Reducing alcohol-related cancer: What can public health advocates, policy makers and cancer charities do? Norman Giesbrecht & Susan Flynn

Transcription

1 Reducing alcohol-related cancer: What can public health advocates, policy makers and cancer charities do? Norman Giesbrecht & Susan Flynn Public Health Ontario Rounds January 23, 2018 Toronto, Ontario 1

2 Outline Introduction and objectives Alcohol-related cancers Habits and awareness of alcohol as a cancer risk Policies and interventions to reduce cancer risks associated with alcohol use What can public health, policy makers and cancer charities do? Summary 2

3 The Alcohol Working Group (AWG), is a subcommittee of the Toronto Cancer Prevention Coalition Comprised of representatives from agencies and organizations across Toronto in the areas of public health, addictions, mental health, treatment, research and cancer prevention. 3

4 AWG Objectives Mobilize collective action on TCPC priorities Support/ promote an alcohol control strategy for Ontario Support/ promote regulation controls on alcohol Support municipal level action Monitor and take action on other current alcoholrelated initiatives 4

5 By the end of this session: Describe the public health burden of alcoholrelated cancers in Ontario Analyze the relationship between alcohol marketing, alcohol industry sponsorship and cancer. Identify alcohol pricing policies and other interventions that have been effective in reducing levels of alcohol consumption List opportunities for action and advocacy for public health practitioners, policy makers and cancer charities 5

6 Alcohol Related Cancer Nearly half of Canadians are expected to be diagnosed with cancer at some point in their lives and 1 in 4 Canadians is expected to die of it. The International Agency for Research on Cancer (IARC) classifies alcoholic beverages as carcinogenic to humans. Alcohol is one of the top three leading causes of cancer deaths in Canada. In 2015, an estimated 10,700 cancer diagnoses in Canada were related to alcohol consumption. Source: 2017 Canadian Cancer Society Statistics 6

7 Outline Introduction and objectives Alcohol-related cancers Habits and awareness of alcohol as a cancer risk Policies and interventions to reduce cancer risks associated with alcohol use What can public health, policy makers and cancer charities do? Summary 7

8 Alcohol Related Cancers Biological pathways for carcinogenesis: Acts as a solvent other carcinogens can penetrate cells more easily and cause genetic damage. Alcohol acetaldehyde, an identified carcinogen, damages a cell s DNA and prevents repairing any damage. Acetaldehyde causes liver cells to grow faster than normal more likely for genetic changes in cells could lead to cancer. Source: M. Bassier-Palto (2017 ) Presentation at CDC Conference, Atlanta, August 15, 2017.

9 Alcohol Related Cancers 9

10 Alcohol Related Cancers Drinking about 3.5 drinks a day doubles or even triples the risk of developing cancer of the mouth, pharynx, larynx and esophagus Drinking about 3.5 drinks a day increases the risk of developing colorectal cancer and breast cancer by 1.5 times Studies suggest that women are at increased risk for breast cancer even at a low level of one drink per day Source: Canadian Centre on Substance Use and Addiction. (2017). The National Alcohol Strategy monitoring project: a status report. Ottawa, Ont.: Author. Canadian Cancer Society. (2017). Alcohol. from: 10

11 Alcohol Consumption & Cancer Mortality Population-level consumption has been linked with longterm trends in mortality: suicide, homicide, traffic crashes, chronic disease -- studies in Canada, Europe & USA Research by N. Schwartz et al. focuses on 17 countries: annual sales in alcohol over several decades in connection cancer mortality among males: larynx; esophageal and lip, oral cavity and pharynx (LOCP). Significant associations between alcohol sales and cancer mortality were found in the majority of countries examined, which remained after controlling for tobacco use. Significant associations were observed with rising, declining or stable trends in alcohol consumption and corresponding lagged trends in mortality from specific cancer types Source: N. Schwartz et al.. (2017) The association between trends in alcohol consumption and cancer mortality: findings from a multi-country analysis European J. of Cancer Prevention /CEJ

12 LOCP mortality and alcohol (12 year lag), France Mortality Alcohol sales Year 12

13 Larynx mortality and alcohol (12 year lag), France Mortality Alcohol sales Year 13

14 Outline Introduction and objectives Alcohol-related cancers Habits and awareness of alcohol as a cancer risk Policies and interventions to reduce cancer risks associated with alcohol use What can public health, policy makers and cancer charities do? Summary 14

