Educating women about alcohol and breast cancer risks

ARC Discovery Project: Risk, Trust and Socio-economic Status: Understanding Australian women’s responses to alcohol and breast cancer risks.

Research summary

Recent statistics reveal that the incidence of drinking alcohol among middle-aged (45–64 years) Australian women is worryingly high. This rising consumption pattern significantly increases their risk of developing breast cancer, with 6% of all breast cancer cases attributable to alcohol. Despite this emerging evidence, there is a lack of research exploring their understanding of alcohol as a risk factor for breast cancer and what can be done to reverse the trend of increasing alcohol consumption. Moreover, there is no research on whether or how women in different socio-economic status (SES) groups perceive and respond to the risks of alcohol in relation to breast cancer. The overarching aim is to identify new opportunities for transforming the current dissemination of alcohol-related information.

Research impact

This project will develop a strategy to enhance the communication of alcohol prevention messages to middle-aged women from both high and low SES groups. Developing effective communication strategies tailored to different SES groups will have implications for addressing numerous alcohol-related societal harms, which prevention messages have so far failed to mitigate in alcohol-saturated societies. The harms associated with alcohol extend far beyond health outcomes, encompassing legal, social and economic damages for individuals and society. Identifying strategies to improve the reception of, and response to, messages about risks associated with alcohol consumption should increase the cost-effectiveness of health promotion efforts, thereby offering a means to reduce alcohol-related health expenditure.

The project will specifically identify SES factors that influence the communication of risk and inform strategies to lessen disparities for disadvantaged groups, thus potentially enhancing the health and wellbeing of vulnerable populations. We will develop specific resources for government and non-government agencies to utilise in communicating with middle-aged women about the risks of alcohol and breast cancer. In addition to the generation of new knowledge and innovative methods described above, the completed project will deliver social benefits in the form of risk information resources designed and formatted for non-specialist audiences.

Project significance

This project is proposed at a time when public health agencies are increasingly highlighting the cancer risks associated with alcohol. There is a clear dose-response relationship between alcohol consumption and breast cancer – in women who drink heavily, the excess risk of breast cancer relative to non-drinkers is 60%. Therefore, finding ways to reduce alcohol intake is crucial for decreasing breast cancer incidence. Additionally, devising varied communication strategies to meet the needs of women from high and low SES groups is particularly important, as it moves away from a one-size-fits-all approach. Alcohol and cancer are both key priority areas for the Australian Government, which is committed to reducing the negative impact of preventable risk factors on the burden of disease.

The National Alcohol Strategy 2006–2009 specifically outlines Priority Area 4 ‘Cultural Place and Availability’, aimed at transforming Australia’s drinking culture to mitigate alcohol-related harms. This includes an objective to “facilitate safer and healthier drinking cultures by developing community understanding of alcohol’s special properties”. Australia is a signatory to the United Nations Non-Communicable Disease goals, which include a target to reduce alcohol-related harms by 10%. Cancer has been a National Health Priority Area since 2006, with breast cancer identified as one of seven specific cancers within this priority area. The project directly aligns with the strategic directions of A National Cancer Strategy for Australia to “Improve efforts to distil and communicate key messages from the data”, requiring outputs “...to be customised to the needs of laypeople as well as policymakers”. The project also aligns with the Cancer Australia Strategic Plan 2014-2019, aiming to “Strengthen capability for national cancer control”, specifically to “Undertake analysis, synthesis, and interpretation of evidence to develop informed responses to issues in cancer control”.

Conceptual innovation

The conceptual basis lies in what has been variously termed “lay epidemiology,” “lay expertise,” and/or “lay knowledge,” linked theoretically to Public Understanding of Science. This presents a cultural critique of scientific rationality and its inability to provide objective guidance on matters of public health and safety to a lay public who are increasingly questioning and potentially distrusting, and who are assertive and knowledgeable about risk. Research on lay knowledge (a focus of research by CI Warin and PIs Bissell and Macdonald) has been instrumental in highlighting both the complex and rational theories of lay people and groups about the creation/maintenance of health and the causation of breast cancer.

