Physical inactivity and alcohol use are common behaviors associated with increased cancer risk (1–5). Physical activity recommendations for adults are 150 minutes of moderate intensity or greater aerobic activity and muscle-strengthening activities at least two days per week (6). Recommendations for alcohol use in adults are to not drink at all or to drink in moderation by limiting intake to two drinks or less per day for men; and 1 drink or less per day for women (7). Although health risk behaviors are expected to cluster in a functionally consistent manner (8), physical activity has consistently been associated with greater alcohol use (9–11). However, we are not aware of any studies that examined this association in rural cancer survivors. Adults residing in rural areas tend to be older, poorer, and sicker (12) and engage in more health risk behaviors than their urban counterparts (13). In addition to being less active and more sedentary (14, 15), rural adults tend toward extremes of alcohol use compared to their urban counterparts (16). Although more likely to abstain from alcohol use, rural adults who drink alcohol are more likely to be moderate or heavy drinkers (13). Furthermore, over half of cancer survivors in the United States identify as drinkers (17, 18).

To our knowledge, only one study has examined associations between physical activity and alcohol use in cancer survivors and found that survivors who engaged in greater light intensity physical activity were more likely to consume alcohol (19). That study focused on urban breast cancer survivor, and it is unclear whether findings would generalize to rural cancer survivors or hold true for sedentary behavior. Thus, we explored associations between physical activity, sitting time, and alcohol use in a sample of rural cancer survivors and hypothesized that physical activity would be positively associated with alcohol use in this secondary analysis.

Rural cancer survivors were recruited to a cross-sectional study to understand barriers and preferences for physical activity adoption and maintenance. The study was approved by the Institutional Review Boards at The Pennsylvania State University and The University of Texas MD Anderson Cancer Center and informed consent was provided prior to participation. Detailed descriptions of recruitment methods, participants, and procedures have been published previously and are described briefly below (20, 21).

Eligible adults had a history of cancer, lived within a 28-county area in central Pennsylvania, and were English-speaking. Participants were mailed a brief questionnaire assessing demographics (e.g., age, gender, education) and cancer history (e.g., type, time since diagnosis, treatment status). Participants who returned the brief questionnaire were enrolled in the study and sent additional questionnaires assessing physical activity, sitting time, and alcohol use. The International Physical Activity Questionnaire (IPAQ) long form was used to assess physical activity and sitting time (22, 23). The IPAQ assesses domain-specific (e.g., occupation, leisure-time) and intensity-based (e.g., moderate, vigorous) physical activity. Participants reported the frequency and duration for each activity over the last 7 days and the average duration of sitting time on weekends and weekdays. To assess alcohol use over the past three months, participants were asked to report the number of drinks consumed on average for each day of the week, the maximum number of drinks they consumed on any one occasion, and the number of times they consumed five or more drinks over the past three months (24). A drink was defined as one beer, one wine cooler, one glass of wine, one shot, or one mixed drink.

Physical activity, sitting time, and alcohol use were categorized as shown in Table 1 and binary logistic regression models were used to explore associations between physical activity, sitting time, and alcohol use, adjusting for age, gender, and education. Statistical analyses were performed using SPSS version 24 (IBM SPSS Inc., Armonk, NY). All statistical tests were 2-sided, and p less than .05 was considered statistically significant.

Of the 263 rural cancer survivors enrolled in PPCC, 219 (83.3%) completed all questionnaires. Participant characteristics, physical activity, sitting time, and alcohol use are shown in Table 1 . Participants were mostly women, in their mid-60s with overweight or obesity and reported high socioeconomic status. Nearly half of the participants were post-treatment breast or prostate cancer survivors.

Most cancer survivors self-reported meeting (29.7%) or exceeding (49.8%) physical activity recommendations of 150 minutes of moderate or greater-intensity physical activity each week (6, 25). Compared to those who reported low (24.4%) physical activity and did not meet recommendations, more cancer survivors who reported moderate (58.7%) or high (63.1%) physical activity drank alcohol at least once per week [χ²(2)=18.5, p<.001]. Physical activity was not significantly associated with binge drinking [χ²(2)=5.1, p=.078], and sitting time was not associated with either alcohol use [χ²(1)=2.2, p=.138] or binge drinking [χ²(1)=0.9, p=.334].

Associations between physical activity, sitting time, and alcohol use are shown in Table 2 . Cancer survivors who reported moderate (OR=4.4, 95% CI: 1.8-10.5) or high (OR=5.3, 95% CI: 2.3-12.0) physical activity had over four times the odds of consuming alcohol at least once per week than those who reported low activity in unadjusted models. After adjusting for age, gender, and education, cancer survivors who reported moderate (OR=5.0, 95% CI: 1.9-12.9) or high (OR=4.5, 95% CI: 1.9-10.9) physical activity had greater odds of consuming alcohol than those who reported low physical activity. There were no significant associations between physical activity and binge drinking or sitting time and alcohol use in unadjusted or adjusted models.

Physical activity and alcohol use were positively associated in rural cancer survivors in this study, mirroring results for adults (9–11) and other subgroups, including African American adults, Mexican American adults, and cancer survivors (19, 26, 27). Understanding the co-occurrence of behavioral risk factors is critical to developing effective behavioral interventions to reduce cancer risk and recurrence (28–30). Our results emphasize the need for multiple health behavior change interventions that stress the importance of being physically active while curtailing alcohol use among rural cancer survivors.

Although there has been recent emphasis on the link between alcohol and cancer, the cancer burden due to alcohol is not fully understood (31–33) and less is known about how alcohol impacts cancer survivorship, long-term outcomes, and cancer health disparities (34). Our findings work toward filling that gap for rural cancer survivors who tend to be less physically active and report greater alcohol consumption (14, 16). Limitations of this study include the cross-sectional design, which limits causal inferences, the use of self-reported measures of physical activity and alcohol use, potential sample bias, as the sample was predominantly non-Hispanic White and reported moderate to high socioeconomic status, and the limited generalizability of findings to other countries and populations with greater diversity (e.g., racial and ethnic minority groups, low-income, etc.).

Physical activity and alcohol use were positively associated in rural cancer survivors in this study. Additional research is needed to further characterize rural cancer survivors who are physically active and drink alcohol and to identify common motivational, social, and environmental factors (e.g., stress management, peer influence, and community resources) related to these co-occurring behaviors. Comprehensive cancer control strategies are needed that address multiple health behaviors to create synergies, optimize risk reduction, and reduce health disparities.

The datasets analyzed for this study are available from the corresponding author upon reasonable request.

This study was reviewed by the Institutional Review Boards at The Pennsylvania State University (STUDY00006779) and The University of Texas MD Anderson Cancer Center (Protocol ID 2021-0138), and informed consent was provided prior to participation. The patients/participants provided their written informed consent to participate in this study.

SM obtained funding, collected data, and performed statistical analyses. SM, NH, and DC designed the study. SM, HJ and DC drafted the original manuscript, and NH, HJ, and DC reviewed and edited the manuscript. All authors contributed to the article and approved the submitted version.

This work was supported by a grant with the Pennsylvania Department of Health using Tobacco CURE Funds (TRK08-Mama-PSU-2016F to SM). SM is supported by a career development award from the National Cancer Institute at the National Institutes of Health (grant number K07 CA222335). The funders had no role in the design of the study; the collection, analysis, and interpretation of data; the writing of the manuscript; or the decision to submit the manuscript for publication. The Pennsylvania Department of Health specifically disclaims responsibility for any analyses, interpretations or conclusions.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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