Sobering Figures: Alcohol's Link to GI Cancer
This transcript has been edited for clarity.
In January 2025, the US Surgeon General released an important advisory that 'highlights alcohol use as a leading preventable cause of cancer in the United States, contributing to nearly 100,000 cancer cases and about 20,000 cancer deaths each year.' This is in line with epidemiologic evidence for the carcinogenicity of alcohol.
However, the advisory also noted that approximately 72% of American adults drink alcohol at least once a week, and fewer than half realize that alcohol use contributes to an increase in cancer risk.
In this video, we will explore the research linking alcohol to gastrointestinal (GI) cancers and suggest ways that physicians and public health experts can help individuals dramatically reduce their alcohol consumption. Through careful discussions in the clinic and public health initiatives, we can hopefully prevent many cancer deaths related to alcohol use.
The Toll of Alcohol-Associated GI Cancer
The association between alcohol consumption and cancer risk was first appreciated during the late 1980s. Over time, a growing body of research has demonstrated 'a causal relationship between alcohol use and increased risk for at least seven different types of cancer, including breast (in women), colorectum, esophagus, liver, mouth (oral cavity), throat (pharynx), and voice box (larynx).'
The advisory publication noted that in 2020, approximately 741,300 patients developed cancer in part due to alcohol. In the United States, there are approximately 20,000 cancer deaths annually related to alcohol consumption, more than the number of alcohol-related motor vehicle collisions each year, which totals 13,500.
Breast cancer makes up 60% of cancer-related deaths for women, while liver cancer (approximately 33%) and colorectal cancer (approximately 21%) make up the most cancer-related deaths for men. These figures should be sobering.
Although the risk of developing cancer in people who consume fewer than two drinks per day is lower compared with higher levels of alcohol ingestion, there are a greater number of people who consume one to two drinks per day. Therefore, the total number of cancer cases is similar. In 2020, 185,100 patients who drank one to two drinks daily developed cancer attributed to alcohol usage, compared with 153,400 patients who consumed four to six drinks per day and 192,900 patients who consumed more than six drinks per day.
A standard drink of alcohol amounts to 5 fluid ounces of wine, 12 fluid ounces of beer, or 1.5 fluid ounces of hard liquor.
Knowledge Gap
The International Agency for Research on Cancer — a specialty arm of the World Health Organization — now classifies alcohol as a Group 1 carcinogen along with tobacco, asbestos, and formaldehyde. In fact, 25 years ago, the US National Toxicology Program announced that alcoholic beverage consumption is carcinogenic.
Yet, there remains a knowledge gap among the American public about the fact that alcohol is a strong cancer risk factor. A 2019 survey indicated that only 45% of Americans realized alcohol is a cancer risk factor, while those surveyed had higher awareness of the cancer risks posed by other factors, such as radiation exposure (91%), tobacco (89%), and asbestos (81%).
Scientists have been studying alcohol as a potential risk factor for cancer over 20 years, using the same template of observational studies that researchers previously applied to studying smoking as a cancer risk factor.
A large global meta-analysis comprising 572 research studies and 486,538 cancer deaths concluded that alcohol is indeed a cancer risk factor. A pooled analysis of 26 studies found the odds of developing oral cancer increased by 40% for those who drank one alcoholic beverage daily compared with those who did not. Furthermore, another meta-analysis showed the relative risk of cancer development compared with people who don't drink was 1.0 for light drinkers, 1.21 for moderate drinkers, and 1.52 for heavy drinkers (ie, more than four drinks per day).
How Alcohol Causes Cancer
Acetaldehyde is a breakdown byproduct of alcohol that can cause cancer by binding to DNA and damaging it. As a result, a cell can begin to grow uncontrollably and produce a cancerous tumor. In addition, alcohol can produce reactive oxygen species, which has the potential to create inflammation through oxidation, also damaging DNA, proteins, and lipids.
Studies have shown that providing ethanol or acetaldehyde, which is the metabolic breakdown product of ethanol, led rats to develop more tumors in the body compared with controls. Alcohol can even increase estrogen levels, which can potentially predispose to breast cancer development.
