Alcohol Consumption and Colorectal Cancer: Evidence and Prevention

Colorectal cancer (CRC) ranks as the third most common type of cancer and is the second leading cause of cancer deaths globally. A sedentary lifestyle, obesity, metabolic syndrome, and alcohol consumption can be factors that increase the risk of early-onset CRC (1).

 Alcohol consumption, even in small amounts, has been linked to an increased risk of colorectal cancer (CRC). The relationship between alcohol intake and CRC risk depends on the dose consumed. The risk of CRC is particularly evident in cases of heavy alcohol consumption, although evidence regarding the risk associated with light to moderate consumption is varied (2).

 Several mechanisms link alcohol consumption to the development of cancers in general, with genotoxicity being one of the most scientifically understood factors. In this process, acetaldehyde, a byproduct of alcohol metabolism, causes DNA damage, such as breaks and alterations in its structure. These changes can result in errors during DNA replication, leading to mutations. Over time, the accumulation of these mutations may culminate in the development of cancer (3).

 In addition to alcohol consumption itself, other alcohol-related factors may influence the risk of colorectal cancer (CRC). A family history of the disease is one such factor, with the risk of CRC being significantly higher in individuals with a family history of cancer (4). Gender also appears to have an impact, with men tending to have a higher risk of developing alcohol-associated CRC compared to women. Body mass index (BMI) and body weight may also interact with alcohol, increasing the risk of CRC, especially in obese individuals (5). Although smoking is an established risk factor for CRC, there is no conclusive evidence that it modifies the alcohol-induced CRC risk (6).

 In light of the evidence, it is crucial to raise awareness about the risks of alcohol consumption in relation to colorectal cancer. Although various factors can influence this risk, alcohol consumption alone is a significant modifiable risk factor. Prevention strategies, including moderating alcohol consumption and adopting healthy lifestyle habits, are essential to reduce the incidence of CRC. Continued research is also necessary to better understand the mechanisms by which alcohol contributes to the development of CRC.

References:

1. Sung, H., Ferlay, J., Siegel, R. L., Laversanne, M., Soerjomataram, I., Jemal, A., & Bray, F. (2021). Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA: a cancer journal for clinicians, 71(3), 209–249. https://doi.org/10.3322/caac.21660
2. Cai, S., Li, Y., Ding, Y., Chen, K., & Jin, M. (2014). Alcohol drinking and the risk of colorectal cancer death: a meta-analysis. European journal of cancer prevention : the official journal of the European Cancer Prevention Organisation (ECP), 23(6), 532–539. https://doi.org/10.1097/CEJ.0000000000000076
3.  International Agency For Research On Cancer. IARC Handbooks of Cancer Prevention: volume 20A - Reduction or cessation of alcoholic beverage consumption. Lyon: IARC, 2024
4. Cho, E., Lee, J. E., Rimm, E. B., Fuchs, C. S., & Giovannucci, E. L. (2012). Alcohol consumption and the risk of colon cancer by family history of colorectal cancer. The American journal of clinical nutrition, 95(2), 413–419. https://doi.org/10.3945/ajcn.111.022145
5. Fedirko, V., Tramacere, I., Bagnardi, V., Rota, M., Scotti, L., Islami, F., Negri, E., Straif, K., Romieu, I., La Vecchia, C., Boffetta, P., & Jenab, M. (2011). Alcohol drinking and colorectal cancer risk: an overall and dose-response meta-analysis of published studies. Annals of oncology : official journal of the European Society for Medical Oncology, 22(9), 1958–1972. https://doi.org/10.1093/annonc/mdq653
6. Fagunwa, I. O., Loughrey, M. B., & Coleman, H. G. (2017). Alcohol, smoking and the risk of premalignant and malignant colorectal neoplasms. Best practice & research. Clinical gastroenterology, 31(5), 561–568. https://doi.org/10.1016/j.bpg.2017.09.012

Research conducted by the Brazilian Consumer Protection Association (Proteste) revealed surprising findings of alcohol levels exceeding legal limits in sliced breads. What does this mean for your health?

Recently, an analysis by the Brazilian Consumer Protection Association – Proteste, alarmed (and concerned) Brazilian consumers by disclosing that major brands of sliced bread in the country had alcohol levels above the permissible limit. The study, which examined 10 brands of sliced bread, found that only 4 brands had alcohol content below 0.5%, the percentage threshold to consider a product non-alcoholic.

According to Proteste, which did not disclose the details of the study's methodology, fermentation and preservatives are responsible for the alcohol in sliced bread, and a large portion of this alcohol should evaporate during the manufacturing process. The analysis raised significant concern among consumers, as some brands had alcohol levels similar to those in a 350 mL can of beer (between 2.5% and 5%).

How Does Alcohol Arise in the Production of Sliced Bread?

