Awareness of alcohol as a risk factor for cancer is associated with public support for alcohol policies

The global burden of illness and injury from alcohol consumption is high: alcohol is causally related to over 60 major health conditions, is estimated to be responsible for 4.5% of the global burden of disease and injury and accounts for 2.5 million deaths a year worldwide [1]. Rehm and colleagues have listed the range of negative health states which are currently known to be associated with alcohol consumption [2] showing that, among many other diseases, alcohol consumption plays a causal role in several types of cancer. The burden of alcohol-related harm is borne across society, for example through health, social care, justice and lost productivity costs [3, 4]. For example, in the UK in 2009–10 the cost to the National Health Service alone was £3.5 billion and, although the overall cost to society is difficult to estimate, the most widely cited figure, including crime and loss of productivity, is £21 billion a year [5]. Alcohol policy makers charged with balancing government revenue generation, industry regulation, individual freedom and the burden of alcohol need to prioritise the high levels of alcohol-related harm.

Globally, a range of policies are implemented to reduce alcohol-related harm and promote social wellbeing; for example by altering the drinking context, regulating availability and marketing, providing screening and brief interventions or more intensive treatment for heavier drinkers, protecting those at risk from drinkers’ actions, and enhancing the availability of information about the effects of alcohol [6, 7]. Policies with the strongest evidence of effectiveness and cost-effectiveness are those that increase the price of alcohol, and those that restrict availability and marketing [6, 8]. The evidence that information and education policies reduce alcohol-related harm is weaker, although these approaches may be used to reduce the knowledge deficit and change public opinion on policies that are more effective and cost-effective [8].

Public support for health-behaviour policy in general has an inverse relationship with the intrusiveness and/or restrictiveness of the policy, with people tending to prefer policies that they perceive to impact other people and not themselves [9]. This holds true for alcohol-related policies. Internationally, the most effective policies, such as increasing price and restricting availability tend to be the least supported while those with less evidence of effectiveness, such as education, are better supported [10]. For example, of 10 alcohol policy options presented to 1200 UK adults, self-regulation of alcohol advertising gained the most support, whilst a 20–40% reduction in outlets and a minimum unit price of £1 were the least popular policy options [11]. Furthermore, support for increased tax and earlier closing times declined in Ireland between 2002 and 2010, suggesting falling support for effective policies in that country [12]. The lack of public support may contribute to the limited political enthusiasm for some of the policies with the strongest evidence of effectiveness and cost-effectiveness by decision makers [13]; in short, governments are likely to be sensitive to public attitudes towards policy options [9].

There are several factors that are associated with support for effective alcohol policies. Being female, increasing age and consuming none or lower levels of alcohol, compared to high levels, are associated with higher levels of support for more effective policies [11, 14–17]. A higher level of education is associated with greater support for increasing price [16], promotion of limits and warnings, and controlling public spaces [18], and is associated with lower support for restricting availability and greater law enforcement [16]. However, demographic factors are largely non-modifiable. Modifiable factors such as knowledge have also been associated with support for alcohol policy. For example, knowledge of the domain specific (e.g. impact on crime, impact on health), likely positive outcomes of a policy [11] and awareness that alcohol can cause cancer [19] have been associated with support for alcohol policies. So, awareness of potential negative outcomes of alcohol consumption may be a relevant factor in understanding public support for alcohol polices.

A recent review determined that alcohol is now recognised as a risk factor for seven types of cancer including of the liver, mouth and oropharynx and breast [2] however there is an increasing amount of evidence that alcohol has a casual role in other cancers [20] and as such the list of cancers that are attributed to alcohol may grow. Globally, 12.5% of all alcohol-attributable deaths and 8.6% of alcohol-attributable Disability Adjusted Life Years (DALYs) are associated with cancer [1]. Research supports a linear dose-response relationship with an increase in average alcohol consumption positively associated with an increased risk of cancer [21, 22] and even low levels of alcohol consumption have been associated with a small increase in the absolute risk of some types of cancer [23]. Despite this substantial negative health impact, an earlier analysis of the 2015 English population survey data, on which the analyses in this paper are also based, found low levels of awareness of the link between alcohol and cancer [24] with awareness varying by cancer type, from 18% for breast cancer to 80% for liver cancer. These findings echoed similarly low levels of awareness of the alcohol-cancer link in the UK reported six years earlier [25] and are also consistent with findings from an Australian survey [19].

