Surgeon General’s advisory sparks a conversation about alcohol, cancer and health – OregonLive
To drink or not to drink. The Surgeon General’s advisory has Americans thinking about cancer risks.Photo by Michael AlbertyU.S. Surgeon General Vivek Murthy recently stated that alcohol-attributable cancers kill 20,000 Americans annually. His final advisory as America’s “top doctor” recommends placing warning labels on alcohol containers and revising downward the federal recommendations for daily alcohol consumption.I write about wine for a living and for several years I have attempted to keep up with the massive number of studies done on alcohol and health. As a professional, I do a lot of spitting. As a civilian, I do my best to heed the federal government’s guidelines for moderate consumption. The Surgeon General’s advisory made me take an even deeper dive into the literature.The 2020-2025 Dietary Guidelines for Americans recommend that when adults choose to drink alcohol, women should have one drink or less in a day, with men consuming two drinks or less in a day.One standard drink is defined in the guidelines as any beverage containing 0.6 fluid ounces or 14 grams of pure alcohol, such as one five-fluid-ounce glass of non-fortified wine (12% ABV), 12 fluid ounces of beer (5% ABV) or 1.5 fluid ounces of distilled spirits (40% ABV)The Dietary Guidelines, developed by the U.S. Department of Agriculture and the U.S. Department of Health and Human Services, are based on the best available science. They are reviewed every five years, and a new report is due later in 2025.The Surgeon General’s 20,000 deaths figure is based on a research brief titled “Reducing Alcohol Use to Prevent Cancer Deaths: Estimated Effects Among U.S. Adults” by Marissa Esser et al., published last year in the American Journal of Preventive Medicine. The study states that “an estimated 20,216 cancer deaths were alcohol-attributable/year during 2020-2021.”The study also noted that 83% of those deaths “could have been prevented/year if adults who drank alcohol in excess of the Dietary Guidelines had instead reduced their consumption to ≤2 drinks/day for men or ≤1 drink/day for women.”This means the vast majority of the 20,216 alcohol-attributable deaths in 2020-2021 were due to excessive drinking beyond current federal recommendations for modest consumption.In contrast, the number of alcohol-attributable deaths that year for people adhering to the moderate consumption guidelines was 3,437. That number is 0.57% of the 608,00 total cancer deaths estimated by the American Cancer Society (ACS) for that same year.To add more perspective to the 3,437 deaths figure, The Los Angeles Times reported in 2015 on a study in Circulation that estimated that drinking sugary drinks appears to kill 125,000 Americans each year through obesity-fueled cancer, cardiovascular disease and diabetes.Dr. Dariush Mozaffarian, the study’s lead author, told The Los Angeles Times, “This is not complicated. There are no health benefits from sugar-sweetened beverages, and the potential impact of reducing consumption is saving tens of thousands of deaths each year.”With alcohol, it is complicated, as decades worth of studies are routinely used to argue that low-to-moderate alcohol consumption offers health protections to be weighed against harm.For example, Dr. Miles Hassell, an internal medicine specialist who practices in the Comprehensive Risk Reduction Clinic and established the Integrative Medicine Program at Providence Cancer Institution of Oregon in Portland, said, “In every major epidemiological study of which I am aware, and I don’t use the word ‘every’ lightly, when you look at alcohol consumption, people with low to moderate consumption have lower total mortality than those who drink too much or don’t drink at all.”When looking at these studies, Hassell pointed out that alcohol consumption is one of the factors most strongly associated with lower total mortality. “The other factors are eating an omnivorous diet, exercising, not smoking and not being fat,” he said. “Alcohol consumption is right up there with them as a stand-alone item, and that, in my view, deserves some note before someone starts condemning it too much.”Out of more than 200 known cancers, The Surgeon General singled out seven that he links to an increased cancer risk due to alcohol consumption – mouth (oral cavity), throat (pharynx), voice box (larynx), esophagus, breast (in women), liver, colon and rectum. Cancers for which moderate alcohol consumption may offer a protective effect are not mentioned.The 20,000 deaths study mentioned earlier uses relative risk numbers taken from a meta-analysis published in 2015 by Vincenzo Bagnardi et al. in The British Journal of Cancer.The researchers reported that they “consistently observed” an inverse association of alcohol with both Hodgkin’s and non-Hodgkin’s lymphomas (NHL).While another study mentioned by Bagnardi et al. found no such protective effect, the researchers say they found a similar inverse association in an analysis they conducted in 2012.Other studies have similarly reported an inverse association between moderate alcohol consumption and NHL. For example, a 2005 study in Lancet Oncology found that people who drank alcohol had a lower risk of NHL than did non-drinkers and that compared with non-drinkers, risk estimates were lower for current drinkers than for former drinkers.Another study published in the International Journal of Cancer in 2017 reported that “All categories of lifetime alcohol intake were associated with about 20% lower incidence of NHL compared with lifetime abstention, but there was no evidence of a trend by amount consumed.”Bagnardi et al. also concluded that “Our meta-analysis supports the hypothesis of a protective effect of moderate alcohol consumption on the risk of renal cell cancer.” The authors theorized that “alcohol could protect from renal cell cancer because of its effect on insulin sensitivity or because of its diuretic effect, even though the association between total fluid intake and cancer risk remains still open to debate.”The ACS estimates that 1,150 and 19,390 people will die in the United States this year due to Hodgkin lymphoma and non-Hodgkin’s lymphoma (NHL), respectively. They project approximately 13,000 deaths from renal cell cancer, the most common form of kidney cancer.