Smoking while drinking poses additional risks. Carcinogens from tobacco smoke can dissolve in alcohol liquid and more easily enter the body, which is especially concerning for the potential contribution to throat and oral cancers. Acetaldehyde can sometimes be used as a food additive and aroma agent, and is a significant carcinogenic component found in cigarette smoke. The acetaldehyde concentration in cigarette smoke is 1000 times greater than that in other significant carcinogens such as polycyclic aromatic hydrocarbons or nitrosamines from tobacco. Drinking alcohol in combination with smoking cigarettes can have a synergistic negative effect on the risk for colorectal cancer, and the combination can have a sevenfold effect on the upper digestive tract's exposure to carcinogenic acetaldehyde.
Additional research has focused on whether folate deficiency, sometimes caused by heavy alcohol use, might also place patients at risk through an alternative pathway.
Esophageal and Liver Cancer
According to the National Cancer Institute (NCI), heavy alcohol consumption can increase esophageal cancer risk fivefold. Even light drinking can increase the risk by 1.3-fold, highlighting the importance of limiting alcohol consumption.
The NCI also reports that heavy alcohol ingestion can multiply the risk of developing hepatocellular carcinoma and intrahepatic cholangiocarcinoma by two times compared with the regular population.
Although additional research needs to be conducted, it has been hypothesized that alcohol can cause liver cancer by altering the immune response, causing reactive oxygen species production, and producing changes in the immune response.
Unfortunately, alcohol can act synergistically with hepatitis B and C to cause liver cancer.
Also, consistently drinking two or more alcoholic beverages per day is associated with an increased risk for liver cancer.
Gastric Cancer
Recent studies have shown that alcohol consumption could increase gastric cancer risk. Acetaldehydes may act as a possible mechanism by creating a local toxic effect, and ethanol may also disturb gastric mucosal protection.
A meta-analysis that reviewed 10 case-control studies investigating alcohol and gastric cancer risks validated it as a risk factor even at low levels of alcohol consumption. A Korean population-based retrospective cohort study found that 'the risk of GI cancer increased linearly with the frequency of drinking in a dose-dependent manner.'
Pancreatic Cancer
The same Korean study found that the risk for pancreatic cancer increased with weekly alcohol drinking.
A meta-analysis published in the British Journal of Cancer also showed a 20% increase in pancreatic cancer risk with alcohol consumption.
In a study of over 450,000 Americans living in California, Florida, Louisiana, North Carolina, Pennsylvania, and New Jersey, the risk of developing pancreatic cancer in heavy alcohol users (at least three drinks per day) was 1.35 compared with light users (less than one drink per day) in never smokers.
Another study, of over 33,000 patients in Sweden, found the relative risk of pancreatic cancer for intermediate and heavy alcohol use was 2.13 in former smokers.
Colorectal Cancer
In 2025, the NCI published a guide indicating that moderate to heavy alcohol consumption is associated with a 1.2- to 1.5-fold increased risk for colorectal cancer compared with patients who were abstinent.
In an earlier review, from 2015, researchers showed that alcohol consumption of more than 30 grams per day was associated with an increased risk of developing colorectal cancer. Estimates from the World Cancer Research Fund/American Institute for Cancer Research indicate that there was a 9% risk of developing colorectal cancer for every 10 grams of alcohol consumed daily.
In addition, folate deficiency has been shown to worsen the effects of drinking alcohol on colorectal cancer risks.
A 2022 meta-analysis published in Clinical Gastroenterology and Hepatology found that consuming alcohol was associated with a 1.71 relative risk of developing early-onset colorectal cancer. Interestingly, cigarette smoking was not statistically significant for establishing such an association. Consumption of processed meat and fried foods, as well as lack of exercise, also contributed to the development of early-onset colorectal cancer. As physicians, we should encourage patients to make lifestyle modifications to avoid those other risk factors.
While additional research needs to be conducted, a cohort study in California and Hawaii, led by Dr Song-Yi Park, indicated that the relationship between alcohol and colorectal cancer might vary by ethnicity. In addition, it found that colorectal cancer risk was increased by wine and beer, but not liquor. The association with alcohol was greatest for rectal and left colon cancers.
