Commentary on 'Communicating Messages About Drinking': Using the 'Big Legal Guns' to Block Alcohol Health Warning Labels

"I Can See a Story from the Warning": Understanding the Role of Perceived Narrativity in Pictorial Warning Labels

This study examined the role of perceived narrativity in pictorial warning labels (PWLs) in countering warning reactance and increasing warning effectiveness and support in the context of communicating the cancer risk of alcohol. Findings from a randomized experiment (N = 1,188) showed that PWLs with imagery of lived experience were perceived higher in narrativity than those with imagery of graphic health effects. Adding a one-sentence narrative (vs. non-narrative) text statement to PWLs with imagery of lived experience did not affect perceived narrativity. Perceived narrativity predicted lower reactance to warnings and subsequently higher intentions to stop drinking and higher policy support. Total effects showed that PWLs with imagery of lived experience and non-narrative text led to the lowest reactance, the highest intentions to stop drinking, and the highest level of policy support. This study adds to a growing body of evidence that PWLs featuring narrative content are promising in communicating health risks.

Evolution of the major alcohol companies key global policy vehicle through the prism of tax records 2011-19

BACKGROUND

Important insights have been generated into the nature of the activities of the International Center for Alcohol Policies (ICAP). Its successor, the International Alliance for Responsible Drinking (IARD) is less well understood. This study aims to rectify evidence limitations on the political activities of the alcohol industry at the global level.

METHODS

Internal Revenue Service filings were examined for ICAP and IARD each year between 2011 and 2019. Data were triangulated with other sources to establish what could be gleaned on the internal workings of these organisations.

RESULTS

The stated purposes of ICAP and IARD are near identical. The main declared activities were similar for both organisations and comprised public affairs/policy, corporate social responsibility, science/research and communications. Both organisations work extensively with external actors and it has become possible more recently to identify the main contractors supplying services to IARD.

DISCUSSION

This study sheds light on the political activities of the alcohol industry at the global level. It suggests that the evolution of ICAP into IARD has not been accompanied by shifts in the organisation and activities of the collaborative efforts of the major alcohol companies.

CONCLUSION

Alcohol and global health research and policy agendas should give careful attention to the sophisticated nature of industry political activities.

International investment liberalization, transnational corporations and NCD prevention policy non-decisions: a realist review on the political economy of tobacco, alcohol and ultra-processed food

BACKGROUND

Public health concerns relating to international investment liberalization have centred on the potential for investor-state dispute settlement (ISDS)-related regulatory chill. However, the broader political and economic dimensions that shape the relationship between the international investment regime and non-communicable disease (NCD) policy development have been less well explored. This review aimed to synthesise the available evidence using a political economy approach, to understand why, how and under what conditions transnational corporations may use the international investment regime to promote NCD prevention policy non-decisions.

MAIN BODY

Methods: Mechanisms explaining why/how the international investment regime may be used by transnational health-harmful commodity corporations (THCCs) to encourage NCD prevention policy non-decisions, including regulatory chill, were iteratively developed. Six databases and relevant grey literature was searched, and evidence was extracted, synthesized and mapped against the various proposed explanatory mechanisms.

FINDINGS

Eighty-nine sources were included. THCCs may be incentivised to use the ISDS mechanism since the costs may be outweighed by the benefits of even just delaying regulatory adoption, particularly since the chilling effect tends to ripple out across jurisdictions. Drivers of regulatory chill may include ambiguity in treaty terms, inconsistency in arbitral rulings, potential arbitrator bias and the high cost of arbitration. Evidence indicates ISDS can delay policy adoption both within the country directly involved but also in other jurisdictions. Additionally, governments are adopting standard assessments of public health regulatory proposals for trade and ISDS risk. Various economic, political and industry-related factors likely interact to increase (or decrease) the ultimate risk of regulatory chill. Some evidence indicates that THCCs take advantage of governments' prioritization of foreign investment over NCD prevention objectives to influence the NCD prevention regulatory environment.

