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Alcohol attributable burden of incidence of cancer in eight European countries based on results from prospective cohort study

BMJ 2011; 342 doi: (Published 07 April 2011) Cite this as: BMJ 2011;342:d1584
  1. Madlen Schütze, PhD student1,
  2. Heiner Boeing, professor, department chair1,
  3. Tobias Pischon, scientist, group head1,
  4. Jürgen Rehm, professor, director23,
  5. Tara Kehoe, statistician2,
  6. Gerrit Gmel, data analyst2,
  7. Anja Olsen, scientist4,
  8. Anne M Tjønneland, department head4,
  9. Christina C Dahm, postdoctoral researcher5,
  10. Kim Overvad, professor of epidemiology6,
  11. Françoise Clavel-Chapelon, department head78,
  12. Marie-Christine Boutron-Ruault, senior scientist78,
  13. Antonia Trichopoulou, professor of nutrition9,
  14. Vasiliki Benetou, scientist10,
  15. Dimosthenis Zylis, scientist10,
  16. Rudolf Kaaks, professor, division head11,
  17. Sabine Rohrmann, senior scientist11,
  18. Domenico Palli, unit chief12,
  19. Franco Berrino, department chief13,
  20. Rosario Tumino, director14,
  21. Paolo Vineis, chair of environmental epidemiology, unit chief1528,
  22. Laudina Rodríguez, section chief16,
  23. Antonio Agudo, scientist17,
  24. María-José Sánchez, lecture director18,
  25. Miren Dorronsoro, unit chief19,
  26. Maria-Dolores Chirlaque, scientist2021,
  27. Aurelio Barricarte, department head21,
  28. Petra H Peeters, professor of epidemiology22,
  29. Carla H van Gils, associate professor of epidemiology22,
  30. Kay-Tee Khaw, professor of clinical gerontology23,
  31. Nick Wareham, director24,
  32. Naomi E Allen, scientist25,
  33. Timothy J Key, deputy director25,
  34. Paolo Boffetta, professor, deputy director2627,
  35. Nadia Slimani, scientist, group head26,
  36. Mazda Jenab, scientist26,
  37. Dora Romaguera, research associate28,
  38. Petra A Wark, research fellow28,
  39. Elio Riboli, director28,
  40. Manuela M Bergmann, scientist1
  1. 1Department of Epidemiology, German Institute of Human Nutrition Potsdam-Rehbruecke, 14558 Nuthetal, Germany
  2. 2Centre for Addiction and Mental Health (CAMH), Toronto, Canada
  3. 3Institute for Clinical Psychology and Psychotherapy, TU Dresden, Germany
  4. 4Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen
  5. 5Department of Clinical Epidemiology, Aarhus University Hospital, Aalborg, Denmark
  6. 6Department of Epidemiology, School of Public Health, Aarhus University, Aarhus
  7. 7Centre for Research in Epidemiology and Population Health, U1018, Institut Gustave Roussy, F-94805, Villejuif, France
  8. 8Paris South University, UMRS 1018, F-94805, Villejuif
  9. 9WHO Collaborating Center for Food and Nutrition Policies, Department of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School and Hellenic Health Foundation, Greece
  10. 10WHO Collaborating Centre for Food and Nutrition Policies, Department of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School
  11. 11Division of Cancer Epidemiology, German Cancer Research Centre, Heidelberg, Germany
  12. 12Molecular and Nutritional Epidemiology Unit, Cancer Research and Prevention Institute, Florence, Italy
  13. 13Department of Preventive and Predictive Medicine, Epidemiology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
  14. 14Cancer Registry and Histopathology Unit “Civile M.P.Arezzo” Hospital, ASP 7 Ragusa, Italy
  15. 15Institute for Scientific Interchange Foundation, Turin, Italy
  16. 16Public Health and Participation Directorate, Health and Health Care Services Council, Asturias, Spain
  17. 17Unit of Nutrition, Environment and Cancer, Cancer Epidemiology Research Programme, Catalan Institute of Oncology (IDIBELL), Barcelona, Spain
  18. 18Andalusian School of Public Health, Granada (Spain) and CIBER de Epidemiología y Salud Pública (CIBERESP), Spain
  19. 19Public Health Department of Gipuzkoa and CIBERESP, San Sebastian, Spain
  20. 20Department of Epidemiology, Murcia Regional Health Council, Murcia, Spain
  21. 21CIBER Epidemiología y Salud Pública (CIBERESP), Spain
  22. 22Centre for Health Sciences and Primary Care, University Medical Centre, Utrecht, Netherlands
  23. 23Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
  24. 24MRC Epidemiology Unit, Cambridge
  25. 25Cancer Epidemiology Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford
  26. 26International Agency for Research on Cancer, IARC, Lyon, France
  27. 27Tisch Cancer Institute, Mount Sinai School of Medicine, New York, NY, USA
  28. 28Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London
  1. Correspondence to: M Schütze m.schuetze{at}
  • Accepted 4 January 2011


Objective To compute the burden of cancer attributable to current and former alcohol consumption in eight European countries based on direct relative risk estimates from a cohort study.