Breast cancer risks are understood and theorised by individuals and groups through a process of living in an environment of health risks or engaging in particular behaviours, observation of others within their social networks, and discussions across these networks and within the public sphere. A complex weighing-up of evidence then occurs, relating to a variety of lifestyle, heredity, environmental factors, and political, economic, and social factors, leading to the concept of “cancer candidacy” (developed by PI Macdonald and to be further interrogated in the proposed project). Within “cancer candidacy,” different explanations (e.g., fate, bad luck) are proposed for the causes of breast cancer, with lay people not only gathering and using expert information and scientific data but also emphasising social factors as part of the causal chain of disease. This highlights the differences between population risk and individual risk – individuals may rationalise to themselves why they do not conform to the “cancer risk” as identified for the whole population, thereby not regarding themselves as candidates. CI Wilson shows that although women are aware of potential modifiable risk factors, they often see the causes of breast cancer as outside their control, possibly to reduce self-blame, stigma, or feelings of helplessness. Indeed, cancer survivors have described feeling responsible for “bringing on” their cancer and receive criticism for not reducing their alcohol consumption.

For women to make any changes to alcohol behaviour in relation to its risk for breast cancer, they have to first access information and secondly “trust” that information. The increasing uncertainty of if/how to manage risk factors for breast cancer contributes to “existential anxiety,” a constant questioning and thus a lack of certainty, which then leads to the need for “trust” – but which information should be trusted? CI Ward and PI Meyer are experts in the sociology of trust and will lead the examination of women’s trust in various sources of information about breast cancer risks and the SES factors impacting on both perceptions of risk factors for breast cancer and willingness/ability to make behavioural changes in relation to alcohol consumption. This trust-based analysis will be conceptually innovative, in that it will explore, for the first time, the nature of and conditions for trust in different SES groups around alcohol and breast cancer risks.

The aim of our study is not to dismiss women’s perceptions or concerns as naïve or superficial (compared to “scientific evidence”), but to provide a deep understanding of the rationalities underpinning their perceptions of different risk factors for breast cancer (in particular, alcohol) and how these are shaped by SES. Our focus on SES within the project will heighten our analytical sensitivity to differences between high and low SES groups in terms of how they think about risk, trust, alcohol, and breast cancer. In our SES-based analysis, we will apply the concept of “short horizons,” (developed by CIs Ward and Warin) which we developed to explain how low SES groups focus on the “here and now” pleasures of life, in an attempt to obscure, and therefore not respond to, potential future health risks. The proposed project will examine if/how “short horizons” might help us to understand how middle-aged women negotiate their alcohol consumption practices in relation to the longer-term risks of breast cancer, and if/how this might differ between SES groups.

Academic publications

Book chapters

  • Foley K, Lunnay B, Ward PR. When the politics of contextuality (can) subvert science: A case study of Australian women’s perceptions of alcohol consumption and breast cancer risk. In Farina M & Lavazza, A (Eds) (2024). Philosophy, Expertise and The Myth of Neutrality. London, Routledge.
  • Lunnay B, Warin M, Foley K, Ward PR. Is Happiness a Fantasy only for the Privileged? Exploring Women’s Classed chances of being happy through alcohol consumption during COVID-19. In Ward PR, Foley K (Eds) (2023). The Emerald Handbook of the Sociology of Emotions for a Post-Pandemic World: Imagined Emotions and Emotional Futures. Emerald Press, UK
  • Foley K, Lunnay B, Ward PR. Feeling and (Dis)trusting in Modern, Post-Truth, Pandemic Times. In Ward PR, Foley K (Eds) (2023). The Emerald Handbook of the Sociology of Emotions for a Post-Pandemic World: Imagined Emotions and Emotional Futures. Emerald Press, UK
  • Ward PR, Lunnay B, Foley K, Meyer S, Thomas J, Huppatz E, Olver I, Miller E (2022). Uncertainty, fear and control during COVID-19… or … making a safe boat to survive rough seas: the lived experience of women in South Australia during early COVID-19 lockdowns. In Brown P & Zinn J (Eds). COVID-19 and the Sociology of Risk and Uncertainty: Studies of Social Phenomena and Social Theory Across 6 Continents. Palgrave MacMillan, London.

