Impact of health warning labels communicating the risk of cancer on alcohol selection: an online experimental study

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.

Restricting the content of alcohol advertising and including text health warnings: A between-group online experiment with a non-probability adult sample in the United Kingdom

BACKGROUND

Statutory options for restricting alcohol advertising include limiting it to product-orientated information and requiring health warnings. We assess the impact of removing positive contextual factors from alcohol advertising and including a health warning among adults in the United Kingdom (UK).

METHODS

We conducted a 2 × 2 online between-group experiment with adults (18+) (n = 2421) recruited from a non-probability research panel in the United Kingdom. Participants were randomized to see an alcohol (vodka) advertisement (advert) which varied by context (no context vs. imagery depicting positive social interactions around alcohol) and message (multiple text health warning vs. "drink responsibly"). The multiple text health warning, based on recent legislation in Ireland, comprised three separate warnings (liver disease, cancers, drinking during pregnancy) and a web address for alcohol-related information and support. The "drink responsibly" control reflected the self-regulatory messages commonly used by alcohol companies. Participants rated the advert on 7-point scales for advert attractiveness, product appeal, trial intentions, perceived harm, and whether it made drinking alcohol seem enjoyable.

RESULTS

Removing the positive social context reduced positive advert and product reactions (difference in estimated marginal means [EMM]: -1.57 [makes drinking alcohol seem enjoyable] to -0.23 [intention to try]). Including the multiple text health warning also reduced positive advert and product reactions (difference in EMM: -0.55 [advert attractiveness] to -0.25 [intention to try]) and increased perceived product harm (difference in EMM: +0.25). There were no interactions between advert context and message for any outcome.

CONCLUSIONS

Restricting content and including a multiple text health warning (compared to a "drink responsibly" message) may attenuate the persuasive impact of alcohol advertising and increase perceived product harm. Further research is needed to examine different degrees of content restrictions, alternative warning content and design, generalizability to different alcohol products and advert formats, and whether the impact of content controls varies among population subgroups.

"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.

Impact on wine sales of removing the largest serving size by the glass: An A-B-A reversal trial in 21 pubs, bars, and restaurants in England

BACKGROUND

Interventions that alter aspects of the physical environments in which unhealthy behaviours occur have the potential to change behaviour at scale, i.e., across populations, and thereby decrease the risk of several diseases. One set of such interventions involves reducing serving sizes, which could reduce alcohol consumption. The effect of modifying the available range of serving sizes of wine in a real-world setting is unknown. We aimed to assess the impact on the volume of wine sold of removing the largest serving size by the glass from the options available in licensed premises.

METHODS AND FINDINGS

The study was conducted between September 2021 and May 2022 in 21 licensed premises in England that sold wine by the glass in serving sizes greater than 125 ml (i.e., 175 ml or 250 ml) and used an electronic point of sale till system. It used an A-B-A reversal design, set over 3 four-weekly periods. "A" represented the nonintervention periods during which standard serving sizes were served and "B" the intervention period when the largest serving size for a glass of wine was removed from the existing range in each establishment: 250 ml (18 premises) or 175 ml (3 premises). The primary outcome was the daily volume of wine sold, extracted from sales data. Twenty-one premises completed the study, 20 of which did so per protocol and were included in the primary analysis. After adjusting for prespecified covariates, the intervention resulted in -420·8 millilitres (ml) (95% confidence intervals (CIs) -681·4 to -160·2 p = 0·002) or -7·6% (95% CI -12·3%, -2·9%) less wine being sold per day. There was no evidence that sales of beer and cider or total daily revenues changed but the study was not powered to detect differences in these outcomes. The main study limitation is that we were unable to assess the sales of other alcoholic drinks apart from wine, beer, and cider, estimated to comprise approximately 30% of alcoholic drinks sold in participating premises.

CONCLUSIONS

Removing the largest serving size of wine by the glass from those available reduced the volume of wine sold. This promising intervention for decreasing alcohol consumption across populations merits consideration as part of alcohol licensing regulations.

TRIAL REGISTRATION

ISRCTN https://doi.org/10.1186/ISRCTN33169631; OSF https://osf.io/xkgdb.

Impact of health warning labels and calorie labels on selection and purchasing of alcoholic and non-alcoholic drinks: A randomized controlled trial

AIMS

To estimate the impact on selection and actual purchasing of (a) health warning labels (text-only and image-and-text) on alcoholic drinks and (b) calorie labels on alcoholic and non-alcoholic drinks.

