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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Cancer Epidemiol Biomarkers Prev. Author manuscript; available in PMC 2010 October 1.
Published in final edited form as:
PMCID: PMC2759847

Associations between smoking, alcohol consumption and colorectal cancer, overall and by tumor microsatellite instability status



Both smoking and alcohol consumption have been associated with modestly increased risks of colorectal cancer (CRC). Reports have suggested that these associations may differ by tumor molecular subtype, with stronger associations for microsatellite unstable (MSI-H) tumors.


We used a population-based case-unaffected sibling design including 2,248 sibships (2,253 cases; 4,486 siblings) recruited to the Colon Cancer Family Registry to evaluate the association between smoking, alcohol consumption and CRC. Associations were assessed using conditional logistic regression, treating sibship as the matching factor.


Although there were no statistically significant associations between any smoking variable and CRC overall, smoking did confer an increased risk of certain types of CRC. We observed an association between pack years of smoking and rectal cancer (OR=1.85, 95% CI 1.23—2.79 for > 40 pack years vs. non-smokers, p for trend = 0.03), and there was an increased risk of MSI-H CRC with increasing duration of smoking (OR=1.94, 95% CI 1.09—3.46 for >30 years of smoking vs. non-smokers). Alcohol intake was associated with a modest increase in risk for CRC overall (OR=1.21, 95% CI 1.03—1.44 for 12+ drinks per week vs. non-drinkers), with more marked increases in risk for MSI-L CRC (OR=1.85, 95% CI 1.06—3.24) and rectal cancer (OR=1.48, 95% CI 1.08—2.02).


We found associations between cigarette smoking and increased risks of rectal cancer and MSI-H CRC. Alcohol intake was associated with increased risks of rectal cancer and MSI-L CRC. These results highlight the importance of considering tumor phenotype in studies of risk factors for CRC.

Keywords: colorectal cancer, cigarette smoking, alcohol consumption, microsatellite instability


Cigarette smoking and alcohol consumption have been evaluated extensively as risk factors for colorectal cancer (CRC). The relationship between smoking and CRC has not been entirely clear; however, two recently published meta-analyses have reported a modest, but statistically significant, increased risk of CRC for smokers (RR = 1.20 for 40 years of duration) with evidence for a stronger association with rectal cancer (1, 2). Although not entirely consistent, epidemiologic studies also suggest that alcohol consumption is associated with increased CRC risk (3, 4). The 2007 World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) report concluded that alcohol consumption was a risk factor for CRC with a summary relative risk of 1.06 (95% CI 1.01—1.12) per 10g alcohol/day in a meta-analysis of 9 cohort studies (5).1

Microsatellite unstable (MSI-H) tumors, which account for 10—20% of sporadic CRC, differ from microsatellite stable (MSS) tumors by clinical and patient characteristics. MSI-H tumors are associated with location in the right colon, female sex, older age at diagnosis, and more favorable prognosis when compared with MSS tumors (69). Thus it is plausible that risk factors differ between MSI-H and MSS CRC. Previous epidemiologic studies have reported that the associations between CRC and both smoking (1013) and alcohol consumption (12, 14, 15), differ by tumor MSI status, with both factors increasing risk of MSI-H cancers in particular.

In this analysis, we evaluated the relationships between smoking and alcohol consumption and CRC risk overall, and by tumor location and MSI status, using data from the Colorectal Cancer Family Registry (Colon CFR).


Study Sample

Individuals were recruited from the six centers of the Colon CFR: University of Hawaii (Honolulu, HI), Fred Hutchinson Cancer Research Center (Seattle, WA), Mayo Clinic (Rochester, MN), University of Southern California Consortium (Los Angeles, CA), Cancer Care Ontario (Toronto, ON), and the University of Melbourne (Victoria, Australia). All centers recruited cases of CRC from population-based cancer registries. Some centers recruited all incident cases of CRC while others over-sampled cases with a family history of CRC or early age at onset. Standardized procedures were used to collect epidemiologic data, and tumor blocks from cases were obtained from the Colon CFR Jeremy Jass Memorial Pathology Bank. Detailed information about the Colon CFR can be found online2 and is summarized by Newcomb et al. (16).