The ethanol present in sliced bread is not added directly as an ingredient. Instead, it forms naturally in the bread due to the fermentation process involved in the dough's rise. This occurs through fermentation with yeast – microorganisms used to leaven the bread, which consume the sugars in the dough and produce carbon dioxide (CO2) and ethanol as byproducts. The CO2 causes the dough to rise while most of the ethanol evaporates or may remain in the bread after baking. Typically, the amount of ethanol in the bread fermentation process is very low and within safe consumption limits (1).

Ethanol is also used in the preservation of sliced bread due to its antimicrobial properties (2.3). It helps prevent mold and bacteria growth, thereby extending the product's shelf life without significantly affecting the bread's flavor or texture. Ethanol is often applied as a vapor or as part of the packaging system that releases ethanol over time. However, most of the ethanol usually evaporates, leaving minimal residues in the final product (2,3).

Products classified as non-alcoholic, such as sliced bread, must not exceed the 0.5% alcohol limit set by law, even if they use additives or ingredients containing alcohol. To ensure this, industries must maintain strict quality control over their products. A product with alcohol content exceeding the legal limit may pose a risk to certain individuals, such as children, pregnant women, and people with specific health conditions like liver problems.

In response, the Brazilian Association of Biscuit, Pasta, and Industrialized Bread & Cake Industries (Abimapi) questioned the validity of Proteste's test, criticizing the methodology used and other factors that could compromise its validity, reiterating that the products are safe for consumption.

What Are the Health Impacts of Ethanol in Foods?

Several factors regarding ethanol content in sliced bread and other foods should be considered:

1. Sensitivity: Some individuals may be more sensitive to ethanol, especially if they have specific medical conditions such as liver problems.
2. Quantity: The ethanol present in sliced bread that adheres to legal standards is very small compared to alcoholic beverages. Therefore, consuming bread should not result in ethanol-related adverse effects.
3. Alcohol Metabolism: Since alcohol is primarily metabolized by the liver, the residual amounts found in bread generally do not impact health for most people. However, due to the results of Proteste’s research, further studies are needed to assess blood alcohol concentration after consumption.
4. Children and Pregnant Women: The amount of alcohol in bread meeting standards is considered harmless, even for children and pregnant women. Therefore, quality control must be stringent to detect alcohol levels exceeding the legal limit and prevent such products from reaching consumers, ensuring the safety of these groups.

Breathalyzer Test

Another concern mentioned by Proteste is the possibility that drivers could be accused of intoxication on a breathalyzer test after consuming at least 2 slices of sliced bread from some of the tested brands. However, Proteste did not conduct tests to measure blood alcohol concentration in drivers.

It is possible for a breathalyzer to give a positive (false-positive) result after eating sliced bread, as well as after consuming other products with small amounts of alcohol, such as mouthwashes or liqueur chocolates. However, due to the volatile nature of alcohol, residual alcohol is quickly eliminated within minutes. If this occurs, it is recommended to inform the traffic officer about the consumption of the product and request a retest.

It is worth noting that the breathalyzer is a device used to measure blood alcohol concentration by analyzing the air exhaled from the lungs. When someone "blows" into the breathalyzer, the device estimates the amount of alcohol in the body based on the concentration of alcohol in the exhaled air.

The Importance of Quality Control

Regular consumption of foods with residual alcohol does not have a negative impact on health for most people. However, consumers have the right to choose to avoid foods with any amount of alcohol, even if residual. Official oversight by agencies such as Anvisa and the Ministry of Agriculture, as well as quality control by qualified laboratories during production, are crucial to ensure that products not meeting legal standards do not 

compromise consumer safety.

References:

1. Ebrahimi, F., Khanahmadi, M., Roodpeyma, S., & Taherzadeh, M. J. (2008). Ethanol production from bread residues. Biomass and bioenergy, 32(4), 333-337.
2. Jideani VA, Vogt K. Antimicrobial Packaging for Extending the Shelf Life of Bread—A Review. Critical Reviews in Food Science and Nutrition. 2015 Jan 20;56(8):1313–24.
3. Latou, E., Mexis, S. F., Badeka, A. V., & Kontominas, M. G. (2010). Shelf life extension of sliced wheat bread using either an ethanol emitter or an ethanol emitter combined with an oxygen absorber as alternatives to chemical preservatives. Journal of Cereal Science, 52(3), 457-465.

The precariousness of the work environment is a social determinant of health; research shows that being employed in an unstable manner in early adulthood is associated with an increased risk of mental health problems and higher alcohol consumption (1).

The rise of non-standard forms of work has blurred the boundaries between being employed and unemployed. Jobs without formal contracts tend to be less secure and often come with fewer benefits compared to more traditional forms of employment, such as permanent labor contracts, commonly known in Brazil as CLT (Consolidação das Leis do Trabalho, or Consolidation of Labor Laws). Disadvantages may include lack of contractual security (e.g., temporary employment), low wages, economic difficulties, limited social protection, and reduced workplace rights.

