Testing Alcohol Labels as a Tool to Communicate Cancer Risk to Drinkers: A Real-World Quasi-Experimental Study

Patient-Provider Discussions About Alcohol Use by Cancer History

INTRODUCTION

The U.S. Preventive Services Task Force recommends that all adults be screened for alcohol use and those with hazardous use be provided a brief discussion. However, it is unclear to what extent healthcare providers screen for and discuss alcohol use with cancer survivors.

METHODS

Frequency and content of alcohol prescreening and provider discussion about alcohol use was examined comparing cancer survivors and non-cancer controls in the 2015-2019 National Survey on Drug Use and Health. Multivariable Poisson regression with robust variance and complex survey procedures were used to estimate prevalence ratios (PR) adjusted for demographic characteristics. Data were analyzed in 2022.

RESULTS

The prevalence of alcohol prescreening in a healthcare setting (78.4% vs 74.3%; PR: 1.05 [95% CI: 1.03-1.08]) and self-report of an in-person discussion about alcohol use with a healthcare provider (58.7% vs 55.0%; PR: 1.07 [95% CI: 1.03-1.10]) was higher among cancer survivors compared with non-cancer controls. Among those who had a discussion, the prevalence of being asked about drinking quantity was higher among cancer survivors compared with non-cancer controls (PR: 1.05 [95% CI: 1.02-1.08]). Among cancer survivors who reported usually consuming 3+ drinks per day in the past 30 days, only 15% (95% CI: 10.8-20.5) reported that a healthcare provider advised them to cut down on their drinking.

CONCLUSIONS

Cancer survivors are being screened for alcohol use, but heavier users are infrequently advised by healthcare providers to reduce their consumption.

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.

The effects of alcohol container labels on consumption behaviour, knowledge, and support for labelling: a systematic review

Alcohol container labels might reduce population-level alcohol-related harms, but investigations of their effectiveness have varied in approach and quality. A systematic synthesis is needed to adjust for these differences and to yield evidence to inform policy. Our objectives were to establish the effects of alcohol container labels bearing one or more health warnings, standard drink information, or low-risk drinking guidance on alcohol consumption behaviour, knowledge of label message, and support for labels. We completed a systematic review according to Cochrane and synthesis without meta-analysis standards. We included all peer-reviewed studies and grey literature published from Jan 1, 1989, to March 6, 2024, in English, French, German, or Spanish that investigated the effects of alcohol container labels compared with no-label or existing label control groups in any population on alcohol consumption behaviour, knowledge of label message, or support for labels. Data were synthesised narratively as impact statements and assessed for risk of bias and certainty in the evidence. A protocol was preregistered (PROSPERO CRD42020168240). We identified 40 publications that studied 31 labels and generated 17 impact statements. 24 (60%) of 40 publications focused on consumption behaviour and we had low or very low certainty in 13 (59%) of 22 outcomes. Alcohol container labels bearing health warnings might slow the rate of alcohol consumption (low certainty), reduce alcoholic beverage selection (moderate certainty), reduce consumption during pregnancy (low certainty), and reduce consumption before driving (moderate certainty). Interventions with multiple types of rotating alcohol container labels likely substantially decrease alcohol use (moderate certainty) and reduce alcohol sales (high certainty). To the best of our knowledge, this is the first systematic review on multiple types of alcohol container labels assessing their effects for certainty in the evidence. Limitations included heterogeneity in label designs and outcome measurements. Alcohol container labels probably influence some alcohol consumption behaviour, with multiple rotating messages being particularly effective, although effects might vary depending on individual health literacy or drinking behaviour. Alcohol container labels might therefore be effective components of policies designed to address population-level alcohol-related harms.

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.

An assessment of federal alcohol policies in Canada and priority recommendations: Results from the 3rd Canadian Alcohol Policy Evaluation Project

OBJECTIVE

To systematically assess the Canadian federal government's current alcohol policies in relation to public health best practices.

METHODS

The 2022 Canadian Alcohol Policy Evaluation (CAPE) Project assessed federal alcohol policies across 10 domains. Policy domains were weighted according to evidence for their relative impact, including effectiveness and scope. A detailed scoring rubric of best practices was developed and externally reviewed by international experts. Policy data were collected between June and December 2022, using official legislation, government websites, and data sources identified from previous iterations of CAPE as sources. Contacts within relevant government departments provided any additional data sources, reviewed the accuracy and completeness of the data, and provided amendments as needed. Data were scored independently by members of the research team. Final policy scores were tabulated and presented as a weighted overall average score and as unweighted domain-specific scores.

