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Alcohol & cancer: Evidence to action

Mehrotra, Ravi1,*; Kapahtia, Siddharth2; Kaur, Tanvir2; Priyanka, K. Yamini1; Dhaliwal, Rupinder Singh2

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Indian Journal of Medical Research: February 2022 - Volume 155 - Issue 2 - p 227-231
doi: 10.4103/ijmr.IJMR_4037_20
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Harmful use of alcohol is associated with morbidity and mortality worldwide alongside many physical and mental disorders including cancer. Numerous studies have indicated a causal association of alcohol consumption with oropharyngeal, laryngeal, oesophageal (squamous cell), colorectal, hepatocellular and female breast carcinoma12345. Despite this well-reported association, public awareness about the risk of alcohol consumption with cancer remains low. The Global Burden of Disease (GBD) 2016 study6 reported alcohol to be a major risk factor for deaths and disability-adjusted life years (DALYs) worldwide and accounted for 2.2 and 6.8 per cent of age-standardized female and male deaths, respectively. More importantly, consumption of alcohol was the leading risk factor for death in the 15-49 yr age group globally. ‘The per capita alcohol consumption is defined as the amount of alcohol consumed in litres of pure alcohol per person (age >15 yr) in a year after adjusting for tourist consumption’1. The global per capita alcohol consumption between 1990 and 2017 has increased from 5.9 to 6.5 l and is further expected to reach 7.6 l by 20307.

Epidemiology and pattern of alcohol use in India

There has been a marked increase in alcohol consumption in low- and middle-income countries over the last decade. From 2010 to 2017, India recorded a 38 per cent increase in per capita alcohol consumption7. Consumption of country liquor predominates in rural areas, whereas Indian-made foreign liquor is the preferred alcoholic beverage in urban areas. Country liquor is known by various names such as desi daru, tharra, toddy, tari and arrack and contains about 33 per cent (w/v) ethanol8. Traditional rice beer preparations are unique to the North-East of India. Almost every tribe has a unique way of preparing alcoholic beverages using locally available plant components as starter cultures9. The prevalence of alcohol use is high in the age group of 25-34 yr in the northeastern States. Mizoram and Meghalaya have reported a higher prevalence of alcohol use in comparison to other northeastern States as per the fourth round of district-level household survey10.

The per capita alcohol consumption is higher in India (5.7 l) as compared to the average for Southeast Asian region (SEAR) countries (4.5 l)1. According to the report on the magnitude of substance use, there are about 160 million alcohol users in India in the 10-75 yr age group. There is a considerable gender difference in the use of alcohol, while 27.3 per cent of men use alcohol, the corresponding figure for women is 1.6 per cent. More importantly, there are about 57 million problem users and 29 million dependent users who require treatment intervention11. A substantial proportion of alcohol users in India (around 43% of all users) consume more than four drinks on a single occasion11. Furthermore, there is a huge treatment gap for alcohol use disorders in our country. According to the National Mental Health Survey of India 2015-201612, the treatment gap for alcohol use disorders was 86.3 per cent. For a given level of alcohol consumption, disadvantaged social groups suffer from greater alcohol-attributable harm as compared to individuals from upper socioeconomic strata13.

Alcohol and cancer

Alcohol induces carcinogenesis via multiple mechanisms. Acetaldehyde produced during alcohol metabolism is mutagenic to human DNA. The amount of acetaldehyde generated depends on the activity of ethanol-metabolizing enzymes, namely alcohol dehydrogenase and aldehyde dehydrogenase (ALDH)14. Due to genetic polymorphism, ALDH2 has extremely low activity in 40-50 per cent of Asians, which increases the risk of alcohol-related cancers. The oxidation of ethanol to acetaldehyde by the alternate microsomal CYP2E1 pathway leads to the generation of reactive oxygen species and mediates DNA damage by lipid peroxidation and DNA adduct formation1415. Alcohol also causes carcinogenesis through epigenetic alterations. These include activation of oncogenes and inhibition of tumour suppressor genes by aberrant DNA methylation16. Alcohol consumption increases oestrogen levels by altering the hepatic redox state leading to reduced steroid degradation. In addition, chronic alcohol consumption leads to an increase in aromatase activity in peripheral tissues causing increased conversion of androgens to oestrogen17. Oestrogen is known to have proliferative effects on breast tissue and excess exposure to oestrogen is known to promote tumour growth17. Ethanol also has immunomodulatory properties and evidence suggests that it may modify innate immune responses by affecting antigen recognition and intracellular signalling18. A study19 from the northeast region of India has suggested that alcohol and tobacco act as important risk factors in the causation of head and neck cancer.