The "emerging adulthood" phase is a particular stage of life that describes the transition from youth to the workforce, which can be considered a challenging and delicate period (2). Young adults, aged between 15 and 29, entering the job market after completing their studies face particular vulnerability due to a lack of professional experience, job opportunities, and social protection in cases of unemployment. Additionally, there is evidence that difficulty in establishing oneself in the job market can result in long-term negative health effects (3).

A Swedish study aimed to analyze whether freelance (self-employed) or informal contract work during early adulthood is related to an increased risk of developing alcohol-related health problems in the long term, such as alcohol-related liver disease, alcohol use disorder, and intoxication. To conduct this analysis, data from national registers in Sweden were used, tracking a large population of young adults over 28 years. The results of this study suggest that being employed as a freelancer or in informal work during "emerging adulthood" is associated with an increased risk of alcohol-related morbidity later in life, especially among young men, but also among young women (4). The reasons for this increased risk may be related to using alcohol as a coping strategy for stress, and this habit may persist when these individuals transition to more stable jobs with greater benefits.

It is important to highlight that in a context where flexible employment forms are becoming increasingly common, understanding the implications of employment type on the health of young people is crucial. Evidence suggests that, in addition to economic effects, this form of work may have significant consequences for mental and physical health. Therefore, it is essential that public policies and interventions are directed not only towards improving working conditions but also towards providing adequate support to these young individuals, preventing future alcohol-related health issues.

References:

1. Benach J, Vives A, Amable M, et al. Precarious employment: understanding an emerging social determinant of health. Annu Rev Public Health 2014;35:229–53. 
2. Thern E, Matilla-Santander N, Hernando-Rodriguez JC, et al. Precarious employment in early adulthood and later mental health problems: a register-linked cohort study. J Epidemiol Community Health 2023;77:755–61.
3. Gray BJ, Grey C, Hookway A, et al. Differences in the impact of precarious employment on health across population subgroups: a scoping review. Perspect Public Health  2021;141:37–49.
4. Thern, E., Elling, D. L., Badarin, K., Hernando Rodríguez, J. C., & Bodin, T. (2024). Precarious employment in young adulthood and later alcohol-related morbidity: a register-based cohort study. Occupational and environmental medicine, 81(4), 201–208.

Effects of Reducing or Ceasing Alcohol Consumption on Cancer Risk

In 2020, it was estimated that 741,300 new cancer cases worldwide were caused by alcohol consumption. This represents 4.1% of all new cancer cases, with 6.1% among men and 2.0% among women (1). 

An independent group of international experts convened by the International Agency for Research on Cancer (IARC) reviewed the existing literature to assess the effectiveness of reducing or stopping alcohol consumption in decreasing the risk of alcohol-related cancers, such as cancers of the oral cavity, pharynx, larynx, esophagus, colorectal area, liver, and female breast. Additionally, the group identified and evaluated the mechanisms of alcohol-induced carcinogenesis that may be reversed with cessation of consumption (2).

The IARC classifies alcoholic beverages, ethanol in these beverages, and acetaldehyde associated with alcohol consumption as carcinogens for humans. In addition to ethanol and acetaldehyde, alcoholic beverages may contain various toxins derived from raw materials used or that may arise during the production process.

There are several mechanisms linking alcohol to cancer, one of the most well-understood scientifically being genotoxicity, where acetaldehyde causes damage to our DNA, such as breaks and structural changes. These alterations can lead to errors in DNA replication, resulting in mutations. Over time, these mutations can accumulate and lead to cancer development, especially in parts of the body that come into direct contact with alcohol, such as the mouth, throat, and esophagus (2).

An important measure used is the Population Attributable Fraction (PAF), which helps understand how many cancer cases can be attributed to alcohol consumption in a population. To calculate PAF, researchers use data on: how much people drink; the cancer risk associated with alcohol; how many cancer cases exist. However, there are limitations, such as incomplete data, underreporting of alcohol consumption, other factors affecting the data (like smoking), and population differences. Despite these limitations, PAF is useful for understanding and preventing alcohol-related cancers.

CISA, in its annual report “Alcohol and Brazilian Health,” uses these fractions to calculate the burden of alcoholic beverages on the Brazilian population. To learn more, download the report for free on our website.

According to the study conducted by the IARC, reducing or ceasing alcohol consumption is associated with a lower risk of oral and esophageal cancers, with sufficient evidence to support this conclusion. There is limited evidence suggesting a reduction in the risk of laryngeal, colorectal, and breast cancers with the cessation of alcohol consumption. However, there is inadequate evidence to indicate that reducing or ceasing alcohol consumption lowers the risk of pharyngeal and liver cancers. Overall, researchers conclude that stopping alcohol consumption may be beneficial for reducing the risks of certain types of cancer, but the strength of the evidence varies among different cancer types.

