Table Of Content

ALCOHOL AND SOCIETY 30% of all alcohol-attributable “If you’re too tired to take your cancer cases in Sweden are kid to the football match on caused by moderate or low Sunday, you drank too much levels of alcohol consumption. on Saturday night.” Claudia Fahlke, Professor of Psychology THEME 2016/2017: ALCOHOL AND CANCER The Swedish Society of Medicine and IOGT-NTO are voluntary organisations independent of commercial interests. The Swedish Society of Medicine is the scientific organisation of the Swedish medical pro- fession and has a broad range of interests across the entire field of medicine. The importance of lifestyle to people’s health at both individual and societal level, is a priority issue. IOGT-NTO focuses on the effects of alcohol and narcotics on individuals and society, but is also engaged in broad social and club activities. CERA is an interdisciplinary and collaborative centre for education and research into hazardous use, abuse and addiction at Gothenburg University – which works to strengthen and develop research and education in the field of addiction, and to disseminate scientific expertise to people working professionally in the field of abuse and addiction, and other interested parties. Published by IOGT-NTO, the Swedish Society of Medicine and CERA in cooperation with Forum Ansvar, 2016/2017 A Swedish language version of this report is also available from www.iogt.se or www.sls.se. © IOGT-NTO & Swedish Society of Medicine & CERA, 2016 Graphic design: ETC kommunikation Printers: Fridholm och Partners, Hindås URN: urn:nbn:se:iogt-2016-aos-en CENTRUM FÖR UTBILDNING OCH FORSKNING KRING RISKBRUK, MISSBRUK OCH BEROENDE (CERA) 3 TABLE OF CONTENTS Foreword ...................................................................................4 Executive Summary .............................................................7 Introduction Alcohol as a cause of cancer .....................................10 How does alcohol cause cancer? .................................12 Cancers accepted by IARC as caused by alcohol ...............................................................................14 Other cancers probably caused by alcohol consumption ....................................................17 Cancer possibly caused by alcohol ..............................18 Possible underestimation of alcohol-related cancers ....................................................19 Methods used to estimate alcohol caused cancers in Sweden .............................................20 Results Awareness .............................................................................28 Report Prevention policy ................................................................30 Find out more about the latest research showing clear links between alcohol and cancer. References ............................................................................32 PAGE 6 Interview Addiction doesn’t discriminate ....................................34 It’s important to talk about alcohol ...........................40 Current research Should the alcohol industry be regulated in the same way as the tobacco industry? .............39 Alcohol policies have long-term effect on consumption ..................................................................44 Interview Interview Is moderate alcohol consumption good Jonas Sjögreen: Claudia Fahlke, for health? ............................................................................44 Alcohol – a sensitive Professor of Health issue in health care. Psychology, on Alcohol Dependence. PAGE 40 PAGE 34 4 Foreword Clear link between alcohol and cancer Healthy living and lifestyles are a strong to intensify initiatives aimed at prevention trend in Sweden, but no other EU national- and information provision. ity knows less about or is less aware of the The Swedish Society of Medicine and link between alcohol and cancer. And given IOGT-NTO, with the financial support of that alcohol is the second most common Forum Ansvar, publishes an annual research contributory factor in terms of the global report entitled “Alcohol & Society”, with the cancer burden, according to the World aim of illustrating the harmful effects of Health Organisation, this is something we alcohol consumption at both an individual are keen to change. Which is why we hope and a societal level. This year’s report, which that this report can help boost knowledge is on the theme of alcohol and cancer, was levels and awareness, and increase interest also produced in partnership with CERA, an in the issue, both in the health care sector interdisciplinary centre for education and and in society as a whole. research into hazardous use, abuse and International research has shown that addiction at Gothenburg University. alcohol can cause cancer, even at moderate The report is produced by a group headed consumption levels. This report includes by Harold Holder and comprising some of estimates that almost 30% of the cases of the foremost researchers in the field of alcohol-induced cancer in Sweden are due international alcohol research. The group to moderate or low levels of alcohol con- collates and aggregates facts and fig- sumption, and that the more the individual ures from international studies, and then draws conclusions and proposes measures tailored for use in Sweden and the other “ It is our hope that readers will find Nordic countries. They receive no financial the report thought-provoking and remuneration for this work. Previous years’ reports have addressed that it will provide you with valuable such issues as alcohol and young people, information on the latest findings in the effects of low dose consumption, and the second-hand harm caused by alcohol. alcohol-related research! The report’s articles are aimed at a broad target group and can be read by anyone consumes, the greater the risk. It should interested in public health. An English-lan- also be noted that the cost of hospital guage version with a full bibliography is also treatment of alcohol-induced cancer ex- provided for more in-depth study, and is ceeded SEK 320 