By April Lanux

United States Surgeon General Dr Vivek Murthy has reignited a public health debate by proposing cancer warning labels on alcoholic beverages.

Murthy’s proposal accompanied a new advisory (PDF) highlighting growing evidence linking alcohol consumption to several types of cancer.

Why is this call for warning labels significant, and what does the science say about the risks associated with drinking? Why is the US surgeon general calling for cancer warnings on alcohol bottles now? The current text-only alcohol warning labels, introduced in 1988, address pregnancy risks and impaired driving but fail to mention cancer risks.

Murthy argues these labels are outdated and insufficient given today’s understanding of alcohol’s health impact.

“For individuals, be aware that cancer risk increases as you drink more alcohol,” Murthy wrote on Friday on the social media platform X. “As you consider whether or how much to drink, keep in mind that less is better when it comes to cancer risk.”

How big a cancer risk is alcohol?

The report (PDF) from the surgeon general claims that alcohol consumption in the country is directly linked to approximately 100,000 cancer cases and 20,000 deaths annually. It is also the third leading preventable cause of cancer, following tobacco use and obesity.

Similar findings have also been published in other parts of the world. In 2018, alcohol consumption was linked to 180,000 cancer cases and 92,000 deaths in the World Health Organization’s European region, accounting for 4.2 percent of all cancer cases.

In China, alcohol consumption is linked to 93,596 cancer cases (3.6 percent of total cases) and 78,881 cancer deaths (4.4 percent of total deaths), with men being significantly more affected than women. Women in China typically consume alcohol much less than men.

Other studies have also demonstrated this link. One published in the British Journal of Cancer analysed data from 572 studies involving 486,538 cancer cases, establishing alcohol as a key carcinogen that damages DNA and disrupts cell repair.

Despite these concerns, public awareness remains low — only 45 percent of Americans recognise alcohol (PDF) as a cancer risk, compared with 91 percent for tobacco.

How much alcohol does it take to raise cancer risk?

There is no “safe” level of alcohol consumption when it comes to cancer risk. The WHO and other public health bodies stress that even small amounts can harm health.

For instance, consuming two drinks per day is linked to an increased lifetime risk of developing cancer in about five out of 100 women and three out of 100 men, according to data in US surgeon general advisories. Will the warning curb drinking?

The surgeon general proposes updated warning labels on alcoholic beverages, drawing parallels to cigarette warnings, which studies have linked to reduced smoking rates. However, there are some doubts over how effective text warnings are.

In its push for cigarette packs to carry graphic new health warnings, including pictures, the US Food and Drug Administration (FDA) said in 2019 that existing text warnings on cigarette packs, unchanged since 1984, are deemed ineffective and “virtually invisible”.

However, Timothy Naimi, director of the University of Victoria’s Canadian Institute for Substance Use Research, argues that warning labels serve a fundamental role in promoting transparency and consumer rights, regardless of their immediate effect on public health.

Naimi points out that while other packaged food and beverage products are required to display detailed information — such as ingredients, calorie content, and potential health risks — alcohol labels in North America lack even basic consumer information.

“In most parts of the world there’s just not a lot of information about what people are consuming when it comes to alcohol,” he told Al Jazeera. “People should be allowed to make their own decisions but at least have information that’s accessible.”

Dr Carina Ferreira-Borges, head of alcohol, drugs, and prison health at the WHO’s Europe regional office, says these types of labels play a broader role beyond individual behaviour.

“Alcohol health warning labels are a systemic tool for change — they raise awareness, support broader alcohol policies, and reduce the marketing appeal of alcohol packaging,” she told Al Jazeera.

How else can alcohol consumption be curbed?

Experts say additional regulatory measures would also be key to reducing consumption.

“The single most effective step would be to increase the federal excise tax on alcohol; instead Congress decreased it in 2017, and made that tax cut permanent in 2020,” said David Jernigan, professor of health law, policy and management at the Boston University School of Public Health.

He adds that the greater value of strong labels lies in framing alcohol as “a different and potentially unhealthy product”, which could help pave the way for more effective measures, such as tax increases, to gain legislative support.

