Earlier this month, then U.S. Surgeon General Vivek Murthy called for alcoholic beverages to feature cancer-warning labels similar to the ones on packs of cigarettes. Dr. Ernest Hawk is vice president and head of the division of Cancer Prevention and Population Sciences at The University of Texas MD Anderson Cancer Center and holds the T. Boone Pickens Distinguished Chair for Early Prevention of Cancer. He talks with host Krys Boyd about the ways alcohol causes cancer and what your risk might be. And later in the hour, Isabella Cueto, who covers chronic disease for Stat, talks about the fight the alcohol lobby is waging to stop this idea.
Beyond the hangover, alcohol causes cancer
By Madelyn Walton, Think Intern
Former U.S. Surgeon General Vivek Murthy turned heads by calling for cancer warning labels on alcohol, but doctors and researchers have been aware of the link for decades.
Dr. Ernest Hawk is Vice President and Head of the division of Cancer Prevention and Population Sciences at the University of Texas MD Anderson Cancer Center and he holds the T. Boone Pickens Distinguished Chair for Early Prevention of Cancer. He joined host Krys Boyd to discuss why alcohol causes cancer and what risks are associated with it.
“It is seen as the third leading preventable cause of cancer in the American population, trailing behind tobacco, which remains as the number one risk, as well as obesity, which is estimated to be the second most prevalent cause for concern as relates to cancer,” Dr. Hawk says.
The use of alcohol doesn’t just affect the liver, it increases the risk of all types of cancer.
“Alcohol is now convincingly associated with seven sites of cancer,” Dr. Hawk says. “They extend from the mouth, the pharynx or the throat, the voice box or larynx, esophagus, colorectal, as well as breast and liver, of course, which is probably the best understood and longest understood.”
In the past, doctors advised women to one drink per day and men to two per day. As research evolves, the recommendations are changing.
“It’s broadly felt that more is worse, and particularly daily consumption is unwise,” he says.
Americans do drink a generous amount, and some people may be reluctant to take scientists’ suggestions to cut down on their beverage intake.
“I would hope that it would be instantaneous, but of course, that’s never the case,” he says. “Usually, it takes five to fifteen years for this messaging to start impacting behavior.”
Dr. Hawk and other experts encourage patients to take these risks seriously and acknowledge what harm can be done.
“The real point of all of this is to raise awareness and to try to help patients modify their behavior once they understand the risk.”
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Transcript
Krys Boyd [00:00:00] When the Biden administration, Surgeon General Vivek Murthy, called for cancer warning labels on alcohol, the collective response seemed to be a gasp. But Murthy says doctors and researchers have known about the correlation between alcohol and a variety of cancers for years.
Surgeon General Vivek Murthy [00:00:16] But actually, the research has been building for years now. We’ve had more and more evidence that keeps accumulating year by year. That’s giving us a strong connection, a causal link between alcohol and cancer.
Krys Boyd [00:00:28] From Kera in Dallas, this is Think. I’m Krys Boyd. Even moderate drinking can raise the risk of liver cancer, colorectal cancer, even breast cancer. So why doesn’t the general public know much about this information? And how many drinks put an average person at risk? My guest today will help talk us through those questions. Dr. Ernest Hawk is Vice President and head of the Division of Cancer Prevention and Population Sciences at the University of Texas MD Anderson Cancer Center and holds the T. Boone Pickens distinguished chair for the Early Prevention of Cancer. Dr. Hawk, welcome to Think.
Dr. Ernest Hawk [00:01:05] Thank you. Good to be with you.
Krys Boyd [00:01:07] What sort of research exists that suggests causal relationships between alcohol consumption and cancer?
Dr. Ernest Hawk [00:01:14] Well, there’s a lot of it, and it’s occurred over the last 30, 40 years. Fundamentally, it comes from two lines of evidence, one that’s mechanistic and largely conducted in animals or observational, and the bulk of it is observational in nature that is looking at populations, those who drink versus those who don’t, and finding out what happens to them over time.
Krys Boyd [00:01:39] So one challenge, as I understand it with population based studies, is that if you’re looking at people’s behavior and health outcomes over years, you can’t control all the conditions of their lives, right? And compare apples to apples. What’s different with animal studies?
Dr. Ernest Hawk [00:01:55] No, you’re exactly right. Regarding the observational data that exists, there are many potential confounders or modifiers have an effect, and so they always lead to their graded generating hypotheses and a little bit more difficult to interpret in terms of mechanisms or causality. Animal studies, you can control all of the other variables and really expose them to exposures that to humans might be harmful In an attempt to better understand what the exposure does in terms of its impact on outcomes, as well as gain insights into how those outcomes are generated.