References:

1. Rumgay, H., Shield, K., Charvat, H., Ferrari, P., Sornpaisarn, B., Obot, I., Islami, F., Lemmens, V. E. P. P., Rehm, J., & Soerjomataram, I. (2021). Global burden of cancer in 2020 attributable to alcohol consumption: a population-based study. The Lancet. Oncology, 22(8), 1071–1080. https://doi.org/10.1016/S1470-2045(21)00279-5
2. International Agency For Research On Cancer. IARC Handbooks of Cancer Prevention: volume 20A - Reduction or cessation of alcoholic beverage consumption. Lyon: IARC, 2024

Is it possible to treat a hangover?

Scientists develop gel that can intercept alcohol and prevent hangovers.

A hangover is a combination of mental and physical symptoms that can be experienced after an episode of alcohol consumption, beginning when the blood alcohol concentration (BAC) approaches zero. The cause of these symptoms is primarily attributed to acetaldehyde, the main product of alcohol metabolism (1).

Existing therapies, mainly based on endogenous enzymes, offer only temporary relief from hangover symptoms such as nausea and headaches, but fail to address other issues like drowsiness and exhaustion (2). Nanocomplexes with various liver enzymes have emerged as an effective approach to accelerate alcohol metabolism in the human body (3). However, a major challenge is that commercially available enzymes are not sufficiently active, leading to the accumulation of a more dangerous byproduct, acetaldehyde, which can cause organ damage. Moreover, natural enzymes have significant drawbacks such as high cost, low physicochemical stability, and storage difficulties, which have so far hindered the practical use of these complexes for alcohol detoxification (4).

A recent study evaluated a biomimetic nanoenzyme substance designed to alleviate the harmful effects of alcohol when administered orally. This nanoenzyme demonstrates an ability to catalyze the oxidation of alcohol into acetic acid, rather than the more toxic acetaldehyde. When administered to alcohol-intoxicated mice, the gelatinous nanoenzyme significantly reduced blood alcohol levels without causing additional acetaldehyde accumulation. The hydrogel also showed a protective effect on the liver and reduced intestinal damage and dysbiosis (imbalance in the composition of intestinal microbiota) associated with chronic alcohol consumption.

This study offers promising opportunities for the development of effective, targeted antidotes for alcohol, with potential benefits for liver protection and gastrointestinal health, which could be favorable for hangover prevention. However, further research is needed to confirm these findings in humans and to develop new therapies that can be used practically and affordably. Continued investigations in this area are crucial to advance understanding and treatment of the adverse effects of alcohol consumption, providing better solutions for public health.

References:

1. Verster JC, van Rossum CJI, Scholey A. Unknown safety and efficacy of alcohol hangover treatments puts consumers at risk. Addict Behav. 2021 Nov;122:107029. doi: 10.1016/j.addbeh.2021.107029. Epub 2021 Jun 27. PMID: 34225031.
2. Xie, L. et al. The protective effects and mechanisms of modified Lvdou Gancao decoction on acute alcohol intoxication in mice. J. Ethnopharmacol. 282, 114593 (2022). 
3. Liu, Y. et al. Biomimetic enzyme nanocomplexes and their use as antidotes and preventive measures for alcohol intoxication. Nat. Nanotechnol. 8, 187–192 (2013).

Can alcohol cause premature aging?

A study conducted by the University of Nagoya in Japan shows an association between the harmful effects of aldehydes on DNA, which may be related to premature aging.

It is known that aging is a normal developmental process involving physiological changes (1). Additionally, the body is influenced by environmental and sociocultural factors such as quality of life, lifestyle, diet, sedentarism, and physical exercise, which are directly related to healthy or pathological aging (1).

In light of this, alcohol consumption has been cited as a factor that may be involved in the process of premature aging. A British study (2) aimed at investigating the effects of alcohol on aging showed that excessive alcohol consumption can damage DNA, specifically in telomeres – repetitive structures of proteins and DNA that form the ends of chromosomes and act to prevent genetic material wear and tear. According to the study, increased oxidative stress caused by excessive alcohol may directly contribute to the shortening of these DNA structures.

Similarly, a recent Japanese study published in the journal Nature Cell Biology (3) demonstrated how the harmful effects of aldehydes on DNA may also be associated with premature aging. But where does alcohol fit into this scenario?

After alcohol ingestion, ethanol is rapidly absorbed by our body. Alcohol metabolism begins with the action of the enzyme alcohol dehydrogenase (ADH), which converts alcohol into acetaldehyde, a substance that is toxic to the body even in small concentrations. Then, the enzyme aldehyde dehydrogenase (ALDH) converts acetaldehyde into acetate.

