How alcohol industry organisations mislead the public about alcohol and cancer

The role of alcohol consumption in the lives of older Australian women: qualitative insights and an agenda for further research, policy and practice

BACKGROUND

Alcohol consumption presents a threat to the health and wellbeing of women. The alcohol industry often pushes back at global efforts to prioritise the prevention of alcohol harms to women. Qualitative researchers have investigated how younger and midlife women conceptualise their alcohol consumption, but there is very limited research relating to older women (those 60 years and over).

METHODS

Using data collected from an online qualitative survey, this paper explored the factors that influence how older Australian women drinkers (n = 144. 60-88 years) conceptualised the role of alcohol in their lives. The study used a 'Big Q' reflexive approach to thematic analysis, drawing upon sociological theories of risk and symbolic interactionism to construct four themes from the data.

RESULTS

First, alcohol consumption was viewed by participants as an accepted and normalised social activity, that was part of Australian culture. Second, alcohol played a role for some participants as a way to cope with life changes (such as retirement), as well as managing stressful or challenging life circumstances (such as loneliness). Third, alcohol was part of the routines and rituals of everyday life for some women. For example, women discussed the consumption of wine with their evening meal as an important part of the structure of their day. Fourth, participants had clear personal expectancies about what it meant to be a 'responsible drinker'. They had clear narratives about personal control and moral obligation, which in some cases created a reduced perception of their own risk of alcohol-caused harm.

CONCLUSIONS

This research provides a starting point for future public health research examining the factors that may shape older women's alcohol consumption beliefs and practices. Public health activities should consider the unique needs and potential vulnerabilities of older women drinkers, and how these may be potentially exploited by the alcohol industry.

Dark patterns, dark nudges, sludge and misinformation: alcohol industry apps and digital tools

Many alcohol-industry-funded (AIF) organizations disseminate eHealth/mHealth tools that claim to assist users in making health decisions by monitoring alcohol consumption, e.g. blood alcohol calculators, AUDIT scores, consumption trackers. Previously, AIF materials were found to contain health misinformation that could increase consumption (dark nudges) or make healthy behaviour change more difficult (sludge). The accuracy and functionality of AIF tools have never been analysed, and given the history of AIF materials it is possible they contain misinformation and function as covert marketing channels to promote alcohol-industry-friendly narratives on the causes and possible solutions of alcohol-related harms. We evaluated the information accuracy and framing, behaviour change techniques (BCTs), and functions of AIF digital tools (n = 15, from the UK, Ireland, the USA, Canada, New Zealand, Australia; including Drinkaware, Drinkwise, Educ'alcool and others), compared to a non-industry-funded independent sample (n = 10). We identified misinformation and 'dark patterns' (interface design strategies for influencing users against their interest) throughout AIF tools; significantly fewer provided accurate feedback (33% vs 100%), and significantly more omitted information on cancer (67% vs 10%) and cardiovascular disease (80% vs 30%) and promoted industry-friendly narratives (47% vs 0%). AIF tools encouraged consumption through priming nudges (53%) and social norming (40%). AIF tools utilized fewer BCTs, provided users with more limited pre-set options (54%), and fewer drink choices (mean 24 vs 275). Their input structure often impeded their ability to provide guideline advice. We conclude that AIF tools contain pro-industry misinformation strategies and dark patterns that misinform users about their consumption and could 'nudge' them towards continuing to drink alcohol-characteristics of 'Dark Apps' designs.

Shouldn't We Know This Already? UK Women's Views About Communicating the Link Between Alcohol Consumption and Risk of Breast Cancer

Alcohol is a causal factor in about 10% of breast cancer (BCa) cases, but awareness of this link is low. This study explored how to raise awareness and inform the development of an intervention using the COM-B model (capability, opportunity, motivation, behavior) framework. Eight online focus groups were conducted with 36 participants (6 expert stakeholders,and 30 women aged 40-65). Participants reflected on a package of information about alcohol and BCa and discussed how to impart this information and encourage women to reduce drinking. Thematic analysis of focus group transcripts was undertaken. Three themes were identified: understanding ineffective messaging; transitions and challenges; and message acceptability. Current health information about alcohol was perceived as judgmental and BCa was put down to chance. Mid-life consisted of many challenges that could lead to increased consumption, but menopause transition may be a key moment for alcohol reduction. Barriers and enablers to communicating risk information and encouraging alcohol reduction were mapped onto the COM-B model. Psychological capability (relating to knowledge), social opportunity (in the form of social pressure) and automatic motivation (relating to drinking to cope) were barriers to behavior change.  These will be targeted in an alcohol reduction intervention. It is important to tailor information to women's experiences, taking into account the social benefits of drinking, and encourage the development of healthy coping strategies. Acceptable intervention messages may include personal stories, clear statistics, and suggest healthy alternatives to drinking. It is vital that messaging does not appear judgmental or patronizing.

Dynamics of combatting market-driven epidemics: Insights from U.S. reduction of cigarette, sugar, and prescription opioid consumption

Misuse and overconsumption of certain consumer products have become major global risk factors for premature deaths, with their total costs in trillions of dollars. Progress in reducing such deaths has been slow and difficult. To address this challenge, this review introduces the definition of market-driven epidemics (MDEs), which arise when companies aggressively market products with proven harms, deny these harms, and resist mitigation efforts. MDEs are a specific within the broader landscape of commercial determinants of health. We selected three illustrative MDE products reflecting different consumer experiences: cigarettes (nicotine delivery product), sugar (food product), and prescription opioids (medical product). Each met the MDE case definition with proven adverse health impacts, well-documented histories, longitudinal product consumption and health impact data, and sustained reduction in product consumption. Based on these epidemics, we describe five MDE phases: market expansion, evidence of harm, corporate resistance, mitigation, and market adaptation. From the peak of consumption to the most recent data, U.S. cigarette sales fell by 82%, sugar consumption by 15%, and prescription opioid prescriptions by 62%. For each, the consumption tipping point occurred when compelling evidence of harm, professional alarm, and an authoritative public health voice and/or public mobilization overcame corporate marketing and resistance efforts. The gap between suspicion of harm and the consumption tipping point ranged from one to five decades-much of which was attributable to the time required to generate sufficient evidence of harm. Market adaptation to the reduced consumption of target products had both negative and positive impacts. To our knowledge, this is the first comparative analysis of three successful efforts to change the product consumption patterns and the associated adverse health impacts of these products. The MDE epidemiological approach of shortening the latent time to effective mitigation provides a new method to reduce the impacts of harmful products.

Industries, citizens, and non-governmental organizations' positioning and arguments used in European Union initiatives for alcohol taxation and cross-border regulation

BACKGROUND

The European region has the highest daily alcohol consumption per capita and a high alcohol-related burden of disease. Policymaking at the European Union level is open to participation by interest groups, from public health organizations to alcohol industry representatives. This study aimed to map the interest groups present in the alcohol taxation and cross-border regulation initiatives and identify which arguments were used to support positions in favor or against them.

METHODS

We used qualitative content analysis on the comments submitted on the official European Commission website during the 2017, 2018, 2020, and 2022 participation periods. Interest groups were characterized considering their positioning, and arguments were identified and compared by position and type of initiative.

RESULTS

Opponents of changes to the structures of alcohol excise duties and cross-border regulations were mostly representatives of the alcohol and agricultural industries, and the proponents were mostly health-related nongovernmental organizations. Opponents of these initiatives used a wide variety of arguments, from economic and trade to health arguments, while proponents focused mainly on health arguments, such as the effectiveness of alcohol taxation in preventing alcohol-related morbidity and mortality.