Peer-reviewed journal articles

  • Foley K, Lunnay B, Warin M, Ward PR. Recalibrating temporalities of risk: Alcohol consumption and breast cancer risk for Australian women pre-midlife before and during COVID-19. Health, Risk & Society (accepted) DOI: https://doi.org/10.1080/13698575.2024.2318545
  • Lunnay B, Seymour J, Foley K, Musolino C, Ward PR. Through the wine glass: How biographical midlife transitions and women’s affective interpretations interact with alcohol consumption. International Journal of Drug Policy 2023; 117: 104046. DOI: https://doi.org/10.1016/j.drugpo.2023.104046
  • Batchelor S, Lunnay B, Macdonald S, Ward PR. Extending the sociology of candidacy: Bourdieu’s relational social-class and midlife women’s perceptions of alcohol-related breast cancer risk. Sociology of Health and Illness 2023; 45 (7): 1502-1522. DOI: https://doi.org/10.1111/1467-9566.13644
  • Foley K, Lunnay B, Kevin K, Ward PR. Developing a Women’s Thought Collective methodology for health research: the roles and responsibilities of researchers in the reflexive co-production of knowledge. Health Expectations 2023; 26: 1954–1964. DOI: https://doi.org/10.1111/hex.13804
  • Lunnay B, Foley K, Meyer S, Warin M, Wilson C, Olver I, Thomas J, Ward PR. “I have a healthy relationship with alcohol”: Australian midlife women, alcohol consumption and social class. Health Promotion International 2022: 37; 4. DOI: https://doi.org/10.1093/heapro/daac097
  • Lunnay B, Nicholls E, Pennay A, MacLean S, Wilson C, Meyer S, Foley K, Warin M, Olver I, Ward PR. Sober curiosity: A qualitative study exploring women’s preparedness to reduce alcohol by social class. International Journal of Environmental Research and Public Health 2022; 19: 14788. DOI: https://doi.org/10.3390/ijerph192214788
  • Meyer SB, Lunnay B, Warin M, Foley K, Olver IN, Wilson C, MacDonald S, Ward PR. Examining social class as it relates to heuristics women use to determine the trustworthiness of information regarding the link between alcohol and breast cancer risk. PLoS ONE 2022; 17(9): e0270936. DOI: https://doi.org/10.1371/journal.pone.0270936
  • Thomas J, Morris J, Trigg J, Miller E, Ward PR. Exploring the potential of citizen science for public health through an alcohol advertising case study. Health Promotion International 2022; 37 (2): daab139. DOI: https://doi.org/10.1093/heapro/daab139
  • Thomas J, Miller E, Ward PR. Lifestyle interventions through participatory research: a mixed methods systematic review of alcohol and other breast cancer behavioural risk factors. International Journal of Environmental Research and Public Health 2022; 19 (2): 980.
  • Ward PR, Foley K, Meyer S, Wilson C, Warin M, Miller E, Olver I, Thomas J, Batchelor S, Lunnay B. How does social class shape women’s alcohol stockpiling during COVID-19?: A qualitative study in South Australia during the 2020 lockdown. SSM Qualitative Research in Health 2022; 2: 100080.
  • Huppatz E, Lunnay B, Foley K, Miller E, Warin M, Wilson C, Olver I, Ward PR. Adaptive capacity: A qualitative study of midlife Australian women’s resilience during COVID-19. SSM - Mental Health 2022; 2: 100080.
  • Ward PR, Foley K, Meyer SB, Wilson C, Warin M, Batchelor S, Olver I, Thomas J, Miller E, Lunnay B. The place of alcohol in the ‘wellness toolkits’ of midlife women in different social classes: a qualitative study in South Australia. Sociology of Health and Illness 2022; 44: 488–507.
  • Ward PR, Lunnay B, Foley K, Meyer SB, Thomas J, Olver I, Miller ER. The case of Australia. Trust during pandemic uncertainty - a qualitative study of midlife women in South Australia. International Journal of Social Quality 2021; 11 (1 & 2): 289–308.
  • Foley K, Warin M, Meyer S, Miller E, Ward PR. Alcohol and flourishing for Australian women in midlife: a qualitative study of negotiating (un)happiness. Sociology 2021; 55 (4): 751-767.
  • Rudge A, Foley K, Lunnay B, Miller E, Batchelor S, Ward PR. How are the links between alcohol consumption and breast cancer portrayed in Australian newspapers?: A paired thematic and framing media analysis. International Journal of Environmental Research and Public Health 2021; 18: 7657.
  • Batchelor S, Miller ER, Lunnay B, Macdonald S, Ward PR. Revisiting candidacy: What might it offer cancer prevention? International Journal of Environmental Research and Public Health 2021; 18: 10157.
  • Miller E, Olver I, Wilson C, Lunnay B, Meyer S, Foley K, Thomas J, Toson B, Ward PR. COVID-19, and alcohol consumption and stockpiling practices in midlife women: repeat surveys during lockdown in Australia and the United Kingdom. Frontiers in Public Health 2021; 9: 642950.
  • Lunnay B, Toson B, Wilson C, Miller E, Meyer S, Olver I, Foley K, Tomas J, Ward PR. Social class and changes in Australian women’s affect and alcohol consumption during COVID-19. Frontiers in Public Health 2021; 9: 645376.
  • Lunnay B, Foley K, Meyer SB, Warin M, Wilson C, Olver I, Miller E, Thomas J, Ward PR. Alcohol consumption and perceptions of health risks during COVID-19: A qualitative study of middle-aged women in South Australia. Frontiers in Public Health 2021; 9: 616870.
  • Thomas T, Wilson A, Tonkin E, Miller E, Ward PR. How the media places responsibility for the COVID-19 pandemic – An Australian media analysis. Frontiers in Public Health (Special Issue: COVID-19 - Social Science Research during a Pandemic) 2020; 8: 483.
  • Meyer SB, Foley K, Olver I, Ward PR, McNaughton D, Mwanri L, Miller E. Alcohol and breast cancer risk: Middle-aged women's logic and recommendations for reducing consumption in Australia. PLOS ONE 2019; 14(2): e0211293