The study points out that aldehydes are genotoxic agents* because they interfere with DNA-protein replication and transcription, and such types of damage are particularly harmful since they can lead to cell death if not repaired. As a result, researchers suggest that aldehydes as metabolic by-products are associated with premature aging.

The research first identified a previously uncharacterized DNA repair pathway: transcription-coupled DNA-protein crosslink repair. As a result, the study showed that transcription-coupled DNA-protein repair, as well as aldehyde clearance, were crucial for protection against metabolic genotoxins. This could explain the molecular pathogenesis of AMeDS (aldehyde metabolic deficiency syndrome, characterized by bone marrow deficiency, intellectual deficiency and dwarfism) and other disorders associated with defects in transcription-coupled repair, such as Cockayne syndrome (rare, autosomal recessive disorder, with unknown pathogenesis and with impairment in growth and progressive neurological dysfunction).

According to researchers (4), this study has implications beyond genetic diseases, as its findings suggest that aldehyde-induced DNA damage may also play a role in the aging process in healthy individuals. They also mention the importance of strategies to combat aging in healthy individuals, such as controlling exposure to substances that induce aldehyde production, such as alcohol intake and exposure to pollution and smoke.

*Genotoxic agents are those that interact with DNA producing changes in its structure or function.

References:

1. Santos FH dos, Andrade VM, Bueno OFA. Envelhecimento: um processo multifatorial. Psicologia em Estudo [Internet]. 2009 Mar 1;14:3–10. Available from: https://www.scielo.br/j/pe/a/FmvzytBwzYqPBv6x6sMzXFq/
2. Topiwala A, Taschler B, Ebmeier KP, Smith S, Zhou H, Levey DF, et al. Alcohol consumption and telomere length: Mendelian randomization clarifies alcohol’s effects. Molecular Psychiatry [Internet]. 2022 Jul 26;1–8. Available from: https://www.nature.com/articles/s41380-022-01690-9#Sec10

3‌. Oka Y, Nakazawa Y, Shimada M, Ogi T. Endogenous aldehyde-induced DNA–protein crosslinks are resolved by transcription-coupled repair. Nature Cell Biology [Internet]. 2024 Apr 10;1–13. Available from: https://www.nature.com/articles/s41556-024-01401-2

4. Impact of aldehydes on DNA damage and aging [Internet]. NU Research Information. [cited 2024 Jul 1]. Available from: https://www.nagoya-u.ac.jp/researchinfo/result-en/2024/04/20240411-01.html

Alcohol and Hepatic System

Excessive alcohol consumption damages nearly every organ in the body. However, the liver suffers the earliest and most severe degrees of tissue injury due to excessive alcohol consumption, as it is the organ responsible for almost all ethanol metabolism (1). In this text, we will explore how the liver is affected by harmful alcohol consumption.

The liver's function

Normal liver function is essential for life. The liver is the largest internal organ in the human body and, in some aspects, the most complex. One of its main functions is to break down toxic substances absorbed from the intestine or produced in other areas of the body, and then excrete them via bile or blood as harmless by-products.

Additionally, the liver secretes bile into the small intestine to aid in the digestion and absorption of fats, stores vitamins, synthesizes proteins and cholesterol, metabolizes and stores sugars. The liver controls blood viscosity and regulates clotting mechanisms (2).

Alcoholic liver disease

One study estimated that 23.6 million people worldwide have alcohol-associated cirrhosis, with approximately 10% of these cases being decompensated disease (3). However, the true burden of alcoholic liver disease is likely underestimated, as it is often undiagnosed.

There is a clear amount-dependent relationship between the amount of alcohol consumed and the risk of severe liver disease. A meta-analysis demonstrated that even very low levels of alcohol consumption increase the risk of cirrhosis-related mortality. This risk is heightened with increased consumption, with men and women who consume more than 60 grams of alcohol per day having a 14 and 22.7 times greater risk, respectively, of cirrhosis-related death compared to non-drinkers (4).

How alcohol affects liver metabolism (5)

When consumed in excess, alcohol interferes with an enzyme called AMPK, which normally helps regulate fat metabolism. AMPK activates another protein, PPARα, which is important for fatty acid burning. Alcohol inhibits AMPK, resulting in reduced fat burning by the liver. Additionally, alcohol damages mitochondria, the cell's "energy factories," which also reduces the liver's ability to burn fats.

Alcohol also increases fatty acid production in the liver. Furthermore, alcohol consumption reduces the production of adiponectin, a hormone that helps control fat levels, and increases the release of fatty acids from body fat deposits.