DESIGN

Parallel-groups randomised controlled trial.

SETTING

Drinks were selected in a simulated online supermarket, before being purchased in an actual online supermarket.

PARTICIPANTS

Adults in England and Wales who regularly consumed and purchased beer or wine online (n = 651). Six hundred and eight participants completed the study and were included in the primary analysis.

INTERVENTIONS

Participants were randomized to one of six groups in a between-subjects three [health warning labels (HWLs) (i): image-and-text HWL; (ii) text-only HWL; (iii) no HWL] × 2 (calorie labels: present versus absent) factorial design (n per group 103-113).

MEASUREMENTS

The primary outcome measure was the number of alcohol units selected (with intention to purchase); secondary outcomes included alcohol units purchased and calories selected and purchased. There was no time limit for selection. For purchasing, participants were directed to purchase their drinks immediately (although they were allowed up to 2 weeks to do so).

FINDINGS

There was no evidence of main effects for either (a) HWLs or (b) calorie labels on the number of alcohol units selected (HWLs: F(2,599)  = 0.406, P = 0.666; calorie labels: F(1,599)  = 0.002, P = 0.961). There was also no evidence of an interaction between HWLs and calorie labels, and no evidence of an overall difference on any secondary outcomes. In pre-specified subgroup analyses comparing the 'calorie label only' group (n = 101) with the 'no label' group (n = 104) there was no evidence that calorie labels reduced the number of calories selected (unadjusted means: 1913 calories versus 2203, P = 0.643). Among the 75% of participants who went on to purchase drinks, those in the 'calorie label only' group (n = 74) purchased fewer calories than those in the 'no label' group (n = 79) (unadjusted means: 1532 versus 2090, P = 0.028).

CONCLUSIONS

There was no evidence that health warning labels reduced the number of alcohol units selected or purchased in an online retail context. There was some evidence suggesting that calorie labels on alcoholic and non-alcoholic drinks may reduce calories purchased from both types of drinks.

Impact of pictorial warning labels on meat meal selection: A randomised experimental study with UK meat consumers

Meat consumption has been linked to adverse health consequences, worsening climate change, and the risk of pandemics. Meat is however a popular food product and dissuading people from consuming meat has proven difficult. Outside the realm of meat consumption, previous research has shown that pictorial warning labels are effective at curbing tobacco smoking and reducing the consumption of sugary drinks and alcohol. The present research extends this work to hypothetical meat meal selection, using an online decision-making task to test whether people's meal choices can be influenced by pictorial warning labels focused on the health, climate, or pandemic risks associated with consuming meat. Setting quotas for age and gender to approximate a UK nationally representative sample, a total of n = 1001 adult meat consumers (aged 18+) were randomised into one of four experimental groups: health pictorial warning label, climate pictorial warning label, pandemic pictorial warning label, or control (no warning label present). All warning labels reduced the proportion of meat meals selected significantly compared to the control group, with reductions ranging from -7.4% to -10%. There were no statistically significant differences in meat meal selection between the different types of warning labels. We discuss implications for future research, policy, and practice.

Designing Cancer Warning Labels for Alcoholic Beverages: Examining the Impact of Visual Elements

Alcohol is a known carcinogen. However, public awareness of cancer risk associated with alcohol use is low. A promising approach to raising awareness is to include cancer warning labels on alcohol-containing products, but there is limited knowledge of the design and effect of such warnings. The present study investigated the impact of visual elements on the effectiveness of cancer warning labels. In a randomized online experiment, alcohol consumers (N = 1,190) were randomly assigned to one of three conditions: exposure to (a) text-only warning labels, (b) pictorial warning labels showing graphic health effects (e.g., diseased organs), and (c) pictorial warning labels showing lived experience (e.g., cancer patients in a medical setting). The results showed that whereas the three warning types did not differ significantly in behavioral intentions, pictorial warnings featuring health effects led to greater disgust and anger than text-only warnings and pictorial warnings featuring lived experience. Moreover, anger predicted lower intentions to reduce alcohol use and was a significant mediator of the effects of warning type on behavioral intentions. The findings highlight the role of emotions in responses to health warning labels with different visual elements and suggest that text-only warnings and pictorial warnings with lived experience may be useful in preventing boomerang effects.