CONCLUSION

This study highlights the wide range of arguments used by opponents around alcohol control policies, contrasting with the health-centered arguments of proponents. It further shows that there is a lobbying network at the European Union level, combining national and international representatives of industry and non-governmental organizations. These findings provide an opportunity for better preparation for upcoming discussions on alcohol control at national and regional levels.

Cluster analysis of cancer knowledge, attitudes and behaviors in the Moroccan population

BACKGROUND

Cancer has become a major health concern due to the increasing morbidity and mortality rates, and its negative social, economic consequences and the heavy financial burden incurred by cancer patients. About 40% of cancers are preventable. The aim of this study was to assess the knowledge, attitudes, and practices regarding cancer prevention, and associated characteristics to inform the development of targeted cancer prevention campaigns and policies.

METHODS

We conducted a cross-sectional survey of adult patients at Mohamed Sekkat and Sidi Othmane Hospitals in Casablanca, Morocco. Data collection was conducted by two trained interviewers who administered the questionnaire in-person in the local language. An unsupervised clustering approach included 17 candidate variables for the cluster analysis. The variables covered a wide range of characteristics, including demographics, health perceptions and attitudes. Survey answers were calculated to compose qualitative ordinal categories, including a cancer attitude score and knowledge score.

RESULTS

The cluster-based analysis showed that participants in cluster 1 had the highest mean attitude score (13.9 ± 2.15) and percentage of individuals with a high level of knowledge (50.8%) whereas the lowest mean attitude score (9.48 ± 2.02) and knowledge level (7.5%.) were found in cluster 3. The participants with the lowest cancer attitude scores and knowledge levels were aged 34 to 47 years old (middle age group), predominantly females, living in rural settings, and were least likely to report health professionals as a source of health information.

CONCLUSIONS

The findings showed that female individuals living in rural settings, belonging to an older age group, who were least likely to use health professionals as an information source had the lowest levels of knowledge and attitudes. These groups are amenable to targeted and tailored interventions aiming to modify their understanding of cancer in order to enhance the outcomes of Morocco's on-going efforts in cancer prevention and control strategies.

The impact of "pinkwashed" alcohol advertisements on attitudes and beliefs: A randomized experiment with US adults

OBJECTIVE

To examine the impact of alcohol advertisements related to breast cancer awareness or charities (i.e., pinkwashed ads) on attitudes and beliefs.

METHODS

In 2023, an online experiment randomized 602 US adults to view three pinkwashed ads for beer, wine, and liquor, or three standard ads for the same products.

RESULTS

Breast cancer risk perceptions (average differential effect [ADE] = 0.03; p = 0.58)) and intentions to purchase the advertised product (ADE = -0.01, p = 0.95) did not differ by ad type. When informed about the link between alcohol and breast cancer, participants who viewed pinkwashed ads reported the ads were more misleading (ADE = 0.51, p < 0.001) and had stronger support for requiring alcohol breast cancer warnings (ADE = 0.23, p < 0.001). The pinkwashed ads for beer (but not for wine or liquor) led to greater: perceived product healthfulness (ADE = 0.16, p = 0.03), perceived social responsibility of the company (ADE = 0.18, p = 0.02), and favorable brand attitudes (ADE = 0.14, p = 0.03).

CONCLUSIONS

Informing the public about pinkwashing increases perceptions of misleadingness and support for alcohol policies.

POLICY IMPLICATIONS

Exposing the industry practice of pinkwashing could be a promising theme for campaigns to reduce alcohol consumption and increase support for alcohol policies.

Alcohol industry-sponsored music festivals, alcohol marketing and drinking practices among young Nigerians: Implications for policy

INTRODUCTION

The global alcohol industry sponsors social/music events targeting young people; however, existing literature focuses on Westernised contexts. Given the decline in young people's drinking in many Western countries, it appears that multinational alcohol companies are importing the strategies they have used in high-income countries to the Global South countries like Nigeria to recoup profits. This study aims to examine the Guinness Show- a free one-month annual music festival, alcohol marketing at the festival and the extent to which the event encourages diverse drinking practices among its attendees.

METHODS

We observed the music festival before collecting data through 53 interviews and 3 focus groups (N = 26). Data were analysed to generate themes with the aid of NVivo 12 software.

FINDINGS

Over 6000 participants attend the Guinness Show daily, and participants gave detailed descriptions of the music festival, alcohol marketing activities that occur in it and the drinking practices of attendees, indicating that they were highly knowledgeable of the event. The Guinness Show attracts famous music artistes and other entertainers. Therefore, young people attend to see them perform free of charge. However, diverse alcohol promotions (e.g., quantity deals, low prices, giveaways) that happen daily, the strategic use of young women as 'beer promoters', and the pleasure the event induces by fusing music/entertainment into alcogenic environments, encourage drinking and drunkenness. All the attendees drank alcohol, and some engaged in impulse buying, while many consumed excessively due to promotions (e.g., buy-two-get-one free), which facilitated intoxication and the loss of control.

CONCLUSIONS

Guinness Nigeria organises the event for strategic brand communication, generating brand capital, and encouraging alcohol purchases and consumption among young people. Policymakers should reconsider self-regulation and implement national alcohol control policies and other public health interventions to restrain the alcohol industry from sponsoring such events.

The Pitfalls of Ascribing Moral Agency to Corporations: Public Obligation and Political and Social Contexts in the Commercial Determinants of Health

Policy Points Government and civil society should be held more accountable for creating food and beverage regulatory policies rather than assigning moral agency to the food and beverage industry. Nutrition policymaking institutions should ensure civil society's ability to design regulatory policy. Government policymaking institutions should be isolated from industry interference.

Addressing the global obesity burden: a gender-responsive approach to changing food environments is needed

Obesity is a leading cause of death and disability globally. There is a higher proportion of women living with obesity than men, with differences in prevalence rates between women and men particularly staggering in low- and middle-income countries. The food environments that most people live in have been defined as 'obesogenic', characterised by easy access to energy dense, highly palatable foods with poor nutritional value. There is an established need to intervene to change food environments to prevent obesity. However, minimal successes are evident with no country set to meet the WHO goal of reducing obesity prevalence to 2010 numbers by 2025. In this review, we provide a narrative around the sex (biological)- and gender (sociocultural)-related considerations for the relationship between nutrition, interactions with the food environment and obesity risk. We provide an argument that there are gendered responses to food environments that place women at a higher risk of obesity particularly in relation to food industry influences, due to gendered roles and responsibilities in relation to paid and unpaid labour, and due to specific food security threats. This review concludes with hypotheses for addressing the obesity burden in a gender-responsive manner, with a call for gender equity to be a key component of the development, implementation and monitoring of obesity prevention focused policies going forward.

Investigating the impact of 'dark nudges' on drinking intentions: A between groups, randomized and online experimental study

OBJECTIVES

This study explored how 'dark nudges' (tactics used in alcohol industry-funded responsible drinking campaigns) affect drinking intentions, perceived source credibility and whether individual differences in perceptions of prototypical drinkers moderated these effects.

DESIGN

Two 2 × 2 between-groups online experimental studies.

METHODS

Study 1 (N = 164) presented three alcohol health messages per condition, comprising social norm (healthy/unhealthy ("dark nudge")) by frame (loss/gain). Study 2 (N = 229) presented one message per condition, comprising cancer causality (single cause/multiple causes (dark nudge)) by funding disclosure (disclosure/non-disclosure (dark nudge)). Outcomes were drinking intentions and perceived source credibility. Exploratory analyses considered prototype perceptions as a between-subjects moderator.

