in the coming years. As with recent changes to guidelines for mammography and prostate cancer screening (PSA), communication challenges may arise.

It is necessary for behavioral scientists, public health professionals, and healthcare providers to identify challenges to message acceptance and clarify any contradictory evidence about the risks and benefits of alcohol consumption, in order to reduce any information overload or confusion.  In large, diverse samples of adults in the United States, cancer information overload and cancer risk uncertainty are exceedingly common (Cunningham et al., 2019; Paskett et al., 2019; Rawl et al., 2019). Message strategies to reduce backlash and fatalism (Jensen et al., 2017) that provide rationale for any guideline changes will be needed to optimize public message acceptance.

Multiple opportunities for behavioral science expertise. Expertise is needed to address these challenges across a range of disciplines including behavioral health, communication science, social psychology, public health/health education, and dissemination and implementation. Message strategies must challenge existing social and cultural norms, help the public manage seemingly contradictory information, and reconcile evolving guidelines. Making communication strategies available to healthcare providers that support patient discussions will be essential to reduce confusion and support informed decision-making. It may take time and consistent messaging from multiple sources to achieve public acceptance concerning the cancer risks associated with alcohol consumption (Bagnardi et al., 2015). Careful crafting of communication and strategic public health messaging are an important starting point. Anticipating such challenges will galvanize the research agenda to reduce alcohol consumption and the associated cancer risk over the next few years.



Allen, N. E., Beral, V., Casabonne, D., Kan, S. W., Reeves, G. K., Brown, A., . . . on behalf of the Million Women Study Collaborators. (2009). Moderate alcohol intake and cancer incidence in women. JNCI: Journal of the National Cancer Institute, 101, 296-305.

Bagnardi, V., Rota, M., Botteri, E., Tramacere, I., Islami, F., Fedirko, V., . . . La Vecchia, C. (2015). Alcohol consumption and site-specific cancer risk: A comprehensive dose-response meta-analysis. Br J Cancer, 112, 580-593.

Cunningham, S. A., Yu, R., Shih, T., Giordano, S., McNeill, L. H., Rechis, R., . . . Shete, S. (2019). Cancer-related risk perceptions and beliefs in Texas: Findings from a 2018 population-level survey. Cancer Epidemiology, Biomarkers & Prevention, 28, 486-494.

GBD 2016 Alcohol Collaborators. (2018). The global burden of disease attributable to alcohol and drug use in 195 countries and territories, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet Psychiatry, 5, 987-1012.

Jensen, J. D., Pokharel, M., Scherr, C. L., King, A. J., Brown, N., & Jones, C. (2017). Communicating uncertain science to the public: How amount and source of uncertainty impact fatalism, backlash, and overload. Risk Analysis, 37, 40-51.

Karami, S., Daugherty, S. E., & Purdue, M. P. (2015). A prospective study of alcohol consumption and renal cell carcinoma risk. Int J Cancer, 137, 238-242.

Koppes, L. L., Dekker, J. M., Hendriks, H. F., Bouter, L. M., & Heine, R. J. (2005). Moderate alcohol consumption lowers the risk of type 2 diabetes: A meta-analysis of prospective observational studies. Diabetes Care, 28, 719-725.

Li, X.-H., Yu, F.-f., Zhou, Y.-H., & He, J. (2016). Association between alcohol consumption and the risk of incident type 2 diabetes: A systematic review and dose-response meta-analysis. The American Journal of Clinical Nutrition, 103, 818-829.

Lindberg, M. L., & Amsterdam, E. A. (2008). Alcohol, wine, and cardiovascular health. Clinical Cardiology, 31, 347-351.

Paskett, E. D., Young, G. S., Bernardo, B. M., Washington, C., DeGraffinreid, C. R., Fisher, J. L., & Huerta, T. R. (2019). The CITIES project: Understanding the health of underrepresented populations in Ohio. Cancer Epidemiology, Biomarkers & Prevention, 28, 442-454.

Petticrew, M., Maani Hessari, N., Knai, C., & Weiderpass, E. (2018). How alcohol industry organisations mislead the public about alcohol and cancer. Drug and Alcohol Review, 37, 293-303.

Rawl, S. M., Dickinson, S., Lee, J. L., Roberts, J. L., Teal, E., Baker, L. B., . . . Haggstrom, D. A. (2019). Racial and socioeconomic disparities in cancer-related knowledge, beliefs, and behaviors in Indiana. Cancer Epidemiology, Biomarkers & Prevention, 28, 462-470.

Rehm, J., & Shield, K. (2014). Alcohol consumption International Agency for Research on Cancer World Cancer Report 2014 (pp. 96-104).

Santo, L., Liao, L. M., Andreotti, G., Purdue, M. P., & Hofmann, J. N. (2019). Alcohol consumption and risk of multiple myeloma in the NIH‐AARP Diet and Health Study. Int J Cancer, 144, 43-48.

Scheideler, J. K., & Klein, W. M. P. (2018). Awareness of the link between alcohol consumption and cancer across the world: A review. Cancer Epidemiology, Biomarkers & Prevention, 27, 429-437.

U.S. Department of Health and Human Services and U.S. Department of Agriculture. (2015). 2015-2020 Dietary Guidelines for Americans.  Retrieved from https://health.gov/dietaryguidelines/2015/guidelines/.

U.S. Department of Health and Human Services National Toxicology Program. (2016). 14th Report on Carcinogens 2016.  Retrieved from https://ntp.niehs.nih.gov/go/roc14.

Wiseman, K. P., & Klein, W. M. P. (2019). Evaluating correlates of awareness of the association between drinking too much alcohol and cancer risk in the United States. Cancer Epidemiology, Biomarkers & Prevention.

Youl, P. H., Janda, M., & Kimlin, M. (2009). Vitamin D and sun protection: The impact of mixed public health messages in Australia. Int J Cancer, 124, 1963-1970.