Data for this analysis were abstracted from the Colon CFR central data repository in October 2007 and included population-based cases diagnosed with colon or rectal cancer from July 1998 – July 2005. We included sibships in which both a case and at least one unaffected sibling control had completed the epidemiologic risk-factor questionnaire. Data from 2,248 sibships (N=2,253 cases and 4,486 unaffected siblings) were available for the analysis of smoking, alcohol consumption and overall risk of CRC. Approximately 50% of the cases had one unaffected sibling control, an additional 25% had 2 unaffected sibling controls, and the remaining cases had > 2 sibling controls (range 3 – 10). All of the cases were interviewed within 3 years of diagnosis (86% within 2 years). In the analyses stratified by MSI status, we included 1,564 cases with microsatellite instability data and their unaffected siblings (N=3,102). For the sex-specific analyses, we included 753 male cases (532 with MSI data) and 1,806 unaffected brothers as well as 806 female cases (553 with MSI data) and 1,752 unaffected sisters. A subset of the cases in this analysis were included in a previously published analysis of smoking, NSAID use and MSI-H CRC (13).

All participants provided informed consent. The study was approved by the Institutional Review Board at each of the Colon CFR sites.

Exposure Variables

Epidemiologic data were collected using a risk-factor questionnaire administered to all participants at recruitment. A detailed smoking history was collected, including information on current and former smoking habits. Information was collected for cigarette, pipe and cigar smoking; however, only cigarette smoking was included in these analyses due to the small number of regular cigar and pipe smokers (N=154 exclusive pipe/cigar smokers; N=450 current and 123 former cigarette smokers also reported pipe/cigar smoking). Individuals were categorized as current/former/never smokers. In addition, we evaluated dose and duration of smoking, including the number of cigarettes smoked per day, total number of years of regular smoking and pack years of smoking.

Participants were asked to report alcohol consumption during three time periods: ages 20–30, 30–50 and after age 50 years. We evaluated the number of drinks per week of all types of alcohol during the time period corresponding to the participant’s age at completion of the risk-factor questionnaire. For example, we evaluated alcohol consumption during the ages 30–50 years for an individual 45 years old when the questionnaire was completed.

Data were also collected data for potential confounders, including age, sex, income, education, body mass index (BMI), ethnicity, physical activity (average weekly total lifetime MET hours), and regular NSAID use (never/former/current) (16).

Tumor Location

Tumors located in the cecum, ascending colon, hepatic flexure, transverse colon, and splenic flexure (International Classification of Diseases for Oncology, third edition (ICD-O-3) codes (17) C180, C182, C183, C184, and C185) were classified as right colon. Tumors located in the descending colon and sigmoid colon (ICD-O-3 codes C186 and C187) were classified as left colon. Rectal tumors included the rectosigmoid junction and rectum (ICD codes C199 and C209).

Microsatellite instability status

Microsatellite instability (MSI) was evaluated for all cases with available tumor tissue using a panel of 10 markers (BAT25, BAT26, BAT40, MYCL, D5S346, D17S250, ACTC, D18S55, D10S197, and BAT34C4) (16). Results were required for at least four markers to determine MSI status. Tumors were deemed MSI-H if instability was observed at ≥30% of markers, MSI-L if >0 and <30% of markers were unstable, and MSS if all markers were stable. Tumor MSI results were available for 69% of the cases included in this analysis.

Mismatch Repair (MMR) Mutations

Mutations in the MMR genes MSH2, MLH1, and MSH6 were screened for in selected participants in the Colon CFR using a combined approach of DHPLC/direct sequencing and multiplex ligation dependent probe amplification (MLPA). All clinic-based probands, all MSI-H or MSI-L population-based probands, and a sample of 300 MSS population-based probands were screened.

Statistical Analysis

We estimated associations using multivariable conditional logistic regression with sibship as the matching factor. Potential confounders that changed the odds ratio (OR) by more than 10% were included in the final model. Tests for linear trend were performed by treating a categorical variable as a continuous variable in the logistic regression model. We evaluated differences in the associations by MSI status and by tumor location by stratifying the matched sets on the tumor characteristics of the case. We assigned the unaffected sibling to the same MSI or tumor site category as the case and included interaction terms in the logistic regression models to estimate these stratum specific ORs. Heterogeneity of the ORs by tumor location and MSI status was evaluated using a likelihood ratio test comparing a model with interaction terms for the stratum specific associations with a model including main effects of the respective smoking or alcohol variable. Analyses were repeated after excluding individuals with a known MMR gene mutation. Statistical analyses were performed using SAS v9.1 for Windows (SAS Institute, Cary, N.C.).