Media and events

Submission to Parliamentary Inquiry. Foley, K., Ward, P. & Lunnay, B. (2023) Murdoch Media Inquiry Bill (Senate Standing Committee on Environment and Communications). Torrens University Australia. Submission 5: https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Environment_and_Communications/MurdochMediaBill2023/Submissions

October 2022 – Article in The Conversation: “I take it with a pinch of salt: Why women question health warnings linking alcohol with breast cancer” https://theconversation.com/oh-well-wine-oclock-what-midlife-women-told-us-about-drinking-and-why-its-so-hard-to-stop-188882

October 2022 – Article in MJA InSight+: “Delivering a message: Alcohol causes breast cancer” https://insightplus.mja.com.au/2022/41/delivering-a-message-alcohol-causes-breast-cancer/

August 2022 – Article in The Conversation: “Oh well, wine o’clock': What midlife women told us about drinking – and why it's so hard to stop” https://theconversation.com/oh-well-wine-oclock-what-midlife-women-told-us-about-drinking-and-why-its-so-hard-to-stop-188882

Research team

Torrens University Australia

  • Professor Paul Ward (Chief Investigator)
  • Doctor Belinda Lunnay (Postdoctoral Research Fellow)
  • Samantha Batchelor (PhD student funded by the ARC DP scholarship)
  • Kristen Foley (PhD student funded by a linked NHMRC PhD Scholarship University of Adelaide)

University of Melbourne

  • Professor Carlene Wilson

University of Adelaide

  • Professor Megan Warin
  • Professor Ian Olver

Glasgow Caledonian University (Scotland)

  • Professor Sara MacDonald

University of Chester (England)

  • Professor Paul Bissell

University of Waterloo (Canada)

  • Associate Professor Samantha Meyer

Research objectives

  • Understand, in depth, the place of alcohol in the lives of women in different SES groups and the perceived risk for breast cancer, exploring:
    • Experiences of the past and present function of alcohol in women’s lives;
    • Knowledge and perceptions of the risk and role of alcohol (and other risk factors) in breast cancer;
    • Critical awareness of, and trust in, information sources about risks for breast cancer.
  • Statistically analyse the perceived risk of alcohol in the development of breast cancer and perceptions of the role of alternative risk factors against potential modifiers (such as SES, trust, social networks).
  • Synthesise data from the above objectives to develop an evidence-based compendium of perceived risk factors for breast cancer (differentiated by SES group), including women’s accounts for/against the risk, appropriate for research translation to lay and professional audiences.
  • Subject the outcomes of the synthesis to Deliberative Symposia with women in different SES groups to facilitate informed and critical discussion of alcohol and risks for breast cancer, and develop innovative, appropriate, and tailored alcohol-related communication strategies for middle-aged women in different SES groups.