Public Health Approaches
Alcohol is the most consumed drug in the United States, a statistic that requires validated approaches for addressing.
In the future, Congress can vote to include alcohol warning labels on bottles and cans. There's evidence that health warning labels are effective in teaching the public about alcohol-induced health consequences. Interestingly, multiple studies have illustrated a decrease in alcohol consumption following viewership of alcohol warning labels. In addition, alcohol warning labels depicting liver cancer or negative alcohol consequences have been shown to reduce drinking and drunk driver situations.
A 2024 meta-analysis showed with 'moderate certainty' that alcohol warning labels might decrease selection of alcoholic drinks and drinking before driving. However, there was 'low evidence' demonstrating that warning labels might reduce alcohol drinking per occasion, or alcohol drinking speeds, which would be important considerations at parties and social gatherings.
A 2020 study showed that alcohol selection was lower for all kinds of alcohol warning labels compared with no warning labels. Specifically, alcoholic drink selection was 56% with warning labels that consisted of an image and text, 49% for image only, and 61% for text only.
During the 1990s and 2000s, physicians and public health experts learned a lot about how to motivate patients to quit smoking. One successful public health approach was the use of the transtheoretical model, where patients go through various stages, such as precontemplation, contemplation, preparation, action, and maintenance, when trying to decide when to quit smoking. This behavioral modification model could be used for alcohol prevention too.
Key public policy interventions also helped, including a tobacco taxation, advertising bans, and tobacco marketing restrictions in smoke-free zones. Similar interventions could work well for alcohol. Alcohol taxation can be used to deter heavy drinkers and young drinkers who don't have as much money to spend, given that tobacco taxation was successful for smoking reductions.
Furthermore, policies could be set to maintain minimum unit pricing to prevent the sale of ultracheap liquor. States could also limit the hours of alcohol purchasing or even the days, such as banning alcohol sales on Sunday. These public health strategies could work in tandem to help decrease alcohol drinking rates in the United States.
Alcohol and smoking are very similar social activities that for years were depicted as stylish and cool in movies and on TV. Then smoking ads were banned on TV through the Public Health Cigarette Smoking Act of 1970. During the 1970s, cigarette companies shifted their advertising from TV to print.
So, it would be important in the future to ban alcohol ads from all media and printed marketing.
As highlighted by the World Health Organization, advertising bans and restrictions were helpful in Nordic countries with decreasing the per-capita drinking amount.
Finally, physicians should screen patients for heavy alcohol consumption using the validated AUDIT- C questionnaire and biomarkers such as phosphatidyl ethanol. When needed, Alcoholics Anonymous or a similar 12-step program can be offered to patients who drink heavily to reduce alcohol consumption.
Tips to Reduce Alcohol Consumption
Here are some helpful tips to encourage patients and friends to reduce alcohol consumption.
Set a quit date and avoid triggers such as meeting friends at bars.
Drink mocktails at social gatherings and parties. Patients can also choose from a plethora of innovative and tasty alcohol-free beers when drinking with friends. Several beer companies, such as Heineken, Budweiser, Guinness, and Samuel Adams, have developed great alcohol-free beer alternatives, which are extremely helpful for patients trying to remain abstinent and also for those trying to prevent cancer.
Mass media initiatives such as the Ad Council and celebrity public service announcement television spots could be used to shift social norms around alcohol consumption. Public service announcements could also be shared at sporting events and concerts where alcohol consumption is common.
Public health campaigns could place posters in bars and liquor stores informing consumers about the link between alcohol and cancer.
Social media could teach target populations about alcohol reduction in fun and engaging ways.
By talking with patients in clinic and working on public health campaigns, gastroenterologists have a unique opportunity to inspire behavioral lifestyle changes in patients and to prevent many cancers.