“If risk increases for some cancers but decreases for others, then why emphasize only increase? Do you say these seven cancers mentioned by the Surgeon General are more important than these others?” Dan Malleck, chair of the health sciences department at Brock University in St. Catharines, Ontario, Canada, said in a telephone interview.The Surgeon General’s focus on cancer risk also omits the effects of moderate consumption on cardiovascular health, the number one killer of Americans for 100 straight years.Malleck suggested the cancer focus was designed to elicit an emotional response. “Pay attention to the use of cancer to frighten the public. Evidence consistently shows that moderate alcohol consumption is protective against cardiovascular disease,” Malleck said on the social media platform X. “But unlike cancer risk, talk of which gets instant panic responses, talk of cardiovascular disease risk gets little traction. Is this just playing on broad cultural fears? Or is reducing the risk of some cancers more important than reducing cardiovascular risk?”Murthy also had a pragmatic reason for focusing on cancer – spurring Congressional action on a warning label. While appearing on the radio program “Science Friday,” Murthy said that cancer prevention was a “bipartisan issue that has enjoyed broad support” in Congress.Suggesting that Congress acts when cancer is involved, Murthy then drew a comparison to tobacco. “Going back to 1964, when the Surgeon General’s office issued the first report on tobacco, linking smoking to cancer, the very next year, Congress passed legislation that put a warning label on boxes of cigarettes,” Murthy said.This cancer focus led Dr. Vinay Prasad, MD MPH, a professor in the Department of Epidemiology and Biostatistics at the University of California, San Francisco, and a practicing hematologist-oncologist at San Francisco General Hospital, to ask in a telephone interview, “Is the Surgeon General’s advisory meant to be a scientific document or a piece of propaganda? What he’s saying is that the most effective propaganda is to talk about cancer.”Another way to look at the relationship between alcohol and health is all-cause mortality. It’s exactly what it sounds like, a kind of “big picture” view of a problem, like the amount in which mortality changes as a result of alcohol exposure, irrespective of specific cause of death.In December 2024, the National Academies of Sciences, Engineering, and Medicine (NASEM) released a report titled “Review of Evidence on Alcohol and Health.” One of their conclusions, made with “moderate confidence,” is that based on their meta-analysis of data from eight eligible studies conducted from 2019 to 2023, there was “a 16% lower risk of all-cause mortality among those who consumed moderate levels of alcohol compared with those who never consumed alcohol.”NASEM came to similar conclusions on all-cause mortality in their 2010, 2015 and 2020 reports. The committee added that “moderate certainty” is typically as high a grade as they assign a conclusion in the absence of a randomized controlled trial.The NASEM report is notable for excluding studies that combine people who used to drink but stopped because of health issues, known as “sick quitters,” with “never drinkers” to compare with moderate drinkers. A frequent critique of studies that find health benefits in moderate alcohol consumption is that including “sick quitters” skews the results by making moderate drinkers appear healthier.“NASEM excluded ‘sick quitter’ data, and it still shows a lower risk through moderate drinking, both for cardiovascular health and all-cause mortality, and those causes include cancer. The Surgeon General’s cherry-picking of the cancer data and ignoring all-cause mortality is problematic,” Malleck said.Prasad agreed with Malleck’s assessment: “It’s problematic because if you avoid 1 in 100 cancers, but you double the rate of heart attacks, nobody would want that.”Looking at all-cause mortality also involves more nuance than just looking at cancer. “The NASEM summaries show that you actually survive better, with all-cause mortality, when drinking alcohol in moderation. The improved mortality rates likely reflect these cardiovascular benefits combined with other factors like better overall health behaviors in moderate drinkers, making it clear that context and individual health are essential when interpreting these findings,” Dr. Brian Lewanda, MD, a radiation oncologist at Advocate Radiation Oncology based in Fort Myers, Florida, said.When discussing health and alcohol consumption, it is duly noted that some people, such as those with certain pre-existing conditions, should not drink any alcohol. In addition, no one is advocating alcohol consumption beyond current federal guidelines, nor in pursuit of health benefits. Please speak with your physician when making decisions about alcohol consumption.One of those doctors might be Hassell. His “big picture view” of the situation is that “If we look at the raw data, one to two drinks a day for men, one drink for women, maybe up to two, but that’s pushing it, we clearly see a lower overall death rate, lower rates of diabetes, especially in women, lower rates of heart disease and stroke, tiny bit lower rates of dementia and virtually no signal with respect to cancer at those levels.”If Congress would like Hassell’s advice, he would tell them: “We can say at current federal recommended alcohol consumption guidelines that alcohol is relatively neutral with respect to cancer, except maybe breast cancer at higher levels in women, but beneficial in these other areas.”One last piece of advice: “New discoveries about what causes (or might cause) cancer seem to be made nearly every day. When you see a story in the news linking something to cancer, especially if it’s something you’re exposed to on a regular basis, your first reaction is often to think that we need to avoid it at all costs. But it’s not usually that simple. Often, it’s hard to get the full story.”The author of this sage advice is the American Cancer Society.Next up is an examination of the new Interagency Coordinating Committee for the Prevention of Underage Drinking report, which directly contradicts the NASEM report. I will also discuss ways to resolve all of the conflicting studies on alcohol consumption and health.The Surgeon General’s office denied a request for an interview with Murthy.– Michael Alberty writes about wine for The Oregonian/OregonLive and Wine Enthusiast Magazine. He can be reached at malberty0@gmail.com. To read more of his coverage, go to oregonlive.com/wineIf you purchase a product or register for an account through a link on our site, we may receive compensation. 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