Selected characteristics of the study population are presented in Table 1. The age distribution was similar for CRC cases and unaffected siblings, and the majority of the study population reported non-Hispanic white ethnicity. As expected, the majority of MSI-H tumors were located in the proximal colon, while MSI-L and MSS tumors were more equally distributed throughout the large bowel (i.e. including the rectum) (Table 1).

Table 1
Selected characteristics of the study population

We observed no overall association between CRC and current smoking status, duration of smoking, number of cigarettes smoked per day, or pack years of smoking in age- and sex-adjusted models (Table 2). No potential confounders changed the OR more than 10% and the more parsimonious models are presented. Adjustment for pipe and cigar smoking also did not alter the risk estimates and was not included in the final models. There were statistically significant associations for the highest categories of cigarettes per day and pack years for rectal, but not colon, cancer, with a statistically significant trend over pack years. The relationship between smoking and CRC did not differ for males and females (For > 40 pack years of smoking: OR=1.10, 95% CI 0.78—1.55, p trend 0.24 for males vs. OR=1.33, 95% CI 0.85—2.07, p trend 0.51 for females).

Table 2
Risk of colorectal cancer by smoking status and alcohol consumption overall and by tumor location

In the overall analysis, we observed a small, but statistically significant, increase in risk of CRC in individuals who consumed more than 12 drinks per week compared with non-drinkers (OR=1.21, 95% CI 1.03—1.44, p trend 0.02). This association was observed only for males (OR=1.24, 95% CI 0.94—1.65, p trend 0.05 for males; OR=0.92, 95% CI 0.62—1.35, p trend 0.78 for females). In males who consumed alcohol, 28% reported drinking beer, 9% reported drinking wine, 9% reported drinking hard liquor, and 54% reported drinking more than one type of alcoholic beverage. In women, the corresponding frequencies were 10%, 38%, 13% and 39% for beer, wine, liquor and more than one type. The reported median alcohol consumption was seven drinks per week in both males and females. Alcohol consumption was statistically significantly associated with an increased risk of rectal cancer, while the associations for right or left colon cancer did not reach statistical significance (Table 2). This association was also restricted to males (OR=1.60, 95% CI 0.95—2.68, p trend = 0.03 in males vs. OR=0.87, 95% CI 0.41—1.84, p trend 0.94 in females).

In analyses stratified by tumor MSI status, we observed no association between any smoking variable and risk of MSS CRC (Table 3). However, there was an increased risk of MSI-H CRC with increasing duration of smoking (P trend 0.02) and a statistically non-significant increase for pack-years of smoking (P trend 0.10), although the tests for heterogeneity of ORs by MSI status were not statistically significant. We also observed a statistically significant association between > 40 pack years of smoking and MSI-L CRC (OR=2.03, 95% CI 1.03—4.00). Alcohol consumption was associated only with MSI-L CRC, though in both males and females (OR=2.02, 95% CI 0.78—5.26, p trend 0.08 in males vs. OR=12.3, 95% CI 1.26—120, p trend 0.006 in females).

Table 3
Risk of colorectal cancer by smoking status and alcohol consumption, stratified by MSI status

We repeated the analyses stratified by MSI after excluding 36 MSI-H cases with a known MMR gene mutation (12 MLH1, 18 MSH2 and 6 MSH6). The results did not differ substantially from those shown above (data not shown).


Overall, we did not observe a statistically significant association between smoking and CRC. Duration and pack years of smoking were associated with an increased risk of MSI-H CRC; however, the tests for heterogeneity across categories of MSI status did not reach statistical significance. Our data also suggest that the associations between CRC and both smoking and alcohol consumption were stronger for rectal cancer than for colon cancer, although these differences were not statistically significant.

Results from two recent meta-analyses have suggested a small, but statistically significant association between CRC and smoking status, with evidence that the association is apparent following a long duration of smoking (1, 2). While we did not observe any statistically significant associations for CRC overall, our data are compatible with the summary ORs estimated in these reports. The meta-analysis data also suggested a stronger association for rectal cancer than for colon cancer (1, 2), in general agreement with our findings.

