'IF You Drink Alcohol, THEN You Will Get Cancer': Investigating How Reasoning Accuracy Is Affected by Pictorially Presented Graphic Alcohol Warnings

Perception is reality: qualitative insights into how consumers perceive alcohol warning labels

AIMS

This study explores perspectives of on-pack alcohol warning labels, and how they might influence alcohol purchase and/or consumption behavior to inform culturally appropriate label design for effective behavior change.

METHODS

New Zealand participants ≥18 years, who reported having purchased and consumed alcoholic beverages in the last month were recruited via a market research panel and grouped into 10 focus groups (n = 53) by ethnicity (general population, Māori, and Pacific peoples), age group, and level of alcohol consumption. Participants were shown six potential alcohol health warning labels, with design informed by relevant literature, label framework, and stakeholder feedback. Interviews were transcribed and analyzed via qualitative (directed) content analysis.

RESULTS

Effective alcohol labels should be prominent, featuring large red and/or black text with a red border, combining text with visuals, and words like "WARNING" in capitals. Labels should contrast with bottle color, be easily understood, and avoid excessive text and confusing imagery. Participants preferred specific health outcomes, such as heart disease and cancer, increasing message urgency and relevance. Anticipated behavior change included reduced drinking and increased awareness of harms, but some may attempt to mitigate warnings by covering or removing labels. Contextual factors, including consistent design and targeted labels for different beverages and populations, are crucial. There was a strong emphasis on collective health impacts, particularly among Māori and Pacific participants.

CONCLUSIONS

Our findings indicate that implementing alcohol warning labels, combined with comprehensive strategies like retail and social marketing campaigns, could effectively inform and influence the behavior of New Zealand's varied drinkers.

A systematic review on the impact of alcohol warning labels

Findings on the effects of alcohol warning labels (AWLs) as a harm reduction tool have been mixed. This systematic review synthesized extant literature on the impact of AWLs on proxies of alcohol use. PsycINFO, Web of Science, PubMED, and MEDLINE databases and reference lists of eligible articles. Following PRISMA guidelines, 1,589 articles published prior to July 2020 were retrieved via database and 45 were via reference lists (961 following duplicate removal). Article titles and abstracts were screened, leaving the full text of 96 for review. The full-text review identified 77 articles meeting inclusion/exclusion criteria which are included here. Risk of bias among included studies was examined using the Evidence Project risk of bias tool. Findings fell into five categories of alcohol use proxies including knowledge/awareness, perceptions, attention, recall/recognition, attitudes/beliefs, and intentions/behavior. Real-world studies highlighted an increase in AWL awareness, alcohol-related risk perceptions (limited findings), and AWL recall/recognition post-AWL implementation; these findings have decreased over time. Conversely, findings from experimental studies were mixed. AWL content/formatting and participant sociodemographic factors also appear to influence the effectiveness of AWLs. Findings suggest conclusions differ based on the study methodology used, favoring real-world versus experimental studies. Future research should consider AWL content/formatting and participant sociodemographic factors as moderators. AWLs appear to be a promising approach for supporting more informed alcohol consumption and should be considered as one component in a comprehensive alcohol control strategy.

Alcohol Health Warning Labels: A Rapid Review with Action Recommendations

A rapid review of research on health warning labels located on alcohol containers (AWLs) was conducted. Using five search engines (Embase, Medline, Pubmed, Scopus, Psyinfo), 2975 non-duplicate citations were identified between the inception date of the search engine and April 2021. Of those, 382 articles were examined and retrieved. We selected 122 research papers for analysis and narrative information extraction, focusing on population foci, study design, and main outcomes. Research included public opinion studies, surveys of post-AWL implementation, on-line and in-person experiments and real-world quasi-experiments. Many studies focused on the effects of the 1989 United States Alcoholic Beverage Labeling Act on perceptions, intentions and behavior. Others focused on Australia, Canada, the United Kingdom, England or Scotland, Italy and France. There was substantial variation in the design of the studies, ranging from small-scale focus groups to on-line surveys with large samples. Over time, evidence has been emerging on label design components, such as large size, combination of text and image, and specific health messaging, that is likely to have some desired impact on knowledge, awareness of risk and even the drinking behavior of those who see the AWLs. This body of evidence provides guidance to policy-makers, and national and regional authorities, and recommendations are offered for discussion and consideration.