The WHO also recommends three “best buys” to reduce alcohol consumption: raising taxes, limiting marketing, and reducing physical availability, such as restricting the number of sellers and their operating hours.

Nordic countries and Thailand have successfully reduced alcohol consumption by increasing taxes and restricting marketing.

How does drinking alcohol affect your health?

Alcohol consumption increases the risk of at least seven cancers, including breast, colon, liver, mouth, throat, oesophageal, and laryngeal cancers, according to the surgeon general.

This happens through several mechanisms such as:

DNA damage: Alcohol metabolises into acetaldehyde, a toxic compound that damages DNA, the molecules that guide how humans grow and function, and prevents cells from repairing themselves.

Hormonal disruption: Alcohol disrupts hormone levels, particularly oestrogen, increasing breast cancer risk.

Absorption of carcinogens: Alcohol heightens the body’s absorption of other carcinogens, such as those found in tobacco.

Does moderate drinking have health benefits?

It is complicated.

One widely-cited 1991 study in The Lancet introduced the “French Paradox”, suggesting that moderate wine consumption might protect against heart disease despite high-fat diets. This was supported by observational studies over the years that associated moderate drinking (one or two drinks per day) with lower cardiovascular disease rates.

However, new studies have largely debunked these claims, revealing problems in earlier research and pointing to the overall risks outweighing any potential benefits.

A 2022 review in JAMA Network Open, which analysed 107 studies, found that previous claims about heart benefits of moderate drinking were based on flawed methodologies, particularly failure to account for “sick quitters” — people who stopped drinking due to health problems.

Naimi acknowledges that debates over whether small amounts of alcohol may benefit heart health have complicated public understanding, but says emerging evidence supports the message that drinking less is better for both heart health and cancer prevention.

“Even if you believe a little bit of alcohol might be good for your heart, it’s only a very small amount — maybe a drink or two a week,” Naimi explains. Beyond very low levels, alcohol increases the risk of heart disease, including heart attacks, high blood pressure, heart failure, and irregular heartbeats.

However, industry voices, like Amanda Berger, senior vice president of science and research of the Distilled Spirits Council, argue that moderate drinking may have some health benefits and that any label updates should reflect a comprehensive review of scientific evidence.

“Many lifestyle choices carry potential risks, and it is the federal government’s role to determine any proposed changes to the warning statements based on the entire body of scientific research,” Berger said in a statement.

Ferreira-Borges, the WHO representative, says the alcohol industry’s responsibility lies not in promoting responsible drinking campaigns, but in reducing the harm caused by their products through regulatory measures and reformulation.

“Alcohol industry claims that alcohol harms are a matter of personal responsibility serve to deny the widespread nature of, and misrepresents who experiences, alcohol harms,” she said. Will Congress approve new labels?

Despite the surgeon general’s advisory and new research on alcohol’s risks, Congress is unlikely to act quickly on updating warning labels.

The last alcohol warning label, which addressed pregnancy risks and impaired driving, was approved nearly 40 years ago.

Called the Alcoholic Beverage Labeling Act of 1988, the bill was introduced in the House in September 1988 and became law within a few months. But it faced significant opposition from the alcohol industry, which argued that the warnings would be ineffective and could hurt business. The resulting labels were also relatively small and lacked detailed health warnings.

Efforts to add a cancer warning would likely face strong opposition from the powerful alcoholic beverage industry, which spends $30m annually lobbying Congress.

Analysts also anticipate pushback.

“This seems to be one of the industry’s greatest fears – that this marks the beginning of their going down the same road as tobacco,” said Jernigan.

Regardless of whether the labels are approved, alcohol use among young Americans is already declining — 49.6 percent of those aged 18-25 reported drinking in the past month in 2023, down from 59.6 percent in 2013, according to the 2023 National Survey on Drug Use and Health. Trends among them indicate a growing preference for non-alcoholic alternatives, with movements like “Dry January” gaining traction, while social shifts may also play a role.

“Young people are starting to drink later in life, which likely affects their later drinking years,” says Jernigan. He adds that other risky behaviours, like teen pregnancy, have also declined as teenagers increasingly connect digitally rather than in person, leading to more time spent alone.