RESULTS

No significant effects of message frame, social norm, fundi or multiple cancer causality arguments on drinking intentions were found. In Study 2, in the dark nudge multiple cancer causality conditions, perceived source credibility was high when funding was undisclosed, but significantly lower when it was disclosed. Exploratory analyses suggested effects were moderated by prototype similarity. In Study 1, higher perceived similarity to a heavy drinker and lower perceived similarity to a responsible drinker were associated with higher drinking intentions in the unhealthy norm/gain frame condition, but lower drinking intentions in the other conditions.

CONCLUSIONS

Framing, social norm, funding disclosure and multiple causality manipulations as tested in this study did not exert a dark nudge effect on drinking intentions. However, the exploratory analyses suggest it could be hypothesised that the types of messages used in alcohol industry-funded responsible drinking campaigns may result in greater drinking intentions among those who identify more as heavy drinkers and less as responsible drinkers. Perceived prototype similarity may be an important moderator of the impact of alcohol health messages that warrants further research. Study 2 suggests disclosure of industry funding guides judgements of the credibility of sources of misleading messages about alcohol and cancer.

Online commentaries of the sugar-sweetened beverages tax in Malaysia: Content analysis

INTRODUCTION

Implementing taxes on sugary drinks, or SSBs, has been a controversial topic in many countries, including Malaysia. This study aimed to examine how Malaysian Facebook users responded to the announcement and implementation of the SSBs tax through netnography.

METHODS

This cross-sectional study employed qualitative and quantitative methods and used an inductive approach and thematic content analysis to analyze online commentaries on news articles published on popular online news portals from November 2018 to August 2019. Data was collected by downloading the commentaries onto Microsoft Word and importing them into NVivo.

RESULTS

Of the commentaries analyzed, 60.9% rejected the SSBs tax, and 39.1% favored it. No association was found between the online news articles and the slants of the commentaries.

CONCLUSION

The results of this study demonstrate a clear divide in public opinion regarding the SSBs tax in Malaysia, with many online readers expressing opposition to the tax despite evidence of the harmful effects of sugar presented in the articles they are commenting on. These findings have implications for policymakers and public health advocates seeking to implement similar taxes in the future.

Public awareness of the alcohol-cancer link in the EU and UK: a scoping review

BACKGROUND

Alcohol increases cancer risk, but less is known about public awareness of this link. This scoping review summarizes recent findings on the public awareness of alcohol as a cancer risk factor in European Union and UK.

METHODS

Four databases (Web of Science, MEDLINE, PsycInfo, CINAHL) were searched for papers containing data on awareness of alcohol as cancer risk factor in EU or UK published between January 2017 and December 2022, and complemented with grey literature searches.

RESULTS

In total, 45 studies were included covering 18 EU countries (Austria, Belgium, Cyprus, Czechia, Denmark, Finland, France, Germany, Hungary, Ireland, Italy, Netherlands, Poland, Romania, Slovakia, Slovenia, Spain, Sweden) and UK, presenting data collected between 2009 and 2022. Studies covered general population (17 studied a nationally representative sample), women, health professionals, patients and young people. Awareness of alcohol causing cancer in general was higher and studied more often than awareness of alcohol's impact on specific cancers. Among the EU general population, awareness of the link between alcohol and breast cancer ranged between 10% and 20%, head and neck cancer 15-25%, colorectal and oesophagus cancer 15-45% and liver cancer 40%. Awareness was higher among young people and specialized health professions and lower among women (the latter specifically for the breast cancer).

CONCLUSIONS

While awareness rates varied depending on the exact question wording, many studies showed low awareness of the alcohol-cancer link, especially for specific types such as breast and colon cancer. Public should be better informed about alcohol consumption-related cancer risk.

Under the influence: system-level effects of alcohol industry-funded health information organizations

There is now an established body of evidence that the alcohol industry seeks to obstruct public health policies that could affect the availability, affordability or marketing of alcohol. In parallel, the alcohol industry is active in funding corporate social responsibility initiatives, with a particular focus on 'responsible drinking' campaigns, often facilitated by national-level charities established and/or funded by the alcohol industry and associated organizations. While evidence continues to grow regarding biases in the content produced by such health information organizations, they remain active in partnerships with government health departments on national health promotion campaigns and provide a range of health-related information to the public, community organizations and schools. To understand the implications of such access for policymakers, researchers and the public, there is a need to consider the wider, system-level influences of such organizations and their place in wider alcohol industry strategies. In this article, we describe evolving evidence of the direct and indirect strategic effects of such organizations and demonstrate how they serve key roles in the alcohol industry through their existence, content, partnerships and public profiles. We end by considering the implications for how we conceptualize charities established or funded (entirely or partly) by harmful commodity industries, and to what extent current conflicts of interest guidelines are sufficiently effective.

The symbolic consumption processes associated with 'low-calorie' and 'low-sugar' alcohol products and Australian women

The influence of commercial actors, practices and processes on the health and wellbeing of women is still not well understood. The alcohol industry has developed a range of products to appeal to new 'health conscious' markets, such as 'low-calorie' and 'low-sugar' products. While these products may have specific appeal for women, there has been little in-depth research that has sought to understand how women conceptualize these products and the range of symbolic meanings that women associate with these products. An online qualitatively led survey was conducted with n = 497 Australian women who had consumed alcohol in the last year. Questions related to the reasons for and influences on alcohol use, the purchasing of 'low-calorie' or 'low-sugar' products and the influence that these products might have on women's alcohol use. Data were interpreted using reflexive thematic analysis. Women consumed alcohol to relax, cope with everyday stressors and because of the alignment with social practices and social connection. Women perceived that these products provided a healthier alternative to traditional alcohol products and that they aligned with women's values relating to weight and the thin ideal. Some women were concerned that these products could increase alcohol consumption by reducing the perceptions of risk associated with alcohol. Policy consideration is needed to address how product claims and attributes may influence population groups' interpretations of the risks and benefits of these alcohol products, including the illusion that these products have protective potential and are better for overall health and wellbeing.

Assessing the impact of providing digital product information on the health risks of alcoholic beverages to the consumer at point of sale: A pilot study

INTRODUCTION

There is an ongoing policy debate in the European Union regarding the best method of providing information to consumers on the health risks of alcohol use. One of the proposed channels is via the provision of QR codes. This study tested the usage rate of QR codes placed on point-of-sale signs in a supermarket in Barcelona, Catalonia over a 1-week period.

METHODS

Nine banners with beverage-specific health warnings in large text were prominently displayed in the alcohol section of a supermarket. Each banner provided a QR code of relatively large image size that linked to a government website providing further information on alcohol-related harms. A comparison was made between the number of visits to the website and the number of customers in the supermarket (number of unique sales receipts) in a single week.

RESULTS

Only 6 out of 7079 customers scanned the QR code during the week, corresponding to a usage rate of 0.085%, less than 1 per 1000. The usage rate was 2.6 per 1000 among those who purchased alcohol.

DISCUSSION AND CONCLUSIONS

Despite the availability of prominently displayed QR codes, the overwhelming majority of customers did not make use of the QR codes to obtain further information on alcohol-related harms. This corroborates the results from other studies investigating customers' use of QR codes to obtain additional product information. Based on the current evidence, providing online access to information through QR codes will likely not reach a significant portion of consumers.

Corporate social and community-oriented support by UK food retailers: a documentary review and typology of actions towards community wellbeing

AIM

This article provides a comprehensive exploration of the varied Corporate Social Responsibility (CSR) actions in relation to supporting communities reported by the UK's leading food retailers. Findings are discussed against a backdrop of enduring inequalities, exacerbated by the on-going global Coronavirus pandemic, with actions considered for their potential contribution to community-based approaches to addressing local wellbeing and inequalities.

