Smoking, drinking, and dietary habits linked to head and neck cancer risk, study finds

A recent JAMA Otolaryngoly-Head Neck Surgery explores the association between the risk of developing head and neck cancer (HNC) and smoking, drinking, and dietary habits.

Study: Smoking, Drinking, and Dietary Risk Factors for Head and Neck Cancer in Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial Participants. Image Credit: create jobs 51 /

What causes HNC?

In 2020, HNC accounted for 3.4% of new cancer cases and 2.5% of deaths in the United States. Smoking and drinking have been established as risk factors for HNC; however, their association with various subsites of the head and neck remains unclear.

Previous studies have used the European Prospective Investigation into Cancer and Nutrition (EPIC) data to evaluate the effects of alcohol, tobacco, and diet on HNC. Large-scale prospective trials are ideal for identifying novel risk factors; however, these types of studies are often expensive.

About the study

In the United States, the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial used questionnaires and follow-up interviews with patients to gather data on smoking, drinking, and diet patterns. Data from this cohort was used to perform a nested cohort survival analysis to elucidate the role of these risk factors in the development of HNC. Relevant human papillomavirus (HPV) data was also included from previous studies. 

The participants were recruited across ten centers in the U.S. between November 1993 and July 2001. All study participants were between 55 and 74 years years of age, with HNC patients matched with healthy controls based on family history of HNC and demographics to analyze smoking habits.

To analyze diet and drinking habits, matching was performed on smoking status and duration in addition to demographics and family history of HNC. Data were analyzed between January and November of 2023, and the primary outcome variable was the diagnosis of HNC.

Key findings

The smoking-associated cancer risk increased with greater proximity of the lungs to the head and neck subsite. The most significant cancer risks were associated with the larynx, oropharynx, and oral cavity in descending order. This is related to the airflow patterns during cigarette smoking, whereby smoke travels from the oral cavity to the oropharynx to the larynx. This finding is consistent with prior research on HNC risk associated with smoking.

Statistically significant associations were observed between HNC risk and smoking status, frequency, and duration. Duration was more significantly associated with HNC than frequency, which could be due to the inaccurate carcinogen exposure metric provided by the frequency measured by cigarettes each day.

Heavy drinking was associated with an increased risk of HNC, particularly for the heavy consumption of liquor and beer rather than wine. There was no effect noted for moderate drinking, with the absence of any interaction effect between smoking and drinking also observed. Nevertheless, further research is needed to determine whether a safe level of alcohol consumption exists in relation to the risk of developing HNC.

Overall, healthy eating was associated with a modest reduction in HNC risk. Healthy eating was based on the increased consumption of dark green and orange vegetables, fruits, and whole grains. Non-whole grains, potatoes, and red meat were not associated with a reduced risk of HNC. 


The risk of smoking-associated HNC was higher for subsites that were closer to the lung, whereas heavy drinking of beer and liquor, rather than wine, was associated with a greater risk of HNC. Overall healthy eating was also associated with a modest reduction in HNC risk, particularly when an individual reported consuming whole fruits and whole grains. These findings reiterate the importance of reducing smoking and drinking, as well as engaging in healthy eating habits to reduce the risk of developing HNC. 

A vital limitation of the current study included selection bias in the study population, which prevented the meaningful assessment of HNC risk associated with dietary and drinking habits by subsite. An additional limitation was associated with small sample sizes for nasopharynx and hypopharynx cancer. Furthermore, the lack of racial and ethnic diversity in the PLCO cohort limits the generalizability of the study findings. 

Journal reference:

  • Lander, P. D., Kallogheri, D., & Piccirillo, J. F. (2024) Smoking, Drinking, and Dietary Risk Factors for Head and Neck Cancer in Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial Participants. JAMA Otolaryngology-Head & Neck Surgery. doi:10.1001/jamaoto.2023.4551, 


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