Alcohol and non-communicable diseases-cancer, heart disease and more

Evidence has strengthened on alcohol's role in cancer, and alcohol is also important in other non-communicable diseases (NCDs). Now the global prevention of NCDs as part of the Millennium Development Goals is the subject of a September 2011 United Nations General Assembly session. Alcohol issues should be included in these new initiatives. The International Agency for Research on Cancer (IARC) is a specialist World Health Organization agency headquartered in Lyon, France. Its signature production is a monograph series in which the evidence concerning the causal role of potential cancer-producing agents is reviewed exhaustively by expert committees. These reviews are sensitive, as they impact upon huge economic interests and have changed laws, but overall IARC is seen as a fair and thorough evaluator. With respect to alcohol, in 1988 [1], IARC had already found that ‘alcoholic beverages are carcinogenic to humans’, its highest classification of causality (Group I). A new review meeting was held in 2007, and the list of cancers impacted by alcohol was enlarged by breast and colorectal cancer [2], in addition to cancers of the oral cavity, pharynx, larynx, oesophagus and liver already on the list. Also, for the pathways, acetaldehyde, the first breakdown product from ethanol as the body metabolizes it, was identified as a Group 1 carcinogen [3,4]. Cancer non-governmental organizations (NGOs) have moved increasingly to bring alcohol within their scope of concern. Thus the Union for International Cancer Control (UICC) includes reducing alcohol consumption in the targets for 2020 in its current World Cancer Declaration ( http://www.uicc.org/declaration), but it is clear that the news has been slow to reach the general public (e.g. [5,6]). Governments and public health NGOs should consider initiating campaigns to inform the public about the risk of various cancers from drinking, and that the risk rises steadily with greater volumes of drinking and thus level of exposure over time. Consumers should also be aware that cessation or reduction of drinking will reduce cancer risks, albeit slowly over time [7]. The experience with tobacco suggests that, apart from their value as consumer education, such campaigns may increase public acceptance of control measures to reduce alcohol-related harms. The issue of public awareness extends beyond cancer. While there has been a substantial increase in public concern about harms from drinking in countries such as the United Kingdom and Australia in recent years, the main emphasis has been on alcohol's role in violence and injury. In Britain, doctors have warned that emphasis is also needed on alcohol's roles in chronic diseases. ‘There is enormous focus on the law and order aspects of drink, but what is being overlooked are the medical consequences’, noted Ian Gilmore of the Royal College of Physicians [8]. Increasingly, this issue is being framed by public health agencies in terms of alcohol's role in ‘non-communicable diseases’ (NCDs). Obviously, NCDs exclude infectious diseases and injuries; less obviously, mental disorders are not included either. For alcohol, the connection with liver disease is well known, but the NCD categories where alcohol is a large contributor to numbers of deaths globally are cancer and heart disease. Of all the alcohol-attributable deaths in 2008, about 15% come from liver cirrhosis, 20% from cancer and 22% from cardiovascular disease [9,10]. When the non-fatal burden is included into the alcohol-attributable disease burden, all three categories share about the same proportion (8–9% each; see [9,10]). This is taking into account only the detrimental effects of alcohol, not considering beneficial effects on ischaemic disease (see [10] for estimates), but both for deaths and burden of disease, the detrimental effect on cardiovascular disease outweighs the beneficial effect by a factor of at least 2.5. In the coming months, the general issue of preventing NCDs will receive substantial and sustained attention at a global level. There is now a global NCD Alliance, formed by four large international NGOs: the UICC, the World Heart Federation, the International Diabetes Federation and the International Union against Tuberculosis and Lung Disease (http://www.ncdalliance.org/node/9). A major thrust of the Alliance is to push international intergovernmental organizations, and particularly the United Nations (UN), into recognizing the importance of NCDs in global health, in low-income as well as high-income societies. The Alliance seeks to amend or transcend the UN's Millenium Development Goals (MDGs) as the main goals guiding international development activities until 2015, so that as much attention is given to NCDs as to infectious diseases. Currently, the MDGs do not mention NCDs, although three of the seven goals are concerned with health (http://www.un.org/millenniumgoals/). To provide a major forum for this discussion, the UN has agreed to convene a ‘high-level meeting’ (involving heads of state) of the UN General Assembly on the prevention and control of NCDs in September 2011 [11]. The conceptual banding together of the NCDs is partly to secure attention to dealing with and preventing these diseases in the context of international development policy. However, there is another factor clearly recognized as binding them together: that to a considerable extent the different major NCDs involve common risk factors. In the sessions on NCDs of the UN's recent annual international NGO Conference in Melbourne [12], alcohol was recognized as one of the four major common risk factors, along with tobacco, diet and lack of physical exercise. To a greater or lesser extent, all four of these risk factors involve substantial conflict between public health interests and market, trade and commercial interests. The initiative to move the debate to the UN General Assembly can be seen as recognition that these are issues which cannot be left only to the World Health Organization (WHO) to deal with. While WHO will continue to play an important role, effective action on the market-involved risk factors needs to reach more broadly across international agencies, including for instance development and trade agencies—just as dealing with alcohol, diet and tobacco requires a ‘whole-of-government’ approach at national and subnational levels. The forthcoming UN high-level meeting will require sustained and focused action in the coming months by those concerned with alcohol policy and reducing harms from drinking, particularly at the international level. The shifting of the NCD discussion to the UN level is an important initiative to support in its own right, one which sets precedents for the future about the handling of preventative health policies at the international level. Given the epidemiological evidence [10], it is also important to ensure that alcohol issues are included and discussed on a prominent basis in the coming discussions and planning concerning the prevention of NCDs. 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