Impact on sales of adding a smaller serving size of beer and cider in licensed premises: an A-B-A reversal design

BACKGROUND

Smaller serving sizes of alcoholic drinks could reduce alcohol consumption across populations thereby lowering the risk of many diseases. The effect of modifying the available range of serving sizes of beer and cider in a real-world setting has yet to be studied. The current study assessed the impact on beer and cider sales of adding a serving size of draught beer and cider (2/3 pint) that was between the current smallest (1/2 pint) and largest (1 pint) standard serving sizes.

METHODS

Twenty-two licensed premises in England consented to taking part in the study. The study used an ABA reversal design, set over three 4-weekly periods, with A representing the non-intervention periods, during which standard serving sizes were served and B the intervention period when a 2/3 pint serving size of draught beer and cider was added to the existing range, along with smaller 1/2 pint and larger 1 pint serving sizes. The primary outcome was the daily volume of beer and cider sold, extracted from sales data.

RESULTS

Fourteen premises started the study, of which thirteen completed it. Twelve of those did so per protocol and were included in the primary analysis. After adjusting for pre-specified covariates, the intervention did not have a significant effect on the volume of beer and cider sold per day (3.14 ml; 95%CIs -2.29 to 8.58; p = 0.257).

CONCLUSIONS

In licensed premises, there was no evidence that adding a smaller serving size for draught beer and cider (2/3 pint) when the smallest (1/2 pint) and largest (1 pint) sizes were still available, affected the volume of beer and cider sold. Studies are warranted to assess the impact of removing the largest serving size.

TRIAL REGISTRATION

ISRCTN: https://doi.org/10.1186/ISRCTN33169631 (08/09/2021), OSF: https://osf.io/xkgdb/ (08/09/2021).

Warning labels on alcoholic beverage containers: a pilot randomized experiment among young adults in Mexico

BACKGROUND

Little is known about the potential impacts of visible and up-to-date health warning labels on alcoholic beverage containers on a range of outcomes in low- and middle-income countries. We conducted an experimental study to test the potential impacts of visible health warning labels (on the principal panel of the package) on thinking about health risks, product attractiveness, visual avoidance, and intention to change alcohol use among students in Mexico aged 18-30 years.

METHODS

A double-blind, parallel-group, online randomized trial was conducted from November 2021 to January 2022 in 11 states in Mexico. In the control group, participants were presented with the image of a conventional beer can with a fictional design and brand. In the intervention groups, the participants observed pictograms with a red font and white backgrounds (health warning label in red-HWL red) or with a black font and yellow backgrounds (health warning label in yellow-HWL yellow), located at the top, covering around one-third of the beer can. We used Poisson regression models -unadjusted and adjusted for covariates- to assess differences in the outcomes across study groups.

RESULTS

Using intention-to-treat analysis (n = 610), we found more participants in groups HWL red and HWL yellow thought about the health risks from drinking beer compared to the control group [Prevalence Ratio (PR) = 1.43, CI95%:1.05,1.93 for HWL red; PR = 1.25, CI95%: 0.91, 1.71 for HWL yellow]. A lower percentage of young adults in the interventions vs control group considered the product attractive (PR 0.74, 95%CI 0.51, 1.06 for HWL red; PR 0.56, 95%CI 0.38, 0.83 for HWL yellow). Although not statistically significant, a lower percentage of participants in the intervention groups considered buying or consuming the product than the control group. Results were similar when models were adjusted for covariates.

CONCLUSIONS

Visible health warning labels could lead individuals to think about the health risks of alcohol, reducing the attractiveness of the product and decreasing the intention to purchase and consume alcohol. Further studies will be required to determine which pictograms or images and legends are most contextually relevant for the country.

TRIAL REGISTRATION

The protocol of this study was retrospectively registered on 03/01/2023: ISRCTN10494244.

Designing Effective Alcohol Warnings: Consumer Reactions to Icons and Health Topics

Introduction

New warning labels for alcohol could reduce alcohol-related health harms. This study examined consumer responses to alcohol warnings with different designs.

Methods

A national sample of 3,051 U.S. adults completed an online survey in August 2021. Participants were randomized to 1 of 4 warning topics (addiction, liver damage, early death, or colon cancer). Participants viewed 3 labels, presented in random order: 2 types of warning labels (text-only and icon) showing a newly developed warning message about their assigned topic and a text-only control label showing a neutral message. Participants rated each label on effectiveness at discouraging alcohol consumption (primary outcome) and attention (secondary outcome) using 1 to 5 Likert-type scales. Participants also rated warnings with different causal language variants (e.g., "increases risk of," "contributes to") and marker words (e.g., "WARNING," "SURGEON GENERAL WARNING").