Krys Boyd [00:02:36] Is it possible to put any numbers to this, like how many premature deaths alcohol might contribute to from cancer in any given year or for a particular population?
Dr. Ernest Hawk [00:02:47] It is possible and the surgeon general’s warning that recently came out attempted to do that. I don’t recall the numbers exactly, but
Krys Boyd [00:03:15] This is so interesting because I think the you know, there’s great public awareness around the correlation between smoking and cancer. It doesn’t seem like drinking in cancer is on the radar screens maybe of non-scientists, especially people outside the field of cancer care.
Dr. Ernest Hawk [00:03:33] Yeah, no, you’re exactly right. There are even been studies here over the last decade suggesting that people are very familiar with the risks of cancer risks and things like asbestos or or smoking. But they’re much less aware of obesity and even more less aware of alcohol. And I think that’s one of the things that really prompted the surgeon general to issue his advisory.
Krys Boyd [00:03:57] Is alcohol use linked to an increased risk of all kinds of cancer, or are there certain forms that seem to be especially related to people’s drinking habits?
Dr. Ernest Hawk [00:04:07] Yeah, that’s a very good question. The evidence is now felt to be convincing by both the surgeon general, as well as other major public health agencies like the CDC or the National Cancer Institute. Alcohol is now convincingly associated with seven sites of cancer. They extend from the mouth, the pharynx or the throat, the voice box or larynx, esophagus, colorectal, as well as breast and liver, of course, which is probably the best understood and longest understood.
Krys Boyd [00:04:42] Yeah, These are all cancers that I think people who think about cancer at all would be concerned about. Do we know anything about the mechanisms that might make alcohol a contributor to the risk of those cancers?
Dr. Ernest Hawk [00:04:55] Yes. And there there are these four mechanisms that have been identified reliably, again, predominantly in animal studies. The first of them is that the metabolism of alcohol results in a substance called acetaldehyde, which is toxic to DNA and can cause mutations in DNA. So that’s the first thing. It can alter the structure of our DNA, which is one of the ways that cancer develops. Secondly, it’s oxidative stress. It causes changes in a number of different molecules that can interrupt cell signaling. Third, it can boost levels of estrogen, particularly in women. And that’s important because estrogen drives some of the cancers that occur in estrogen responsive tissues like the breast ovary or uterus. And then finally, it’s also been demonstrated that alcohol, when ingested, particularly with other substances, can serve as a solvent, helping them to kind of magnify or synergize their toxicity. That’s particularly relevant with tobacco, since historically, many individuals who practice one of those things smoked, also drank. And that’s particularly problematic.
Krys Boyd [00:06:13] There’s also this question of how much alcohol might raise someone’s risk of cancer. Most people understand that heavy drinking habits are detrimental to our health in all kinds of ways. What have you learned in recent years about the hazards of light or moderate alcohol consumption?
Dr. Ernest Hawk [00:06:29] Yeah, well, first of all, you’re exactly right. And the definition of light or moderate is different across the span of observational studies. And so it’s been difficult to pinpoint exactly how much is enough to raise risk. And I will say that the literature continues to accumulate in that regard. And right now, most experts working in the field feel that as little as one drink a day or four or more per week is where the risk becomes significant enough to increase the risk of cancer, particularly cancers of the mouth, breast and esophagus. But yet the recommendation from most agencies at this point is therefore as relates to cancer risk. No alcohol is the best choice. But there is a lot of a lot of debate around the lowest level. Can you get by with one drink a week? And the data really aren’t there convincingly to demonstrate that. And so the recommendation coming from most agencies is none is best.
Krys Boyd [00:07:35] Dr. Hawk, a lot of people who might drink four drinks per week or one per day barely think of themselves as drinkers because this is, you know, alcohol consumption is something that happens in our society pretty commonly. It’s socially acceptable in most communities. How do patients respond when you face them with these facts?
Dr. Ernest Hawk [00:07:59] Well, first of all, most are unaware. Just as we discussed earlier, you know, this is not well known by anybody. So and I would say it’s very important to not necessarily attribute someone’s cancer to their exposure to alcohol. We can never at an individual level point out the cause for any individual’s cancer, at least in most every circumstance. So very important to avoid making anyone feel guilty over their exposure to alcohol. The real point of all of this is to raise awareness and to try to help patients modify their behavior once they understand the risk.
Krys Boyd [00:08:39] So you think it was a smart move for the former surgeon general to raise the red flag on those?
Dr. Ernest Hawk [00:08:44] I definitely do. I mean, I think it’s been a long time coming because, again, in the world of cancer risk, this had been discussed for about the last decade without any similar sort of action coming from the surgeon general’s office or the CDC or other agencies. And so it was really helpful, I think, for him to put the spotlight on alcohol as a modifiable cancer risk for our population.