Research approach


  • Phase 1: Understand, in depth, the place of alcohol in the lives of women in different SES groups
    In-depth, semi-structured interviews will be undertaken in Year 1 with approximately 60 women in high and low SES groups (30 high and 30 low SES) and of varying perceived likelihood of breast cancer. These interviews will build on Pilot Study 2, and will allow us to explore in-depth the ‘lay expertise’ around rationalities for risk factors for breast cancer. Interviews will facilitate participant-driven explanations and justifications of the evidence used for their belief (or not) in different risk factors, reasons for alcohol consumption, trust in different sources of evidence, perceptions of the role of alcohol as a risk factor for breast cancer and barriers and enablers to changing alcohol consumption in response to breast cancer risks. Participants will be free to raise experiences and perceptions that might otherwise remain unexplored. The successfully piloted interview schedule was developed during Pilot Study 2 from CI Miller’s ARC Linkage, CI Olver’s vast experience of qualitative research on cancer and CI Ward and PI Meyer’s theoretically-driven qualitative studies on the key concept of trust. We will recruit women (aged 45–64 years) in South Australia with no cancer history who have therefore not contemplated cancer-related behavioural changes – we are interested in perceived risks of cancer and barriers and enablers to future changes in alcohol consumption. Using information provided in a brief pre-recruitment survey administered to potential participants, we will purposely sample participants on the basis of their SES (assessed by a mixture of the Socio-economic Indicator for Area (SEIFA) score for their postcode of residence,42 income and highest educational qualification), self-assessed alcohol consumption status, aiming to get a range of ‘light’, ‘moderate’ and ‘heavy’ drinkers (as perceived by the participants). Given the socio-economic, educational and age differences in trust, we will also purposively sample using these criteria, aiming to obtain a diverse sample in order to explore different risk perceptions and levels of trust (we are not sampling for ethnicity, since it would require a separate project with a different methodology and dedicated resources for fieldwork, translation and interpretation). Recruitment will be based on our success in numerous qualitative studies (including Pilot Study 2) advertising in community centres, libraries and local free newspapers. Interviews will be audio-recorded with the participants’ permission and transcribed verbatim by professional transcribers. Our analysis will follow CI Ward and PI Meyer’s three phase progressive method for synthesising social theory within qualitative analysis: pre-coding; conceptual and thematic categorisation; and theoretical categorisation. Transcripts will be analysed using NVivo 10 software.
  • Phase 2: Statistically analyse the perceived risk of alcohol in the development of breast cancer in different SES groups
    In year 2, a national online survey will be conducted to confirm and extend findings from our single-state (SA) qualitative analysis (Phase 1) within a broader national population of middle-aged women. CIs Wilson and Miller have expertise in designing and implementing online surveys (using approaches successfully piloted in Pilot Study 1) and will lead this phase. The survey will collect demographic data (e.g. age, sex, number and age of children, education level), usual patterns of drinking (using the validated three-item AUDIT-C screening tool), existing attitudes to prevention messages in general and about alcohol in particular and individual differences in Consideration of Future Consequences (14 items) and in scores on the Multi-dimensional Health Locus of Control (Form C; disease specific, 18 items).46 We will also include the validated social quality survey used by CI Ward and PI Meyer to measure participant trust in individuals (e.g. doctors) and institutions (e.g. the media, science and government). Other items will be based on the barriers and facilitators to responding to alcohol risk messages identified in Phase 1. We will engage a large web panel provider to sample a large sample of middle-aged women that is representative in terms of age-group, geography, ethnic group (although English proficiency will be required to complete the survey), Indigenous status and socio-economic status. Additionally, our survey will include a range of demographic data to allow for stratified analysis according to these characteristics. We will survey at least 2000 participants across Australia.
  • Phase 3: Develop an evidence-based compendium of perceived risk factors for different SES groups
