Alcohol-Related Cancer Risk: Updates from the United States Surgeon General Advisory
Sunita Pirmal, PharmD
3-min
Alcohol-Related Cancer Risk: Updates from the United States Surgeon General Advisory
Although alcohol consumption of at least one drink per week is reported in 72% of Americans, only 45% recognize the link between alcohol and cancer; suggesting little has changed in the past two decades ago on public perspective. Extensive alcohol use is linked to numerous other complications such as hepatotoxicity, pancreatitis, cardiomyopathy, delayed wound healing, infection, and stroke. As alcohol consumption is identified as the third leading cause of preventable cancer in the US after tobacco and obesity, the U.S. Surgeon General has advised increased public awareness of alcohol-related cancers. [1-3]
The mechanism for alcohol-related cancers is multifaceted. Alcohol is metabolized into aldehyde, which may bind to and alter deoxyribonucleic acid (DNA). It may also promote oxidation or alter hormones, like estrogen, which are protective against cancer. Additionally, alcohol may be contaminated with known carcinogens (i.e., nitrosamines, aflatoxins, and urethane) through the fermentation process, further increasing one’s cancer risk. Although the levels of these components in alcohol have decreased over time, the true risk is noncalculable as alcohol product recipes are confidential proprietary data. Researchers are also examining whether folate deficiency may play a role in cancer occurrence. [1,4]
Data suggests that even patients adhering to current recommendations for alcohol consumption (i.e., 1 drink/day in women and 2 drinks/day in men) are at risk of alcohol-related cancers. Out of 741,300 worldwide cases of any alcohol-related cancer, over 185,000 diagnoses were in patients who ingest no more than 2 drinks (i.e. 14 grams of pure alcohol) per day. This suggests that although increased alcohol still heightens cancer risks, current limits may still result in negative outcomes. This was especially evident with breast and oropharyngeal cancers, with increased risk seen with daily limits of one drink per day or less. Additional reported data include the absolute and relative risks for any cancer, breast, and mouth cancer in men and women, as seen in Table 1. The most extreme example presented was the relative odds of acquiring oral cancer in those only drinking one drink (40%) versus two drinks (97%) per day. Considering the lifetime absolute risk of oral cancer is usually around 0.8%, this indicates a need for re-examination of how alcohol consumption is managed. [1-5]
Variables that may lead to increased consumption and therefore increase subsequent alcohol-related risks include socioeconomic factors (i.e. targeted advertisement, peer pressure, societal norms), being of East Asian descent (i.e., genetic variant with reduced aldehyde metabolism), or environmental factors (i.e. occupational carcinogen exposure). [1]
A 2025 study compared how alcohol screening and brief counseling (ASBC) were applied in primary care settings for 150,332 patients aged 18–64. The study evaluated four outcomes:
- Quantity assessment: Measuring how much alcohol patients drank
- Problem assessment: Evaluating the impact drinking may have on participants
- Brief counseling: Advising for decreased alcohol consumption
- Treatment information: Providing or offering treatment related to alcohol use [6]
Key Findings:
- Improvements in Quantity Assessment: The percentage of patients who received a quantity assessment rose from 40.5% in 2013 to 46.7% in 2017 to 2019.
- Low Rates for Problem Assessment and Brief Counseling: Problem assessments stayed below 12%, and brief counseling was under 7%, even for patients with heavy drinking or alcohol use disorder (AUD).
- Small Gains in Treatment Information: For patients with AUD, receiving treatment information increased slightly, from 6.2% to 8.6%. [6]
Disparities:
- Racial Disparities: White patients showed the largest increases in all ASBC outcomes. Black patients saw much smaller improvements, especially in quantity assessments, where White patients experienced nearly 4 times the increase compared to Black patients who drank heavily.
- Insurance Disparities: Privately insured patients showed more improvements than those with Medicaid.