15 Habits and Perceptions Canadians drink about 50% more than the global average. In 2013, an estimated 22 million Canadians, almost 80 percent of the population, drank alcohol in the previous year. Consistent findings reported in Ontario showed 8 out of 10 adults consumed alcohol between 1998 and Daily drinking in Ontario increased from 5.3% in 2002 to 8.6% in Sources: Government of Canada 2016, The chief public health officer s report on the state of public health in Canada 2015: alcohol consumption in Canada. Public Health Agency of Canada, Ottawa, ON. CAMH Health Promotion Resource Centre (Public Health Ontario), 2013, Making the case: tools for supporting local alcohol policy in Ontario. The Chief Public Health Officer s Report on the State of Public Health in Canada 2015 ALCOHOL CONSUMPTION IN CANADA 15

16 Habits and Perceptions What is one drink? 16

17 Habits and Perceptions Our understanding of the dose-dependent health effects of alcohol continues to evolve Cancer risk increases in a dose-dependent manner; no safe level of drinking with regard to cancer Drinking any type of alcohol raises cancer risk Intensity and duration of drinking impacts different cancer types in different ways Risk of cancer declines once drinking stops Source: "Report on the State of Public Health in Canada, 2015: Alcohol Consumption in Canada". Dr. Gregory Taylor Canada's Chief Public Health Officer, February,

18 Habits and Perceptions Cancer Low-Risk Alcohol Drinking Guidelines No alcohol Less than 1 drink a day for women Less than 2 drinks a day for men Source: The International Agency for Research on Cancer s World Cancer Report 2014 Canadian Cancer Society s Advisory Committee on Cancer Statistics (2015). 18

19 Habits and Perceptions Spurce: Zupan Zorana, Evans Alexandra, CouturierDominique-Laurent, Marteau Theresa M. Wine glass size in England from 1700 to 2017: a measure of our time BMJ 2017; 359 :j

20 Habits & Perceptions Category Heard of Canada s Alcohol 17% Low risk drinking guidelines A Exceed guidelines recommended by Canadian Cancer Society B Perceived safe to drinking is above CCS guidelines B Results - Ontario 60% among women 41% among men 35% for men 51% for women Drink above what they 33% perceive to be a safe level B Were more likely to reduce 69% consumption if they learned that drinking alcohol increases their risk of cancer B Main carcinogens B Tobacco, toxic chemicals and UV rays Perceived as more likely to Electromagnetic waves, stress cause cancer than alcohol B Percent who think that 30% alcohol consumption can cause cancer B A. PHO 2014 Study B. Survey by Leger in 2015 Ontario and Quebec, commissioned by CCS 20

21 Promising Intervention Health advisory tags Yukon Intervention: Tag was added to each bottle of alcohol with, among other information, a warning stating excess alcohol consumption can increase the risk of developing colon, breast and other cancers Current status: Campaign halted after a few weeks due to pressure from big alcohol producers threatening to sue the territorial government. Source: Hobin, E. et al. (2017) 21

22 Outline Introduction and objectives Alcohol-related cancers Habits and awareness of alcohol as a cancer risk Policies and interventions to reduce cancer risks associated with alcohol use What can public health, policy makers and cancer charities do? Summary 22

23 Policy Alcohol Pricing Strategies Minimum or floor price for all on-premise & offpremise venues, indexed to keep pace with inflation [indexed minimum unit price] Pricing by alcohol content in standard drink -- e.g. 341 ml of 6.5% beer is priced higher than 3.5% Average price keeps pace with cost of living, Consumer Price Index Sources. N. Giesbrecht et al. (2015) Pricing of alcohol in Canada: A comparison of provincial polilcies and harm-reduction opportunities. Drug and Alcohol Review. Published on-line. T. Stockwell (2017) Minimum unit pricing for alcohol: the most cost effective of cancer prevention strategies?, Expert Review of Anticancer Therapy, 17:11, , DOI: /

24 Intervention Minimum Prices - Saskatchewan Intervention: In April 2010 the Saskatchewan Liquor and Gaming Authority (SLGA) introduced a comprehensive set of new and increased minimum prices. These applied directly to all liquor stores and indirectly alcohol sold in bars and restaurants. The price was $1.16 and $1.84 per standard drink and among the highest in Canada at the time. Impact: A 10% increase in minimum prices significantly reduced consumption of beer by 10.06%, spirits by 5.87%, wine by 4.58%, and all beverages combined by 8.43%. Consumption of higher-strength beer & wine declined the most Source: T. Stockwell et al. (2012) The raising of minimum alcohol prices in Saskatchewan, Canada: Impacts on consumption and implications for public health. American Journal of Public Health 102(12): e