Results

Both the text-only and icon warnings were perceived as more effective (Average Differential Effects [ADEs]=0.79 and 0.86, respectively) and more attention-grabbing (ADEs=0.43 and 0.69, respectively) than control labels (all ps<0.001). The icon warnings were rated as more effective and attention-grabbing than the text-only warnings (ADEs=0.07 and 0.27, respectively, both ps<0.001). Although all warning topics outperformed the control messages, warnings about addiction were rated as less effective and attention-grabbing than the other topics. A majority (60%) of participants selected "increases risk of" as the most discouraging causal variant and a plurality (47%) selected "SURGEON GENERAL WARNING" as the most discouraging marker word.

Conclusions

New alcohol warnings could discourage alcohol consumption, especially if warnings include icons.

Nudging Interventions on Alcohol and Tobacco Consumption in Adults: A Scoping Review of the Literature

Background: The World Health Organization identified alcohol and tobacco consumption as the risk factors with a greater attributable burden and number of deaths related to non-communicable diseases. A promising technique aimed to modify behavioral risk factors by redesigning the elements influencing the choice of people is nudging. Methodology: A scoping review of the literature was performed to map the literature evidence investigating the use of nudging for tobacco and alcohol consumption prevention and/or control in adults. Results: A total of 20 studies were included. The identified nudging categories were increasing salience of information or incentives (IS), default choices (DF), and providing feedback (PF). Almost three-quarters of the studies implementing IS and half of those implementing PF reported a success. Three-quarters of the studies using IS in conjunction with other interventions reported a success whereas more than half of the those with IS alone reported a success. The PF strategy performed better in multi-component interventions targeting alcohol consumption. Only one DF mono-component study addressing alcohol consumption reported a success. Conclusions: To achieve a higher impact, nudging should be integrated into comprehensive prevention policy frameworks, with dedicated education sessions for health professionals. In conclusion, nudge strategies for tobacco and alcohol consumption prevention in adults show promising results. Further research is needed to investigate the use of nudge strategies in socio-economically diverse groups and in young populations.

Testing the effectiveness of alcohol health warning label formats: An online experimental study with Australian adult drinkers

Health warning labels (HWLs) on alcohol containers may help reduce population-level alcohol consumption. However, few studies have examined the most effective formats for alcohol HWLs. This study tested the effects of three different types of alcohol HWLs. In an online experiment, N = 1,755 Australian adult drinkers were randomly assigned to one of five conditions: (a) No HWL control; (b) DrinkWise control (industry-developed labels currently on some containers); (c) Text-Only HWLs; (d) Text + Pictogram HWLs; or (e) Text + Photograph HWLs. In the three intervention conditions, participants were exposed to eight HWLs, each depicting a different long-term harm. Exposure occurred during an initial session, and repeatedly over the subsequent eight days. Differences between conditions were assessed immediately following initial exposure and at nine-day follow-up. Compared to participants in the No HWL control, participants exposed to Text + Pictogram HWLs were more likely to have intentions to avoid drinking alcohol completely in the next month (post-exposure) and intentions to drink less alcohol in the next week (follow-up), and participants in all three intervention conditions reported stronger negative emotional arousal (follow-up) and weaker positive emotional arousal (follow-up). Compared to participants in the DrinkWise control, those exposed to Text + Pictogram HWLs had stronger intentions to drink less alcohol in the next week and intentions to avoid drinking alcohol completely in the next month (follow-up), participants in the Text + Photograph condition reported significantly weaker positive emotional arousal, and all three intervention conditions resulted in stronger negative emotional arousal. There would likely be benefits to public health if any of the three types of intervention HWLs were implemented. However, there is some evidence that Text + Pictogram HWLs should be recommended over Text-Only or Text + Photograph HWLs, given they were the only HWLs to increase intentions to drink less.

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.

