Small Steps, Big Living: Why What You Don’t Do Matters – Sami Mansfield

Part 3: Risk Reduction — Why What You Don’t Do Matters

In lifestyle medicine, much of the conversation focuses on what we can add: more whole foods, more movement, better sleep, and strength-building habits. But the habits we subtract—those that pose risks to long-term health—can be just as powerful, if not more so.

This isn’t just about patients. Globally, 42% of healthcare providers report experiencing burnout, much of it tied to emotional exhaustion, chronic overload, and systemic stressors in medicine (World Health Organization, 2024). As both patients and professionals, we often focus on doing more, while overlooking the profound impact of simply doing less of what harms us.

In cancer prevention and survivorship, four lifestyle factors stand out as consistently high-risk behaviors that are also highly modifiable: tobacco use, alcohol consumption, sedentary behavior, and sugar-sweetened beverage intake. Small shifts in these areas can dramatically reduce cancer risk and support better survivorship outcomes.

Tobacco: Still the Leading Preventable Cause of Cancer

Tobacco use remains the number one preventable cause of cancer globally, responsible for nearly 20% of all cancer-related deaths (World Health Organization, 2024). The risks are well established: smoking is associated with increased incidence of lung, throat, bladder, pancreatic, and multiple other cancers.

Importantly, quitting tobacco use improves not just long-term health outcomes, but also enhances treatment response, reduces side effects, and promotes recovery in cancer survivors. Smoking cessation support, including behavioral counseling, pharmacotherapy, and ongoing accountability, should be a core part of every survivorship plan.

Alcohol: A Normalized Carcinogen

Alcohol is widely accepted in social settings, including celebrations in survivorship. However, it is also a Group 1 carcinogen, placed in the same category as tobacco and asbestos by the International Agency for Research on Cancer (IARC, 2022).

Contrary to public perception, all types of alcohol—including wine and beer—contribute to cancer risk. No form of alcohol is considered safe when it comes to cancer prevention. A 2020 global analysis found that alcohol use was linked to 6.3 million cancer cases and 3.3 million cancer deaths globally (Rumgay et al., 2021).

In the United States, alcohol is responsible for approximately 100,000 cancer cases and 20,000 cancer-related deaths annually. These numbers exceed the 13,500 annual alcohol-related traffic fatalities (U.S. Department of Health and Human Services, 2024). Yet public awareness remains low.

In January 2024, Surgeon General Vivek Murthy issued an advisory highlighting the preventable cancer burden caused by alcohol and recommending updated health warning labels to reflect this risk. Alcohol is currently the third leading preventable cause of cancer in the U.S., following tobacco use and obesity.

It is linked to at least seven types of cancer, including breast, colorectal, liver, esophageal, oral cavity, pharynx, and larynx. Even one drink per day can increase risk, particularly for hormone-sensitive cancers such as breast cancer. The biological mechanisms behind alcohol-related carcinogenesis include DNA damage, oxidative stress, and increased estrogen levels.

The risks are cumulative and influenced by a range of biological, social, and environmental factors—making education, rather than shame, a critical strategy in reducing harm (U.S. Department of Health and Human Services, 2024).

Sedentary Behavior: The Overlooked Risk Factor

Sedentary behavior, defined as any waking activity performed while sitting or reclining that expends minimal energy, is now recognized as an independent risk factor for cancer and other chronic diseases. Even among individuals who meet exercise guidelines, extended periods of sitting can contribute to metabolic dysfunction and increased mortality risk (Patel et al., 2019).

On average, American adults spend more than nine hours per day seated.

For cancer survivors, especially those undergoing or recovering from treatment, this number is often higher. Research has shown that prolonged sitting is linked to insulin resistance, systemic inflammation, decreased immune function, and poorer treatment tolerance.

A study published in JAMA Oncology revealed that adults with the highest levels of sedentary behavior had an 82% greater risk of cancer-related mortality (Gilchrist et al., 2020). The same study found that replacing just 30 minutes of sedentary time with light physical activity decreased mortality risk by 8%, while replacing it with moderate-intensity activity reduced the risk by 31%.

Even small breaks from sitting—standing, walking, or stretching—can improve circulation, balance hormones, and support overall health. Reducing sedentary time may also support better mood and cognitive function, both of which are crucial for survivorship.