RESULTS

Compared to public health best practices, the federal government of Canada scored 37% overall. The three most impactful domains-(1) pricing and taxation, (2) marketing and advertising controls, and (3) impaired driving countermeasures-received some of the lowest scores (39%, 10%, and 40%, respectively). Domain-specific scores varied considerably from 0% for minimum legal age policies to 100% for controls on physical availability of alcohol.

CONCLUSION

Many evidence-informed alcohol policies have not been adopted, or been adopted only partially, by the Canadian federal government. Urgent adoption of the recommended policies is needed to prevent and reduce the enormous health, social, and economic costs of alcohol use in Canada.

Investigating the impact of 'dark nudges' on drinking intentions: A between groups, randomized and online experimental study

OBJECTIVES

This study explored how 'dark nudges' (tactics used in alcohol industry-funded responsible drinking campaigns) affect drinking intentions, perceived source credibility and whether individual differences in perceptions of prototypical drinkers moderated these effects.

DESIGN

Two 2 × 2 between-groups online experimental studies.

METHODS

Study 1 (N = 164) presented three alcohol health messages per condition, comprising social norm (healthy/unhealthy ("dark nudge")) by frame (loss/gain). Study 2 (N = 229) presented one message per condition, comprising cancer causality (single cause/multiple causes (dark nudge)) by funding disclosure (disclosure/non-disclosure (dark nudge)). Outcomes were drinking intentions and perceived source credibility. Exploratory analyses considered prototype perceptions as a between-subjects moderator.

RESULTS

No significant effects of message frame, social norm, fundi or multiple cancer causality arguments on drinking intentions were found. In Study 2, in the dark nudge multiple cancer causality conditions, perceived source credibility was high when funding was undisclosed, but significantly lower when it was disclosed. Exploratory analyses suggested effects were moderated by prototype similarity. In Study 1, higher perceived similarity to a heavy drinker and lower perceived similarity to a responsible drinker were associated with higher drinking intentions in the unhealthy norm/gain frame condition, but lower drinking intentions in the other conditions.

CONCLUSIONS

Framing, social norm, funding disclosure and multiple causality manipulations as tested in this study did not exert a dark nudge effect on drinking intentions. However, the exploratory analyses suggest it could be hypothesised that the types of messages used in alcohol industry-funded responsible drinking campaigns may result in greater drinking intentions among those who identify more as heavy drinkers and less as responsible drinkers. Perceived prototype similarity may be an important moderator of the impact of alcohol health messages that warrants further research. Study 2 suggests disclosure of industry funding guides judgements of the credibility of sources of misleading messages about alcohol and cancer.

How effective are health messages/warnings in improving knowledge and awareness of alcohol-related harm? The Slovenian case on using a mobile app

BACKGROUND

Consumers generally lack access to information on alcoholic beverages, in spite of it being readily available for food and non-alcoholic beverages. Given the rights of consumers, and as with other products harmful to the population, there have been increasing calls for health warnings to be placed on alcoholic beverages, similar to those implemented on tobacco products. The aim of our research was to assess whether knowledge and awareness of the risks and harms associated with alcohol can be improved with a mobile app.

METHODS

Intervention was conducted using VKJ mobile app, which enables users to scan the barcode of an alcoholic beverage and receive feedback on its labelled alcohol content and estimated energy value. At each search, eleven different health messages/warnings about the risks and harms of alcohol are also displayed randomly, rotating on the screen. A survey was conducted before and after the intervention, to assess the knowledge and awareness of the risks and harms associated with drinking alcohol.

RESULTS

Significant differences were found for eight of the twelve tested statements. The improvement was seen to a greater extent in the group of high-risk drinkers. The results also showed that the vast majority of participants (78%) who were exposed to the health messages supported mandatory labelling of alcoholic beverages with information on ingredient listing and energy value, and 72% would like to have health warnings on alcohol products.

CONCLUSIONS

The use of a mobile app can be an option to improve knowledge and raise awareness of the risks and harms related to alcohol.