On the other hand, alcohol inhibits the secretion of fatty acids by the liver, further contributing to fat accumulation in the organ. It also affects various cellular signaling pathways, including those associated with inflammation and regulation of autophagy (cellular cleaning process). These changes contribute to the progression of alcoholic fatty liver disease, a condition characterized by excessive fat accumulation in the liver.

Additionally, alcohol can cause an imbalance in gut bacteria, worsening liver disease. This imbalance increases ethanol metabolism in the intestine and causes intestinal dysfunction. Bacteria and toxins can enter circulation and reach the liver, activating an inflammatory pathway called NFκB. The pro-inflammatory cytokines released in this process contribute to inflammation and fibrosis in the liver. Alcohol also favors necrosis (uncontrolled cell death) over apoptosis (programmed cell death), which can further aggravate the liver condition.

Types of alcohol-induced liver damage

In individuals who abuse alcohol, the most common liver diseases encountered are:

1. Alcoholic steatosis (fatty liver): Fat deposition occurs in almost all individuals who abuse alcohol excessively and frequently. Steatosis corresponds to the first stage of alcoholic liver disease. Steatosis can also occur in diabetic individuals, obese individuals, those with severe protein malnutrition, and users of certain medications  (1).

1. Alcoholic hepatitis: This condition involves inflammation and/or destruction (e.g., necrosis) of liver tissue. Symptoms include loss of appetite, nausea, vomiting, abdominal pain, fever, and in some cases, confusion (2).

1. Alcoholic cirrhosis: It is an advanced form of liver disease resulting from progressive damage to liver cells. A cirrhotic liver is characterized by extensive fibrosis that compromises liver function and can impair the functioning of other organs such as the brain and kidneys (2).

1. Hepatocellular carcinoma (Liver cancer): Chronic and abusive alcohol consumption is also associated with an increased risk of developing hepatocellular carcinoma, a type of liver cancer. This cancer can arise in a liver already presenting cirrhosis or, in some cases, directly due to the carcinogenic effects of alcohol (6).

How alcohol damages the liver?

Alcohol damages the liver through various mechanisms, and not all alcoholics develop liver problems regardless of the amount consumed. Genetic factors may influence the predisposition to cirrhosis, with collagen synthesis in the liver being affected by the activation of specific genes (5). Genetic variations in enzymes that metabolize alcohol, such as the ALDH gene, can also increase susceptibility to liver damage. Alcohol metabolism generates free radicals and acetaldehyde, which cause cellular damage in the liver (7).

Women are more susceptible to cirrhosis with lower accumulated doses of alcohol due to lower gastric ADH activity and differences in fatty acid metabolism (1,5,8). Additionally, nutrition interacts with alcohol toxicity, exacerbating liver damage. Infection with hepatitis C virus also increases the risk and progression of liver injuries in alcoholics (3). In summary, intense and chronic alcohol consumption predisposes individuals to liver diseases, but only a portion of them develop hepatitis or cirrhosis due to the influence of factors such as heredity, gender, diet, and comorbidities. Most alcohol-induced liver injuries result from its metabolism and toxic by-products. Continuous research is essential to better understand these mechanisms and develop effective treatments to improve prevention and management of alcoholic liver diseases.

References:

1. Lieber CS. Alcohol and the liver: metabolism of alcohol and its role in hepatic and extrahepatic diseases. Mt Sinai J Med. 2000 Jan;67(1):84-94. PMID: 10677787.
2. Yamada, T., Alpers, D. H., Kalloo, A. N., Kaplowitz, N., Owyang, C., & Powell, D. W. (2009). Textbook of Gastroenterology, Fifth Edition. Blackwell Publishing Ltd. https://doi.org/10.1002/9781444303254
3. Asrani SK, Mellinger J, Arab JP, Shah VH. Reducing the global burden of alcohol-associated liver disease: a blueprint for action. Hepatology. 2021;73(5):2039–50. 
4. Rehm J, Taylor B, Mohapatra S, Irving H, Baliunas D, Patra J, et al. Alcohol as a risk factor for liver cirrhosis: a systematic review and meta-analysis. Drug Alcohol Rev. 2010;29(4):437–45. 
5. Seitz, H. K., & Stickel, F. (2007). Molecular mechanisms of alcohol-mediated carcinogenesis. Nature Reviews Cancer, 7(8), 599-612.
6. Huang DQ, Tan DJH, Ng CH, Amangurbanova M, Sutter N, Lin Tay PW, Lim WH, Yong JN, Tang A, Syn N, Muthiah MD, Tan EXX, Dave S, Tay B, Majzoub AM, Gerberi D, Kim BK, Loomba R. Hepatocellular Carcinoma Incidence in Alcohol-Associated Cirrhosis: Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol. 2023 May;21(5):1169-1177. doi: 10.1016/j.cgh.2022.06.032. Epub 2022 Aug 5. PMID: 35940513; PMCID: PMC10792532.
7. Edenberg HJ. The genetics of alcohol metabolism: role of alcohol dehydrogenase and aldehyde dehydrogenase variants. Alcohol Res Health. 2007;30(1):5-13. PMID: 17718394; PMCID: PMC3860432.
8. Parlesak A, Billinger MH, Bode C, Bode JC. Gastric alcohol dehydrogenase activity in man: influence of gender, age, alcohol consumption and smoking in a caucasian population. Alcohol Alcohol. 2002 Jul-Aug;37(4):388-93. doi: 10.1093/alcalc/37.4.388. PMID: 12107043.

