Is Alcohol the New Tobacco?

In 2013, when the Irish Department of Health proposed a series of measures to reduce alcohol use and harm, the country had one of the highest rates of alcohol consumption in the world, at 14 L of pure alcohol per capita per annum.

While that rate fell to 9.9 L per capita in 2023, surveys have found that almost 15% of the population older than 15 years has an alcohol use disorder. The rates are much higher within the 15-24 years age group, at 37% for men and 38% for women.

In 2018, Ireland passed the Public Health Alcohol Act with the goal of reducing alcohol consumption and harm, delaying the initiation of alcohol consumption by children and young people, and regulating the supply and price of alcohol. Many of the 31 recommendations were watered down by the time they became law in 2018. But the labeling requirement made it through unharmed, despite it taking another 4 years for the secondary legislation to pass on the shape, size, and dimension of the label.

From 2026, Ireland will become the first country in the world to legally mandate alcohol producers to provide comprehensive warnings on alcohol products. Beer, wine, and liquor will be required to have a label in red capital letters warning that: “THERE IS A DIRECT LINK BETWEEN ALCOHOL AND FATAL CANCERS” and “DRINKING ALCOHOL CAUSES LIVER CANCER.”

For Sheila Gilheany, PhD, chief executive of Alcohol Action Ireland, the labeling is “a big win” for the 60 organizations that fought hard for it under one umbrella platform, the Alcohol Health Alliance.

“Alcohol is the only substance that is somehow not subject to the same regulations as milk and water; it’s totally unregulated. The labeling is a big win for Ireland and globally, and it’s groundbreaking because it’s comprehensive,” she told Medscape Medical News.

“The consumer has a right to know the risks, but the industry is keen to downplay the risks and pretend that they don’t exist or that they are complex. Enforcing a label takes away a little bit of the marketing power from the industry and puts it back in the hands of the government.”

Labeling is part of a wider package of interventions that Ireland is slowly implementing. For example, since 2018, the country has taken modest steps to restrict alcohol advertising, such as banning advertising within 200 m of schools and playgrounds and on public transport. In response, there has been a proliferation of zero-alcohol marketing.

A Well-Established Link With Little Mention

Almost 40 years ago, the World Health Organization (WHO) concluded that alcohol is carcinogenic to humans and, in the decades since, research has continued to support that conclusion, linking it to multiple cancers including breast, liver, mouth, colon, and throat cancer.

An estimated 740,000 global cancer cases in 2020 were caused by alcohol use, with almost a quarter occurring in Europe. In 2023, the WHO and its corresponding International Agency for Research on Cancer issued a statement saying: “There is also clear evidence of an increased risk of cancer from light or moderate alcohol drinking. No safe amount of alcohol consumption for cancers can be established.”

Paula O’Brien, PhD, associate professor of law and director of Health Law and Ethics at the University of Melbourne, Melbourne, Australia, told Medscape Medical News that, while the link between alcohol and cancer has long been well established, there is little public knowledge about it.

“The link between alcohol and cancer is very well established, [but] it hasn’t been the subject of health campaigns and hasn’t been a message taken up by governments,” she said.

“Ireland in this sense is taking a big step forward as a government to draw public attention to this. While it’s about changing drinking behavior, the main thing is to get people to think about alcohol differently. I think the big power of labels is that you’re marking something as not safe, you’re starting to change the cultural conversation about the product, and that’s exactly why the industry really opposes labels.”

Ireland’s long campaign to get warning labels on alcohol containers has raised the question: If the link between alcohol and cancer is so well established, why has action been so slow?

Daša Kokole, PhD, a WHO consultant working on alcohol labeling in Europe, told Medscape Medical News that opposition from alcohol producers continues to be a “major impediment” in developing alcohol policies.

The opposition is not always direct, she explained, but can happen via European Union member states at big international forays like within the World Trade Organization. “Studies show that arguments used by member states very often echo the arguments used by the alcohol industry.”

An increasing number of countries are however addressing the cancer risks for alcohol. Earlier this year, the US Surgeon General called for alcoholic beverages to carry warning labels about cancer risks. South Korea has a label warning about liver cancer, but producers have the option of picking alternative labels that do not mention cancer. Canada, Norway, and Thailand are also in the process of developing cancer warnings.

Gilheany points to Norway’s “leading approach to alcohol.” The country does not have any guidelines on the number of alcohol beverages that are deemed low risk because it understands that zero is what they should be striving for and has banned all alcohol advertising.

However, numerous countries continue to publish guidelines on the recommended weekly alcohol guidelines.

In Ireland, the recommended weekly low-risk alcohol guidelines include 11 standard drinks for women and 17 standard drinks for men spread out over the week. The United Kingdom recommends that people drink no more than 14 units spread out over the week.

The mixed messaging amidst pervasive alcohol advertising has made it difficult for doctors to discuss alcohol use, Gilheany explained.

“We have all absorbed industry messaging that this is a risk-free product. About three quarters of Ireland’s population have drunk something in the past year. Doctors are among that group, and I can understand that discussing alcohol with a patient may mean that their own drinking habits might be put under the microscope,” she said.

“At the end of the day, we do not take health advice from the alcohol industry.”

Experts point to the success numerous countries have had in tackling tobacco use — largely attributed to the implementation of plain packaging, health warnings, and tobacco advertising bans — as potential for where alcohol regulations could go. But, while many countries have experienced major declines in tobacco use, vaping has emerged as a major problem. Similarly, there are concerns about the rise of no- and low-alcoholic beverages and whether these products could be a gateway into alcohol consumption.

“With decreasing alcohol consumption in some countries, we should be more vigilant about the alcohol industry focusing on new markets, often in low- and middle-income countries where regulations are often absent and there is greater potential to grow the market,” Kokole said.

Nevertheless, experts agree that Ireland’s alcohol warnings will have impacts way beyond its borders.

“I think that once one country does it, others will follow…research has shown that where there are warnings on alcohol containers, consumers become more open to stricter regulations of the product. Public health is all about incremental steps and how much society can bear in terms of regulation,” O’Brien said.

Gilheany, O’Brien, and Kokole had disclosed no relevant financial relationships.

Sophie Cousins is a global health journalist currently in South Asia.