Krys Boyd [00:09:12] Did you find yourself attending events and conferences and speaking with colleagues, all of whom were baffled that this message has somehow failed to really, until quite recently, to really reach the surface of of public knowledge?
Dr. Ernest Hawk [00:09:26] Yes. And several of the agencies that I’ve referenced earlier, the National Cancer Institute, CDC, American Cancer Society, had been trying to get the word out for quite a while, and yet it really hadn’t changed the public’s perception. Still, less than 40-45% of individuals were aware of the association, aware of the fact that since 1989, alcohol has been considered a carcinogen of the highest degree. And yet so little of the public had any awareness around that. It was somewhat baffling to a scientist, yet not to the general public.
Krys Boyd [00:10:03] I would imagine one enormous problem from a public health messaging standpoint is that for years many of us heard with delight that consuming red wine in modest amounts could be beneficial for our hearts. First of all, tell us what we what is known about that assumption today.
Dr. Ernest Hawk [00:10:22] Yeah, it’s a great question because it remains the most active area of debate. You may be aware that last month the National Academies came out with a report that still demonstrated a cardioprotective event that is reduction in heart attacks and strokes with low levels of consumption. Everyone is convinced, I think, that high levels of consumption are problematic across the board. They increase cardiovascular risk, they increase cancer risk, they increase the risk of cirrhosis, liver disease. It’s really that low level of consumption up to four drinks per week where they’re still in the cardiovascular literature, a suggestion that in particular, wine consumption, maybe cardio preventive, that is reducing the incidence of heart attacks and strokes. Many scientists look at that data and say, well, that’s explained by confounding by the fact of other lifestyle behaviors that track with the consumption of wine, higher household incomes, more healthy lifestyles and other ways more physical activity. And that explains the Protective Association of wine drinking. But it’s not uniformly felt across the all fields. And so that is still the area of active debate.
Krys Boyd [00:11:46] I’ve read that there were some studies that asked people whether they drank at all or not and put people who had quit drinking because they had a problem with alcohol in the same category as people who had never drunk at all. Talk about why that would be a problem for the science.
Dr. Ernest Hawk [00:12:03] Yeah. Well it’s it’s it’s fundamentally is a misclassification of the exposure. And so it can suggest that there’s risk when that risk is actually due to, to something else. So it’s the issue of misclassification, particularly at low levels of consumption that creates the ambiguity around the cardiovascular benefits or risks of low levels of consumption. That is the key question where there’s more research that’s needed before we have a definitive answer.
Krys Boyd [00:12:37] Who pays for this kind of research? I mean, how how invested is the alcohol industry in funding research into the relative benefits and dangers of alcohol?
Dr. Ernest Hawk [00:12:46] Yeah. Krys, again, that’s really a wonderful question. And even in the National Academies report recently, within the last couple of months, my understanding is in the early days of that, they identified a couple of individuals who had been supported by the alcohol industry in their past at least, and therefore were felt to have a conflict of interest and removed from the panel. So it is and you know, of course, we’ve seen that in the tobacco field for 50 years. And so who funds this research is a very important question. Most of what I’ve shared with you in terms of alcohol and its risks have been funded by public monies. Agencies like the NIH or the or the grantees that work receiving money from public funds. And I think that still, anyone who was reading an article that was supported by the alcohol industry, you know, alcohol producers would hold those data as suspect.
Krys Boyd [00:13:53] In terms of cancer risk. Can we assume all forms of alcohol are equally hazardous if we take them serving for serving? Like, is there a reason to think a glass of beer is better for us than a shot of vodka under otherwise equal conditions? Or should we assume they’re the same?
Dr. Ernest Hawk [00:14:13] Scientists, I think, have largely demonstrated over the body of literature that alcohol exposure is the problem. And it’s regardless of the type of alcohol that you consume. The only remaining question is this issue of wine consumption and whether that is spurious or indeed a beneficial relationship, so that the type of alcohol is not really felt to be impactful. All alcohol is the problem.
Krys Boyd [00:14:45] Many people had heard that a certain amount of alcohol, had once heard could be considered safe for most people. Right? For a while it was one drink a day for women, two for men. Are those guidelines have they been eliminated from most public health messaging?