Awareness that alcohol is a risk factor for cancer has been associated with greater support for alcohol policies in the domains of pricing and taxation, availability, marketing and labelling in Australia [19]. While there has been some research within the North-east of England that has examined the impact of a mass-media campaign on awareness of the link between alcohol and cancer and policy support [26], the authors of the current paper were not able to locate any UK-based research that has directly examined the relationship between awareness of the increased risk of cancer and support for alcohol-related policies. Therefore, the aim of the study was to assess which factors are associated with support for different alcohol policies, including awareness of the alcohol-cancer link, in an English sample using policy options of relevance to current UK policy context.

The demographic characteristics are displayed in Table 1. One third (31.4%) of the respondents were current smokers, 24.9% were ex-smokers and 43.7% were non-smokers. The proportions of respondents reporting highest risk, increasing risk, and lower risk drinking were 9.8, 31.5 and 46.8% respectively with 11.9% reporting no alcohol use. When asked about health conditions related to drinking too much, 12.9% listed cancer unprompted and a further 34.3% selected ‘yes’ when cancer was listed as one of a number of potential health conditions resulting from drinking too much. The remaining 52.8% selected ‘no’ or ‘don’t know’.

Awareness of alcohol as a risk factor for cancer is associated with greater support for four different types of policies: Price and Availability and Marketing and Information, Harm Reduction and Drink Driving. This study used a three-category variable to distinguish between those that were aware of the alcohol-cancer link unprompted and prompted. This enabled the authors to identify that unprompted cancer awareness is a stronger predictor of support for alcohol policies across all four factors compared with both those who indicated their awareness when prompted or those who were not aware of the risk. Being female and lower levels of alcohol consumption were also both associated with higher levels of support for all policies.

These findings are broadly consistent with previous Australian research, which identified 1) that a similar proportion of the population were aware (either prompted or unprompted) that alcohol is a risk factor for cancer, and 2) that awareness alcohol consumption can cause cancer is associated with support for pricing, availability, marketing and labelling polices [19]. Similarly a British survey that indicated awareness of the link between alcohol and cancer was around 50% in 2015 [33]. We were able to build on this study by examining differential effects of alternative measures of awareness and using PCA in order to examine support for different policy types, thereby increasing the potential generalisability of our results. The findings also reflect results from tobacco-control research in which knowledge of the negative impact of smoking is associated with support for smoking policies [34]. It is likely that the widespread awareness of health risks associated with smoking contributed to the public support for restrictive tobacco policies [35]. In comparison, the awareness of the alcohol-cancer link is low and thus there is a need to increase awareness to allow the public to form informed opinions regarding alcohol policies.

Efforts to improve awareness of the alcohol-cancer link may contribute to decreasing the knowledge deficit. There is some evidence that public campaigns can increase public awareness of the link between alcohol and cancer [24]. In the North-east of England, people who were exposed to a mass-media campaign to raise awareness were more aware of the link between alcohol and cancer than those who had not and support for alcohol policies increased following the campaign [26]. In Denmark, a week-long annual alcohol campaign run over 10 years increased public knowledge of safe drinking limits [36]. Within this study, it is not known whether increased awareness has an impact on support for policies; however, Pechey and colleagues have demonstrated that preferences for policies could be altered if the probable positive outcomes are presented alongside the policy [11]. For example, the popularity of minimum unit pricing policies was much greater (supported by an additional one-fifth of participants) when all probable positive outcomes were presented compared to when no outcomes were presented. A study conducted in New Zealand found that public support for alcohol control policies was maintained in communities exposed to alcohol-related health promotion media campaigns and community-based intervention activities whereas it declined in those communities without any such intervention [37]. Together, these studies suggest that public awareness of the health risks of alcohol consumption can be increased and that increased awareness may have an impact on public support for alcohol policy, particularly where there is a clear description of anticipated policy effects. However, attempts to raise public awareness may be resisted by alcohol-funded organisations as has been reported to have occurred recently in response to warning labels on alcohol products in Canada [38]. Although there is evidence to indicate that increased awareness does not necessarily reduce actual consumption of alcohol [39], this study indicates that awareness is associated with greater support for policies and thus has the potential to reduce alcohol-related harm indirectly through generating an environment where restrictive policies are more likely to be implemented.