million in Sweden in 2014. available on our respective websites. This year’s report also includes estimates It is our hope that readers will find the re- of the percentage of Swedish deaths from port thought-provoking and that it will pro- cancer where alcohol was a factor, in order vide you with valuable information on the to highlight the importance of the issue and latest findings in alcohol-related research! STEFAN LINDGREN, CLAUDIA FAHLKE, DIRECTOR JOHNNY MOSTACERO, CHAIRMAN SWEDISH CERA UNIVERSITY OF CHAIRMAN IOGT-NTO SOCIETY OF MEDICINE GOTHENBURG 5 6 Report 7 EXECUTIVE SUMMARY • Alcohol causes cancer. Any among men, and breast cancer Authors alcohol consumption increases among women. the risk of certain cancers, and • More than 10% of breast higher levels of consumption cancer deaths in Sweden are further increase those risks. Sven Andréasson attributable to alcohol. • Evidence for the relationship Karolinska Institutet, Department of between alcohol and cancer • Critically, the evidence Public Health Sciences, Stockholm, comes from chemical toxicology summarised in this report Sweden. indicates that approximately studies, animal studies, and 30% of all alcohol-attributable Tanya Chikritzhs epidemiological studies among cancer cases and deaths humans. Alcohol is considered Curtin University, National Drug in Sweden are caused by a Group I carcinogen (highest Research Institute, Perth, Western moderate or low levels of level) by the International Australia. alcohol consumption. Agency for Research on Cancer of the World Health • The number of alcohol- Frida Dangardt Organization. attributable cancer deaths in Sahlgrenska Academy and Univer- Sweden has increased by 7.3 sity Hospital, The Queen Silvia Chil- • Human cancers that are percent since 2001 dren´s Hospital – Paediatric Clinical considered causally related Physiology, Goteborg, Sweden. to alcohol consumption • Hospitalizations from alcohol- include cancers of the oral attributable cancers cost at Harold Holder cavity (mouth), pharynx least 324 million SEK in 2014 Senior Scientist Emeritus och tidig- (throat), larynx (voice box), • The public and members of the are chef för Director of Prevention esophagus, stomach, liver, medical professions are largely Research Center, Pacific institute for colon and rectum, and female unaware of the role of alcohol Research and Evaluation, Berkely, breast. Other cancers that as a cause of cancer. Among CA, USA. are associated with alcohol the general public in European consumption and are probably Union nations, Swedes had Timothy Naimi causally related to alcohol include cancers of the pancreas the lowest recognition of the Boston Medical Center, Section on and prostate. There are other relationship between alcohol General Internal Medicine, Boston, cancers that are associated and cancer in a recent study. MA, USA. with alcohol consumption (e.g., • A number of steps should be Tim Stockwell lung cancer, melanoma) but taken to raise public awareness where a causal relationship is of the link between alcohol Dept of Psychology – Centre for Ad- more speculative in nature. consumption and cancer, dictions Research of BC, University of Victoria, BC, Canada including the labeling of alcohol • In Sweden in 2014, there were containers with warnings about an estimated 996 alcohol- the risk of specific cancers. We are grateful to Dr. Jinhui Zhao attributable cancer deaths and to Adam Sherk of the Centre (4.5% of all cancer deaths) • Population-level reductions for Addictions Research of BC at among the 10 cancers listed in excessive and overall the University of Victoria in Canada above. This includes 795 alcohol consumption are the who applied the WHO methods to alcohol-attributable cancer best way to prevent future generate the estimates of alcohol deaths (3.6% of cancer deaths) alcohol-related cancers. The caused deaths and hospitalizations from the eight for the cancers most effective means to in Sweden. where evidence for a causal achieve this is by adopting and We are also grateful to Drs. relationship with alcohol is strengthening evidence-based Jürgen Rehm and Kevin Shield who considered to have the highest alcohol policies, including provided training and advice on the level of evidence. maintaining and strengthening methods for estimating the burden the Swedish retail alcohol • The leading causes of alcohol- of disease and injury from alcohol. monopoly, limiting overall attributable cancer deaths in access to alcohol, and raising Sweden are colorectal cancer alcohol prices. for the entire population and 8 Report 9 INTRODUCTION Alcohol causes cancer. Cancer is among the of all cancers are attributed to a known risk leading causes of death and disease world- factor.1 wide. Worldwide the incidence of cancer Thus while improving the diagnosis and has increased from 12.7 million in 2008 to treatment of cancer is essential, there is 14.1 million in 2012 as a result of population also a compelling case for a public health Consumption of growth, ageing, and adoption of indus- approach to the prevention of cancer. alcohol is the second trialized lifestyles with increased use of Towards this end, the International Agency largest contribution tobacco, consumption of alcohol and highly on Research on Cancer (IARC) was estab- to the global processed foods, and a lack of physical ac- lished in 1965 as the WHO expert agency on burden of disease tivity. Consumption of alcohol is the second cancer and charged with identification of for cancer, second largest contribution to the global burden of the causes of human cancers as a first step only to tobacco use according to recent disease for cancer, second only to tobacco in cancer prevention.4 estimates made for use according to recent estimates made for Even though awareness on the part of the World Health the World Health Organization (WHO).1 In the public is low, in scientific circles alcohol Organization (WHO). the last decades, the total number of alco- has been known to cause cancer for several hol-attributable cancer cases has increased decades. In its first evaluation of the sub- to approximately 