Dr. Ernest Hawk [00:15:03] Uh no. As recently as last year, those guidelines were still in place. But that’s part of what the surgeon general’s report is all about. He’s called the action now, number one, raising public awareness. Number two, he’s advocated for more effective labeling on alcohol products to raise awareness again. A third thing that he recommended was reconsideration of current guidelines. And so that’s under active consideration by all the guideline producing agencies now, I think and we may very well see refinements in what you just stated, which is up to two drinks per day for men to one drink per day for women. It’s it’s broadly felt that more is worse and particularly daily consumption is unwise.
Krys Boyd [00:15:56] Why were those guidelines different for women and men? Presumably, the average woman weighs more than half of what the average man weighs.
Dr. Ernest Hawk [00:16:04] Yeah, it has to do exactly with the metabolism and the impact of alcohol on risk, a whole host of risks. And generally, women are more susceptible to the risks of alcohol, particularly at low levels and for the cancers that I just referenced that are associated with low levels of exposure, mouth, esophagus, and then of course, breast. The breast is the one thing that I think worried most people and why the standards were set a little bit lower for women than men.
Krys Boyd [00:16:38] These kinds of shifts in science, you know, a message that held for 10 or 20 years now being changed can frustrate non-scientists. It is actually a sign of progress, though, right, that recommendations might change as new evidence emerges and gains the confidence of the broader scientific community.
Dr. Ernest Hawk [00:16:57] Absolutely. Yeah you know, look back 50 years ago, we didn’t have nearly the evidence of tobacco and its associated harms. Now, we associate 17 different sites of cancer with tobacco exposure. And we realize that even low levels of exposure or indirect exposure, second hand exposure, someone in your family smoking, but you’re around them a long time, raises your risk. We had no idea of that 50 years ago. All of that knowledge has been transported out now to the public. And, you know, we have things like clean air laws that are benefiting much more broadly. So I think it’s exactly that. The fact that these recommendations change over time as a result of science is a very good thing. It may be frustrating, but it’s very important that the public is kept aware of the risks that we’re aware that have been identified.
Krys Boyd [00:17:53] Please correct me if I get any of the following incorrect. But my understanding is that for people who have smoked for a long time, quitting smoking does reduce the risks of lifelong risks of cancer from smoking. Your body can recover in some ways. First of all, is that accurate? And if so, are there similar benefits that we can see from quitting drinking after maybe years of having a nightly drink or two?
Dr. Ernest Hawk [00:18:20] Yes, you’re exactly right that when someone stop smoking, their risk is mitigated. Not never entirely, never 100% back to what it was. Had they not been exposed, but vastly better than continuing. And we even have evidence now in individuals with with cancer who smoke that getting to them sooner in there and following a diagnosis and helping them to quit successfully extends and extends their life by as much as 25% even in the face of other treatments that they’re receiving. So it’s very important to get someone early and to help them quit. The same is felt to be true with alcohol. However, there’s less data around alcohol than there is around tobacco at this point. So I think the exact amounts, the exact sequence then the timing of when risk reverts back to to that of a non drinker is part of the question. And what we discussed earlier in the conversation.
Krys Boyd [00:19:24] Thinking about messaging to young people, it occurs to me that a lot of the talk about alcohol is ultimately about the hazards of drunkenness, right? Like drinking too much and the behaviors that might be involved in that and the potential for accidents. Do we need to also remake the way we talk about alcohol when we’re speaking to populations that maybe even have never even taken a first drink yet?
Dr. Ernest Hawk [00:19:49] Yes. And there’s a lot of data suggesting that binge drinking, you know, consuming a lot, even if infrequently is associated with more harms and in a wider range of harms, not only long term damage to organs such as we’re talking here resulting in cancer or liver disease, but also, of course, short term neurologic and issues of judgment that that can place others, that the individual as well as others at risk because of unwise choices such as operating a motor vehicle.
Krys Boyd [00:20:22] Looking back at the history of something like public health campaigns to convince Americans of the hazards of smoking, Dr. Hawk, how long do you think it might take between this moment when there is this surge of messaging about alcohol and cancer risk and broad changes in Americans drinking behaviors?
Dr. Ernest Hawk [00:20:40] Now, it’s another great question. I would hope that it would be instantaneous, but of course, that’s never the case. Usually it takes 5 to 15 years for this messaging to start impacting behavior. I’m encouraged, however, because younger generations of Americans seem to be drinking less and less frequently, and that cultural shift is what, I hope, will change the public’s, that is, plus, these public education campaigns will together result in a quicker benefit.
Krys Boyd [00:21:14] Dr. Hawk, thank you for making time to talk about this.
Dr. Ernest Hawk [00:21:17] Very nice to be with you, Krys. Thanks for the invitation.