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Despite their advertised flavor profile, Back to Nature Cheddalicious Cheese Flavored Crackers contain no actual cheese or dairy-based ingredients. Instead, these crunchy bites are completely vegan, relying on plant-based ingredients to replicate the cheddar flavor so beloved by consumers. The crackers are also free of GMOs, artificial colors, artificial flavors, high-fructose corn syrup, and hydrogenated oils. In 2022, Back to Nature Cheddalicious Cheese Flavored Crackers came under scrutiny after they failed to deliver on their dairy-free promise. More precisely, it was discovered that certain batches of the crackers contained both undeclared milk and eggs. The mislabeled products had been shipped to Arizona, California, Colorado, Connecticut, Florida, Georgia, Indiana, Maryland, Maine, New Jersey, New York, Tennessee, and Wisconsin. Luckily, no adverse health issues were linked to the products at the time, with the recall issued "out of an abundance of caution." Undeclared allergens are one of the most common reasons for food being pulled off supermarket shelves in the U.S. Whether it's peanuts, wheat, milk, or soybeans, even trace amounts of some ingredients can have disastrous consequences for individuals suffering from severe food allergies. This is why proper and transparent labeling is so critical. One case of mislabeling that could have proven fatal took place in 2021, when Simple Mills, a brand known for its gluten-free and nutrition-conscious snacks, announced a recall of its Fine Ground Sea Salt Almond Flour Crackers. The issue arose when boxes of the product were mislabled and accidentally filled with Farmhouse Cheddar Almond Flour Crackers, which contain milk. Simple Mills was alerted about the mix-up by a consumer who discovered the blunder. Fortunately, only one individual reported experiencing mild symptoms after eating the mislabeled product. Introduced by the National Biscuit Company (Nabisco) — today a subsidiary of Mondelēz Global — in 1934, Ritz crackers were marketed as a budget-friendly luxury snack during the Great Depression. It wasn't long before the buttery, slightly flaky biscuits became a hit with consumers, taking the spot as the top selling cracker globally by the end of the 1930s. Building on this success, today Ritz offers a wide range of cracker flavors and format choices like hot honey, zesty herb, and sour cream and onion. One of the Ritz variants is the Ritz Cheese Cracker Sandwiches, which combines two buttery crackers with a cheese filling. In 2020, the popular product drew public attention after Mondelēz Global was forced to pull it off the shelves due to the possible presence of an undeclared allergen. The issue arose due to mispackaging. More specifically, some boxes labeled as Ritz Cheese Cracker Sandwiches actually contained Ritz Peanut Butter Sandwich Crackers. Peanut butter is a known allergen that can trigger potentially life-threatening reactions in those sensitive to the ingredient. No adverse health issues had been linked to the product at the time — perhaps because the packaging featured a label warning that the so-called cheese crackers "may contain peanuts." Launched by the National Biscuit Company (Nabisco), now under the umbrella of Mondelēz Global, in 1955, Cheese Nips Baked Snack Crackers were invented to compete with Sunshine Biscuits' Cheez-It crackers, which had been on the market since 1921. Known for their crunchy texture and rich cheddar flavor, the Nabisco snack did reasonably well until 2019, when it became the subject of a nationwide recall. Mondelēz Global issued the product recall due to fears of possible plastic contamination. To be more precise, it was discovered that some of the Cheese Nips may have been tainted with "food-grade yellow plastic pieces" that had dislodged from the dough scraper used in their manufacturing process. No injuries or adverse health effects had been connected to the product at the time of the recall. If you would like to find out more about some of this company's other blunders, take a look at our roundup of Nabisco recalls that affected millions. The founder of Pepperidge Farm, Margaret Rudkin, was a force to be reckoned with. Not only did she teach herself to bake nutritious, preservative-free bread after her son started to develop food allergies, but she turned what she learned into a thriving business. She also authored a 1963 "Pepperidge Farm Cookbook" and was the first woman to serve on the board of directors of the Campbell Soup Company after it acquired Pepperidge Farm in 1961. Rudkin was also the business mind behind the launch of Goldfish Crackers in the U.S. in 1962, after she discovered them on her vacation in Switzerland. Today Pepperidge Farm's Goldfish Crackers come in a range of flavor variants. Unfortunately, four of these had to be recalled in 2018 due to potential contamination