770,000 worldwide or stance in 1988, IARC concluded that alcohol 5.5% of the total number of cancer cases. was carcinogenic. IARC repeated this Correspondingly estimated cancer deaths evaluation in 2007 and found evidence that attributable to alcohol consumption are the contribution of alcohol to cancer was estimated to be approximately 480,000 or larger than previously appreciated. In the 5.8% of the total number of cancer deaths. same year the World Cancer Research Fund Alcohol-attributable cancer cases are par- (WCRF) published its conclusions about the ticularly high in the Western Pacific, Europe- state of the science on cancer which agreed an and South-East Asia WHO regions.2 with IARC. In recent years the evidence has The predicted global cancer burden is strengthened that alcohol is causally impli- expected to exceed 20 million new cancer cated in an increasing array of cancer types. cases annually by 2025. Cancer treatment and care of cancer patients has an escalating Given the importance of cancer to Swedish economic impact as do the wider corre- society, the purpose of this report is to pro- sponding losses to economic productivity. vide an overview of alcohol’s contribution All countries including those with the high- to cancer in general, to provide estimates of est-incomes will struggle to cope with the alcohol-related cancer mortality and mor- increasing costs associated with cancer. 3 bidity in Sweden as well as in comparison to other Nordic countries, and to discuss In the first part of the 20th century causes implications for Swedish policies concern- of cancer were not commonly known and ing public health and alcohol. In this report the hopes of physicians and the public were we apply methods used by the WHO Global focused initially on improved treatment Burden of Disease study to estimate the and early detection. Over time, epidemio- proportions of cancer deaths and hospitali- logical cancer research increasingly found zations caused by alcohol in 2014. In our dis- that external factors were associated with cussion of the research literature we have differences in observed cancer rates across conducted systematic searches of scholarly countries and regions. Such research has databases and given priority to systematic supported a conclusion that the great ma- reviews published in peer reviewed scientif- jority of cancers, could be due to external ic journals and major reports from interna- factors.4, 5 A recent estimate of the global tional expert bodies such as the Interna- burden of disease for 2013 found that 42% tional Agency for Research on Cancer. 10 Report Alcohol as a cause of cancer This report builds on international evidence “ If you drink alcohol of any summaries generated by the IARC and the type, limit your intake. Not WCRF on the relationships between alcohol and cancer. drinking alcohol is better for In particular, IARC has developed a meth- odology for examining studies published cancer prevention.” in the scientific literature to determine the IARC has evaluated strength of evidence in relation to external, 990 agents of which 118 have been and often preventable, causes of cancer in to the list of cancers caused by alcohol.6 classified as Group humans. The most recent IARC monograph In 2016 the World Cancer Research Fund 1 as carcinogens in on alcohol was published in 2012. concluded that stomach cancer also was humans. Group 1 IARC collect and summarize all available causally related to alcohol consumption.8 carcinogens include human and animal studies on the carcino- In its European Code Against Cancer, the substances such as genicity of potential agents and closely European Commission also recognizes and benzene, aflatoxin, consider study quality, temporal effects, highlights the causal role of alcohol for a soot, tobacco and alcohol. use of biomarkers, plausible mechanisms range of cancers. There are 12 recommenda- and apply an overall causality criteria. tions in the most recent Code and alcohol is To date, IARC has evaluated 990 agents listed sixth: “If you drink alcohol of any type, of which 118 have been classified as Group 1 limit your intake. Not drinking alcohol is as carcinogens in humans. Group 1 carcino- better for cancer prevention.”9 For alcohol- gens include substances such as benzene, related cancers, risk increases as alcohol aflatoxin, soot, tobacco and alcohol.7 intake increases. However, for most of Alcohol was classified as a Group 1 car- these cancers increased risk is evident even cinogen in 1988 when it was concluded that at low or “moderate” levels of drinking. there was sufficient evidence that alcohol played a causal role in cancers of the oral cavity, pharynx, larynx, esophagus and liver. Since that time, several hundred more European Code Against epidemiological studies have reported on Cancer the association between the consumption of alcoholic beverages and the risk for cancer If you drink alcohol of any type, limit your intake. Not drinking alcohol is better for at various sites. In 2007, the IARC added can- cancer prevention. cers of the female breast, colon and rectum Is drinking alcohol a cause of cancer? Yes. There is no doubt that drinking alcohol can cause at least seven types Potential carcinogenic of cancer: those of the mouth, gullet agents are classified (oesophagus), throat (pharynx and larynx), liver, large bowel (colon and rectum), and according to the following: breast. Consumption of any amount of alcohol Group 1: The agent is carcinogenic to increases your cancer risk. The more humans. alcohol you drink, the higher the risk Group 2A: The agent is probably of developing cancer. Reducing your carcinogenic to humans. consumption or – even better – avoiding Group 2B: The agent is possibly alcohol completely will help reduce your carcinogenic to humans. cancer risk. Group 3: The agent is not classifiable as to http://cancer-code-europe.iarc.fr/ its carcinogenicity to humans. index.php/en/ecac-12-ways/alcohol- Group 4: The agent is probably not recommendation/19-drinking-alcohol- carcinogenic to humans. cause-cancer Ref: 4, pp 145-6, pp 9-35