Krys Boyd [00:21:20] That was Dr. Ernest Hawk. He is vice president and head of the Division of Cancer Prevention and Population Sciences at the University of Texas, MD Anderson Cancer Center. He also holds the T. Boone Pickens distinguished chair for Early Prevention of Cancer. We turn now to what it would take for warning labels to appear on alcoholic beverages, similar to the warning labels on packages of cigarettes. Isabella Cueto is chronic disease reporter for Stat News and has been writing about this. One of her latest articles is “The Surgeon General wants the U.S. to know alcohol causes cancer. Plenty stands in his way.” Isabella, welcome to Think.
Isabella Cueto [00:21:58] Thanks so much for having me.
Krys Boyd [00:22:00] We will assume for the sake of this conversation that the idea of changing alcohol labeling will persist. Even now that Vivek Murthy has stepped aside for President Trump’s nominee. What kind of labeling is required on alcoholic beverages now?
Isabella Cueto [00:22:15] Well, right now it depends. So most alcohol is regulated by the TTB which is a tax agency in the Treasury Department. And pretty much what’s required is the surgeon general’s warning that has been on there for decades. There are some alcohol regulated by the Food and Drug Administration that needs to have the basic nutrition facts like you would find on any other food. But that’s about it right now.
Krys Boyd [00:22:40] Do surgeon generals and does any surgeon general have the power to enact something like a labeling change on alcohol?
Isabella Cueto [00:22:47] No. So this would go to Congress and Congress would ultimately decide whether to take up Vivek Murthy’s request or not. But the surgeon general does carry some sway. And mostly this raises public awareness of the link between alcohol and health problems, which could create a groundswell of support for a change like this. So it is important.
Krys Boyd [00:23:07] So Congress passed something called the Alcoholic Beverage Labeling Act in 1988. What were the primary health concerns identified around alcohol at that time?
Isabella Cueto [00:23:18] At that time, it really had to do with drinking during pregnancy and the risk of birth defects and also drunk driving and accidents, things like that. It does say on the government warning. Alcohol may cause health problems, but that’s about as specific as it got at that point.
Krys Boyd [00:23:36] So didn’t the 1988 law mandate that the Alcohol and Tobacco Tax and Trade Bureau of the TTB go back and report to lawmakers that the science around alcohol in health had changed significantly?
Isabella Cueto [00:23:49] Yeah, that’s right.
Krys Boyd [00:23:51] Okay. So how have public health advocacy groups tried to persuade the TTP to do so? Because they haven’t, right? They haven’t gone to the Congress to talk about changing labels.
Isabella Cueto [00:24:03] That’s right. And this has been an ongoing issue that public health advocates and consumer advocates have been fighting for. They’ve written citizens petitions to the TTP. They have gone to court over nutrition labeling and trying to get a clear ingredients list. And that actually just came out recently that the TTP put out a proposed rule about listing nutrition and nutrition information and major allergens. So this has been a long time coming and an ongoing fight really to get more information about alcohol.
Krys Boyd [00:24:43] How is it that all other packaged food products, including beverages, are required to list ingredients and calories? But most packaged drinks containing alcohol don’t have to do the same thing? Or are they just regulated by different agencies?
Isabella Cueto [00:24:57] Yeah, that’s really what it comes down to, is that TTB is basically a tax agency and so public health officials say they don’t see themselves as a health agency like the Food and Drug Administration. And so if you see, for example, a hard seltzer that would be regulated by the FDA and would have nutrition facts on it, but some other types of alcohol would not because they’re under TTB. So it’s this interesting difference in how they’re regulated. That’s what it comes down to.
Krys Boyd [00:25:25] So I suppose the fact that TTB doesn’t have a specific mandate to serve a public health interest is a bit of a disincentive to go to the trouble of going to Congress and trying to get labeling changed when that’s not really their area of expertise.
Isabella Cueto [00:25:39] That’s definitely what public health advocates have said and what they’ve criticized the agency for. I will say in the most recent proposals to add the nutrition labeling, they do take into account the science on health harms and the appeals from those advocates. And so the language seems to have shifted a little bit in trying to incorporate that. And it’s essentially its clients, which is the alcohol industry, the companies it regulates.
Krys Boyd [00:26:10] That’s interesting that their clients are presumably an industry that is not so interested in adding these warning labels or labels of any kind.
Isabella Cueto [00:26:19] Right. There’s the inherent conflict. And the alcohol industry has said, you know, we’ll do voluntary labeling, we’ll start offering more information and all of our own accord. There’s been some movement towards that. I think the main thing, they don’t want mandatory disclosures of any kind. Definitely have fought against ingredient lists and things like that. And I think it’s likely that we could see any potential cancer warning label go through a legal fight on First Amendment grounds, which is what’s happened with tobacco and cigarettes as well.