25 Intervention Minimum prices British Columbia Intervention: Increase in minimum prices of distilled spirits in: August 2004; September 2006; January 2008 and April Increase in minimum price of packaged and draft beer in May 2006 and January Overall a 10% increase in average minimum prices. Impact: A 9% decrease in acute alcohol-attributable admissions and a 9% reduction in chronic alcohol-attributable admissions. A 19% reduction in alcohol-related traffic violations, a 9% reduction in crime against persons, a 9% reduction in total crime outcomes examined. Sources: T. Stockwell et al. (2013) Minimum alcohol prices and outlet densities in British Columbia, Canada: Estimated impacts on alcohol attributable hospital admissions. American Journal of Public Health April 18, 2013: e1 e7. doi: /ajph T Stockwell et al. (2015) Relationships between minimum alcohol pricing and crime during the partial privatization of a Canadian government alcohol monopoly. Journal of Studies on Alcohol & Drugs 76:

26 Policy Physical Availability of Alcohol Density Number of alcohol outlets per capita or per sq. kilometer Hours of sale: stores and licensed places Opening days Longer hours for special events e.g. World Cup, Olympics, film festivals Zoning regulations where outlets can be located 26

27 Policy Type of Alcohol Control & Retailing System Several Options Public monopoly: all retail stores are government run Mixed system: some are government stores others are private Private limited: Alcohol only sold in private liquor stores Private expanded: Alcohol sold in private liquor stores, grocery stores, supermarkets, corner stores, etc. Also variations by type of beverages via type of outlet 27

28 Type of Alcohol Control & Retailing System Québec 1978 & 1984, higher access to wine: A significant and permanent effect of the policy change in The sale of wine increased by 10%, but the effect was not so large as to affect total sales. In 1983 to 1984, no immediate significant increase in sales of wine was found. Source: B. Trolldal (2005) The privatization of wine sales in Quebec in 1978 and 1983 to Alcoholism: Clinical and Experimental Research 29 (3): Alberta, , privatization: The analyses focused on three stages of privatization. It demonstrated that most of the privatization events resulted in either temporary or permanent increases in suicide mortality rates. Source: R. Flam Zalcman & R.E. Mann (2007) Effects of privatization of alcohol sales in Alberta on suicide mortality rates. Contemporary Drug Problems 34:

29 Type of Alcohol Control & Retailing System B.C : The rapidly rising densities of private liquor stores in British Columbia from 2003 to 2008 was associated with a significant local-area increase in rates of alcohol-related death, especially in privatization areas. Source: T. Stockwell et al. (2011) Impact on alcohol-related mortality of a rapid rise in the density of private liquor outlets in British Columbia: A local area multi-level analysis. Addiction, 106(4),

30 Policy Alcohol Marketing and Advertising Volume of advertising Content - links to images of violence, sexual adventures, financial success, etc. Media & mechanism print, billboards, on transit vehicles, TV, radio, electronic media, internet, on-site in bars/stores, sports venues Social media often not same controls Youth access & targeting Sponsorship by beverage companies or licensed premises Links with price & other dimensions of alcohol accessibility 30

31 Policy Alcohol Marketing and Advertising Alcohol Marketing Ready to drink/alcopops/flavoured Alcohol Beverages Very popular among underage youth (Canada, U.S., Britain, Sweden Germany) 31

32 Policy Alcohol Marketing and Advertising Public Transit Online article Huffington Post

33 Policy Alcohol Marketing and Advertising Alcohol targeted to female market

34 Policy Alcohol Marketing and Advertising Beer for women! "Our goal was to fill a gap in the market and to celebrate women in brewing and all women who love craft beer. - Kristi McGuire, Founder, High Heel Brewing Source: Samanta Cukier

35 Policy Alcohol Marketing and Advertising Consensus is widespread- exposure to alcohol advertising should be limited Sources: P. Anderson et al. (2009) Alcohol and Global Health 2: Effectiveness and costeffectiveness of policies and programmes to reduce the harm caused by alcohol. Lancet, 373, P. Anderson et al. (2009). Impact of alcohol advertising and media exposure on adolescent alcohol use: a systematic review of longitudinal studies. Alcohol and Alcoholism, 44(3), British Medical Association Board of Science. (September, 2009). Under the influence: The damaging effect of alcohol marketing on young people. UK: British Medical Association. Retrieved from: Department of Health and Human Services. (2007). The Surgeon General's call to action to prevent and reduce underage drinking. U.S. Department of Health and Human Services, Office of the Surgeon General. Evaluation of U.S. Beer Advertising code: 35% to 74% of ads during NCAA basketball games had code violations. Industry self-regulatory framework is ineffective in preventing content violations, code can be improved with new rating procedures Sources:T.F. Babor et al. (2013) An empirical evaluation of the US Beer Institute s Self-Regulation Code Governing the Content of Beer Advertising. American Journal of Public Health, 103, 10: e45-e51 A. Wettlaufer et al. (2017) Comparing alcohol marketing and alcohol warning message policies across 35 Canada Substance Use and Misuse 52:10, , DOI: /