METHOD

This article presents the structure and key characteristics of community-oriented CSR in food retailing in the UK. A thematic analysis of comprehensive documentary evidence from the 11 principle UK food retailers was conducted, drawing on asset-based frameworks of community-centred actions towards wellbeing.

FINDINGS

The findings suggest an increasing acknowledgement in food retail that local community is of key importance. Initiatives were categorised according to a typology, comprising national partnerships, local store-based funding and support actions, targeted programmes on healthy lifestyles or employability, and changes to store operations, in the favour of priority groups, prompted by the pandemic.

CONCLUSION

The article combines an up to date overview of community-focused CSR agendas and support by food retailers at a time of significant economic and social challenge for the UK. It highlights the potential of the sector to contribute more strategically to reducing inequalities and supporting community wellbeing, alongside statutory and voluntary sector partners.

Influencing and implementing mandatory alcohol pregnancy warning labels in Australia and New Zealand

Alcohol labelling laws and policy are contentious and highly politicized. Very few countries have been able to implement health warnings on alcohol labels due to complex legal and governance systems and coordinated industry lobbying. In 2020, Australia and New Zealand implemented a mandatory and evidence-based legal standard for pregnancy warning labels on alcohol products. This article discusses some of the challenges faced in achieving policy change and how these barriers were overcome by public health advocacy groups to build the evidence, counter industry conflicts of interest, consumer test health messages, mobilize community support and gather political support. Reflecting on the decades of ineffective regulation and politicization of this health issue, lessons for other countries include the importance of creating and maintaining relationships with decision makers and regularly updating them with evidence and recommendations, highlighting industry failures and tactics, building broad-based coalitions and sharing lived-experiences.

Evaluating an alcohol harm-reduction campaign advising drinkers of the alcohol-cancer link

INTRODUCTION

Public awareness of the alcohol-cancer link is low. Provision of this information could reduce alcohol consumption and related harms. The Spread campaign is a multi-media education campaign implemented in Western Australia to inform people about the carcinogenic properties of alcohol and associated harms. The aims of the present study were to (i) examine attitudinal and behavioural outcomes of the Spread campaign and (ii) identify demographic and drinking status factors associated with enactment of harm-reduction behaviours resulting from exposure.

METHOD

A cross sectional survey of Western Australian drinkers (consumed alcohol at least a few times in the previous 12 months, n = 760) examined campaign recognition, campaign perceptions, and behaviours resulting from campaign exposure. Chi-square analyses and a generalised linear model were used to identify demographic and alcohol-related factors associated with behavioural outcomes.

RESULTS

Around two-thirds of respondents recognised the campaign (65%), and of these, 22% reported successfully reducing how often or how much they drank due to seeing the campaign. Three quarters (73%) of all respondents considered the campaign message about the alcohol-cancer link to be believable. Respondents drinking at levels above the Australian guideline were less likely to have positive perceptions of the campaign than those complying with the guideline, but were more likely to report enacting the assessed harm-reduction behaviours as a result of campaign exposure.

DISCUSSION AND CONCLUSION

The results suggest that provision of information about the alcohol-cancer link has the potential to motivate reduced alcohol consumption. Implementing such campaigns could constitute an effective alcohol harm-reduction strategy.

Conceptualising the commercial determinants of suicide: broadening the lens on suicide and self-harm prevention

Suicide is preventable, yet, in many settings, robust suicide prevention strategies have not been implemented. Although a commercial determinants of health lens is increasingly being applied to industries important to the field of suicide prevention, the interplay between the vested interests of commercial actors and suicide has received little attention. There is a need to shift attention to the causes of the causes, directing more focus to the ways that commercial determinants influence suicide and shape suicide prevention strategies. Such a shift in perspective, with an evidence base and precedents to draw upon, has transformative potential for research and policy agendas dedicated to understanding and addressing upstream modifiable determinants of suicide and self-harm. We propose a framework intended to help guide efforts to conceptualise, research, and address the commercial determinants of suicide and their inequitable distribution. We hope these ideas and lines of inquiry help to catalyse connections between disciplines and open further debate and discussion as to how to take such an agenda forward.

Exploring correlates of support for restricting breast cancer awareness marketing on alcohol containers among women

BACKGROUND

Although alcohol consumption increases breast cancer risk, some alcohol products include breast cancer awareness marketing (i.e., pink ribbons) on alcohol containers, which poses a contradiction. Some researchers and advocacy groups have called for restrictions on use of the pink ribbon and other breast cancer awareness marketing on alcohol products. This exploratory study aimed to describe individual and behavioral correlates (age, knowledge, attitudes, purchase intention) of reported support for potential policy restrictions of pink ribbon labeling on alcohol containers.

METHODS

The study sample was drawn from the Prolific crowd-sourced research platform in September 2020. Eligible participants included U.S. women aged 21+ years. The primary outcome was policy position for restrictions on pink ribbon labeling on alcohol containers, coded as support, neutral, or oppose. The association between pink ribbon labeling attitudes and support or opposition (vs neutral) was examined using multinomial logistic regression. Covariates were 1) knowledge of the alcohol-cancer link; 2) likelihood of buying an alcohol product with pink ribbon labeling; and 3) age. Models were used to calculate adjusted predicted probabilities for support, oppose, and neutral.

RESULTS

The analytic sample included 511 women. Overall, 46% of women opposed, 34% were neutral, and 20% supported restricting pink ribbon labeling on alcohol containers. Controlling for all covariates, women who reported that wine increases cancer risk had the highest probability of opposing restrictions on pink ribbon labeling (56.4% [95%CI: 48.1%-64.8%]). Women who reported wine had no effect on cancer risk had the highest probability of being neutral about restrictions on pink ribbon labeling (45.5% [95% CI: 35.7%-55.3%]). Across levels of knowledge about the alcohol-cancer risk association, as favorable attitudes toward pink ribbon labeling increased, the probability of policy opposition increased and the probability of being policy neutral decreased.

CONCLUSION

Findings from this study suggest women's favorable attitudes toward pink ribbon labeling on alcohol containers are a stronger predictor of support or opposition for restrictions on pink ribbon labeling than knowledge of the alcohol-cancer link. Future research could examine whether pink ribbon labeling may interact with potential or current health warnings on alcohol containers.

Distilling the distillers: examining the political activities of the Distilled Spirits Council of the United States

BACKGROUND

Understanding of the alcohol industry's means of influencing public policy is increasingly well established. Less is known, however, about the specific organisations that lead the political strategies of the alcohol industry. To fill this gap, this paper explores the Distilled Spirits Council of the United States (DISCUS), a key trade association in the United States (US), which also operates internationally.

METHODS

This study explores how DISCUS is organised and the main political activities it pursues to advance its policy interests. The study triangulates data from several sources, including DISCUS documents, as well as federal lobbying and election expenditure data.

RESULTS

This study demonstrates that DISCUS is a key political actor in the US and global alcohol policymaking context. There are identifiable strategies used by DISCUS to shape alcohol policy debates, including framing and lobbying. We also find key synergies between these strategies and identify their operation at varying levels of policy decision-making.

CONCLUSIONS

Generating more secure inferences about the nature of the alcohol industry's efforts to advance its interests, and with what success and at what cost, requires researchers to investigate other trade associations in different contexts, and use other data sources.

Using the Pan American Health Organization digital conversational agent to educate the public on alcohol use and health: a preliminary analysis

BACKGROUND

Background: There is widespread misinformation about the effects of alcohol consumption on health, which were amplified during the COVID-19 pandemic through social media and internet channels. Chatbots and conversational agents became an important piece of the WHO response during the COVID-19 pandemic to quickly disseminate evidence-based information to the public, related to COVID-19 and tobacco. PAHO seized the opportunity to develop a conversational agent to talk about alcohol related topics and therefore complement traditional forms of health education which have been promoted in the past.