This study has limitations; the respondents were recruited from an existing market research panel and therefore membership of the sampling frame is self-selecting and limited to those who have access to, and are confident using, the internet. Furthermore, of the people that received the email, only approximately 50% started the survey and information is not available about those that did not respond so any potential differences between the responders and non-responders is not known. These factors may have generated a selection bias. However, quota sampling was used with the aim of creating a representative sample of England based on age, gender, region, and education level and weights were applied to adjust for differences between the sample and the population in order to maximise the generalisability of the study findings. The analyses focussed on awareness of alcohol as a risk factor for cancer in general and did not examine whether awareness of the risk of certain cancers are stronger or weaker predictors of support for policies, especially as awareness of the role of alcohol as a risk factor varies depending on the type of cancer [40]. Further, the policy items presented were simply descriptive (e.g. ‘increasing the price of alcohol’) and did not detail what the anticipated policy effects might be and for whom. Including likely positive outcomes of a policy has been associated with preferences for alcohol policy and thus this may have impact on outcomes [11] .Support for policy may also be influenced by personal experience. Greater support has been found among those who have experienced alcohol related-harm or alcohol-related disturbance [41] and so those who have experience of alcohol-attributable cancer may report greater support for policy. This may have confounded the association found between awareness and support for policy. Although information about the type of cancer (i.e. whether it was alcohol-attributable) and personal experience of cancer other than a personal diagnosis (i.e. a diagnosis of a friend or family) was not available, the impact of any cancer diagnosis was controlled for in sensitivity analysis and this did not have an impact on the association between alcohol-cancer awareness and policy support. Finally, we cannot be certain that reported support represents actual support however any increase in support may create environment in which these policies are more likely to be implemented.

Whilst the methods used in the PCA were directed by research recommendations [32], alternative methods could be employed relating to, amongst other things, rotation method and factor selection. Several alternative methods were examined, but they did not have an appreciable impact on the findings reported here. Likewise, alternative regression methods could have been employed, however, the distribution of the dependent variables would strongly suggest that linear regression is the most appropriate method, and this approach is commonplace among other analogous studies.

Several potential future research questions arise from this study. The study was cross-sectional. While previous research has demonstrated that alcohol-awareness campaigns can raise awareness of the link between alcohol and cancer [39] and can increase support for alcohol policies in the North-East of England [26] future prospective research could usefully examine whether exposure to information and an increase in awareness, is associated with a change in policy support in a wider population. This would help us to develop a better understanding of how increasing awareness might change public opinion on effective policies that are politically challenging to implement (e.g. minimum unit pricing). Future research could examine the combined effect of increased awareness of the general health risks of alcohol in addition to providing more detailed information about anticipated policy effects. Finally, future research could examine health or other risks not only to the individual but also people close to them as a predictor of policy support. A previous study examining support for restrictions on tobacco found awareness of the potential harm to others strongly predicted support [34] and it may be that a similar relationship exists for alcohol.

The extent to which any individual supports a government policy is dependent on a range of factors including the behaviour the policy targets (e.g. smoking, alcohol consumption), the type of policy and how intrusive it is (e.g. taxation, regulation), who the policy targets (e.g. children), and the extent to which the individual in question will be affected by the policy. Some predictors of support for policies are modifiable. Awareness, and especially unprompted awareness, of the link between alcohol consumption and cancer may be one such modifiable predictor, given that awareness of the risk is a significant predictor of support for range of alcohol policies. Therefore, improving awareness of the link between alcohol consumption and cancer may increase public support for effective alcohol policies that are otherwise relatively unpopular. These results are useful for policy-makers, because it highlights that understanding of a policy and its context is an important determinant of support and that increasing awareness of the specific harms being addressed may result in greater support for alcohol policies.