Design Combination of prospective cohort study with representative population based data on alcohol exposure.

Setting Eight countries (France, Italy, Spain, United Kingdom, the Netherlands, Greece, Germany, Denmark) participating in the European Prospective Investigation into Cancer and Nutrition (EPIC) study.

Participants 109 118 men and 254 870 women, mainly aged 37-70.

Main outcome measures Hazard rate ratios expressing the relative risk of cancer incidence for former and current alcohol consumption among EPIC participants. Hazard rate ratios combined with representative information on alcohol consumption to calculate alcohol attributable fractions of causally related cancers by country and sex. Partial alcohol attributable fractions for consumption higher than the recommended upper limit (two drinks a day for men with about 24 g alcohol, one for women with about 12 g alcohol) and the estimated total annual number of cases of alcohol attributable cancer.

Results If we assume causality, among men and women, 10% (95% confidence interval 7 to 13%) and 3% (1 to 5%) of the incidence of total cancer was attributable to former and current alcohol consumption in the selected European countries. For selected cancers the figures were 44% (31 to 56%) and 25% (5 to 46%) for upper aerodigestive tract, 33% (11 to 54%) and 18% (−3 to 38%) for liver, 17% (10 to 25%) and 4% (−1 to 10%) for colorectal cancer for men and women, respectively, and 5.0% (2 to 8%) for female breast cancer. A substantial part of the alcohol attributable fraction in 2008 was associated with alcohol consumption higher than the recommended upper limit: 33 037 of 178 578 alcohol related cancer cases in men and 17 470 of 397 043 alcohol related cases in women.

Conclusions In western Europe, an important proportion of cases of cancer can be attributable to alcohol consumption, especially consumption higher than the recommended upper limits. These data support current political efforts to reduce or to abstain from alcohol consumption to reduce the incidence of cancer.


  • Contributors: All authors had full access to all of the data (including statistical reports and tables) and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors MS, MMB, TP, HB, JR, TK, and ER were responsible for study concept and design. HB, TJK, K-TK, PP, AB, MD, M-DC, MJS, LR, AA, PV, RT, FB, DP, AT, RK, FC-C, KO, AMT, AO, CD, M-CB-R, VB, DZ, SR, CvG, NW, MJ, NS, DR, PAW, and ER acquired the data. MS, MMB, HB, TP, JR, TK, GG, PB, NEA, and PP analysed and interpreted the data. MS, MB, TP, HB, JR, TK, NEA, KO, PP, and PB drafted the manuscript, which was critically revised for important intellectual content by all the authors. MS, JR, TK, GG, TP, and MMB were responsible for the statistical analysis. MMB, JR, and HB supervised the study. MS is guarantor.

  • Funding: The work was performed (partly) within the coordinated action EPIC (SP23-CT-2005-006438), which has received research funding from the Community’s Sixth Framework Programme, as well as by the “Europe Against Cancer” Programme of the European Commission (SANCO); Deutsche Krebshilfe; German Cancer Research Center; German Federal Ministry of Education and Research; Danish Cancer Society; Health Research Fund (FIS) of the Spanish Ministry of Health (grant No: Network RCESP C03/09); Spanish Regional Governments of Andalucia, Asturias, Basque Country, Murcia and Navarra; ISCIII, Red de Centros RETIC(RD06/0020) (grant No: C03/09); Cancer Research UK; Medical Research Council, UK; Stroke Association, UK; British Heart Foundation; Department of Health, UK; Food Standards Agency, UK; Wellcome Trust, UK; Italian Association for Research on Cancer (AIRC); Compagnia di San Paolo; Progetto Integrato Oncologia-PIO, Regione Toscana; Dutch Ministry of Public Health, Welfare and Sports; National Cancer Registry of the Netherlands; Greek Ministry of Health and Social Solidarity; Hellenic Health Foundation and Stavros Niarchos Foundation. The funders were independent of the research of the presented study.

  • Role of sponsors: The sponsors had no input in the design, the conduct, the analysis, or the interpretation of the study, and did not influence the manuscript preparation.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The EPIC study was approved by the IARC ethical committee and by the local ethics committees relevant for each study centre. All participants gave informed consent.

  • Data sharing: No additional data available.

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