36 Policy Alcohol Marketing and Advertising Youth Alcohol advertising influenced brand choice among underage youth Among under-age participants the alcohol advertising receptivity score independently predicted onset of drinking, onset of binge drinking & onset of hazardous drinking Sources: M. Siegel. (2015) The relationship between exposure to brand-specific alcohol advertising and brand-specific consumption among underage drinkers United States, The American Journal of Drug & Alcohol Abuse ISSN (print) (Online). S.E. Tanski (2015) Cued recall of alcohol advertising on television and underage drinking behaviour JAMA Pediatrics 169 (3): A. Wettlaufer et al. (2017) Comparing alcohol marketing and alcohol warning message policies across Canada Substance Use and Misuse 52:10, , DOI: /

37 Outline Introduction and objectives Alcohol-related cancers Habits and awareness of alcohol as a cancer risk Policies and interventions to reduce cancer risks associated with alcohol use What can public health, policy makers and cancer charities do? Summary 37

38 Public Health Increase awareness of alcohol as a carcinogen, especially for priority populations such as women and girls, elementary and secondary school students, university students. Reinforce cancer low risk drinking guidelines Join or support alliances or organizations working on collective action Promote evidence-based alcohol policies as recommended by WHO Pricing Controls on physical access Protecting government retail systems More effective controls on alcohol marketing 38

39 Public Health Cancer Risk Factors Atlas of Ontario Developed by Cancer Care Ontario Describes the geographic distribution of 6 modifiable risk factors related to cancer and other chronic diseases at a local level and includes alcohol consumption Addresses the need for detailed, local information on modifiable risk factors. Supports identification of priority populations/areas and development of targeted prevention efforts 39

40 Public Health Screening, brief intervention and referral (SBIR) Public Health Ontario provides a variety of resources and expertise to enable municipal alcohol policies and planning and implementation of alcohol-related interventions Two recently published resources, a Focus On and an Evidence Brief, highlight alcohol screening, brief intervention and referral (SBIR) as an early intervention strategy. SBIR targets individuals who are consuming alcohol above recommended guidelines but do not qualify as alcohol dependent. 40

41 Policy Makers Increase awareness of alcohol as a carcinogen Join or support alliances working on collective action Support and implement alcohol control policies Have information on alcohol in a prominent place on web site Provide specific information on what high risk drinkers can do to reduce their consumption Have a position statement or clear policy on interaction with the alcohol industry Source: M. Bassier-Palto (2017 ) Presentation at CDC Conference, Atlanta, August 15,

42 Cancer Charities Update messaging to become more aligned with cancer LRDG guidelines Consider position statement on alcohol Establish policies for sponsorship by alcohol industry Increase awareness of alcohol as a carcinogen Support alcohol control policies Sources: S Mart & N. Giesbrecht (2015). Red flags on pinkwashed drinks: contradictions and dangers in marketing alcohol to prevent cancer Addiction. doi: /add M. Bassier-Palto (2017) Presentation at CDC Conference, Atlanta, August 15,

43 Outline Introduction and objectives Alcohol-related cancers Habits and awareness of alcohol as a cancer risk Policies and interventions to reduce cancer risks associated with alcohol use What can public health, policy makers and cancer charities do? Summary 43

44 Summary Alcohol causes cancers of the oral cavity, pharynx, larynx, esophagus, colon and rectum, female breast, liver, and possibly pancreas. Current evidence does not identify a safe limit of drinking Drinking any type of alcohol beer, wine or spirits raises the risk of cancer. The less alcohol consumed, the more the risk is reduced Despite the health and social consequences, alcohol is still being consumed in quantities that increase the risk for disease. 44

45 Summary Alcohol use and cancer evidence is extensive. However there is low public awareness of this carcinogen and of programs and policies that can address this growing public To reduce the harm from alcohol, including cancer risk, a combination of individual and population level interventions are needed. Public health advocates, governments and NGOs, including cancer prevention charities, have critical roles to play in a coordinated response 45

46 Acknowledgements We are pleased to acknowledge the other members of Alcohol Working Group of the Toronto Cancer Prevention Coalition: John Atkinson, Canadian Cancer Society; Marcia Brassier-Paltoo, Cancer Care Ontario; Elizabeth Farkouh, Student ; Phat Ha, Toronto Public Health; Ashley Hall; Jessica Nelson, Journalist; Rebecca Truscott, Cancer care Ontario; Ashley Wettlaufer, Centre for Addiction and Mental Health. Thank you also to Naomi Schwartz and Stephanie Young, Cancer Care Ontario, and Samantha Cukier, Dartmouth College, for providing access to the results of research that they lead. 46

47 Contact Norman Giesbrecht Emeritus Scientist Centre for Addiction and Mental Health Susan Flynn Senior Manager, Cancer Prevention Canadian Cancer Society 47