Why Canadians deserve to have mandated health and standard drink information labels on alcohol containers

To reduce deaths, morbidity, and social problems from alcohol in Canada, a multi-dimensional robust response is needed, including a comprehensive alcohol control strategy at the provincial, territorial, and federal levels. Alcohol container labels with health and standard drink information are an essential component of this strategy. This commentary provides a rationale for the mandatory labelling of all alcohol products, summarizes Canadian initiatives to date to legislate alcohol container warning labels, and addresses myths and misconceptions about labels. Canadians deserve direct, accessible information about (1) the inherent health risks associated with alcohol consumption, (2) the number of standard drinks per container and volume of a standard drink, and (3) guidance for preventing or reducing consumption-related health risks. Enhanced health labels on alcohol containers are long overdue.

The effectiveness of alcohol label information for increasing knowledge and awareness: a rapid evidence review

BACKGROUND

Consumers have difficulty understanding alcoholic units and low risk drinking guidelines (LRDG). Labelling may improve comprehension. The aims of this rapid evidence review were to establish the effectiveness of on-bottle labelling for (i) improving comprehension of health risks; (ii) improving comprehension of unit and/or standard drink information and/or LRDG, and (iii) reducing self-reported intentions to drink/actual drinking.

METHODS

Electronic database searches were carried out (January 2008-November 2018 inclusive). Papers were included if they were: published in English; from an Organization for Economic Co-operation and Development country; an experimental/quasi-experimental design. Papers were assessed for quality using the Effective Public Health Practice Project Quality Assessment tool. Ten papers were included. Most studies were moderate quality (n = 7).

RESULTS

Five themes emerged: comprehension of health risks; self-reported drinking intentions; comprehension of unit/standard drink information and/or LRDG; outcome expectancies; and label attention. Labelling can improve awareness, particularly of health harms, but is unlikely to change behaviour. Improved comprehension was greatest for labels with unit information and LRDG.

CONCLUSIONS

Alcohol labelling can be effective in improving people's comprehension of the health risks involved in drinking alcohol enabling them to make informed consumption decisions, and perhaps thereby provide a route to changing behaviour. Thus, effective alcohol labelling is an intervention that can be added to the broader suite of policy options. That being said, the literature reviewed here suggests that the specific format of the label matters, so careful consideration must be given to the design and placement of labels.

Improving alcohol health literacy and reducing alcohol consumption: recommendations for Germany

BACKGROUND

Although the detrimental health effects of alcohol are well established, consumption levels are high in many high-income countries such as Germany. Improving alcohol health literacy presents an integrated approach to alcohol prevention and an important complement to alcohol policy. Our aim was to identify and prioritize measures to enhance alcohol health literacy and hence to reduce alcohol consumption, using Germany as an example.

METHODS

A series of recommendations for improving alcohol health literacy were derived from a review of the literature and subsequently rated by five experts. Recommendations were rated according to their likely impact on enhancing (a) alcohol health literacy and (b) reducing alcohol consumption. Inter-rater agreement was assessed using a two-way intra-class correlation coefficient (ICC).

RESULTS

Eleven recommendations were established for three areas of action: (1) education and information, (2) health care system, and (3) alcohol control policy. Education and information measures were rated high to increase alcohol health literacy but low to their impact on alcohol consumption, while this pattern was reversed for alcohol control policies. The ratings showed good agreement (ICC: 0.85-0.88).

CONCLUSIONS

Improving alcohol health literacy and reducing alcohol consumption should be considered complementary and become part of a comprehensive alcohol strategy to curb the health, social, and economic burden of alcohol.

The emperor has no clothes: a synthesis of findings from the Transformative Research on the Alcohol industry, Policy and Science research programme

BACKGROUND AND AIMS

The Transformative Research on the Alcohol industry, Policy and Science (TRAPS) programme investigates the alcohol industry, with an innovative focus on public health sciences. TRAPS adds to an under-developed literature on the study of alcohol industry influence on alcohol science and policymaking. This paper provides a synthesis of TRAPS findings to inform future research.

METHODS

We conducted an interpretive review of TRAPS research findings across its component studies, identifying and integrating the key contributions made by individual studies to the literature on alcohol policymaking and science, and identifying areas where TRAPS progress was limited. This produced themes for consideration in future research agenda setting.

RESULTS

TRAPS explored the interventions of the alcohol industry in science and policymaking using various methods, including systematic reviews and qualitative interviews. These studies identified the industry's activities in several key areas, such as the debate over minimum unit pricing (MUP), cardiovascular health and alcohol research and a long-running public relations programme developed in close connection with the tobacco industry. Collectively, the research shows that alcohol policymaking has involved a contest between the research community and alcohol industry actors about whether and how science should be used to inform policy.

