Nordic and Baltic Charter on alcohol and cancer
People have the right to know – alcohol is causing cancer
Alcohol is an established carcinogen, and alcohol use has been established as a major cause of cancer. International research has shown that alcohol can cause cancer, even at moderate consumption levels. Principal cancer agencies agree that the following cancer sites are causally impacted by alcohol: lip and oral cavity, pharynx (excluding nasopharynx), oesophagus, colon and rectum, liver, (female) breast, and larynx. Alcohol has been identified as the second-largest risk factor for cancer in a country like France. In the EU in 2016, about 80,000 people died of alcohol-attributable cancer, and about 1.9 million years of life were lost due to premature mortality or due to disability.
As with other noncommunicable diseases, alcohol-related cancer cases are preventable if alcohol exposure is removed or reduced. Around 40 per cent of all cancer cases are preventable. Cancer is a preventable disease that requires significant lifestyle changes. According to the European Code Against Cancer, not drinking alcohol is best for preventing cancer. Yet, national low-risk drinking guidelines appear to ignore that suggestion. A Canadian study from May 2020 concluded that drinkers following weekly low-risk drinking guidelines are not insulated from harm. More than 50% of alcohol-caused cancer deaths occur in people who drink within weekly limits.
Every country in our region has committed to reducing cancer and reducing the harm that cancer causes to our societies. Progress has been made in cooperation with national cancer societies and different non-governmental organisations.
But according to available national surveys and studies, most of our citizens are not aware that alcohol causes cancer. Evidence shows that only 20-40% of people are aware of that link. A recent (2020) study by the Danish Cancer Society found that “unprompted, 22.2% of respondents were aware of the link between alcohol and cancer. When prompted about specific cancer types, only 9.6% were aware of the link between alcohol and breast cancer.”
Not only are people not always well informed, but some are also actually misinformed. There is evidence that the alcohol industry sometimes misrepresents or downplays evidence about the alcohol-related risk of cancer.
RATIONALE FOR ACTION
In our view, this situation needs targeted and precise action from governments, state agencies, cancer societies and institutes and the broader civil society. The fact that many people are not aware of the link between alcohol and cancer poses a significant problem. People have the right to know.
The knowledge that alcohol can cause cancer, or that smoking and drinking at the same time significantly increases the risk of many cancers, would save lives.
Even if that information wouldn't change peoples' behaviour, from the standpoint of consumer rights, it is the consumer's right to be informed.
The scientific evidence shows that there is no safe limit with tobacco. We now know that this is true for alcohol, too - there is no safe limit. This understanding hasn't entered the alcohol policy discussion yet. As there is no safe level of smoking, smoking causes cancer and harms others than the smoker, it is accepted by all WHO member countries that "a comprehensive ban on advertising, promotion and sponsorship would reduce the consumption of tobacco products" and that they should act to protect public health policies from commercial and other vested interests of the tobacco industry.
It appears that with alcohol, the myths of alcohol´s health effects are still very much alive, among the public as well as the policy-makers. These persisting myths increase alcohol as a risk factor for cancer as people are more prone to neglect the warnings and choose to believe what justifies their chosen lifestyle.
The principal obligation lies with the State, which regulates the alcohol industry. The industry works to increase profits and searches continuously for new consumers. How much information the alcohol producers have to share with its customer is decided by the State. In that sense, the State either shares that information with its citizens or actively keeps it from them. The effectiveness of any sharing can be measured through the awareness level of the society. As we already noted, that level is alarmingly poor.
ETHICAL PRINCIPLES to guide the action
# The European Charter on Alcohol stated in 1995 that "all people have the right to valid impartial information and education, starting early in life, on the consequences of alcohol consumption on health, the family and society."
# An informed nation is a result of a planned action. Lack of awareness refers to either inadequate or absent action.
# A significant part of the cancer burden in our societies is preventable. Tolerating preventable harm should be considered unethical.