Effects of alcohol warning labels on alcohol-related cognitions among German adolescents: A factorial experiment

There is evidence that alcohol warning labels (AWL) can have preventive effects on alcohol-related cognitions and behavior, but it is less clear how children and adolescents react to AWL. A total of 9260 German students aged 10-17 participated in a three-factorial experiment, embedded in a health survey. The first experimental factor was the position of the AWL on the questionnaire (before vs. after alcohol items). The second factor was the type of AWL (text only vs. text plus picture). The third factor was the content of the AWL (one out of a pool of ten). Dependent variables were knowledge about alcohol-related risks, self-reports of alcohol use, and negative emotions. Regression analyses revealed that exposure to an AWL significantly increased knowledge about alcohol-related risks. AWL exposure did not influence self-reports of alcohol use in the total sample, but a significant interaction for PositionXAge indicated that older students (15+ years) less frequently reported lifetime (79.8% vs. 84.2%) and current (50.5% vs. 56.6%) use of alcohol if they were exposed to an AWL. Overall, text-only AWL elicited less negative emotions than text-and-picture based AWL. The experiment indicates that exposure to an AWL affected alcohol-related cognitions of children and adolescents. This was true for both, text-based or picture-and-text-based labels. Pictorial messages seem to be more potent to elicit emotions, at least for recipients that already have experience with alcohol use. Future research needs to further explore the long-term effects of repeated exposure to the same message contents.

Image-and-text health warning labels on alcohol and food: potential effectiveness and acceptability

BACKGROUND

Health warning labels (HWLs) using images and text to depict the negative health consequences of tobacco consumption are effective and acceptable for changing smoking-related outcomes. There is currently limited evidence concerning their potential use for reducing consumption of alcoholic drinks and energy-dense foods. The aim of this research was to describe the potential effectiveness and acceptability of image-and-text (also known as pictorial or graphic) HWLs applied to: i. alcoholic drinks and ii. energy-dense snack foods.

METHODS

Two online studies were conducted using between-subjects designs with general population samples. Participants rated one of 21 image-and-text HWLs on alcoholic drinks (n = 5528), or one of 18 image-and-text HWLs on energy-dense snacks (n = 4618). HWLs comprised a graphic image with explanatory text, depicting, respectively, seven diseases linked to excess alcohol consumption, and six diseases linked to excess energy intake. Diseases included heart disease and various cancers. Outcomes were negative emotional arousal, desire to consume the labelled product, and acceptability of the label. Free-text comments relating to HWLs were content analysed.

RESULTS

For both alcoholic drinks and energy-dense snacks, HWLs depicting bowel cancer generated the highest levels of negative emotional arousal and lowest desire to consume the product, but were the least acceptable. Acceptability was generally low for HWLs applied to alcohol, with 3 of 21 rated as acceptable, and was generally high for snacks, with 13 of 18 rated as acceptable. The majority of free-text comments expressed negative reactions to HWLs on alcohol or energy-dense snacks.

CONCLUSIONS

Image-and-text health warning labels depicting bowel cancer showed greatest potential for reducing selection and consumption of alcoholic drinks and energy-dense snacks, although they were the least acceptable. Laboratory and field studies are needed to assess their impact on selection and consumption.

The effectiveness of current French health warnings displayed on alcohol advertisements and alcoholic beverages

Background

Many countries use health warnings in an attempt to regulate alcohol consumption. However, there is a lack of conclusive evidence in the research on alcohol warnings to support decision-making on effective health policies. This study explores the effectiveness of two mandatory warnings introduced in France in 1991 and 2007: the first (Alcohol abuse is harmful) is displayed on alcohol advertisements; the second (a pictogram) on bottles. Given that advertising content regulations have been implemented in some countries to reduce the attractiveness of alcohol marketing (e.g. the Evin law in France), this research also aims to explore whether such regulations can improve the effectiveness of warnings.

Methods

In-depth interviews were conducted with 26 French people aged 15-29 years. The effectiveness of health warnings was assessed in terms of recall, noticeability, credibility, comprehension, responsiveness, and ability to encourage moderate drinking and abstinence during pregnancy. Participants were shown alcohol advertisements and bottles that either followed or challenged content regulations. The data were analyzed using double manual coding and NVivo software.

Results

While both warnings suffered from a lack of visibility and noticeability due to their size, location, and outdatedness and because of competition from marketing design elements, the warning on the advertisement that followed content regulations was most visible. Both warnings were considered to be informationally vague, lacking in credibility and ineffective in terms of making participants feel concerned and influencing consumption habits.

Conclusions

Current French warnings are ineffective and require modification. Improvements are suggested regarding the design and content of warnings to help increase their effectiveness.

A Qualitative Investigation of Australian Young Adult Responses to Pictorial and Graphic Alcohol Product Warnings

This qualitative study aimed to understand whether pictorial and graphic alcohol warnings would be an effective intervention to reduce alcohol-related harms among young adult drinkers. Four focus groups ( n = 26) were conducted examining impressions, reactions, and thoughts about five pictorial warnings and five graphic warnings. Students (58% female) from Melbourne, Australia, aged 18 to 25 years who consumed alcohol participated. The warnings used in this study elicited strong negative emotional reactions, including avoidance. While the use of images increased the salience of the warnings, participants discussed the likelihood of habituation, indicating warning rotation is needed. Targeted messages and statistics appealed to the participants. However, they were unlikely to change their drinking behavior due to the warnings. Consistent with tobacco warning literature, and in line with behavior change and message persuasion theory, warning labels with photographic images and targeted statistics were found to have the most persuasive impact against risky drinking within this sample.