Krys Boyd [00:26:53] So if the alcohol industry mounts, resistance has mounted resistance to any change in labeling that might potentially turn people off drinking. What kinds of voluntary efforts have industry groups proposed as an alternative?
Isabella Cueto [00:27:08] Well, they have adopted this kind of voluntary disclosure, where some companies will start to list ingredients or nutrition information on their containers, or they’ll have a QR code on the containers that can take you to the website to get more information about calories and things like that. You know, so the industry says it’s the Government’s job to determine any changes to the warning statements, but they will definitely push on the science that the Government is using and whether they agree or disagree with the conclusions that researchers are drawing and even down to the specific language that could become a fight like can you print alcohol, causes cancer, or does it need to be something a little bit softer, like alcohol may increase your risk of cancer. So it’ll be some splitting hairs? I think.
Krys Boyd [00:28:02] So why have public health advocates disapprove of things like the QR code. Like why would that be a bad idea for what they’re trying to achieve? If there is more information available, if people just, you know, know how to use their phone and take that picture.
Isabella Cueto [00:28:18] Advocates have said that the QR code places a barrier between the consumer and information. And so what about people who don’t have a cell phone or Internet? High speed Internet access on their phone? Or maybe someone just doesn’t want to have to go through the trouble of going to the website. In my reporting on on labels, I scanned one of the QR codes. This is for a European brand of alcohol. And it was this really beautiful graphic illustration with a lot of movement and visual elements and like beautiful descriptions of the ingredients. And it took me, you know, a pretty long time, about a minute to get through the ingredients list. And so I think there’s a fear also that it could turn into more marketing instead of straightforward health information for the consumer.
Krys Boyd [00:29:06] And I’m thinking of someone like my mom in in no universe and she may be listening now. Is she going to scan a QR code and follow that through? Just not everybody knows how to do this.
Isabella Cueto [00:29:17] Yes, exactly.
Krys Boyd [00:29:19] So as we’ve discussed, there is a wealth of new science that suggests a causal relationship between alcohol and cancer. That science is there and it’s ongoing. There’s also this question, though, of what works to get that message out to the public so that people can make whatever choices they think are right for themselves. What do we know, Isabella, about whether alcohol labeling of any kind increases public awareness of potential health hazards?
Isabella Cueto [00:29:45] So we don’t know a lot. You know, alcohol warning labels are one of the things that the World Health Organization recommends to reduce drinking across the population to try and reduce some of those health problems. But we don’t have a lot of real world evidence because this hasn’t really been implemented in many places. So we have one real world experiment that took place in Canada some time ago, and researchers put labels on about 300,000 containers of alcohol and they saw that those containers were purchased less. And in the area where they did the labels, people consumed or purchased less alcohol versus in the other areas. There’s also some research to suggest that people who drink the most are exposed to the message more often, and so they are receiving it. But we don’t know if that really impacts people down the line and how it changes their drinking behaviors. So that science is still developing.
Krys Boyd [00:30:47] Isabella, I’ve also seen ads that end with Drink responsibly and be 2. And with all due respect to 21 year olds and their choices. Those things don’t automatically go together. I’m guessing this is something perhaps voluntary by the company. It strikes me, though, that the implied message is that as long as someone is of legal age, they are by definition, drinking responsibly. Like the way we write these labels or warnings, whether they are done by the industry or mandated by government. It’s going to matter in terms of how they’re received by people.
Isabella Cueto [00:31:23] Yeah, absolutely. And I think what you’re pointing out is very important where that is a voluntary thing that alcohol companies have decided to include. Many of them have campaigns against drunk driving, for example, and will fund programs in that vein. And so, you know, they say that’s that’s kind of their corporate effort to encourage responsible drinking within moderation.
Krys Boyd [00:31:50] Beyond labeling changes and assuming this country will never return to something like prohibition level bans on alcohol, there are other ways to reduce the amount of alcohol Americans might choose to consume. One is making it more expensive. How might we do that?
Isabella Cueto [00:32:09] Raising taxes on alcohol is another big recommendation. It’s considered a Best Buy, meaning that it could have a big effect for small change. And so there have been efforts at the state level to raise taxes on alcohol. And many of those have failed. Some of them have succeeded. On the federal level, alcohol tax on various levels and on the federal level. President Trump slashed taxes on alcohol in 2017 and those were made permanent. So right now, drinking is basically more affordable for the average person than it’s been in many decades.
Krys Boyd [00:32:47] What do we know about the price sensitivity of drinkers? Like, do people drink less when alcohol gets more expensive or do they just move to less expensive forms of alcohol or less expensive brands?