In 2016, 4.2 per cent of cancer deaths globally were attributable to alcohol consumption1. A study comprising eight European countries from the EPIC cohort showed that 10 [95% confidence interval (CI): 7-13%] and three per cent (95% CI: 1-5%) of all cancer cases in men and women, respectively, were attributable to alcohol consumption and the fractions were highest for cancers of the upper aerodigestive tract and the liver20. The cancer risk attributable to alcohol is also dose dependent. A meta-analysis reported a higher relative risk of cancers of the oropharynx and oesophageal SCC with heavy drinkers as compared to light drinkers and non-drinkers3. This study highlighted that the magnitude of risk varies with the quantity of alcohol consumed as well as the site of cancer. A recent large Australian cohort study reported an increased risk of alcohol-attributable cancers with increasing levels of intake. Consumption of more than 14 drinks per week as compared to less than one drink per week resulted in a higher absolute cumulative risk of 4.4 and 5.4 per cent in men and women, respectively, for alcohol-attributable cancers5. Tobacco and alcohol have a synergistic effect on cancers of upper aerodigestive tracts, though studies have clearly shown an independent association between alcohol and cancers of the upper aerodigestive tract after controlling for the effects of tobacco2122. Alcohol use among women increases the risk of breast carcinoma in a dose-dependent manner523. Regular alcohol consumption for greater than 10 yr increased the risk of breast cancer by threefold among women aged less than 50 yr24.

In 2016, alcohol use contributed 6.6 per cent to the total cancer DALYs in India, second only to tobacco (10.9%), amongst the GBD risk factors25. The WHO Global status report on alcohol and health estimated the alcohol-attributable fractions of cancer in India to be 6.5 and 0.8 per cent amongst males and females, respectively126. A recent meta-analysis from India showed consumption of alcohol increases the overall risk of cancer, with an odds ratio (OR) of 2.32 (95% CI: 1.50-3.47) in case–control studies and relative risk of 1.52 (95% CI: 0.97-2.51) in cohort studies27. A significant relationship between oral cancer and alcohol consumption (current and past drinkers) was observed in Kerala28.

Alcohol-related health policies

Numerous studies have demonstrated the effect of alcohol cessation on cancer risk reduction293031. A meta-analysis showed that alcohol cessation was associated with an average risk reduction of two per cent per year as compared to ‘current drinkers’, i.e., those with ongoing alcohol consumption, for pharyngeal and laryngeal cancers29. A multi-country time-series analysis revealed a significant temporal association between alcohol sales and cancer mortality. Countries with increasing, decreasing and stable alcohol consumption over the years observed similar trends in cancer mortality a few years later30. Strengthening alcohol-related policies can reduce cancer mortality attributable to alcohol. A 10 per cent increase in restrictiveness of alcohol-related policies resulted in an 8.5 per cent decrease in cancer mortality due to alcohol in the USA31. By 2025, the WHO also targets to reduce the harmful use of alcohol by at least 10 per cent. SAFER is a WHO-led initiative and action package that aims to reduce alcohol-related morbidity and mortality32. It provides five high-impact strategic actions that are practical, are cost-effective and can be incorporated into alcohol control policies by all countries to reduce alcohol-related harm.

In India, alcohol comes under the purview of the State government, and therefore, the laws governing sale, taxation and minimum legal drinking age (MLDA) vary from one State to another. In Tamil Nadu and Kerala, the State government has a monopoly over the sale and distribution of alcohol33. This system permits the State to control over the pricing, safety and quality of alcohol and prevents its illegal sale and unauthorized distribution. The maximum permissible blood alcohol concentration for driving a motor vehicle in India is 0.03 per cent34. There is a complete ban on the sale of alcohol in Bihar, Gujarat, Mizoram, Nagaland and Lakshadweep. Mizoram was a dry State till 2014 when the ban on the sale and consumption of alcohol was lifted. Mizoram has reinstated the ban on the sale and consumption of alcohol since 2019 when the new Mizoram liquor prohibition bill was passed35. Alcohol use is prevalent throughout the country, including the States that have enforced prohibition. Chhattisgarh, Tripura and Punjab are amongst the highest alcohol-consuming States in the country11. Underreporting is a challenge, especially in States that have prohibited alcohol such as Bihar and Gujarat. The MLDA also varies from State to State from 18 to 25 yr34. Delhi has recently lowered the MLDA from 25 to 21 yr36. As per the Cable TV Networks Amendment Bill 2000, liquor and tobacco advertisements are banned in India, but surrogate advertising by alcohol companies remains a major issue. Evidence suggests that alcohol promotion and advertisement increase the likelihood of alcohol use amongst adolescents37. Peer pressure, clever surrogate advertising and innovative targeted marketing of young adults, with the involvement of social media, are thought to be the key factors that trigger the use of alcohol by the youth of our country. Some strategies to reduce alcohol consumption and the harms associated with it are suggested in the Box.