The Role of Narrative Pictorial Warning Labels in Communicating Alcohol-Related Cancer Risks

This study examined the role of pictorial warning labels (PWLs) featuring narrative content in communicating alcohol-related cancer risks. In an online experiment, 169 adult alcohol consumers were randomly assigned to view two narrative PWLs, two non-narrative PWLs, or control. Results showed that exposure to narrative PWLs significantly increased participants' worry about, feelings of risk of, and perceived severity of harm of getting alcohol-related cancer, but did not affect their comparative likelihood of getting alcohol-related cancer or intentions to reduce alcohol use. Exposure to narrative PWLs also indirectly influenced intentions through increased worry. Moreover, participants' risk perceptions and intentions in non-narrative PWLs condition did not differ from those in narrative PWLs and control conditions. Therefore, these findings suggest that narrative PWLs are a promising strategy in informing consumers about the cancer risks of alcohol.

Global comparisons of responses to alcohol health information labels: A cross sectional study of people who drink alcohol from 29 countries

AIMS

The aim of this paper was to explore responses to alcohol health information labels from a cross sectional survey of people who drink alcohol from 29 countries.

DESIGN

This paper draws on findings from the Global Drug Survey (GDS) - an annual cross sectional online survey.

PARTICIPANTS

75,969 (64.3% male) respondents from 29 countries were included in the study.

MEASURES

Respondents were shown seven health information labels (topics were heart disease, liver, cancer, calories, violence, taking two days off and myth of benefits of moderate drinking). They were asked if the information was new, believable, personally relevant, and if it would change their drinking. A multivariate multilevel Bayesian logistic regression model was used to estimate predicted probabilities for newness, believability, relevance and if messages would change drinking behaviour by country and information label.

FINDINGS

Predicted probabilities showed substantial variability in responses across countries. Respondents from Colombia, Brazil and Mexico were more likely to consider drinking less as well as have lower levels of previous awareness. Those from Denmark and Switzerland were not as likely to say the labels would make them consider drinking less. The cancer message was consistently the newest and most likely to make people consider drinking less across countries.

CONCLUSIONS

Country differences in responses to messages can be used to create targeted harm reduction measures as well as inform what should be on labels. The provision of such health information on alcohol product labels may play a role in raising awareness of the risk of drinking. Global comparisons of responses to alcohol health information labels: a cross sectional study of people who drink alcohol from 29 countries.

Effect of health warning labels on motivation towards energy-dense snack foods: Two experimental studies

Health warning labels (HWLs) show promise in reducing motivation towards energy-dense snack foods. Understanding the underlying mechanisms could optimise their effectiveness. In two experimental studies in general population samples (Study 1 n = 90; Study 2 n = 1382), we compared the effects of HWLs and irrelevant aversive labels (IALs) on implicit (approach) motivation towards unhealthy snacks, using an approach-avoidance task (Study 1), and a manikin task (Study 2). We also assessed explicit motivation towards unhealthy snacks using food selection tasks. We examined whether labelling effects on motivation arose from the creation of outcome-dependent associations between the food and its health consequences or from simple, non-specific aversive associations. Both label types reduced motivation towards snack foods but only when the label was physically present. HWLs and IALs showed similar effects on implicit motivation, although HWLs reduced explicit motivation more than IALs. Thus, aversive HWLs appear to act both through low level associative mechanisms affecting implicit motivation, and by additionally emphasizing explicit causal links to health outcomes thereby affecting explicitly motivated choice behaviours.

A Narrative Review of the Efficacy and Design of Safety Labels on Tobacco Products to Promote the Use of Safety Labels on Alcohol Products in Canada

Alcohol is consumed by approximately three-quarters of Canadians. Alcohol causes acquired liver disease, increases the risk of cancer, has detrimental effects on mental health, and leads to adverse pregnancy outcomes. Alcohol-related morbidity and mortality are high, and urgent public health measures are warranted to prevent and control these. Tobacco safety labels have been shown in numerous studies to reduce tobacco consumption. Much can be learned from the design of tobacco safety labels in creating promising alcohol safety labels that can possibly help reduce alcohol consumption. The aim of this paper is to review the efficacy of tobacco safety labels in reducing tobacco consumption and the design of tobacco safety labels and to propose a promising design for alcohol safety labels based on our findings. English peer-reviewed papers published in western countries since 2000 were searched on PubMed and Google Scholar. Keywords and synonyms were used to search pertinent papers, which were subsequently screened by title and abstract and fully reviewed if relevant. Findings from studies comparing designs of safety labels on alcohol and tobacco products are similar. Graphics, higher emotion content, and greater size are associated with greater attention, awareness, negative emotions, intention to quit, and reduction in consumption. Mixed results are found for testimonials containing safety labels on tobacco products. It is unclear whether testimonials on alcohol safety labels reduce alcohol consumption or not. Safety labels with specific information, such as tobacco-related costs and alcohol-related cancer risks, are more effective in reducing tobacco consumption. In conclusion, preliminary alcohol safety labels show promise. Large safety labels with graphics and high emotional content appear to be most effective and may reduce alcohol consumption.