Isabella Cueto [00:32:59] The understanding is that kind of across the board, people tend to buy less when prices go up. It’s kind of like that basic economic push and pull. In some cases, people may switch to cheaper brands, but a lot of the experts I’ve spoken to in this field say this is really one of the best tools that we have to help people consume less alcohol.
Krys Boyd [00:33:23] It might be hard to sympathize with giant corporations that make and sell alcoholic beverages and, you know, resist new taxes or higher taxes. But how significant might the knock on effect be for small businesses like bars and restaurants and stores that sell alcohol along with plenty of other products?
Isabella Cueto [00:33:43] Yeah, I think this is one of the big points that the industry trade groups will make is like this could harm businesses, especially after Covid. And so this is not the best approach. Other experts I’ve spoken to who advocate for raising taxes say, well, not really. It’s not like you would lose money from this because the price of of the drink is going up. And so you’d still be making money. It’s just it’s more expensive for the consumer. So that’s definitely a point of contention when it comes to taxes.
Krys Boyd [00:34:20] Do consumer groups tend to get up in arms when someone proposes a new or increased alcohol tax?
Isabella Cueto [00:34:28] Well, I guess it depends which consumer groups you’re talking to. The public health focused ones usually back raising alcohol taxes and especially when we’re talking about highly alcoholic beverages in the US, drinks are not taxed by the alcohol percentage that they’re taxed by volume. And so there are researchers and experts who say you can get a can of something that is extremely alcoholic and way above what you should be drinking for cheaper than, you know, a bottle of water or sports drink. And that shouldn’t be the way that it is. I’m sure there are other groups that are opposed to anything that would raise the price of consumer goods. I will note here that drinking tends to increase with income. And so there’s an argument that this would mostly affect folks that are of lower socioeconomic status. But actually the people who drink the most are those that are wealthier.
Krys Boyd [00:35:30] What do you know, What have you learned about the alcohol industry as a lobbying entity?
Isabella Cueto [00:35:38] It’s extremely powerful. Advocates like to say that there are more lobbyists for each lawmaker on the Hill than there are for for public health. And so it can be hard to put up a fight when we’re talking about issues like this. And in my reporting, I’ve seen that the industry is very powerful, even down to the state or sometimes local level. You know, there’s cases where there are lobbyists who maybe were lobbying for education or some other issue, and then they’re also an alcohol lobbyist. And so lawmakers are having to interact with them on various fronts. They’re very familiar with them. And that makes it difficult, not to mention the fact that this is a global, extremely profitable industry. And so there’s a lot of money to throw into efforts and and squash laws that they don’t like.
Krys Boyd [00:36:38] And this doesn’t necessarily shake out along partizan lines the way many other issues do.
Isabella Cueto [00:36:44] That’s right. I mean, when you think about alcohol, it’s it’s not really a partizan issue at this point. There are people on both sides that would like to see more of a public health focus and those that don’t want any restriction and are fearful of any inching toward prohibition as they see it. So it’s definitely across the board. You know, in Washington where I live, there will be celebrations or happy hours or whatever sponsored by the alcohol industry and people associated with all kinds of positive things usually. And so it doesn’t really take much to make people have a positive opinion of alcohol.
Krys Boyd [00:37:26] It is, you know, whether you think it’s a good thing or a bad thing for human health, it’s definitely a part of American culture.
Isabella Cueto [00:37:35] For sure.
Krys Boyd [00:37:36] So what did you learn about places that have worked to get new taxes passed? I’m thinking of. You write about Anchorage, Alaska. Which boy, the effort there was unrelenting, wasn’t it, to get a new tax.
Isabella Cueto [00:37:53] Yeah, very interesting case study in Anchorage. You know, they tried multiple times to raise the alcohol tax and it never made it pretty far. And then in 2019, the mayor got the issue on the ballot and it still didn’t make it very far. The industry really descended and tried to go against that and voters ultimately rejected it. And then the following year, advocates tried again and they had to do kind of extensive polling to see like, what did Anchorage voters want? Where would they want the tax money to go? And they were able to get it passed. And now there’s a 5% tax on every drink sold in Anchorage, which raised about $14 million in the first year.
Krys Boyd [00:38:49] It’s also turned out to be useful to try and hold lawmakers accountable for their promises. Right. So they don’t say one thing in a room with a certain group of voters and then act a different way. Talk about about Maryland and the Maryland Citizens Health Initiative.