CONCLUSIONS

While ISDS-related regulatory chill is a real risk under certain conditions, international investment-related NCD prevention policy non-decisions driven by broader political economy dynamics may well be more widespread and impactful on NCD regulatory environments. There is therefore a clear need to expand the research agenda on investment liberalization and NCD policy beyond regulatory chill and engage with theories and approaches from international relations and political science, including political economy and power analyses.

Corporate power and the international trade regime preventing progressive policy action on non-communicable diseases: a realist review

Transnational tobacco, alcohol and ultra-processed food corporations use the international trade regime to prevent policy action on non-communicable diseases (NCDs); i.e. to promote policy 'non-decisions'. Understanding policy non-decisions can be assisted by identifying power operating in relevant decision-making spaces, but trade and health research rarely explicitly engages with theories of power. This realist review aimed to synthesize evidence of different forms and mechanisms of power active in trade and health decision-making spaces to understand better why NCD policy non-decisions persist and the implications for future transformative action. We iteratively developed power-based theories explaining how transnational health-harmful commodity corporations (THCCs) utilize the international trade regime to encourage NCD policy non-decisions. To support theory development, we also developed a conceptual framework for analysing power in public health policymaking. We searched six databases and relevant grey literature and extracted, synthesized and mapped the evidence against the proposed theories. One hundred and four studies were included. Findings were presented for three key forms of power. Evidence indicates THCCs attempt to exercise instrumental power by extensive lobbying often via privileged access to trade and health decision-making spaces. When their legitimacy declines, THCCs have attempted to shift decision-making to more favourable international trade legal venues. THCCs benefit from structural power through the institutionalization of their involvement in health and trade agenda-setting processes. In terms of discursive power, THCCs effectively frame trade and health issues in ways that echo and amplify dominant neoliberal ideas. These processes may further entrench the individualization of NCDs, restrict conceivable policy solutions and perpetuate policymaking norms that privilege economic/trade interests over health. This review identifies different forms and mechanisms of power active in trade and health policy spaces that enable THCCs to prevent progressive action on NCDs. It also points to potential strategies for challenging these power dynamics and relations.

Industry submissions on alcohol in the context of Australia's trade and investment agreements: A content and thematic analysis of publicly available documents

INTRODUCTION AND AIMS

Alcohol use is a leading risk factor for death and disability, responsible for 3 million deaths in 2016. The alcohol industry is a powerful player in shaping trade and investment rules in ways that can constrain the ability of governments to regulate alcoholic beverages to reduce harm. This paper analyses publicly available submissions about alcohol in the context of Australia's free trade agreements to determine the key themes put forward by industry.

DESIGN AND METHODS

We searched for submissions made to the Department of Foreign Affairs and Trade by alcohol industry trade associations, alcohol manufacturers, distributors and retailers, general industry association, and government agencies with responsibilities for alcohol trade, about specific free trade agreements involving Australia. Thirty-one submissions in relation to eight trade agreements were included for analysis. The analysis involved both descriptive content analysis and thematic analysis.

RESULTS

Findings suggest that industry is actively seeking to shape trade negotiations around alcohol. Priority issues for the industry include improving market access, harmonising regulation, improving clarity and transparency, reducing the burden of regulation and preventing monopolies on product names.

DISCUSSION AND CONCLUSION

The alcohol industry and associated business and government organisations are actively working to influence trade agreement negotiations for industry economic gain, arguing for rules which may undermine public health goals. The analysis suggests that public health experts should pay attention to trade and investment agreements and develop counter frames to ensure agreements do not create barriers for coherent health policies.

Does Alcohol Use Affect Cancer Risk?

PURPOSE OF REVIEW

To provide an overview of the risk relationships between alcohol use and cancer and of the alcohol-attributable cancer burden; to highlight areas of controversy in the alcohol-cancer relationship; to examine the reasons why these risk relationships have not received greater public attention.

RECENT FINDINGS

In 2016, alcohol caused an estimated 376,200 cancer deaths, 10.0 million cancer years of life lost (YLLs), 236,600 cancer years lived with disability (YLDs), and 10.3 million cancer disability-adjusted years of life (DALYs), representing 4.2%, 4.2%, 4.6%, and 4.2% of all deaths, YLLs, YLDs, and DALYs lost due to cancer, respectively, proportionally highest in high- and upper-middle-income countries. Alcohol use is a major contributor to cancer and is linked to the most prevalent types of cancer. No threshold for the effects of alcohol on cancer has yet been identified, and thus, abstinence is best for cancer prevention. Greater public awareness of the relationship between alcohol use and cancer is advisable.