Suggested strategies to reduce alcohol consumption and the associated harms.

Overall, consumption of alcohol is causally linked with cancer. The European Code of Cancer and the American Society of Clinical Oncology have also recommend minimizing alcohol consumption for cancer prevention3839.

Financial support & sponsorship: None.

Conflicts of Interest: None.


Authors acknowledge the following experts for their scientific advice: Drs GK Rath, Sonali Jhanjee, AIIMS; Suneela Garg, MAMC; Rengaswamy Sankaranarayanan, RTI International; Nimesh Desai, IHBAS; Leimapokpam Swasticharan, MoHFW, New Delhi; Jyotsna Vohra, Cancer Research UK; Partha Basu, IARC, Lyon France; and Linda Bauld, University of Edinburgh, UK.


1. World Health Organization Global status report on alcohol and health 2018 Geneva WHO 2018
2. Boffetta P, Hashibe M Alcohol and cancer Lancet Oncol 2006 7 149 56
3. Bagnardi V, Rota M, Botteri E, Tramacere I, Islami F, Fedirko V, et al. Alcohol consumption and site-specific cancer risk:A comprehensive dose-response meta-analysis Br J Cancer 2015 112 580 93
4. Praud D, Rota M, Rehm J, Shield K, Zatoński W, Hashibe M, et al. Cancer incidence and mortality attributable to alcohol consumption Int J Cancer 2016 138 1380 7
5. Sarich P, Canfell K, Egger S, Banks E, Joshy G, Grogan P, et al. Alcohol consumption, drinking patterns and cancer incidence in an Australian cohort of 226,162 participants aged 45 years and over Br J Cancer 2021 124 513 23
6. GBD 2016 Alcohol Collaborators Alcohol use and burden for 195 countries and territories, 1990-2016:A systematic analysis for the Global Burden of Disease Study 2016 Lancet 2018 392 1015 35
7. Manthey J, Shield KD, Rylett M, Hasan OSM, Probst C, Rehm J Global alcohol exposure between 1990 and 2017 and forecasts until 2030:A modelling study Lancet 2019 393 2493 502
8. Lal R Substance use disorder: Manual for physicians New Delhi NDDTC, AIIMS 1999
9. Das AJ, Deka SC, Miyaji T Methodology of rice beer preparation and various plant materials used in starter culture preparation by some tribal communities of North-East India:A survey Int Food Res J 2012 19 101 7
10. Yadav J, Gautam S, Singh KJ Prevalence and correlates of alcohol consumption in Northeast states, India (evidence from district levels household survey:|p2012-13) Int J Community Med Public Health 2017 4 30 7
11. National Drug Dependence Treatment Centre (NDDTC), All India Institute of Medical Sciences (AIIMS), New Delhi. Ministry of Social Justice and Empowerment, Government of India. . Magnitude of substance use in India Available from: accessed on July 10, 2021
12. National Institute of Mental Health and Neuro Sciences Bengaluru. Ministry of Health and Family Welfare, Government of India. National mental health survey of India, 2015-16: Mental health systems Available from: accessed on July 10, 2021
13. Katikireddi SV, Whitley E, Lewsey J, Gray L, Leyland AH Socioeconomic status as an effect modifier of alcohol consumption and harm:Analysis of linked cohort data Lancet Public Health 2017 2 e267 76
14. Seitz HK, Stickel F Molecular mechanisms of alcohol-mediated carcinogenesis Nat Rev Cancer 2007 7 599 612
15. Ratna A, Mandrekar P Alcohol and cancer:Mechanisms and therapies Biomolecules 2017 7 61
16. Varela-Rey M, Woodhoo A, Martinez-Chantar ML, Mato JM, Lu SC Alcohol, DNA methylation, and cancer Alcohol Res 2013 35 25 35
17. Liu Y, Nguyen N, Colditz GA Links between alcohol consumption and breast cancer:A look at the evidence Womens Health (Lond) 2015 11 65 77
18. Goral J, Karavitis J, Kovacs EJ Exposure-dependent effects of ethanol on the innate immune system Alcohol 2008 42 237 47