CONCLUSIONS

The TRAPS programme demonstrates the need for a transdisciplinary approach to understand the nature of corporate political activity; the crucial role industry involvement in science plays in the development of corporate political power; and how public health actors have successfully overcome industry opposition to evidence-based policies. Advances in alcohol policy should be underpinned by strong, reflexive public health sciences, alert to the role of industry in the alcohol harms under study and thorough in their investigation of the alcohol industry as an object of study in itself.

The health halo effect of 'low sugar' and related claims on alcoholic drinks: an online experiment with young women

AIMS

To investigate whether 'low sugar' and related claims influence consumers' perceptions of the healthiness or other attributes of alcoholic drinks, promote greater consumption or impact diet and activity behaviour intentions.

METHOD

N = 501 Australian women aged 18-35 viewed and rated six images of alcoholic drinks in a randomized online experiment with a 2 (claim: low sugar claim, no claim control) × 2 (drink type: cider, ready-to-drink spirits) between-subjects design.

RESULTS

Participants who viewed drinks with low sugar claims rated them as healthier, less harmful to health, lower in sugar and kilojoules, and more suitable for weight management and a healthy diet than participants who viewed identical drinks with no claim (P < 0.001-P = 0.002). Drinks with low sugar claims were also perceived as being lower in alcohol (P < 0.001) despite being of equivalent alcohol content. There were no significant differences in anticipated social approval associated with consumption or in hypothetical intended consumption of the drinks, but participants who viewed drinks with low sugar claims were less likely to indicate they would compensate for consumption of the drink by modifying food intake or physical activity (P = 0.01).

CONCLUSIONS

Low sugar and related claims on alcoholic drinks can generate a health halo: consumers generalise from a specific favourable attribute (low sugar) to misperceive other favourable health- and nutrition-related attributes, including lower alcohol content. Findings support calls to reconsider the permissibility of low sugar claims on alcoholic drinks as they may mislead consumers.

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.

Liver Transplant Recipients Speak Out on Public Awareness and Education Surrounding Alcohol-Related Health Effects: A Survey Study

BACKGROUND

Compared to other recreational substances in Canada, alcohol consumption incurs the highest healthcare costs. Liver transplant recipients are unique stakeholders as members of the general public with lived experiences of liver disease. We sought to explore their perspectives on the current state of public education on alcohol-related health effects.

METHODS

The most recent 400 liver transplant recipients at Vancouver General Hospital, Canada, were invited to participate in an anonymous online survey on alcohol-related health effects by mail, email, and phone.

RESULTS

Of 372 contacted patients, 212 (57%) completed the survey. Most patients were between 60-79 years, 63% were male, and 69% were Caucasian. The most common liver conditions leading to transplant were viral hepatitis (33%), alcohol-related liver disease (16%), autoimmune liver disease (14%), and non-alcoholic fatty liver disease (15%). Most patients knew that alcohol leads to liver failure (85%), but fewer knew about alcohol leading to cancer (54%), heart disease (50%), and damage to other organs (58%). Most common sources of information included public media (61%), family and friends (52%), and physicians (49%), with narrative comments about learning of alcohol-related health effects after liver diagnosis. Most patients believed that public health education at a middle/high school level would have long-term efficacy (72%) compared to health warning labels (33%) and safety messaging in commercials (39%). Current public education was felt to be adequate by only 20% of patients and 73% of patients supported health warning labels.

CONCLUSIONS

Liver transplant patients reported a high, but not universal, awareness of alcohol-related health effects. A majority thought that current public health efforts were inadequate; it is critical to implement public health interventions to ensure consumers are able to make an informed decision on alcohol consumption.

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.

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.

Alcohol and Cancer: Existing Knowledge and Evidence Gaps across the Cancer Continuum

Alcoholic beverages are carcinogenic to humans. Globally, an estimated 4.1% of new cancer cases in 2020 were attributable to alcoholic beverages. However, the full cancer burden due to alcohol is uncertain because for many cancer (sub)types, associations remain inconclusive. Additionally, associations of consumption with therapeutic response, disease progression, and long-term cancer outcomes are not fully understood, public awareness of the alcohol-cancer link is low, and the interrelationships of alcohol control regulations and cancer risk are unclear. In December 2020, the U.S. NCI convened a workshop and public webinar that brought together a panel of scientific experts to review what is known about and identify knowledge gaps regarding alcohol and cancer. Examples of gaps identified include: (i) associations of alcohol consumption patterns across the life course with cancer risk; (ii) alcohol's systemic carcinogenic effects; (iii) alcohol's influence on treatment efficacy, patient-reported outcomes, and long-term prognosis; (iv) communication strategies to increase awareness of the alcohol-cancer link; and (v) the impact of alcohol control policies to reduce consumption on cancer incidence and mortality. Interdisciplinary research and implementation efforts are needed to increase relevant knowledge, and to develop effective interventions focused on improving awareness, and reducing harmful consumption to decrease the alcohol-related cancer burden.

