Response to Critique 058: Presenting all the facts about cancer, cardiovascular and alcohol consumption
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The authors of Cancer, Cardiovascular Disease and Alcohol Consumption respond to the International Scientific Forum on Alcohol Research’s Critique 058: A misguided statement on alcohol and health from a coalition in Australia. 14 November 2011
On 19 September 2011 the Alcohol Policy Coalition (‘APC’)—which includes the Australian Drug Foundation, Cancer Council Victoria, Heart Foundation (Victoria) and Turning Point Alcohol and Drug Centre released a discussion paper1 about alcohol consumption, the risk of cancer and cardiovascular disease and policy responses. This paper was released to coincide with the United Nations high-level meeting on non-communicable diseases.
To emphasise the importance of this meeting, of the 2.3 million alcohol related deaths in 2008, more than half of these deaths were from non-communicable diseases such as cardiovascular disease (22 per cent) and cancers (20 per cent). Non-communicable diseases including cancer and cardiovascular disease have overtaken infectious diseases to be t e leading causes of deaths worldwide.
Most people drink alcohol, and most people enjoy drinking alcohol. So we did not expect a paper that discusses the link between alcohol and the risk of some cancers and cardiovascular diseases to be popular (see Critique 058: A misguided statement on alcohol and health from a coalition in Australia).2 However, the Alcohol Policy Coalition believes that everyone has a right to know about these risks, whether or not it is the popular thing to do.
Opening comments We were surprised by the opinions expressed by members of the International Scientific Forum on Alcohol Research (‘Forum’); in particular, that the information presented in our issues paper was biased, unscientific and misleading. Indeed, these terms could well be applied to the Forum’s critique.
The Forum’s general opposition to our paper (highlighted in bold, followed by our response) seemed to be that we:
1. Ignored evidence showing the public health benefits of moderate alcohol consumption. Our paper presented a brief overview of the evidence for an increased risk for alcohol related cancers and cardiovascular disease, followed by a discussion of the key policy interventions to reduce alcohol consumption at a population level. We made a deliberate choice to focus on population interventions to reduce alcohol consumption rather than individual drinking behaviours, reflecting the position taken at the high-level UN meeting on non-communicable diseases. That meeting acknowledged—as we did—the epidemic of non-communicable diseases, fuelled by combination of risk factors including harmful alcohol use and recommended—as we did—raising taxes on alcohol and enforcing bans on alcohol advertising to reduce harmful alcohol use.
The Forum has ignored the population and preventive approach of our discussion paper, instead focusing on approaches oriented towards the individual.
2. Inflated existing evidence of the risks of alcohol consumption The evidence linking alcohol consumption and cancer shows no benefit associated with moderate alcohol consumption, or indeed any level of consumption. We stand by this assertion.
The evidence linking alcohol consumption and cardiovascular disease is, as our paper outlined, complex. Our paper presented a snapshot of the evidence for cardiovascular disease and suggests the positive cardiac benefits of moderate consumption have been overstated. Neither the American Heart Association,3 nor the National Heart Foundation of Australia4 or the Dietary Guidelines for Americans 20105 recommend people commence drinking for a health benefit.
3. Promoted a prohibitionist agenda. At no point did we recommend banning or prohibiting alcohol. Our recommendations were for policy interventions to reduce the misuse of alcohol and its negative health impact in the population. Further, we supported Australia’s National Health and Medical Research Council’s Guidelines to reduce health risks from drinking alcohol, which recommend that to reduce the risk of long-term health risks, healthy adults should not exceed more than two standard drinks on any day.6
Alcohol and cancer
We note that Forum members expressed concern that some statements were inaccurate, including the following statement: “Every drinking occasion contributes to the life-time risk of harm from alcohol, therefore, any reduction in the dose – that is the amount and frequency of alcohol consumed – will reduce the annual and life-time risk of alcohol related harm.”
According to the Forum’s critique ‘[t]his statement is not substantiated because there are threshold effects in the association of alcohol intake and cancer mortality.’ The World Cancer Research Fund (WCRF) and the American Institute for Cancer Research, analysed the major international epidemiological studies on cancer causation to an unprecedented extent and concluded the risk of alcohol-related cancer increases with every alcoholic drink consumed. Page 157 of the WCRF’s most recent (2007) comprehensive report says: ‘The evidence does not show any “safe” limit of intake.’7
The Forum cites as an example the same WCRF report to support their critique of our paper; noting evidence of ‘a threshold for the association of alcohol intake and colorectal cancers (30 g/day of ethanol) and liver cancers’.
