Publications

By Carolina Espina PhD, MPH, Scientist, International Agency for Research on Cancer (IARC/WHO)

The 5th edition of the European Code Against Cancer (ECAC) has been launched this year but why is the ECAC important? And why do we need to keep updating it [1]?

In essence, the ECAC is the most comprehensive and evidence-based educational tool on cancer prevention for the European citizens. But the ECAC is not static, each edition:

• • • incorporates new scientific evidence
    • makes the science easier for everyone to understand in order to reach as many Europeans as possible, and in particular,
    • the 5th edition, is the first to include suggested polices that decision-makers should prioritise for fastest and most effective cancer prevention.

The 5th edition of the ECAC includes 14 recommendations that speak directly to people. The more recommendations that an individual follows, the more their cancer risk can be reduced. Research has repeatedly shown that around 40% of cancers are due to risk factors that can be mitigated [2]. We also know that certain interventions effectively and safely reduce the risk of developing cancer and lower the mortality from this disease [3,4,5].

Traditional health behaviour models have proposed knowledge as an antecedent of preventive behaviour [6,7], as health literacy affects people’s capacity to make informed decisions, manage their own health, and navigate health systems. People have the right to access the most reliable and scientifically sound information, but information alone does not change unhealthy behaviours nor persuade people to participate in prevention programmes. The system must facilitate action.

Beyond Information: The Mandate for Policy Reform

That is the reason why the 5th edition of the ECAC also speaks to policymakers – first, as citizens themselves, but also as actors of change. They have the mandate and the power to implement and enforce the population-based measures that are needed to make prevention possible. We know what these measures are and that they work, and the 5th edition of the ECAC summarizes them in 14 policy recommendations ready to be implemented. Some even carry legal force towards EU Member States, as they are based on EU Directives and Regulations. This is the case of the recommendation to regulate tobacco products, packaging, and advertising, backed by the WHO Framework Convention on Tobacco Control and the Directive 2014/40/EU on the manufacture, presentation, and sale of tobacco and related products; the Directive (2010/13/EU) to restrict advertising of alcohol and unhealthy food, especially to children; the Directive (EU) 2024/2881 on ambient air quality and cleaner air for Europe; or the Directive 2004/37/EC on the protection of workers from carcinogens, mutagens, or reprotoxic substances.

We have the tools, yet cancer continues to rise as a public health problem with large disparities in cancer burden across countries [8]. ECAC includes new risk factors and preventive interventions in each edition yet reminds us that the “old” problems are still persistent in many parts of Europe. We have ECAC in the EU for almost 40 years, we lack however a systematic monitoring and evaluation system to deliver its impact at both individual and structural level.

Let’s call for a collective engagement and responsibility to strengthen evidence-based prevention, from public awareness to policy implementation across Europe.

Sources

[1] Espina C, et al.; Working Groups of Scientific Experts. European Code Against Cancer 5th edition: 14 ways you can help prevent cancer. Lancet Reg Health Eur. 2026 Jan 23;63:101592.

[2] Fink H, et al. Global and regional cancer burden attributable to modifiable risk factors to inform prevention. Nat Med. 2026 Apr;32(4):1306-1315.

[3] Jansen EEL, et al.; EU-TOPIA consortium. Effect of organised cervical cancer screening on cervical cancer mortality in Europe: a systematic review. Eur J Cancer. 2020 Mar;127:207-223.

[4] Gini A, et al.; EU-TOPIA consortium. Impact of colorectal cancer screening on cancer-specific mortality in Europe: A systematic review. Eur J Cancer. 2020 Mar;127:224-235.

[5] Zielonke N, et al.; EU-TOPIA consortium. Evidence for reducing cancer-specific mortality due to screening for breast cancer in Europe: A systematic review. Eur J Cancer. 2020 Mar;127:191-206.

[6] Becker MH. The health belief model and sick role behavior. Health Educ Monogr. 1974;2(4):409–19.

[7] Jayanti RK, Burns AC. The antecedents of preventive health care behavior: an empirical study. J Acad Mark Sci. 1998;26(1):6–15

[8] Vaccarella S, et al. Socioeconomic inequalities in cancer mortality between and within countries in Europe: a population-based study. Lancet Reg Health Eur. 2022 Nov 28;25:100551.