Isabella Cueto [00:39:07] Maryland is really interesting because it’s an example that a lot of a lot of proponents of tax increases look to. So they’re one of the first to update their alcohol tax. They passed a 3% increase to the sales tax in 2011. And basically how they did it is the Maryland Citizens Health Initiative surveyed candidates for the state House and Senate and asked them if they would support an increase in the alcohol tax. They made those pledges public and they used polling data to show that constituents would support an increase to the alcohol tax. And then once they the lawmakers got into office, you know, they knew they had the support, the tax hike came up and they voted it through. And ever since it’s resisted challenges, they still have that sales tax in place. And that one is interesting because it is it is a sales tax. And so as the price goes up, the tax goes up with it. Whereas in other places, the tax, you know, becomes relatively smaller as the price increases.
Krys Boyd [00:40:11] Sure. Similar to there’s been an argument over time about fuel taxes in this country which haven’t kept up with the cost of inflation over time.
Isabella Cueto [00:40:21] Exactly.
Krys Boyd [00:40:22] Look, we know Americans as a group, we dislike taxes. We don’t like having to pay extra on anything. But it does strike me that while conservatives in this country are maybe specifically more associated with being against taxes, there is a certain sympathy for like sin taxes, taxes on things that we might enjoy but have to agree are not doing our health any favors or doing our character any favors.
Isabella Cueto [00:40:52] Yeah, there was an effort on sin taxes in Nebraska that included alcohol, which is another interesting case study in recent years.
Krys Boyd [00:41:01] How did that one play out?
Isabella Cueto [00:41:02] Well, the governor there wanted to slash property taxes by 50%. And so he was you know, he was looking all over the place to to search for revenue. And he landed on on sin taxes on cigarets and candy. And that included spirits. And at first, he wanted to quadruple the tax on spirits. That was the proposal. And as soon as that came out, the alcohol industry, trade groups went full force. They sent like thousands of letters and emails in opposition to it. I mean, when you think about the industry, there are restaurants, there are bars, there were raised in every you know, in every city, in every county. And so you can really get your numbers up when you are well organized, which the industry is. And by the end of it, the proposal got totally gutted. And instead of increasing alcohol taxes, it was a tax cut on spirits for for the producers in the state. And then ultimately the alcohol taxes were dropped entirely from the package. So it went from quadruple to nothing. And that kind of shows you what mobilization can do.
Krys Boyd [00:42:17] It would seem, Isabella, that the new President Trump’s choice for Health and Human Services secretary Robert F. Kennedy Jr. would at least be a sympathetic ear to this sort of thing. We know he does not drink himself these days. The president does not drink very publicly. Have these high profile figures who are behind this Make America Healthy Again campaign talked specifically about their views on alcohol.
Isabella Cueto [00:42:47] Well, like you mentioned, neither of them drink, but they have not spoken specifically to whether they will try to target alcohol. It would make sense from one perspective. I mean, some alcoholic drinks are considered ultra processed foods, which is one of the things that RFK Jr. really dislikes and wants to reduce in Americans diets. And obviously both alcohol and ultra processed foods have been linked to, you know, some pretty bad health outcomes and potential addiction. So, you know, some people say, yeah, these would fit squarely together. But so far, we haven’t seen any concrete policy proposals about it.
Krys Boyd [00:43:28] I know you’re in the business of covering what’s actually happening rather than speculating, so I’m not going to hold you too much here. But I wonder the extent to which you think both sides in this argument might take cues from the long public health effort to spread the word about the dangers of smoking and reduce smoking behaviors?
Isabella Cueto [00:43:48] There are definitely a lot of parallels on both sides here. There are public health advocates who think that alcohol has kind of used the tobacco playbook and maybe learned from it in some ways. You know, if you recall, tobacco companies were mostly denying that there was any negative health consequences to smoking, and that got them in trouble. Alcohol companies do not deny that there is a link to health harms. But like I said before, it’s usually a matter of splitting hairs of saying as long as you drink, you know, moderately, as long as you don’t overdo it, you’ll be fine. Whereas the science is kind of calling that into question. And most people agree at this point that there is no health benefit to drinking. Or if there is one, it’s overshadowed by the potential health risks. So, you know, you may in some cases lower your risk of stroke with light drinking. But with that also comes an increased risk of other issues such as liver disease. So it’s this really complicated message to try and get out.
Krys Boyd [00:44:57] My guest, Isabella Cueto, is chronic disease reporter at Stat News. Isabella, thank you so much for being with us today.
Isabella Cueto [00:45:05] Thank you very much.
Krys Boyd [00:45:07] Think is distributed by PRX, the public radio exchange. You can find us on Facebook and Instagram and listen to our podcast for free wherever you get your podcasts. Just search for KERA Think. Our website is think.kera.org. When you’re there, you can find out about upcoming shows and sign up for our free weekly newsletter. Once again, I’m Krys Boyd. Thanks for listening. Have a great day.