OBJECTIVE

Objective: To develop and deploy a digital conversational agent to interact to an unlimited number of users, 24 hours a day, anonymously, about alcohol topics, in several languages, including on ways to reduce risks from drinking, at no cost and accessible through various devices.

METHODS

Methods: The content development was based on the latest scientific evidence on alcohol impacts on health, social norms about drinking and data from the World Health Organization and PAHO. The agent itself was developed through a non-exclusive license agreement with a private company and included Google Digital Flow ES as the natural language processing software, and AWS for cloud services. Another company was contracted to program all the conversations, following the technical advice of PAHO staff.

RESULTS

Results: The conversational agent was named Pahola and it was deployed on November 19, 2021, through the PAHO website after a launch event with high publicity. No identifiable data were used and all interactions were anonymous, and therefore this was considered not research with human subjects. Pahola speaks in English, Spanish and Portuguese, interacts anonymously to a potential infinite number of users through various digital devices. Users were required to accept terms and conditions to enable access to their camera and microphone to interact with Pahola. Pahola attracted good attention from the media, reached 1.6 million people, leading to 236,000 clicks on its landing page, mostly through mobile devices. Only 1,532 users had a conversation after clicking to talk to Pahola. The average time users spent talking to Pahola was five minutes. Major dropouts were observed in different steps of the conversation flow. Some questions asked by users were not anticipated during programming and could not be answered.

CONCLUSIONS

Our findings showed several limitations to using a conversational agent for alcohol education to the general public. Improvements are needed to expand the content to make it more meaningful and engaging to the public. The potential of chatbots to educate the public on alcohol related topics seems enormous but requires a long-term investment of resources and research to be useful and reach many more people.

CLINICALTRIAL

The emperor has no clothes: a synthesis of findings from the Transformative Research on the Alcohol industry, Policy and Science research programme

BACKGROUND AND AIMS

The Transformative Research on the Alcohol industry, Policy and Science (TRAPS) programme investigates the alcohol industry, with an innovative focus on public health sciences. TRAPS adds to an under-developed literature on the study of alcohol industry influence on alcohol science and policymaking. This paper provides a synthesis of TRAPS findings to inform future research.

METHODS

We conducted an interpretive review of TRAPS research findings across its component studies, identifying and integrating the key contributions made by individual studies to the literature on alcohol policymaking and science, and identifying areas where TRAPS progress was limited. This produced themes for consideration in future research agenda setting.

RESULTS

TRAPS explored the interventions of the alcohol industry in science and policymaking using various methods, including systematic reviews and qualitative interviews. These studies identified the industry's activities in several key areas, such as the debate over minimum unit pricing (MUP), cardiovascular health and alcohol research and a long-running public relations programme developed in close connection with the tobacco industry. Collectively, the research shows that alcohol policymaking has involved a contest between the research community and alcohol industry actors about whether and how science should be used to inform policy.

CONCLUSIONS

The TRAPS programme demonstrates the need for a transdisciplinary approach to understand the nature of corporate political activity; the crucial role industry involvement in science plays in the development of corporate political power; and how public health actors have successfully overcome industry opposition to evidence-based policies. Advances in alcohol policy should be underpinned by strong, reflexive public health sciences, alert to the role of industry in the alcohol harms under study and thorough in their investigation of the alcohol industry as an object of study in itself.

Adolescent brain maturation and the neuropathological effects of binge drinking: A critical review

Adolescence is a transitional stage marked by continued brain development. This period is accompanied by physical and neurochemical modifications in the shape and function of the hippocampus, prefrontal cortex, and other limbic system structures. Brain maturation during adolescence, which is typically governed by intrinsic factors, can be dramatically altered by environmental influences such as drugs and alcohol. Unlike many other addictive substances, binge drinking is very common and normative among teenagers and young adults. This repeated pattern of excessive alcohol consumption in adolescents has been shown to cause behavioral changes and neurocognitive impairments that include increased anxiety, risky decision-making, and learning deficits, which could lead to the development of alcohol use disorder (AUD). This manuscript highlights factors that lead to adolescent binge drinking, discusses maturational changes that occur in an adolescent's brain, and then evaluates the effect of adolescent alcohol consumption on brain structure, function, and neurocognitive abilities in both human studies and animal models. The impact of gender/sex and COVID-19 are briefly discussed. Understanding the factors that promote the onset of adolescent binge drinking and its undesirable consequences could serve as a catalyst for developing therapeutic agents that would decrease or eradicate the damaging effects of alcohol on an adolescent brain.

Moving beyond the "Health Halo" of Alcohol: What Will it Take to Achieve Population Awareness of the Cancer Risks of Alcohol?

We discuss the implications of Seidenberg and colleagues' report confirming low levels of accurate awareness of the cancer harms associated with alcohol use, including wine, beer, and liquor consumption. The authors propose that academic and lay messaging describing consumption of wine and other forms of alcohol as reducing heart disease risk has created generalized beliefs about the health benefits of drinking alcohol. This "health halo" surrounding alcohol consumption leads the public to overgeneralize alcohol health benefits to other diseases, including cancer. We discuss the need to address high levels of perceived risk uncertainty to help the public distinguish between the impact of alcohol on heart disease versus cancer, and to overcome other barriers to including alcohol use reduction as a cancer prevention strategy. Given recent increases in U.S. population drinking rates, as well as morbidity and mortality associated with alcohol use, the time is right to marshal multilevel efforts to educate the public regarding the fact that alcohol is carcinogenic. If successful, these efforts will have multiple downstream benefits, including the ability of the lay public to use the most up-to-date scientific evidence to make informed decisions about whether, and how much, to engage in a risky behavior. See related article by Seidenberg et al., p. 46.

Alcohol Health Warning Labels: A Rapid Review with Action Recommendations

A rapid review of research on health warning labels located on alcohol containers (AWLs) was conducted. Using five search engines (Embase, Medline, Pubmed, Scopus, Psyinfo), 2975 non-duplicate citations were identified between the inception date of the search engine and April 2021. Of those, 382 articles were examined and retrieved. We selected 122 research papers for analysis and narrative information extraction, focusing on population foci, study design, and main outcomes. Research included public opinion studies, surveys of post-AWL implementation, on-line and in-person experiments and real-world quasi-experiments. Many studies focused on the effects of the 1989 United States Alcoholic Beverage Labeling Act on perceptions, intentions and behavior. Others focused on Australia, Canada, the United Kingdom, England or Scotland, Italy and France. There was substantial variation in the design of the studies, ranging from small-scale focus groups to on-line surveys with large samples. Over time, evidence has been emerging on label design components, such as large size, combination of text and image, and specific health messaging, that is likely to have some desired impact on knowledge, awareness of risk and even the drinking behavior of those who see the AWLs. This body of evidence provides guidance to policy-makers, and national and regional authorities, and recommendations are offered for discussion and consideration.

Framings of risk and responsibility in newsprint media coverage of alcohol licensing regulations during the COVID-19 pandemic in England

INTRODUCTION

Licensing is recognised as a World Health Organization (WHO) 'best buy' for reducing alcohol harms. In response to the 2020 COVID-19 outbreak, many countries-imposed restrictions on outlets selling alcohol to reduce virus transmission. In England, while shops selling alcohol were deemed 'essential', multiple restrictions were imposed on licenced outlets such as pubs and bars. Media reporting of licensing restrictions during the pandemic might have shaped public discourses of alcohol risks and responsibilities.

