Associations Between Physical Activity and Alcohol Consumption in Rural Cancer Survivors

Purpose Rural adults and cancer survivors are more likely to be physically inactive and exceed recommendations for alcohol use. Physical activity and alcohol use are positively associated in adults and cancer survivors but associations between physical activity and alcohol use in rural cancer survivors is unknown. This cross-sectional study explored associations between physical activity, sitting time, and alcohol use in rural cancer survivors. Methods Cancer survivors residing in central Pennsylvania were recruited to the Partnering to Prevent and Control Cancer (PPCC) study and completed mailed questionnaires assessing physical activity (low, moderate, high), sitting time (<6 or ≥6 hours/day), and alcohol use (0 or ≥1 drinks/week). Binary logistic regression models tested associations between physical activity, sitting time, and alcohol use, adjusting for age, gender, and education. Results Participants (N=219) were in their mid-60s (M age=64.5 ± 12.2 years, 60.7% female), overweight (M BMI=29.6 ± 6.9 kg/m2), and 50.5% were college graduates. Nearly half of participants were breast (22.8%) or prostate (20.5%) cancer survivors and 90.4% were >12 weeks but <5 years post-treatment. Participants self-reported meeting physical activity recommendations (79.5%), sitting <6 hours/day (53.3%), and consuming ≥1 alcoholic drinks/week (54.1%). Participants who reported being moderately (OR=5.0, 95% CI: 1.9-12.9) or highly (OR=4.5, 95% CI: 1.9-10.9) active had higher odds of reporting alcohol use, after adjusting for covariates. Conclusion Results mirror positive associations seen in adults and other subgroups (e.g., racial/ethnic minority adults). Cancer control efforts should stress being physically active while emphasizing messaging to curtail increases in alcohol use among rural cancer survivors.


INTRODUCTION
Physical inactivity and alcohol use are common behaviors associated with increased cancer risk (1)(2)(3)(4)(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)(10)(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.

METHODS
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 domainspecific (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 Abbreviations: CI, Confidence interval; IPAQ, International Physical Activity Questionnaire; OR, Odds ratio; PPCC, Partnering to Prevent and Control Cancer. 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. 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.

DISCUSSION
Physical activity and alcohol use were positively associated in rural cancer survivors in this study, mirroring results for adults (9)(10)(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)(29)(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)(32)(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.).

CONCLUSIONS
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.

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

ETHICS STATEMENT
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.

AUTHOR CONTRIBUTIONS
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.

FUNDING
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.