Finally, the Forum is incorrect when it cites the WCRF report as evidence of a threshold for the association of alcohol intake and liver cancers. Page 170 of the report says ‘Alcoholic drinks are a probable cause of liver cancer. ‘No threshold was identified’ (emphasis added).
The Forum has also presented a limited perspective on when it says there is evidence for threshold effects in the association of alcohol intake and cancer mortality.
In fact, the WCRF report reports no threshold for mouth, pharynx, larynx, oesophageal and breast cancers. As noted by the Forum, there is a threshold for the association of alcohol intake and colorectal cancers. However, the threshold limit remains low (as noted above, less than 30g/day of ethanol from alcohol consumption), with an elevated risk for men as compared with women.7
The Forum’s discussion of alcohol intake and cancer mortality, and in particular, its resentation of the evidence for a safe level of alcohol consumption, also fails to acknowledge the significance of alcohol as a cause of common cancers. Colorectal cancer is the third most common cancer in the world; even with the threshold limit for risk, there is convincing evidence that alcohol causes 7% of bowel cancer in men, and probable evidence that alcohol causes 7% of bowel cancers in women.8
Breast cancer is the most common cancer in women worldwide; and alcohol use is associated with 22% — that is, 1 in 5 — breast cancers.8
Alcohol and cardiovascular disease
With respect to cardiovascular disease, the Alcohol Policy Coalition’s paper1 made the following points:
The relationship between alcohol and cardiovascular disease is complex.
Although red wine contains antioxidants it is not a good source of antioxidants for cardiovascular health. Research suggests that alcohol offers a protective cardiovascular effect, however this is only when consumed at low and moderate levels.
For people who choose to drink alcohol, they should drink within National Health and Medical Research Council guidelines.
The Alcohol Policy Coalition does not recommend people take up drinking alcohol to gain a cardiovascular health benefit.
As well as reiterating these points, there are two points made by the International Scientific Forum on Alcohol Research that warrant a response. These are set out below.
Firstly, the International Scientific Forum on Alcohol Research fails to give a balanced view of our paper, a failure that commences from the outset of their critique. In the fourth paragraph, the Forum quotes directly from our paper, but somehow leaves out the section highlighted below in bold.
“Long-term excessive drinking is associated with heart disease, stroke, blood pressure, heart failure, congenital heart disease,arrhythmias, shortness of breath, cardiac failure and other circulatory problems. Although the negative impact of alcohol consumption varies from person to person, on a global level the adverse effect of alcohol on cardiovascular disease outweighs any protective effect by between two and three-fold. Some research suggests small doses of alcohol offers some protection against cardiovascular disease. A recent systematic review and meta-analysis published in the BMJ concluded that light to moderate drinking (≥1 standard drink) is associated with a 14-25 per cent reduction in the risk of cardiovascular outcomes compared with abstaining from alcohol. However this view is contested.”
By leaving out the section highlighted in bold, the International Scientific Forum on Alcohol Research misrepresents our paper and portrays it as only being concerned with the negative health impact of alcohol. This is not true.
Later in its paper, the Forum makes reference to the BMJ study,9 but this is only done so in passing with the following line: “While the authors of the Australian paper state that moderate drinking has been shown to reduce the risk of cardiovascular diseases …” Our paper presents both sides of the argument and this is not recognised by the International Scientific Forum on Alcohol Research.
Secondly, the International Scientific Forum on AlcoholResearch fails to give a balanced view of the key aspects of the evidence. For example, the Forum cites the most recent Dietary Guidelines for Americans 20105 and quotes from page 31 of those guidelines: “Strong evidence from observational studies has shown that moderate alcohol consumption is associated with a lower risk of cardiovascular disease. Moderate alcohol consumption also is associated with reduced risk of all-cause mortality among middle-aged adults and may help to keep cognitive function intactwith age.”
The Forum chose not to present the full picture of the evidence presented by the Dietary Guidelines for Americans 2010. The very next sentence (from the one quoted above) from the Dietary Guidelines beings with: “However, it is not recommended that anyone begin drinking or drink more frequently on the basis of potential health benefits …”In case there is any confusion, this point is reiterated on page 32 of the Dietary Guidelines for Americans, which state: “For people who drink alcohol should be consumed in moderation. It is not recommended that anyone begin drinking or drink more frequently on the basis of potential health benefits.”