- Hispanic Populations: Hispanic patients with no heavy drinking or AUD improved in quantity assessments but still lagged behind White patients. [6]
Even after considering factors like insurance, socioeconomic status, and primary care visits, disparities persisted, especially between White and Black patients. The findings suggest deeper systemic issues affecting equitable healthcare access and treatment. [6]
The Office of the Surgeon General recommends additional initiatives to increase public awareness of the connection between alcohol and cancer, one of which includes an updated health warning label. This updated label has proven to be beneficial in Canada as these changes resulted in a 10% increase in knowledge within two months. Additionally, more visually dynamic and prominent imagery may be more effective than traditional text-based messaging to elicit behavioral changes. [1]
As additional warning labels may be efficacious in increasing knowledge of alcohol-related risks, this may result in the unintentional consequence of greater stigma associated with drinking due to a change in public perception of the act, leading to underreporting during alcohol screenings. This social desirability bias was acknowledged as a current limitation within the previously mentioned healthcare disparity study, although this was referring to religious and cultural views on drinking. [5,6]
The most recent guideline made by the U.S. Preventative Services Task Force in 2018 recommends screening with 1– to 3-item screening instruments, such as the Alcohol Use Disorders Identification Test (AUDIT-C) or Single Alcohol Screening Question (SASQ), in the primary care settings in adults 18 years and older, including pregnant women, for risky behavior associated with alcohol use. Patients positive for unhealthy alcohol use are encouraged to receive brief behavioral counseling interventions to reduce unhealthy use of alcohol. As these recommendations are under review for updates, they are subject to change. [7-9]
Aside from promoting AUDIT-C or SASQ like the USPSTF, the U.S. Surgeon General Advisory also recommends the reexamination of current recommendations for alcohol consumption, given the evidence suggesting alcohol-related cancers do occur in many patients abiding by current standards. Current clinical practices may be optimized through addressing causes for healthcare disparities exhibited in numerous patient populations, increasing the role of healthcare professionals in the initiation of alcohol-centered interactions, and providing appropriate interventions or referrals for treatment, all with the goal of minimizing alcohol consumption and these subsequent alcohol-related cancers. [1]
References:
[1] U.S. Surgeon General. Alcohol and Cancer Risk: The U.S. Surgeon General’s Advisory. Accessed January 22, 2025. https://www.hhs.gov/sites/default/files/oash-alcohol-cancer-risk.pdf
[2] Alcohol’s effects on the body. National Institute on Alcohol Abuse and Alcoholism (NIAAA). Accessed January 22, 2025. https://www.niaaa.nih.gov/alcohols-effects-health/alcohols-effects-body
[3] Trevejo-Nunez G, Kolls JK, de Wit M. Alcohol Use As a Risk Factor in Infections and Healing: A Clinician's Perspective. Alcohol Res. 2015;37(2):177-184.
[4] National Toxicology Program. 15th Report on Carcinogens. Rep Carcinog. 2021;15:roc15. doi:10.22427/NTP-OTHER-1003
[5] Limit Alcohol. National Center for Health Promotion and Disease Prevention. US Department of Veterans Affairs, Veterans Health Administration. Accessed January 22, 2025. https://www.prevention.va.gov/Healthy_Living/Limit_Alcohol.asp
[6] Cook WK, Ye Y, Zhu Y, Karriker-Jaffe KJ, Mulia N. Trends and disparities in alcohol screening and brief counseling following the U.S. Affordable Care Act. Drug Alcohol Depend. Published online January 15, 2025. doi:10.1016/j.drugalcdep.2025.112558
[7] Unhealthy alcohol use in Adolescents and Adults: Screening and behavioral counseling interventions. Published November 13, 2018. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/unhealthy-alcohol-use-in-adolescents-and-adults-screening-and-behavioral-counseling-interventions#toc
[8] Viral Hepatitis and Liver Disease. US Department of Veterans Affairs, Veterans Health Administration. Accessed January 2022, 2025. https://www.hepatitis.va.gov/alcohol/treatment/audit-c.asp
[9] Screen and assess: Use quick, effective methods. National Institute on Alcohol Abuse and Alcoholism (NIAAA). Published January 6, 2025. https://www.niaaa.nih.gov/health-professionals-communities/core-resource-on-alcohol/screen-and-assess-use-quick-effective-methods
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