Factors Associated with Adolescents' Support for Product Information and Health Messaging on Alcohol Packaging: A Cross-Sectional Study in the United Kingdom

AIMS

Adolescents in the UK are among the heaviest drinkers in Europe. The World Health Organization recommends alcohol product labelling to inform consumers about product information and health risks associated with alcohol use. This study investigates support for product information and health messaging on alcohol packaging among UK adolescents.

METHODS

The 2019 UK Youth Alcohol Policy Survey was an online cross-sectional survey among 3388 adolescents aged 11-19. Participants indicated their support for seven forms of messaging on packaging (e.g. number of alcohol units, links to health conditions). Logistic regression models investigated associations between support for each of the seven forms and alcohol use, perceived risks of alcohol use, and previous exposure to messaging.

RESULTS

Between 60 and 79% of adolescents were supportive of different aspects of product labelling. Compared to lower-risk drinkers, higher-risk drinkers (AUDIT-C 5+) had higher odds of supporting including the number of alcohol units (OR: 1.82, 95% CI: 1.31-2.54), calories (OR: 1.52, 95% CI: 1.04-1.68), and strength of the product (OR: 1.73, 95% CI: 1.19-2.52) but lower odds of supporting including information on alcohol-related health conditions (OR: 0.68, 95% CI: 0.53-0.87). Adolescents who perceived risks of alcohol use more strongly were more likely to support all forms of product information and messaging.

CONCLUSIONS

The majority of adolescents supported improved alcohol labelling. Higher-risk drinkers were supportive of improved product information but less supportive of health-related messaging. Adolescents who believe alcohol carries health risks were more likely to support messaging.

The role of alcohol packaging as a health communications tool: An online cross-sectional survey and experiment with young adult drinkers in the United Kingdom

INTRODUCTION

Alcohol packaging is a potentially valuable means of communicating product and health-related information, with growing academic and political interest in its role as a health communications vehicle.

METHODS

An online cross-sectional survey and experiment were conducted with a non-probability sample of 18-35-year-old drinkers in the United Kingdom (n = 1360). The survey assessed exposure to, and engagement with, current messaging on packs, and support for displaying product and health-related information. For the randomised experiment, participants were shown, and asked questions about, a vodka bottle with either no warnings (control), small text warnings, large text warnings or pictorial (image-and-text) warnings; the main binary outcome measures were negative product appeal and social acceptability, and positive cognitive and behavioural impact.

RESULTS

Two-fifths of the sample rarely or never saw on-pack health-related information, with almost three-quarters rarely or never reading or looking closely at this. There was strong support for displaying a range of product and health-related information (e.g. units, ingredients) on packs. Relative to the control, products with warnings were more likely to be perceived as unappealing and socially unacceptable, and to positively impact alcohol-related cognitions and behaviours. For example, pictorial warnings were 10 times as likely to positively influence cognitions and behaviours (AOR = 10.01, 95% CI: 8.09, 17.46).

DISCUSSION AND CONCLUSIONS

Alcohol packaging could have an important role in delivering health messaging. Large pictorial or text warnings may help counteract the appeal and social acceptability of alcohol products and increase awareness of risks, potentially supporting a reduction in consumption and related harms.

How health warning labels on wine and vodka bottles influence perceived risk, rejection, and acceptance

Background

Wine consumption has a particular place in the culture of many European countries, and beliefs that wine offers health benefits are widespread. High consumption of wine and other alcoholic beverages among many Europeans correlates with alcohol-related accidents and disease burdens. Health warning labels (HWLs) on alcohol containers have been increasingly recommended to deter consumers from drinking. However, findings on the impact of HWLs on consumers’ behavior have been mixed. Moreover, many European consumers have been found to reject the use of warning labels as a policy intervention, especially for wine, perhaps due to its cultural and economic importance.