19. Kumar R, Rai AK, Das D, Das R, Kumar RS, Sarma A, et al. Alcohol and tobacco increases risk of high risk HPV infection in head and neck cancer patients:Study from north-east region of India PLoS One 2015 10 e0140700
20. Schütze M, Boeing H, Pischon T, Rehm J, Kehoe T, Gmel G, et al. Alcohol attributable burden of incidence of cancer in eight European countries based on results from prospective cohort study BMJ 2011 342 d1584
21. Castellsagué X, Muñoz N, De Stefani E, Victora CG, Castelletto R, Rolón PA, et al. Independent and joint effects of tobacco smoking and alcohol drinking on the risk of esophageal cancer in men and women Int J Cancer 1999 82 657 64
22. Fioretti F, Bosetti C, Tavani A, Franceschi S, La Vecchia C Risk factors for oral and pharyngeal cancer in never smokers Oral Oncol 1999 35 375 8
23. Betts G, Ratschen E, Opazo Breton M, Grainge MJ Alcohol consumption and risk of common cancers:Evidence from a cohort of adults from the UK J Public Health (Oxf) 2018 40 540 8
24. Vieira R, Tobar JSS, Dardes R, Claudio L, Thuler S Alcohol consumption as a risk factor for breast cancer development:A case-control study in Brazil Asian Pac J Cancer Prev 2018 19 703 7
25. India State-Level Disease Burden Initiative Cancer Collaborators The burden of cancers and their variations across the states of India:The Global Burden of Disease Study 1990-2016 Lancet Oncol 2018 19 1289 306
26. World Health Organization Cancer country profile India 2020 Available from: accessed on July 10, 2021
27. Singhavi HR, Singh A, Bhattacharjee A, Talole S, Dikshit R, Chaturvedi P Alcohol and cancer risk:A systematic review and meta-analysis of prospective Indian studies Indian J Public Health 2020 64 186 90
28. Cancela Mde C, Ramadas K, Fayette JM, Thomas G, Muwonge R, Chapuis F, et al. Alcohol intake and oral cavity cancer risk among men in a prospective study in Kerala, India Community Dent Oral Epidemiol 2009 37 342 9
29. Ahmad Kiadaliri A, Jarl J, Gavriilidis G, Gerdtham UG Alcohol drinking cessation and the risk of laryngeal and pharyngeal cancers:A systematic review and meta-analysis PLoS One 2013 8 e58158
30. Schwartz N, Nishri D, Chin Cheong S, Giesbrecht N, Klein-Geltink J Is there an association between trends in alcohol consumption and cancer mortality?Findings from a multicounty analysis Eur J Cancer Prev 2019 28 45 53
31. Alattas M, Ross CS, Henehan ER, Naimi TS Alcohol policies and alcohol-attributable cancer mortality in U. S. States Chem Biol Interact 2020 315 108885
32. World Health Organization The SAFER Initiative. World free from alcohol related harm Available from: accessed on July 10, 2021
33. Health Promotion unit, Public Health Foundation of India Alcohol marketing and regulatory policy environment in India Available from: accessed on July 10, 2021
34. Livemint. How to drink and drive and (not) get away with it Available from: accessed on July 10, 2021
35. NDTV. Mizoram again becomes dry state following new liquor law Available from: accessed on July 10, 2021
36. The Indian Express. Delhi reduces legal drinking age to 21 from 25, netizens rejoice with memes Available from: accessed on July 10, 2021
37. Anderson P, de Bruijn A, Angus K, Gordon R, Hastings G Impact of alcohol advertising and media exposure on adolescent alcohol use:A systematic review of longitudinal studies Alcohol Alcohol 2009 44 229 43
38. Soccianti C, Cecchini M, Anderson AS, Berrino F, Boutron-Ruault MC, Espina C, et al. European Code against Cancer 4th Edition:Alcohol drinking and cancer Cancer Epidemiol 2016 45 181 8
39. LoConte NK, Brewster AM, Kaur JS, Merrill JK, Alberg AJ Alcohol and cancer:A statement of the American Society of Clinical Oncology J Clin Oncol 2018 36 83 93
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