# Every person should be equipped to make informed choices and have the right to receive all relevant information that would guide these choices. There is no justification to withhold that information.
The Best Buy recommendations by WHO aim to encourage a healthy lifestyle by imposing restrictions on access, increasing excise taxes, and introducing bans on alcohol advertising. Research evidence suggests that these are the effective corner-stones of a comprehensive alcohol policy to reduce per capita consumption and alcohol-related harm. At the same time, these best-buy policies require additional supporting interventions. Even though reduced societal drinking levels will also reduce alcohol-related cancers, raising taxes and limiting availability will not raise awareness levels on the alcohol and cancer link. Specific and targeted intervention measures are needed to address that problem.
Awareness campaigns. The fact about the link between alcohol and cancer is in no way hidden information. Who wants to learn about it can easily find ample knowledge from every language in our region. Every public health agency in our countries publishes this information on their websites; some have issued booklets or flyers, organised conferences and events. We want to point out, though, that large part of that information does not reach most of our populations. Most people do not search for public health information or visit these websites. And that is the reason why the awareness levels are so low. Our governments should make targeted efforts to reach different age, social and language groups. The information should be shared using language and channels that are understandable and adopted by different target groups. Information can only be considered useful if that information is understandable to different target groups and reaches them.
Alcohol and cancer health warnings. We recommend introducing health warning labelling to inform the public of the direct link between alcohol and cancers, implemented on all alcohol products. The goal would be to ensure that citizens can make informed choices and better appreciate the cancer-related risk of consuming alcohol. In 2018 Ireland became the first country in Europe to introduce such warning labelling but is yet to enforce it.
Low-risk guidelines. States should reconsider national low-risk guidelines in our countries in the light of recommendations by the principal cancer agencies. Even though these national recommendations refer to low risk, many people probably interpret drinking within these limits as entirely acceptable. Yet, as we referred earlier, a recent Canadian study found that more than 50% of alcohol-caused cancer deaths occur among those drinking within weekly limits. European Code Against Cancer (ECAC) states clearly that not drinking alcohol is best for preventing alcohol. This should be reflected in national guidelines. Obviously, people see it as mixed messaging, and ECAC´s position is left in a weaker position. For instance, since 2015 the Netherlands health council is recommending that people abstain from alcohol altogether or drink no more than one glass per day.
Clear messaging from the States. All of the above would guarantee that the States' message on alcohol and cancer would be clear and concise. Considering the context in which alcohol is portrayed and used in our communities, the way the alcohol industry presents it as something inevitable; people use it to define party and fun; it is intertwined into our culture, the way we use our free time, enjoy sports and consider drinking more normal than non-drinking, the State (through its different voices) should always state the facts and stand on scientific evidence. The goal should be to raise the awareness of alcohol and cancer link and through that to prevent alcohol-related cancers. A recommendation "to reduce cancer risk, avoiding alcohol is the best option", should be a well-known statement in all our countries.
Overview of the awareness levels. Our countries do not have a systematic mechanism to identify the awareness levels on the alcohol and cancer link. There are individual surveys and studies, but some countries do not have any evidence of their citizens' awareness. States should work to change that and perform regular surveys to see if the awareness levels change. That evidence can be an essential indicator to decide next steps. Available evidence from Denmark currently even indicates that this awareness level has gone down within the last decade. It is important to find out what are the reasons for these developments and what should be done to change it.
Role of civil society. The civil society organisations, including NGO´s and cancer societies, should raise to leadership in advocating for the prevention of alcohol-related cancers. The message that alcohol causes cancer should become one of the main tools of these organisations. They should work to push this link into the centre of national and international alcohol policy discussion. Civil society has a position to hold the State accountable for taking necessary steps to prevent alcohol-related cancers.
Nordic Alcohol and Drug Policy Network commit to evaluating Nordic and Baltic countries' situation in two years, in April 2023. A progress report will assess the latest developments and give concrete recommendations to Member States and organisations.