Methods

An online study with a between-subjects design was conducted in Switzerland (N = 506) to assess whether HWLs can influence the perceived risk associated with drinking wine and vodka, a beverage insignificant to Swiss culture. Participants were presented an image of either a wine or vodka bottle with or without an HWL presenting a liver cancer warning statement. They were then asked to indicate their perceived risk of regularly consuming the depicted beverage. Acceptance and rejection of HWLs were also assessed.

Results

The perceived risk of vodka consumption exceeded the corresponding risk for wine but was unaffected by an HWL. Perceived health benefits were the main, negative predictor of perceived consumption risk. Participants mainly rejected HWLs due to their perceived effectiveness, perceived positive health effects, social norms, and individualistic values.

Conclusions

Perceived risk is an important determinant of drinking behavior, and our results suggest that HWLs may be unable to alter risk perceptions. Furthermore, a strong belief in the health benefits of alcohol consumption, particularly wine consumption, reduce risk perceptions and may be unaffected by HWLs.

Health warning labels and alcohol selection: a randomised controlled experiment in a naturalistic shopping laboratory

BACKGROUND AND AIMS

Health warning labels (HWLs) on tobacco products reduce smoking. There is an absence of evidence concerning the impact of alcohol HWLs on selection or purchasing in naturalistic settings. Using a commercial-standard naturalistic shopping laboratory, this study aimed to estimate the impact on selection of alcoholic drinks of HWLs describing adverse health consequences of excessive alcohol consumption.

DESIGN

A between-subjects randomised experiment with three groups was conducted: group 1: image-and-text HWL; group 2: text-only HWL; group 3: no HWL.

SETTING

A commercial-standard naturalistic shopping laboratory in the United Kingdom.

PARTICIPANTS

Adults (n = 399, 55% female) over the age of 18 years, who purchased beer or wine weekly to drink at home.

INTERVENTIONS

Participants were randomised to one of three groups varying in the HWL displayed on the packaging of the alcoholic drinks: (i) image-and-text HWL (n = 135); (ii) text-only HWL (n = 129); (iii) no HWL (n = 135). Participants completed a shopping task, selecting items from a range of alcoholic and non-alcoholic drinks, and snacks.

MEASUREMENT

The primary outcome was the proportion of alcoholic drinks selected. Secondary outcomes included HWL ratings on negative emotional arousal and label acceptability.

FINDINGS

There was no clear evidence of a difference in the HWL groups for the percentage of drinks selected that were alcoholic compared to no HWL (44%): image-and-text HWL: 46% (odds ratio [OR] = 1.08, 95% confidence interval [CI] = 0.82, 1.42); text-only HWL: 41% (OR = 0.87, 95% CI = 0.67, 1.14). Concordant with there being no difference between groups, there was extreme evidence in favour of the null hypothesis (Bayes factor [BF] < 0.01). Negative emotional arousal was higher (P < 0.001) and acceptability lower (P < 0.001) in the image-and-text HWL group, compared to the text-only HWL group.

CONCLUSIONS

In a naturalistic shopping laboratory, there was no evidence that health warning labels describing the adverse health consequences of excessive alcohol consumption changed selection behaviour.

Impact of health warning labels on selection and consumption of food and alcohol products: systematic review with meta-analysis

Health warning labels (HWLs) could reduce harmful consumption of food (including non-alcoholic drinks) and alcoholic drinks. A systematic review with meta-analysis using Cochrane methods was conducted to assess the impact on selection (including hypothetical selection) or consumption of food or alcoholic drink products displaying image-and-text (sometimes termed 'pictorial') and text-only HWLs. Fourteen randomised controlled trials were included, three for alcohol, eleven for food. For the primary outcomes, eleven studies measured selection and one measured consumption (two measured only other secondary outcomes). Meta-analysis of twelve comparisons from nine studies (n=12,635) found HWLs reduced selection of the targeted product compared with no HWL (RR=0.74 (95%CI 0.68-0.80)), with participants 26% less likely to choose a product displaying a HWL. A planned subgroup analysis suggested a larger (although not statistically significant) effect on selection of image-and-text HWLs (RR=0.65 (95%CI 0.54-0.80)) than text-only HWLs (RR=0.79 (95%CI 0.74-0.85)). These findings suggest significant potential for HWLs to reduce selection of food and alcoholic drinks, but all experimental studies to date were conducted in laboratory or online settings with outcomes assessed immediately after a single exposure. Studies in field and naturalistic laboratory settings are needed to estimate the potential effects of food and alcohol HWLs.Study registration: PROSPERO 2018 (registration number: CRD42018106522).