METHODS

This study aimed to understand how alcohol licensing changes in England were framed in newsprint media. Two hundred and fifty-three relevant articles from UK newsprint publications were identified through the Nexis database, published within six time points between March and December 2020 reflecting key changes to licencing in England. Thematic analysis, drawing on framing theory, was conducted to identify 'problems' framed in the reporting of these changes.

RESULTS

Four dominant framings were identified: (i) licensed premises as 'risky' spaces; (ii) problematic drinking practices; (iii) problematic policy responses; and (iv) 'victimisation' of licensed premises. The presence of these framings shifted across the reporting period, but consistently, social disorder was constructed as a key risk relating to licensing changes over health harms from alcohol consumption.

DISCUSSION AND CONCLUSIONS

The analysis shows newsprint media reproduced narratives of 'inevitable' drinking culture and social disorder, but also emphasised expectations for evidence-based policy-making, in the context of licensing during the pandemic. Discourses of dissatisfaction with licensing decisions suggests potential for public health advocacy to push for licensing change to reduce alcohol health harms, in England and internationally.

Search Term Identification Methods for Computational Health Communication: Word Embedding and Network Approach for Health Content on YouTube

Background

Common methods for extracting content in health communication research typically involve using a set of well-established queries, often names of medical procedures or diseases, that are often technical or rarely used in the public discussion of health topics. Although these methods produce high recall (ie, retrieve highly relevant content), they tend to overlook health messages that feature colloquial language and layperson vocabularies on social media. Given how such messages could contain misinformation or obscure content that circumvents official medical concepts, correctly identifying (and analyzing) them is crucial to the study of user-generated health content on social media platforms.

Objective

Health communication scholars would benefit from a retrieval process that goes beyond the use of standard terminologies as search queries. Motivated by this, this study aims to put forward a search term identification method to improve the retrieval of user-generated health content on social media. We focused on cancer screening tests as a subject and YouTube as a platform case study.

Methods

We retrieved YouTube videos using cancer screening procedures (colonoscopy, fecal occult blood test, mammogram, and pap test) as seed queries. We then trained word embedding models using text features from these videos to identify the nearest neighbor terms that are semantically similar to cancer screening tests in colloquial language. Retrieving more YouTube videos from the top neighbor terms, we coded a sample of 150 random videos from each term for relevance. We then used text mining to examine the new content retrieved from these videos and network analysis to inspect the relations between the newly retrieved videos and videos from the seed queries.

Results

The top terms with semantic similarities to cancer screening tests were identified via word embedding models. Text mining analysis showed that the 5 nearest neighbor terms retrieved content that was novel and contextually diverse, beyond the content retrieved from cancer screening concepts alone. Results from network analysis showed that the newly retrieved videos had at least one total degree of connection (sum of indegree and outdegree) with seed videos according to YouTube relatedness measures.

Conclusions

We demonstrated a retrieval technique to improve recall and minimize precision loss, which can be extended to various health topics on YouTube, a popular video-sharing social media platform. We discussed how health communication scholars can apply the technique to inspect the performance of the retrieval strategy before investing human coding resources and outlined suggestions on how such a technique can be extended to other health contexts.

Food as harm reduction during a drinking session: reducing the harm or normalising harmful use of alcohol? A qualitative comparative analysis of alcohol industry and non-alcohol industry-funded guidance

BACKGROUND

The aim of this study was to critically analyse information concerning the relationship between alcohol and food consumption provided via alcohol industry (AI) funded and non-AI-funded health-oriented websites, to determine the role it plays within the alcohol information space, and how this serves the interests of the disseminating organisations.

METHODS

Information on food as a harm reduction measure while drinking alcohol was extracted from 15 AI websites and websites of AI-funded corporate social responsibility (CSR) organisations. As a comparison group, non-AI-funded health websites were also searched (n = 16 websites with food and alcohol-related content). Information was included from webpage content and associated downloadable documents. Critical discourse analysis (CDA) was adopted to allow the texts analysed to be situated within the broader political and social context. Analysis was carried out iteratively, involving continuous comparison within and between websites. Discursive themes were identified by three researchers. Identified discursive elements were discussed to reach a consensus, and a final coding framework was then developed. "Tone" analysis was used to assess whether the overall tone within individual websites was considered to be pro-alcohol consumption, neutral or discouraging of alcohol consumption.

RESULTS

There were some commonalities across AI and non-AI-funded websites, whereby both appeared to normalise alcohol consumption and to encourage use of food as a measure to enable sustained drinking, to avoid drinking in a way that results in short-term harms, and to prevent or "cure" a hangover. The fact that both AI-funded and non-AI-funded organisations shared many of these narratives is particularly concerning. However, a discourse of food and alcohol that served to promote "moderate" drinking as beneficial to health was used exclusively by AI-funded organisations, focusing on special occasions and individual-blaming.

CONCLUSIONS

Alcohol consumption, including heavy and harmful consumption, is frequently normalised within the online information space. Emphasising food consumption with alcohol may have the effect of supporting consumers to drink for longer periods of time. Health professionals and independent health organisations should review the information they provide in light of our findings and challenge why AI-funded organisations, with a major conflict of interest, and a history of health misinformation, are often given the responsibility for disseminating health information to the public.

The Alcohol Industry and Social Responsibility: Links to FASD

Fetal Alcohol Spectrum Disorder is directly linked to the consumption of alcohol during pregnancy. Prevention programs have been targeted at women of childbearing age and vulnerable populations. The beverage alcohol industry (manufacture, marketing, distribution, and retail) is often seen as playing a role in prevention strategies such as health warning labels. In this paper we explore the nature of the relationship between the industry and prevention programming. We consider the place of alcohol in society; the prevalence, social and economic costs of FASD; the ethical notion of alcohol-related harm and then move onto the question of public health partnerships with the industry including the potential conflicts of interests and ethical challenges in such partnerships.

Meat, money and messaging: How the environmental and health harms of red and processed meat consumption are framed by the meat industry

Calls to cut consumption of red and processed meat, in order to protect both human and planetary health, are drawing increased attention from policy actors. This poses a potential threat to meat industry profits. It is well evidenced that producers of other harmful commodities (such as fossil fuels or tobacco) respond with a range of tactics to impede policy action when similarly threatened, including framing the issues at stake in a light more favourable to industry interests. In order to investigate how the meat industry in the UK frames discussions about the environmental and health impacts of red and processed meat consumption, thematic content analysis was performed on documents sourced from the websites of 6 organisations representing the UK meat industry. Across the dataset, four main framings were identified; 'still open for debate', 'most people have no need to worry', 'keep eating meat to be healthy' and 'no need to cut down to be green'. These frames work in conjunction to minimise the perception of harm, whilst also encouraging continued consumption. Messages were constructed using 'classic' framing devices employed by other producers of harmful commodities. These findings are of importance as they provide insight into how debates about food policy may be influenced by meat industry framing of the issues at hand.

Reducing the Power of the Alcohol Industry in Trade and Investment Agreement Negotiations Through Improved Global Governance of Alcohol Comment on "What Generates Attention to Health in Trade Policy-Making? Lessons From Success in Tobacco Control and Access to Medicines: A Qualitative Study of Australia and the (Comprehensive and Progressive) Trans-Pacific Partnership"

The power of the alcohol industry pervades the global governance of alcohol. The influence of the industry is seen in trade and investment treaty negotiations, operating through direct and indirect means. Curbing the influence of the industry is vital to improving the treatment of health issues generally and in trade and investment policy particularly. The World Health Organization (WHO) has an opportunity to start to rein in the power of the industry with its current work on drafting an 'action plan' for 2022-2030 to implement the Global Strategy to Reduce the Harmful Use of Alcohol. The WHO working paper, however, proposes inadequate controls on alcohol industry influence. The WHO proposes 'dialogue' with the industry and allows the industry to take a role with government in public health labelling of alcohol. The public's health will suffer if the WHO does not take a firmer stand against the industry in the 'action plan.'