with salmonella. The pulled flavors included Flavor Blasted Xtra Cheddar, Flavor Blasted Sour Cream & Onion, Goldfish Baked with Whole Grain Xtra Cheddar, and Goldfish Mix Xtra Cheddar + Pretzel. Pepperidge Farm issued the recall after learning that the whey powder, which was used to season the crackers, may have been contaminated when it was manufactured at Associated Milk Producers. One suspect ingredient can taint a range of products — including ones made by completely different companies. That is precisely what happened in 2018, when Mondelēz Global joined Pepperidge Farm in issuing a recall after being alerted to the possible salmonella contamination in the whey powder supplied by Associated Milk Producers. The suspect ingredient was used to season a range of the company's Ritz Bitz and Ritz Cracker Sandwiches. The precautionary recall took place in the U.S., as well as the U.S. Virgin Islands and Puerto Rico. Salmonella can manifest itself in a variety of ways, including diarrhea, nausea, vomiting, fever, and abdominal pain. While healthy adults usually recover without complications, the impact of the bacterial infection can be much more serious for certain individuals. For instance, children, the elderly, and people with compromised immune systems are at a particular risk, with the pathogen possibly even leading to hospitalization and death. May Flower International is a distributor of Asian food products, including snacks, pickles, sauces, seasoning, flour and rice noodles, and frozen food. In 2018, the New York-based company recalled 4.4-ounce packages of 3+2 Soda Crackers due to the risk that they could contain undeclared milk. Just like their name suggests, 3+2 Soda Crackers consist of three layers of soda crackers separated by two layers of filling. Once imported to the U.S., the 3+2 Soda Crackers were distributed nationally, making the recall more complex, as the mislabeled products could be found in grocery stores across a wide area. The presence of milk — an ingredient not listed on the packaging — was discovered after routine testing by the New York State Department of Agriculture and Markets Food Inspectors. While there were no reports of any consumers being sickened by the crackers at the time, the product could have had disastrous consequences for individuals allergic to dairy. Just some of the symptoms of a milk allergy include vomiting, diarrhea, and rash. In the worst case scenario, a severe allergic reaction to the product can even lead to anaphylactic shock. Mars Chocolate North America — which merged into Mars Wrigley Confectionery in 2017 — is best known for its Mars chocolate bars. The popular caramel, nougat, and milk chocolate confection was launched in 1932 in the U.K, and has since become a staple grocery item around the globe. The 2016 recall had nothing to do with Mars Bars, instead centering on cracker-based snacks, including Combos Cheddar Cheese Pretzel, Cheddar Cheese Cracker, Pizzeria Pretzel, Sweet and Salty Caramel Pretzel, Pepperoni Cracker, and Buffalo Pretzel. The products were pulled off the shelves due to potential contamination with peanuts, a known allergen that can trigger potentially life-threatening reactions in sensitive individuals. Mars Chocolate North America raised the alarm after one of its suppliers, Grain Craft, issued a recall of the wheat flour used in the products, warning that it was likely to contain traces of peanuts. The products had been distributed nationwide, as well as in the Bahamas, Jamaica, St. Thomas in the U.S. Virgin Islands, Antigua, Colombia, Panama, Puerto Rico, Philippines, South Korea, Taiwan, and Singapore. Unlike most other recalls, which involve product contamination or undeclared allergens, the 1998 Nabisco recall of the company's Cheese Nips CatDog crackers centered around a legal issue. Manufactured as a part of the promotion of Nickelodeon's animated TV show "CatDog," the snack featured fish-shaped Cheese Nips crackers, which Pepperidge Farm claimed looked too much like its trademarked Goldfish Crackers. Pepperidge Farm initiated a lawsuit over this similarity, claiming that Nabisco infringed on its trademark fish-shaped cracker brand. The judge sided with Pepperidge Farm, ordering Nabisco to stop production and recall any Cheese Nips CatDog crackers that may have already found their way onto grocery store shelves. The judge also instructed Pepperidge Farm to post a $3.55 million bond to safeguard Nabisco against any potential losses if the decision was overturned. While the ruling threw a wrench into Nickelodeon's promotional plan with Nabisco, the network continued its "CatDog" advertising with other partners, including Kraft Foods and Burger King. For more food and drink goodness, join The Takeout's newsletter. Get taste tests, food & drink news, deals from your favorite chains, recipes, cooking tips, and more! Read the original article on The Takeout.