Sugar-Sweetened Beverages: Hidden Calories, Visible Risks

Sugar-sweetened beverages (SSBs) such as sodas, sweetened teas, flavored energy drinks, and juice-based beverages are a leading contributor to added sugar intake in the diet. These drinks contribute significantly to obesity, type 2 diabetes, and metabolic syndrome—all of which are known risk factors for cancer development and recurrence (Chazelas et al., 2019).

SSBs are particularly concerning in survivorship due to their impact on insulin sensitivity, inflammation, and fat storage. Excessive intake of added sugars has been associated with an increased risk of several cancers, including colorectal, pancreatic, and endometrial cancers.

In a large cohort study, consuming just one sugary drink per day was associated with an 18% increased overall cancer risk and a 22% increased risk of breast cancer (Chazelas et al., 2019). Many of these drinks also lead to significant calorie overconsumption without providing nutritional value or satiety.

Reducing SSB intake is a simple but high-yield strategy in survivorship. Alternatives such as water, sparkling water with fruit, unsweetened teas, or naturally flavored infusions can help support hydration, energy, and long-term health.

Action Over Intention: What You Don’t Do Can Save Your Life

In survivorship, we often talk about what to add. But what we subtract may be just as impactful. Let’s flip the conversation.

If you’re a survivor:

Be honest with yourself about alcohol use.
Talk to your care team if you need support with tobacco cessation.
Set a timer to stand and stretch every hour—especially during long workdays or evening TV time.

If you’re a clinician:

Don’t avoid the hard topics.
Make alcohol, tobacco, and sedentary behavior part of the conversation.
Offer education and support—not silence or shame.

If you’re supporting someone you love:

Encourage movement breaks.
Don’t pressure with “just one glass.”
Be a partner in accountability, not judgment.

The Bottom Line

What we do – like building strength, eating plants, and walking more—matters.
But what we don’t do – like smoking, drinking excessively, or sitting too long—can be just as impactful.

Lifestyle medicine isn’t just about doing more.
It’s about doing what matters most—and removing what no longer serves your health or healing.

References

Chazelas, E., Srour, B., Desmetz, E., Kesse-Guyot, E., Julia, C., Deschasaux, M., … & Touvier, M. (2019). Sugary drink consumption and risk of cancer: results from NutriNet-Santé prospective cohort. BMJ, 366, l2408. https://pubmed.ncbi.nlm.nih.gov/31292122/

Gilchrist, S. C., Howard, V. J., Akinyemiju, T., Judd, S. E., Cushman, M., Hooker, S. P., … & Diaz, K. M. (2020). Association of sedentary behavior with cancer mortality in middle-aged and older US adults. JAMA Oncology, 6(8), 1210–1217. 

International Agency for Research on Cancer (IARC). (2022). IARC Monographs on the Identification of Carcinogenic Hazards to Humans

Patel, A. V., Maliniak, M. L., Rees-Punia, E., Matthews, C. E., Gapstur, S. M. (2019). Prolonged leisure-time sitting in relation to cause-specific mortality in a large US cohort. American Journal of Epidemiology, 187(3), 423–433.

Rumgay, H., Shield, K., Charvat, H., Ferrari, P., Sornpaisarn, B., Obot, I., … & Soerjomataram, I. (2021). Global burden of cancer in 2020 attributable to alcohol consumption: a population-based study. The Lancet Oncology, 22(8), 1071–1080.

U.S. Department of Health and Human Services. (2024). Surgeon General’s Advisory on Alcohol and Cancer Risk.

World Health Organization. (2024). Global Strategy on Human Resources for Health: Workforce 2030. 

 Written by Sami Mansfield

Sami Mansfield is an exercise oncology and lifestyle medicine consultant with endless curiosity and persistence. As the founder of Cancer Wellness for Life, Sami Mansfield has dedicated her career to empowering cancer survivors and clinicians through innovative, evidence-based programs that improve health outcomes while optimizing cost-efficiency.

Sami is a contributing author to groundbreaking guidelines, including the ASCO Guidelines on Exercise, Nutrition, and Weight Management, and has helped shape numerous state cancer control plans.

Sami Mansfield is the current chair of the Cancer Member Interest Group for the American College of Lifestyle Medicine, where she drives forward initiatives emphasizing the connection between science and implementation. Her patient-facing programs like BUILD and My Lifestyle Shift have reached global audiences, transforming lives through the pillars of lifestyle medicine.

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