Manufacturing doubt: Assessing the effects of independent vs industry-sponsored messaging about the harms of fossil fuels, smoking, alcohol, and sugar sweetened beverages

Background Manufacturers of harmful products engage in misinformation tactics long employed by the tobacco industry to emphasize uncertainty about scientific evidence and deflect negative attention from their products. This study assessed the effects of one type of tactic, the use of "alternative causation" arguments, on public understanding. Methods In five trials (one for each industry) anonymized Qualtrics panel respondents were randomized to receive a message on the risk in question from one of four industry sponsored organizations (exposure), or from one of four independent organizations (control), on risks related to alcohol, tobacco, fossil fuel and sugar sweetened beverages. Logistic regression models were used to evaluate the effect of industry arguments about uncertainty on the primary outcome of public certainty about product risk, adjusting for age, gender and education. The results from all five trials were pooled in a random-effects meta-analysis. Findings In total, n=3284 respondents were exposed to industry-sponsored messaging about product-related risks, compared to n=3297 exposed to non-industry messages. Across all industries, exposure to industry-sponsored messages led to greater reported uncertainty or false certainty about risk, compared to non-industry messages [Summary odds ratio (OR) 1·60, confidence interval (CI) 1·28-1·99]. The effect was greater among those who self-rated as not/slightly knowledgeable (OR 2·24, CI 1·61-3·12), or moderately knowledgeable (OR 1·85, CI 1·38-2·48) compared to those very/extremely knowledgeable (OR 1·28, CI 1·03-1·60). Conclusions This study demonstrates that exposure to industry sponsored messages which appear intended to downplay risk significantly increases uncertainty or false certainty, with the effect being greater in less knowledgeable participants.

Distilling the curriculum: An analysis of alcohol industry-funded school-based youth education programmes

BACKGROUND AND AIM

For decades, corporations such as the tobacco and fossil fuel industries have used youth education programmes and schools to disseminate discourses, ideas and values favourable to their positions, and to pre-empt regulation that threatens profits. However, there is no systematic research into alcohol industry-funded youth education programmes. This article serves to address this important gap in the literature.

METHODS

Using a discourse theoretical approach informed by poststructural discourse theory and critical discourse analysis, we analysed teaching materials from three school-based youth education initiatives which focus on alcohol consumption and health harms: Drinkaware for Education, The Smashed Project (funded by Diageo), and Talk About Alcohol (Alcohol Education Trust). These materials, some of which are disseminated internationally, are provided to schools through intermediary bodies in receipt of alcohol industry funding.

FINDINGS

The analysis found that these materials drew from and presented discourses of personal responsibility, moderate alcohol consumption, and involved a narrowing of the problem definition and causes. The locus of the problem is located by the discourses within individuals including youth, with causes of youth alcohol consumption repeatedly presented as peer pressure and 'poor choices', with little or no mention of alcohol industry marketing or other practices. All programmes promoted familiarisation and normalisation of alcohol as a 'normal' adult consumer product which children must learn about and master how to use responsibly when older. The discourses constructed in these materials closely align with those of other alcohol industry corporate social responsibility discourses which employ selective presentation of harms, including misinformation about cancer, and ambiguous terms such as "responsible drinking". Furthermore, the role of alcohol price, availability and access, and the impacts of alcohol and the industry on inequities were not articulated within the discourses. The research was limited to an analysis of teaching materials and further research is needed to explore their impact on youth, teachers and wider discourses and social norms.

CONCLUSION

Alcohol industry-sponsored youth education programmes serve industry interests and promote moderate consumption while purportedly educating children about harms and influences of alcohol use. There are considerable conflicts of interest in the delivery of alcohol education programmes funded by the alcohol industry and intermediary bodies in receipt of such funding. Alcohol education materials should be developed independent from industry, including funding, and should empower children and young people to understand and think critically about alcohol, including harms and drivers of consumption, and effective interventions needed to protect them and others from alcohol-related harms. Independent organisations can use this analysis to critique their materials to strengthen alignment with meeting student and public health interests. The ongoing exposure of children and young people to such conflicted and misleading materials needs urgent attention from policymakers, practitioners, teachers and parents, and resources dependent on industry support should cease being used in schools.

Alcohol and Head and Neck Cancer: Updates on the Role of Oxidative Stress, Genetic, Epigenetics, Oral Microbiota, Antioxidants, and Alkylating Agents

Head and neck cancer (HNC) concerns more than 890,000 patients worldwide annually and is associated with the advanced stage at presentation and heavy outcomes. Alcohol drinking, together with tobacco smoking, and human papillomavirus infection are the main recognized risk factors. The tumorigenesis of HNC represents an intricate sequential process that implicates a gradual acquisition of genetic and epigenetics alterations targeting crucial pathways regulating cell growth, motility, and stromal interactions. Tumor microenvironment and growth factors also play a major role in HNC. Alcohol toxicity is caused both directly by ethanol and indirectly by its metabolic products, with the involvement of the oral microbiota and oxidative stress; alcohol might enhance the exposure of epithelial cells to carcinogens, causing epigenetic modifications, DNA damage, and inaccurate DNA repair with the formation of DNA adducts. Long-term markers of alcohol consumption, especially those detected in the hair, may provide crucial information on the real alcohol drinking of HNC patients. Strategies for prevention could include food supplements as polyphenols, and alkylating drugs as therapy that play a key role in HNC management. Indeed, polyphenols throughout their antioxidant and anti-inflammatory actions may counteract or limit the toxic effect of alcohol whereas alkylating agents inhibiting cancer cells' growth could reduce the carcinogenic damage induced by alcohol. Despite the established association between alcohol and HNC, a concerning pattern of alcohol consumption in survivors of HNC has been shown. It is of primary importance to increase the awareness of cancer risks associated with alcohol consumption, both in oncologic patients and the general population, to provide advice for reducing HNC prevalence and complications.

Alcohol and Cancer: Existing Knowledge and Evidence Gaps across the Cancer Continuum

Alcoholic beverages are carcinogenic to humans. Globally, an estimated 4.1% of new cancer cases in 2020 were attributable to alcoholic beverages. However, the full cancer burden due to alcohol is uncertain because for many cancer (sub)types, associations remain inconclusive. Additionally, associations of consumption with therapeutic response, disease progression, and long-term cancer outcomes are not fully understood, public awareness of the alcohol-cancer link is low, and the interrelationships of alcohol control regulations and cancer risk are unclear. In December 2020, the U.S. NCI convened a workshop and public webinar that brought together a panel of scientific experts to review what is known about and identify knowledge gaps regarding alcohol and cancer. Examples of gaps identified include: (i) associations of alcohol consumption patterns across the life course with cancer risk; (ii) alcohol's systemic carcinogenic effects; (iii) alcohol's influence on treatment efficacy, patient-reported outcomes, and long-term prognosis; (iv) communication strategies to increase awareness of the alcohol-cancer link; and (v) the impact of alcohol control policies to reduce consumption on cancer incidence and mortality. Interdisciplinary research and implementation efforts are needed to increase relevant knowledge, and to develop effective interventions focused on improving awareness, and reducing harmful consumption to decrease the alcohol-related cancer burden.

