As one of his final official acts, Surgeon General Vivek Murthy has called for the nation to recognize new risks tied to alcohol consumption. That could take many allies, several years, a label revamp, and some lawyers.
On Friday, Murthy recommended an update to a decades-old surgeon general warning printed on all alcohol containers in the United States. He proposed that the labels have a more eye-catching look and warn users that drinking increases cancer risks.
In taking on alcohol as he finishes his term as the nation’s top health educator, Murthy is placing a historically inert issue at the feet of a second Trump administration, including Robert F. Kennedy Jr., who has pledged to get toxins out of the nation’s food supply if confirmed as health secretary. Kennedy has said little about alcohol, but is in long-term recovery; President-elect Donald Trump says he abstains from drinking because his brother died of alcohol use disorder.
A new Congress will ultimately decide whether to take up Murthy’s request or not. In an accompanying report released Friday, Murthy cites a growing body of research tying alcohol consumption to cancer, and especially female breast cancer. While alcohol has been classified as a carcinogen by various health bodies for decades, much of the public remains unaware of its cancer-related dangers.
“The more alcohol consumed, the greater the risk of cancer,” Murthy writes in the report. “For certain cancers, like breast, mouth, and throat cancers, evidence shows that this risk may start to increase around one or fewer drinks per day.”
Studies suggest about 5% of cancer cases in adults over 30, and about 20,000 deaths per year, are attributable to alcohol. A report from the National Academies of Science, Engineering and Medicine last month highlighted the association between even “moderate” alcohol consumption (one drink per day for women) and a heightened risk of breast cancer. Other research has pointed to links between drinking and cancer of the oral cavity, pharynx, larynx, esophagus, liver, and colorectum.
Will it get stuck in court?
Despite its toll — the Centers for Disease Control and Prevention estimates 178,000 deaths are caused by excessive alcohol use each year — alcohol hasn’t been a political priority.
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The alcohol industry and its trade groups donate to both parties, and to races up and down the ballot. Many members of Congress also represent districts and states with alcohol producers, distributors, and retailers like bars and restaurants. The alcohol lobby is a regular presence in Washington, and has the financial backing of a giant industry to push favorable policies and quash unfriendly proposals.
(STAT reached out to major alcohol firms and trade associations for comment. The Distilled Spirits Council of the United States said in a statement, “The current health warning on alcohol products has long informed consumers about the potential risks of the consumption of alcohol. … it is the federal government’s role to determine any proposed changes to the warning statements based on the entire body of scientific research.”)
On the state and local level, representatives from the alcohol industry have fought efforts to increase the price or reduce the availability of drinks. On the federal level, Trump cut alcohol taxes during his first term and Congress made them permanent. There seems to be little appetite to take on such a major industry, even as the incoming administration declares it will “Make America Healthy Again.”
The surgeon general’s push is different, though. It places the science on alcohol and cancer on a major platform, and has the potential to raise public awareness and build support for alcohol-control regulation, experts say. State and local governments could even use Murthy’s advisory as a legal basis for mandating alcohol cancer warnings at store checkout counters or on billboards, said Thomas Gremillion, director of food policy at the Consumer Federation of America.
Murthy also recommended changing existing alcohol labels to make them more “visible, prominent, and effective in increasing awareness.” Researchers have criticized existing warnings as being too dull, small, and meek. They are easy to miss on many alcohol containers.
Congress has the power to redesign the warning labels by passing a law, or it could ask the Alcohol and Tobacco Tax and Trade Bureau to choose new wording and visuals, since TTB oversees alcohol labels.
“Every other day, consumers are confronted with alternating headlines proclaiming that alcohol is either healthful or harmful. The science examining alcohol and health outcomes is complex, but the link between alcohol and cancer is one area where the evidence is clear,” said Eva Greenthal, senior policy scientist at the Center for Science in the Public Interest. Greenthal is an advocate who has been pushing federal regulators to strengthen alcohol labeling, and add nutritional information. Currently, only alcoholic products regulated by the Food and Drug Administration are required to list ingredients, calories, and other information about nutritional value.