Alcohol labelling rules in free trade agreements: Advancing the industry's interests at the expense of the public's health

INTRODUCTION AND AIMS

The Trans-Pacific Partnership Agreement (TPP) included novel rules for wine and spirits requiring parties to allow wine and spirits importers to display information required by the importing country on a supplementary label rather than on the standard label. Since the TPP negotiations concluded, alcohol-specific supplementary labelling rules have begun to appear in other trade agreements. The aim of this paper was to map the new instruments containing these rules and examine developments in the rules with implications for health information on alcohol containers.

DESIGN AND METHODS

Trade agreements signed after the TPP negotiations concluded were retrieved and searched for alcohol-specific labelling provisions. A legal analysis of these provisions and related exceptions was undertaken.

RESULTS

Supplementary labelling rules similar or identical to those in the TPP have been included in five subsequent trade agreements. The United States-Mexico-Canada Agreement also includes several additional provisions about alcohol labelling. Exceptions in the agreements provide some space for governments to defend labelling measure that might otherwise breach the rules, in the event of a dispute.

DISCUSSION AND CONCLUSIONS

By securing these rules, the alcohol industry is better positioned to claim the space on the standard label as industry 'real estate' and to oppose mandatory health information incorporated into the standard labelling. These risks can be mitigated by stemming the adoption of supplementary labelling rules in further trade agreements; clarifying the text of agreements and ensuring that regulators understand that the rules do not prevent the use of 'best-practice' warning labels.

Testing the Effectiveness of Enhanced Alcohol Warning Labels and Modifications Resulting From Alcohol Industry Interference in Yukon, Canada: Protocol for a Quasi-Experimental Study

BACKGROUND

Alcohol warning labels are a promising, well-targeted strategy to increase public awareness of alcohol-related health risks and support more informed and safer use. However, evidence of their effectiveness in real-world settings remains limited and inconclusive.

OBJECTIVE

This paper presents a protocol for a real-world study examining the population-level impact of enhanced alcohol warning labels with a cancer message; national drinking guidelines; and standard drink information on attention, processing, and alcohol-related behaviors among consumers in Canada. Postimplementation modifications to the original protocol due to interference by national alcohol industry representatives are also described.

METHODS

This quasi-experimental study involved partnering with local governments in two northern Canadian territories already applying alcohol warning labels on alcohol containers for sale in liquor stores. The study tested an 8-month intervention consisting of three new enhanced, rotating alcohol warning labels in an intervention site (Whitehorse, Yukon) relative to a comparison site (Yellowknife, Northwest Territories) where labelling practices would remain unchanged. Pre-post surveys were conducted at both sites to measure changes in awareness and processing of label messages, alcohol-related knowledge, and behaviors. Liquor store transaction data were collected from both sites to assess changes in population-level alcohol consumption. The intervention was successfully implemented for 1 month before it was halted due to complaints from the alcohol industry. The government of the intervention site allowed the study to proceed after a 2-month pause, on the condition that the cancer warning label was removed from rotation. Modifications to the protocol included applying the two remaining enhanced labels for the balance of the intervention and adding a third wave of surveys during the 2-month pause to capture any impact of the cancer label.

RESULTS

This study protocol describes a real-world quasi-experimental study that aimed to test the effectiveness of new enhanced alcohol warning labels as a tool to support consumers in making more informed and safer alcohol choices. Alcohol industry interference shortly after implementation compromised both the intervention and the original study design; however, the study design was modified to enable completion of three waves of surveys with cohort participants (n=2049) and meet the study aims.

CONCLUSIONS

Findings from this study will directly inform alcohol labelling policies in Canada and internationally and provide further insight into the alcohol industry's attempts to disrupt research in this area. Additional unimpeded real-world evaluations of enhanced alcohol warning labels are recommended.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/16320.