    The project is designed to facilitate an iterative process of analysis, allowing insights gained during one phase to inform others. Once Phase 1 and 2 data have been collected and analysed, the findings will be synthesized using a Framework approach. This will occur in the first half of Year 3. A hierarchical thematic framework is developed and used to classify and organise data according to key themes, concepts, and emergent categories. This will be undertaken separately for high and low SES groups, allowing for different evidence-based compendia. A series of main themes will be identified, with related subtopics; each theme charted in a matrix, with data sources (or Cases) in rows, and subtopics in the columns. Cells containing relevant summaries from the dataset will be examined to identify patterns and connections. Summarising our collective findings in this systematic way will identify connections between the various information sources and enhance interpretation. Based on this, the research team (led by CI Wilson) will develop evidence-based resources for lay audiences that provide accurate information about the various factors commonly believed (Phases 1 and 2) to be causally linked to breast cancer and factors found to be barriers and facilitators to alcohol prevention messages. The information in the resources will be presented in a format and style appropriate for non-specialist audiences and will be thematically linked to activities generating opportunities for deliberation and critical self-analysis. In developing the resources and linked activities, the team will also draw on the expertise of our Reference Group and relevant experts among our networks. While they are intended primarily for use in Phase 4, all information resources will also be actively promoted to government and non-government agencies both nationally and internationally as suitable resources for dissemination in the broader community. This research translation phase will be led by CI Olver, given his excellent national and international policy and practice networks.
  • Phase 4: Conduct ‘deliberative symposia’ with women from different SES groups to facilitate informed and critical discussion and develop tailored communication strategies
    Recent reviews of deliberative methods outline the range of methods available and the fitness-for-purpose of different methods. Whilst Citizen’s Juries are gaining in popularity in health policy research, and CI Ward and PI Meyer have expertise in their use, their purpose is to debate and vote on particular outcomes which is too narrow for our purposes. The purpose of Phase 4 (in the second half of Year 3) conduct two-day Deliberative Symposia to present evidence on the various risk factors for breast cancer articulated by women in the interviews and on-line survey, and to ask them to debate each of these in turn. Evidence from Pilot Study 2 shows that when women begin to engage in a critical discussion of alcohol and breast cancer, they are more likely to consider changing their alcohol-related behaviours. The outcomes of the symposia will be the in-depth critical analyses of the various risk factors, including alcohol, and possible communication strategies aimed at reducing alcohol consumption in high and low SES groups. These communication strategies may share some similarities, but may also have different components, depending on the outcomes of the symposia. We will run separate symposia for high and low SES women, since we anticipate (from Pilot Study 2) differences in terms of reasons for alcohol consumption and perceptions of their cancer candidacy. The deliberations will involve ‘experts’ providing evidence for and against each risk factor (from Phase 3) and then women discussing why they think or do not think the risk factors are important (lay expert knowledge), what (if anything) they currently do to reduce the risk and what they may or may not be prepared to do in the future. We will run six Deliberative Symposia separately for different SES groups (3 for high and 3 for low SES women), each will last 2-days and include 20 women (120 women in total). Symposia will be run in three major cities around Australia (Adelaide, Melbourne and Darwin to represent different population mixes and facilities available at University campuses of the CIs). At the beginning of each symposium, women will be briefed on the conduct of the symposium and told that it is their role to question the experts, debate and discuss with each other and deliberate on the meaningfulness of each risk factor within their lives. Each ‘expert’ will present evidence for around 30 minutes, followed by questioning of the ‘expert’ by the women and then around 1 hour of deliberation about that specific risk factor. The participants will then divide into two groups (n=10 each) and discuss the risk factor as a group (approximately 1 hour), using linked resources that focus particularly on strength of evidence, validity, and likelihood of them being able to make changes within their lives. This process will continue until all risk factors have been fully discussed. Each Deliberative Symposium will conclude with all women (n=20) discussing the relative strength of evidence and meaningfulness of the various risk factors discussed over the two day period and the most appropriate, feasible and effective communication strategies for changing alcohol consumption in high and low SES groups. In this way, we will have tailored communication strategies developed, discussed and ratified by women in high and low SES groups.