Analysis of the accuracy and completeness of cardiovascular health information on alcohol industry-funded websites

BACKGROUND

The Alcohol Industry (AI), and the Social Aspects/Public Relations Organisations (SAPRO) it funds, has been shown to mis-represent the risk of alcohol with respect to cancer and pregnancy. It is theorized that the AI would position alcohol as 'heart healthy' to further undermine public perceptions of risks from drinking.

METHODS

A comparative analysis (including content, thematic and context analyses) of cardiovascular health information published on the websites of AI-funded (n = 18, such as 'Drinkaware' and the 'Distilled Spirits Council of the US') and non-AI-funded (n = 18, such as 'NHS.uk') organizations based in multiple high-income jurisdictions.

RESULTS

Websites of non-industry-funded health organizations were more likely than AI/SAPRO websites to label alcohol as a risk factor for a range of important cardiovascular diseases (such as myocardial infarction, congestive cardiac failure, hypertension and stroke). Conversely, AI/SAPRO websites were more likely to suggest alcohol was protective in the development of some heart conditions. AI/SAPRO websites frequently referenced the J-shaped curve as proof of benefit from moderate alcohol consumption; suggested a balance between the benefits and harms from drinking; positioned alcohol as consistent with a 'healthy lifestyle'; and framed drinking as a social norm.

CONCLUSIONS

AI-funded health organizations mis-represent the evidence on cardiovascular effects of moderate alcohol consumption. Healthcare professionals should appreciate the role of funding source in biasing content, and exercise caution when directing patients to content funded by the AI. Tighter regulation of messaging that AI/SAPRO's provide to the public is required, to avoid the dissemination of harmful misinformation.

Applying a complex systems perspective to alcohol consumption and the prevention of alcohol-related harms in the 21st century: a scoping review

BACKGROUND AND AIMS

A complex systems perspective has been advocated to explore multi-faceted factors influencing public health issues, including alcohol consumption and associated harms. This scoping review aimed to identify studies that applied a complex systems perspective to alcohol consumption and the prevention of alcohol-related harms in order to summarize their characteristics and identify evidence gaps.

METHODS

Studies published between January 2000 and September 2020 in English were located by searching for terms synonymous with 'complex systems' and 'alcohol' in the Scopus, MEDLINE, Web of Science and Embase databases, and through handsearching and reference screening of included studies. Data were extracted on each study's aim, country, population, alcohol topic, system levels, funding, theory, methods, data sources, time-frames, system modifications and type of findings produced.

RESULTS

Eighty-seven individual studies and three systematic reviews were identified, the majority of which were conducted in the United States or Australia in the general population, university students or adolescents. Studies explored types and patterns of consumption behaviour and the local environments in which alcohol is consumed. Most studies focused on individual and local interactions and influences, with fewer examples exploring the relationships between these and regional, national and international subsystems. The body of literature is methodologically diverse and includes theory-led approaches, dynamic simulation models and social network analyses. The systematic reviews focused on primary network studies.

CONCLUSIONS

The use of a complex systems perspective has provided a variety of ways of conceptualizing and analyzing alcohol use and harm prevention efforts, but its focus ultimately has remained on predominantly individual- and/or local-level systems. A complex systems perspective represents an opportunity to address this gap by also considering the vertical dimensions that constrain, shape and influence alcohol consumption and related harms, but the literature to date has not fully captured this potential.

Exploring the potential of citizen science for public health through an alcohol advertising case study

Citizen science connects academic researchers with the public through combined efforts in scientific inquiry. The importance of involving impacted populations in health research is well established. However, how to achieve meaningful participation and the methodological impact of citizen science needs further examination. We examined the feasibility of using citizen science to understand the impact of alcohol advertising on Australian women through a breast cancer prevention project. Two hundred and eighty-two ('participants') citizen scientists completed demographic and behavioural questions via an online survey. The research participants moved into the role of citizen scientists by completing the data collection tasks of capturing and classifying images of alcohol advertising they saw online. Interrater reliability tests found high levels of agreement between citizen scientists and academic researchers with the classification of alcohol advertising brand (Kappa = 0.964, p < 0.001) and image type (Kappa = 0.936, p < 0.000). The citizen scientists were women aged 18 and over, with 62% between 35 and 55 years old. The majority were from major cities (78%), had attained a bachelor's degree or higher-level education (62%) and were recruited via email or Facebook (86%). The use of citizen science provided methodological gains through the creation of a unique dataset with higher levels of validity than the existing literature, which employed traditional investigator-driven research methodologies. Citizen science enriched the dataset and provided a powerful methodological vehicle to understand an environmental determinant of health. The study illuminates how public participation benefitted the research process, the challenges and the potential for citizen science to improve public health.

Government Options to Reduce the Impact of Alcohol on Human Health: Obstacles to Effective Policy Implementation

Evidence for effective government policies to reduce exposure to alcohol's carcinogenic and hepatoxic effects has strengthened in recent decades. Policies with the strongest evidence involve reducing the affordability, availability and cultural acceptability of alcohol. However, policies that reduce population consumption compete with powerful commercial vested interests. This paper draws on the Canadian Alcohol Policy Evaluation (CAPE), a formal assessment of effective government action on alcohol across Canadian jurisdictions. It also draws on alcohol policy case studies elsewhere involving attempts to introduce minimum unit pricing and cancer warning labels on alcohol containers. Canadian governments collectively received a failing grade (F) for alcohol policy implementation during the most recent CAPE assessment in 2017. However, had the best practices observed in any one jurisdiction been implemented consistently, Canada would have received an A grade. Resistance to effective alcohol policies is due to (1) lack of public awareness of both need and effectiveness, (2) a lack of government regulatory mechanisms to implement effective policies, (3) alcohol industry lobbying, and (4) a failure from the public health community to promote specific and feasible actions as opposed to general principles, e.g., 'increased prices' or 'reduced affordability'. There is enormous untapped potential in most countries for the implementation of proven strategies to reduce alcohol-related harm. While alcohol policies have weakened in many countries during the COVID-19 pandemic, societies may now also be more accepting of public health-inspired policies with proven effectiveness and potential economic benefits.

Commercial use of evidence in public health policy: a critical assessment of food industry submissions to global-level consultations on non-communicable disease prevention

BACKGROUND

Ultra-processed food industry (UPFI) actors have consistently opposed statutory regulation in health policy debates, including at the WHO. They do so most commonly with claims that regulatory policies do not work, will have negative consequences or that alternatives such as self-regulation work well or better. Underlying this are often assertions that industry is aligned with principles of evidence-based policymaking. In this study, we interrogate if this holds true by exploring the extent and quality of the evidence UPFI respondents employed to support claims around regulatory policy, and how they did this.

METHODS

First, we identified all submissions from organisations who overtly represent UPFI companies to consultations held by the WHO on non-communicable disease policy between 2016 and 2018. Second, we extracted all relevant factual claims made in these submissions and noted if any evidence was referenced in support. Third, we assessed the quality of evidence using independence from UPFI, nature, and publication route as indicators. Lastly, where peer-reviewed research was cited, we examined if the claims made could be justified by the source cited.

RESULTS

Across 26 included consultation responses, factual claims around regulation were made in 18, although only 10 referenced any evidence at all. Of all 114 claims made, 39 pieces of identifiable evidence were cited in support of 56 claims. Of the 39 distinct pieces of evidence, two-thirds were industry-funded or industry-linked, with only 16 externally peer-reviewed. Over half of industry-funded or industry-linked academic articles failed to declare a conflict of interest (COI). Overall, of only six claims which drew on peer-reviewed and independent research, none appropriately represented the source.

DISCUSSION

UPFI respondents made far-reaching claims which were rarely supported by high-quality, independent evidence. This indicates that there may be few, if any, benefits from consulting actors with such a clear COI.