Nature and Potential Impact of Alcohol Health Warning Labels: A Scoping Review

Alcohol is toxic to human health. In addition to providing nutritional information, labels on alcohol products can be used to communicate warnings on alcohol-related harms to consumers. This scoping review examined novel or enhanced health warning labels to assess the current state of the research and the key studied characteristics of labels, along with their impact on the studied outcomes. Four databases (Web of Science, MEDLINE, PsycInfo, CINAHL) were searched between January 2010 and April 2021, and 27 papers were included in the review. The results found that most studies were undertaken in English-speaking populations, with the majority conducted online or in the laboratory setting as opposed to the real world. Seventy percent of the papers included at least one cancer-related message, in most instances referring either to cancer in general or to bowel cancer. Evidence from the only real-world long-term labelling intervention demonstrated that alcohol health warning labels designed to be visible and contain novel and specific information have the potential to be part of an effective labelling strategy. Alcohol health warning labels should be seen as tools to raise awareness on alcohol-related risks, being part of wider alcohol policy approaches.

Effects of pairing health warning labels with energy-dense snack foods on food choice and attitudes: Online experimental study

BACKGROUND

There is limited evidence concerning the potential effectiveness of health warning labels (HWLs) using images and text to depict possible negative health consequences of consumption, for reducing selection of energy-dense snack foods. Furthermore, the underlying mechanisms have received little attention; particularly effects on implicit attitudes, which previous work has shown may mediate the effect of aversive images on food choice.

AIM

To assess the impact of pairing image- and text-based HWLs with energy-dense snack foods on a) the selection of, and b) implicit and explicit attitudes towards, those foods.

METHODS

Online experimental study with a representative UK sample (n = 1185), using a 2(Image/No Image) x 2(Text/No Text) factorial between-subjects design. Participants were randomised to one of four study arms, viewing snack food images paired with either: image-only HWLs, text-only HWLs, image-and-text HWLs, or no HWLs (control). HWLs concerned various negative health consequences of excess energy intake, such as heart disease and type 2 diabetes. The primary outcome was hypothetical food choice (energy-dense snack foods versus fruit), assessed post-intervention. Secondary outcomes were implicit and explicit attitudes.

RESULTS

Neither food choice nor explicit attitudes were changed significantly by any type of HWL. Implicit attitudes towards energy-dense snack foods were more negative after exposure to text-only or image-and-text HWLs. Both implicit and explicit attitudes predicted unique variance in food choice.

CONCLUSIONS

This study suggests that short-term repeated exposure to HWLs paired with energy-dense snack foods may not consistently alter food choices, but can change implicit attitudes associated with food choices. Further laboratory and field studies are needed to more definitively assess the impact of HWLs on food selection and consumption in applied contexts and over time, as well as delineate underlying mechanisms.

Impact of health warning labels on snack selection: An online experimental study

Excessive consumption of energy-dense food increases the risk of obesity, which in turn increases the risk of non-communicable diseases, including heart disease, type 2 diabetes and most non-smoking-related cancers. Health warning labels (HWLs) that communicate the adverse health consequences of excess energy consumption could reduce intake of energy-dense foods. The aim of the current study was to estimate the impact on selection of energy-dense snacks of (a) image-and-text HWLs (b) text-only HWLs and (c) calorie information. In a between-subjects, 3 (HWL: image-and-text, text-only, no label) x 2 (calorie information: present, absent), factorial experimental design, participants (N = 4134) were randomised to view a selection of energy-dense and non-energy-dense snacks with one of five label types or no label. The primary outcome was the proportion of participants selecting an energy-dense snack in a hypothetical vending machine task. The proportion of participants selecting an energy-dense snack was reduced in all label groups, relative to the no label group (no label: 59%; calories only: 54%; text-only HWL: 48%; text-only HWL with calories: 44%; image-and-text HWL: 37%; image-and-text HWL with calories: 38%). Compared to the no label group, participants were least likely to select an energy-dense snack in the image-and-text HWL group (OR = 0.46, 95%CI = 0.40, 0.54, p < 0.001). Health warning labels - particularly those including an image and text - have the potential to reduce selection of energy-dense snacks in an online setting. Their impact on selection and consumption in real-world settings awaits testing.