Do low or zero alcohol beers benefit wealthier people more?

While the increased availability of low or zero alcohol products may be a useful tool in reducing overall alcohol consumption among the more affluent sectors of society, it may be less beneficial for the rest of the population.

Alcohol consumption is among the leading factors contributing to health deterioration and premature death (1). In response to this, the World Health Organization (WHO) has set a target in the Global Action Plan on Alcohol 2022-2030 to achieve at least a 10% relative reduction in per capita alcohol consumption among those aged 15 and older by 2030 (2). Recently, this issue has gained increased attention from policymakers and global alcohol markets. However, there are doubts about its potential to reduce alcohol consumption across all sectors of society (3).

Evidence indicates that the choice of lower alcohol products is often driven by previous consumption of higher alcohol content products from the same brand (4). Other studies suggest that factors such as health and well-being, price differences, and reducing the social stigma associated with alcohol-free beverages also influence purchasing decisions and consumption of zero and low alcohol beers (5).

One study used data from British surveys conducted between 2015 and 2018, as well as household purchase data from 2015 to 2020 (6). The analysis used this data to understand consumption and purchasing patterns of low and zero alcohol beers. It included information on purchase frequency, demographic characteristics of buyers such as age, gender, social class, income, and geographical region. Additionally, household purchase data were analyzed to observe trends over time and examine variations in total ethanol consumption resulting from the introduction of these products into the market.

The study's results showed that the introduction of new low and zero alcohol beers was associated with a reduction in ethanol grams purchased, both among beer buyers and purchasers of all other beverages. Specifically, younger households and individuals from higher socioeconomic classes were more likely to purchase and consume these beers, given their higher price compared to products with higher ethanol content.

According to the study, although there is a growing trend in current purchases and consumption of low alcohol and/or alcohol-free beers, such products could only make a small contribution to efforts to reduce alcohol consumption, as they are still not very popular among the less advantaged sectors of society. Therefore, the study's authors emphasize the importance of implementing structural policies that improve the socioeconomic outlook for the entire population, alongside promoting low and zero alcohol products.

References:

1. World Health Organization (WHO)  Global Status Report on Alcohol and Health. WHO Press; Geneva, Switzerland: 2018. 
2. World Health Organization . Global Action Plan for the Prevention and Control of NCDs 2022–2030. World Health Organization; Geneva, Switzerland: 2022.
3. Corfe S., Hyde R., Shepherd J. Alcohol-Free and Low-Strength Drinks Understanding Their Role in Reducing Alcohol-Related Harms. [(accessed on 30 August 2021)]. Available online: https://www.smf.co.uk/publications/no-low-alcohol-harms/
4. Chrysochou P. Drink to get drunk or stay healthy? Exploring consumers’ perceptions, motives and preferences for light beer. Food Qual. Prefer. 2014;31:156–163. doi: 10.1016/j.foodqual.2013.08.006.
5. Silva A.P., Jager G., van Bommel R., van Zyl H., Voss H.-P., Hogg T., Pintado M.M., de Graaf C. Functional or emotional? How Dutch and Portuguese conceptualise beer, wine and non-alcoholic beer consumption. Food Qual. Prefer. 2016;49:54–65. doi: 10.1016/j.foodqual.2015.11.007.
6. Anderson, P., O'Donnell, A., Kokole, D., Jané Llopis, E., & Kaner, E. (2021). Is Buying and Drinking Zero and Low Alcohol Beer a Higher Socio-Economic Phenomenon? Analysis of British Survey Data, 2015-2018 and Household Purchase Data 2015-2020. International journal of environmental research and public health, 18(19), 10347. https://doi.org/10.3390/ijerph181910347

I want to drink less, but how?

Preventing excessive alcohol consumption is a strategy that significantly contributes to reducing the social impacts and damage to physical health that this pattern of consumption is responsible for.

The impact of harmful alcohol use is of great relevance in different areas: individual, family, social and economic. The World Health Organization (WHO) suggests some strategies to reduce the harmful use of alcohol globally, such as, for example, monitoring this use, greater control and supervision over sales to children and adolescents, increasing the ability of  the healthcare system to identify drinkers with problematic use and care for dependents and family members.