Our data suggest that alcohol consumption is associated with a small increased risk of CRC only for males, and that the association may be stronger for rectal cancer than for colon cancer. A pooled analysis (4) and a meta-analysis (3) of prospective cohort studies have confirmed an increased risk of CRC for individuals who consume large amounts of alcohol. However, data evaluating different effects of alcohol by anatomic location in the colorectum have been mixed, and the data from prospective cohorts suggest that the association with alcohol is similar for colon and rectal cancers (3, 4). Previous studies have reported a stronger association between alcohol consumption and CRC in men than in women, and the WCRF/AICR report concluded that there was convincing evidence for a role of alcohol in CRC in males and probable evidence for a role in females (5).

Several studies have previously reported a stronger association between smoking and MSI-H CRC than for MSS/MSI-L CRC. This association has biological plausibility, as sporadic MSI-H tumors have been hypothesized to arise from a serrated pathway rather than through the traditional adenoma-carcinoma sequence (18), and the association between smoking appears to be stronger for serrated lesions than for adenomatous polyps (19, 20). The stronger association for MSI-H CRC was first reported by Slattery et al. (10) in a large population-based case-control study of colon cancer (N=266 MSI-H cases). Three additional studies using either case-control (11, 13) or case-case (12) comparisons have also supported a stronger association between smoking and MSI-H CRC. In contrast, results from two other studies have not supported this hypothesis (21, 22). A more recent publication suggested that the association between smoking and CRC may be restricted to tumors with the CpG island methylator phenotype (CIMP), regardless of MSI status (23). CIMP status was not available for the tumors included in this analysis, so we were unable to evaluate this hypothesis.

The association between alcohol consumption and MSI status has been evaluated previously using case-control and case-case comparisons (12, 14, 15, 22). Three of these studies suggested that alcohol intake was more strongly associated with MSI-H CRC (12, 14, 15), although the associations were modest and did not reach statistical significance in all studies. These studies did not evaluate the cases with MSI-L tumors as a separate subgroup, and our data suggest that the association between alcohol consumption and CRC risk is strongest in this subgroup. Further studies will be required to clarify this interesting relationship.

This study has several strengths, including the large number of tumors with microsatellite instability typing and the inclusion of MSI-L tumors as a separate subgroup. However, several limitations must be considered. This study uses a case-unaffected sibling design, and it is possible that this may have reduced our power to detect associations between CRC and the lifestyle factors investigated here if these factors were strongly correlated within families. Smoking and alcohol consumption were correlated within sibships in our study population (r = 0.21, p<0.0001 for pack years of smoking and r = 0.11, p<0.0001 for number of drinks per week) attenuating the association of these factors with CRC. There is also the possibility that the unaffected siblings have underlying, but undetected, CRC, which would lead to misclassification of the outcome variable. Recall bias may lead to inaccurate risk estimates if smoking and alcohol consumption were reported more accurately by cases than unaffected siblings. In addition, microsatellite instability status was not available for tumors from 31% of cases in this study; however, the overall associations between smoking, alcohol consumption and CRC risk did not differ substantially for cases with and without tumor MSI data.

In conclusion, we observed no statistically significant associations between smoking and CRC overall; however, we did observe statistically significant associations between smoking and rectal cancer, smoking duration and MSI-H CRC, and pack years of smoking and MSI-L CRC. Alcohol consumption was associated with a modest increased risk of CRC in males, and was also significantly associated with MSI-L CRC in both males and females. These results highlight the potential importance of incorporating tumor characteristics in studies of risk factors for CRC.


The authors would like to thank the CFR study coordinators and data managers who helped prepare the dataset for these analyses as well as the participants in the Colon CFR who have generously donated their time for this project.

Financial Support: This work was supported by the National Cancer Institute, National Institutes of Health under RFA # CA-95-011 and through cooperative agreements with the Australasian Colorectal Cancer Family Registry (U01 CA097735), the USC Familial Colorectal Neoplasia Collaborative Group (U01 CA074799), the Mayo Clinic Cooperative Family Registry for Colon Cancer Studies (U01 CA074800), the Ontario Registry for Studies of Familial Colorectal Cancer (U01 CA074783), the Seattle Colorectal Cancer Family Registry (U01 CA074794), and the University of Hawaii Colorectal Cancer Family Registry (U01 CA074806). J.N.P. was supported in part by NCI T32 CA009142. P.T.C. and J.C.F. were supported in part by National Cancer Institute of Canada post-PhD Fellowships (#18735 and #17602).


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