Bruce Scott, president of the American Medical Association, praised Murthy’s decision in a news release, saying: “For years, the AMA has said that alcohol consumption at any level, not just heavy alcohol use or addictive alcohol use, is a modifiable risk factor for cancer. And yet, despite decades of compelling evidence of this connection, too many in the public remain unaware of alcohol’s risk.”
Alcohol warning labels are among the policies the World Health Organization recommends for reducing drinking across the population. To researchers, labels are among the best options for educating drinkers since they go directly on the product — a “mini billboard,” Stanford behavioral scientist Anna Grummon calls it. They could have similar effects as front-of-label warnings on unhealthy food, which the FDA has been considering, or as warnings on tobacco products.
How well could they work?
Tobacco is a parallel in more ways than one. In 2020, the FDA mandated nearly a dozen different graphic warnings be affixed to cigarette packaging and advertisements. Tobacco companies Philip Morris and R. J. Reynolds sued the agency over the rule, and the battle went on for years, delaying its implementation. Alcohol companies may decide to challenge cancer warnings on First Amendment grounds, said Grummon, director of the Stanford Food Policy Lab.
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Corporations are granted the same right as individuals to exercise freedom of speech, including by advertising products. Public health regulations must be carefully constructed as a result.
This is where the Reynolds case is particularly relevant. In March, a judge for the 5th Circuit Court of Appeals upheld the FDA’s warning label regulation, overturning a lower court’s ruling. The labels are set to go into effect in coming months, aligning the U.S. with countries in Europe and elsewhere that already stick hard-to-miss images and language on packs of cigarettes. Reynolds was “an important signal that warning policies can clear court challenges,” Grummon said.
Advocates frequently mention tobacco warning labels as a success story, but they admit those warnings were accompanied by a potent mix of smoking laws, tax hikes, and mass social change that greatly reduced rates of tobacco use in the U.S. after 1966. Alcohol is a different story. It is still a popular and widely used product, despite downward sales trends and slight shifts in public opinion. Alcohol is more affordable to the average worker today than it was decades ago, and it is more ubiquitous.
When compared to policies such as increased taxes and reduced sales, the evidence behind alcohol warning labels is slight. It’s still unclear how much warnings affect drinking long-term, and which consumers are most impacted by the message. Some studies suggest warnings are effective at reaching people who drink heavily, but researchers don’t know exactly how receiving a warning affects drinking patterns.
“Consumers have a right to know about the risks of alcohol, regardless of whether they decide to make any changes to their drinking habits,” researcher Marissa Hall told STAT. Hall studies alcohol labels at the University of North Carolina Gillings School of Global Public Health.
In one of the few real-world experiments of warning labels, researchers in Canada’s Yukon Territory found retail sales of alcohol per person decreased by 6% during the trial. Sales of alcoholic products with warning labels decreased by 6.6% in the target area, and increased by more than that in the unlabeled areas. They found sales remained lower even after the experiment ended and labels returned to normal. (The study was the subject of major media attention, which may have altered the results.)
More recent data published in the Lancet Public Health in July found alcohol labels with a message about cancer risks increased participants’ knowledge of the link, and were rated highest of six labels in impact and relevance. The study surveyed over 19,000 drinking-age people in 14 European countries on their perceptions of different label messages. Cancer warnings with an image of a patient were rated as having lower acceptability and as making people avoid the labels.
In another recent study with over 2,000 American participants of drinking age, researchers tested which alcohol warning topics were most likely to reduce drinking. Among 16 topics, warnings about cancer were the most motivating to consumers.
Researchers say the most effective labels are large, colorful, eye-catching, and have rotating messages to prevent consumers from becoming desensitized to them.
Whether or not Congress decides to take Murthy’s recommendation, how lawmakers execute any makeover — and how potential legal challenges shape the direction — will be key. Those factors will determine how much a new warning changes public perception of alcohol’s risks, and whether drinkers change their ways.
STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.