In addition to broad global strategies, there are clinical strategies that we can implement in everyday life to prevent excessive alcohol consumption. The United States Center for Disease Control and Prevention suggests some actions that can contribute to this prevention, such as:

1. Avoid drinking too much and encourage others to do the same;
2. Monitor your alcohol consumption and find out more about the benefits of drinking less;
3. If you choose to drink alcohol, limit yourself to 2 drinks per day if you are a man or 1 drink per day if you are a woman;
4. Do not serve or provide alcohol to anyone who should not drink, including people under 18, pregnant women or those who have already had too much to drink;
5. Talk to your doctor about your drinking behavior and ask for advice.

We can also point out strategies such as: setting goals, if you decide to consume alcohol, defining the day and the amount you want to drink; identify what triggers your desire to drink; know your limits and learn to say no; pay attention to the alcohol content of the drinks you drink, especially those containing mixes; and reflect on where and why you usually drink, making alcohol consumption more conscious. Practicing activities and going to places that do not combine alcohol, such as sports, parks or cinema, can help reduce the desire to drink.

If you realize that you are drinking excessively and want to reduce your alcohol consumption, whether for health or personal reasons, an important step has already been taken. The important thing now is to define the best strategy for your case. Talk to your doctor or a healthcare professional for help.

References:

Ryan, S. M., Jorm, A. F., Kelly, C. M., Hart, L. M., Morgan, A. J., & Lubman, D. I. (2011). Parenting strategies for reducing adolescent alcohol use: a Delphi consensus study. BMC public health, 11, 13. https://doi.org/10.1186/1471-2458-11-13

Guidelines for the safety of bartenders and other professionals who work with alcoholic beverages

Professions that involve frequent interaction with alcoholic beverages face unique challenges related to alcohol consumption. For these professionals, alcohol is constantly present in the work environment, which can increase the risk of harmful use.

Daily familiarity with alcohol in the routine of some professions can lead to a distorted perception of what constitutes safe and moderate consumption, increasing the risk of developing harmful drinking habits. This may be the case for bartenders, waiters, sommeliers, and other professionals for whom alcohol is part of their work routine. This constant exposure can make it difficult for individuals to recognize and admit possible alcohol-related problems, given the normalization of its consumption in the context of their work.

A study published in 2022, analyzing more than 300 bartenders, revealed that 39% of participants exhibit harmful alcohol consumption and 43.6% report moderate to severe use, which may indicate alcohol dependence. The research shows that, in the case of these professionals, working more than 40 hours a week contributes significantly to the increase in alcohol consumption, with men and individuals between 26 and 40 years old showing greater problematic use when compared to other age groups.

There are no official safety guidelines for alcohol consumption among these professionals in Brazil. However, we can list some protection measures that can be effective for these professionals:

1. Moderation: If you must consume alcohol, especially during work hours, do so in moderation. This means not exceeding one drink, in the case of women, and two, in the case of men. This helps maintain professionalism and ensures they can perform their duties properly.
2. Hydration: Drinking plenty of water between alcoholic beverages can help prevent dehydration and mitigate the effects of alcohol consumption.
3. Pause: It is important for bartenders and sommeliers to drink slowly and take breaks when tasting alcoholic beverages. This can help avoid excessive consumption and the associated risks.
4. Avoid drinking on an empty stomach: Consuming alcohol on an empty stomach can lead to faster intoxication. Eating a balanced meal before or during alcohol consumption can help slow the absorption of alcohol into the bloodstream.
5. Know your limits: Understanding your own alcohol tolerance is crucial. Bartenders and sommeliers must know when to stop drinking and avoid peer pressure to overconsume.
6. Designated driver or alternative transportation: Planning ahead for safe 
7. transportation after work events where alcohol is consumed is important. Having a designated driver who will not consume alcohol or use alternative transportation options can prevent accidents and ensure everyone gets home safely.
8. Training and education: Many establishments offer training and education on service and responsible alcohol consumption for their employees, including bartenders and sommeliers. This includes information about recognizing signs of intoxication in clients and themselves and taking steps to prevent and avoid them.
9. Workplace policies: Some establishments have specific policies regarding employee alcohol consumption, both during and outside of work hours. It is important that bartenders and sommeliers are aware of and follow these policies.

It is also important that public policies and interventions in the workplace are adapted to meet the needs of these workers, offering clear guidelines for consumption and assistance programs for professionals in need. Awareness and prevention programs should focus on education about drinking limits and strategies for dealing with workplace pressure to consume alcohol.

References:

Bell, Deborah, and Florentia Hadjiefthyvoulou. “Alcohol and drug use among bartenders: An at risk population?.” Journal of substance abuse treatment vol. 139 (2022): 108762. doi:10.1016/j.jsat.2022.108762.