This latter statement is entirely consistent with Alcohol Policy Coalition’s recommendation that Australians follow the National Health and Medical Research Council guidelines: that is, healthy men and women should drink no more than two standard drinks on any day. While moderate alcohol consumption may have a health benefit, neither Australia’s National Health and Medical Research Council guidelines or the Dietary Guidelines for Americans recommend that people commence drinking for a health benefit. This is a big difference, but one ignored by the International Scientific Forum on Alcohol.
The failure to give a balanced view of the Alcohol Policy Coalition is further illustrated under the heading ‘Moderate drinking as a component of a “healthy lifestyle”’ in the Forum’s paper, where it cites a report by the US Centres for Disease Control and Prevention (CDC) in which moderate consumption of alcohol is included as one of “four healthy lifestyle behaviours that exert a powerful and beneficial effect on mortality”. Again, the Forum presents only half the picture; the CDC, like the Dietary Guidelines for Americans 2010, do not recommend people take up drinking alcohol for a health benefit. Indeed, CDC Director Thomas Frieden is quoted in a CDC media release as saying: “If you want to lead a longer life and feel better, you should adopt healthy behaviours– not smoking, getting regular physical activity, eating healthy, and avoiding excessive alcohol use”10 [emphasis added]. Avoiding excessive alcohol use is vastly different to recommending people take up alcohol for a health benefit.
Alcohol Policy Coalition welcomes the International Scientific Forum on Alcohol Research’s interest in our paper. While the Forum questions our paper and expresses concern that it “indicated a strong bias against alcohol”, we believe the Forum failed to present a balanced view of our paper and of the key recommendations for alcohol consumption such as those offered by the Dietary Guidelines for Americans 2010 and the National Health and Medical Research Council guidelines.
Finally, we note that members of the Alcohol Policy Coalition do not receive funding from the alcohol industry or related industries. The Forum’s website discloses that its auspices receive funding from “companies in the alcoholic beverage industry and associations of grape growers and wine growers and wineries.”11
1 Alcohol Policy Coalition, Cancer, Cardiovascular Disease and Alcohol Consumption, Position Statement, [cited 24 October 2011], Available from http://alcoholpolicycoalition.org.au/http://alcoholpolicycoalition.org.au/wpcontent/uploads/2009/11/APC-NCD-Position-Paper-September-2011-v1.0.pdf.
2 See International Scientific Forum on Alcohol Research, Critique 058: A misguided statement on alcohol and health from a coalition in Australia – 28 September 2011, [cited 2 November 2011], Available from http://alcoholresearchforum.org/critique-058-a-misguided-statement- on-alcohol-and-health-from-a-coalition-inaustralia- 28-september-2011/.
3. See American Heart Association, ‘Alcohol and cardiovascular disease’, [cited 24 October 2011], http://www.heart.org/HEARTORG/Conditions/Alcohol-and-Cardiovascular-disease_UCM_305173_Article.jsp.
4 National Heart Foundation, Position statement Antioxidants in food, drinks and supplements for cardiovascular health, 2010, [cited 4 November 2011], Available from http://www.heartfoundation.org.au/information-forprofessionals/food-professionals/Pages/guides-policies-position-statement.aspx.
5 U.S. Department of Agriculture and U.S. Department of Health and Human Services, Dietary Guidelines for Americans 2010, Washington, 2010, [cited 4 November 2011], Available from http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/PolicyDoc.pdf.
6 National Health and Medical Research Council, Australian Guidelines to Reduce Health Risks from Drinking Alcohol, 2009, [cited 2 November 2011], Available from http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/ds10-alcohol.pdf.
7 World Cancer Research Fund; American Institute for Cancer Research, Food, nutrition, physical activity, and the prevention of cancer: a global perspective, London: WCRF International, 2007, [cited 7 November 2011], Available from http://www.dietandcancerreport.org/.
8 Winstanley MH, Pratt IS, Chapman K, Griffin HJ, Croager EJ, Olver IN, Sinclair C, Slevin TJ,
‘Alcohol and cancer: a position statement from Cancer Council Australia, MJA, 2011;194 (9): 479-482.
9 Ronksley PE, Brien SE, Turner BJ, Mukamal KJ, and Ghaili WA, ‘Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and
meta-analysis’, BMJ, 2011; 342:d671.
10 Centers for Disease Control and Prevention, ‘CDC report finds people live longer if they practice one or more healthy lifestyle behaviors’, Media Release, August 18, 2011, [cited 2 November 2011], Available from http://www.cdc.gov/media/releases/2011/p0818_living_longer.html.
11 Boston University School of Medicine, Institute on Lifestyle and Health, ‘Disclosure Statement’, [cited 2 November 2011], Available from http://alcoholresearchforum.org/disclosure-statement.