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.

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.

Government Options to Reduce the Impact of Alcohol on Human Health: Obstacles to Effective Policy Implementation

Evidence for effective government policies to reduce exposure to alcohol's carcinogenic and hepatoxic effects has strengthened in recent decades. Policies with the strongest evidence involve reducing the affordability, availability and cultural acceptability of alcohol. However, policies that reduce population consumption compete with powerful commercial vested interests. This paper draws on the Canadian Alcohol Policy Evaluation (CAPE), a formal assessment of effective government action on alcohol across Canadian jurisdictions. It also draws on alcohol policy case studies elsewhere involving attempts to introduce minimum unit pricing and cancer warning labels on alcohol containers. Canadian governments collectively received a failing grade (F) for alcohol policy implementation during the most recent CAPE assessment in 2017. However, had the best practices observed in any one jurisdiction been implemented consistently, Canada would have received an A grade. Resistance to effective alcohol policies is due to (1) lack of public awareness of both need and effectiveness, (2) a lack of government regulatory mechanisms to implement effective policies, (3) alcohol industry lobbying, and (4) a failure from the public health community to promote specific and feasible actions as opposed to general principles, e.g., 'increased prices' or 'reduced affordability'. There is enormous untapped potential in most countries for the implementation of proven strategies to reduce alcohol-related harm. While alcohol policies have weakened in many countries during the COVID-19 pandemic, societies may now also be more accepting of public health-inspired policies with proven effectiveness and potential economic benefits.

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.

'Alcohol causes cancer': a difficult message for Australians to swallow

Alcohol is a modifiable risk factor for cancer. Public awareness of the link between alcohol and cancer risk is poor; thus, alcohol consumers may be unknowingly putting themselves at increased risk of cancer. One way to raise awareness of alcohol-related cancer is through placing labels warning of cancer risk on alcoholic beverage containers; however, little is known about the impact of such labels. We conducted seven focus groups, comprising participants who self-identified as low-to-moderate alcohol consumers, to gauge public attitudes towards the labels and messages relating to alcohol-related cancer risk. Transcripts of discussions were coded to identify emergent themes. Participants expressed a negative response to the alcohol warning labels, and their talk worked to challenge the legitimacy of alcohol-related cancer messages, and the entities responsible for disseminating the information. These responses functioned to counter any implied recommendation for reduction in speakers' alcohol consumption. These findings illustrate how the general population make sense of information about health risks, using this knowledge to make decisions about personal behaviour. In combination with other public health initiatives, alcohol-warning labels have the potential to increase awareness of cancer risk and help in the fight against cancer, but any messaging will need to account for probable consumer resistance.

The burden of alcohol on health care during COVID-19

Alcohol's impact on global health is substantial and of a similar order of magnitude to that from COVID‐19. Alcohol now also poses specific concerns, such as increased risk of severe lung infections, domestic violence, child abuse, depression and suicide. Its use is unlikely to aid physical distancing or other preventative behavioural measures. Globally, alcohol contributes to 20% of injury and 11.5% of non‐injury emergency room presentations. We provide some broad comparisons between alcohol‐attributable and COVID‐19‐related hospitalisations and deaths in North America using most recent data. For example, for Canada in 2017 it was recently estimated there were 105 065 alcohol‐attributable hospitalisations which represent a substantially higher rate over time than the 10 521 COVID‐19 hospitalisations reported during the first 5 months of the pandemic. Despite the current importance of protecting health‐care services, most governments have deemed alcohol sales to be as essential as food, fuel and pharmaceuticals. In many countries, alcohol is now more readily available and affordable than ever before, a situation global alcohol producers benefit from and have helped engineer. We argue that to protect frontline health‐care services and public health more generally, it is essential that modest, evidence‐based restrictions on alcohol prices, availability and marketing are introduced. In particular, we recommend increases in excise taxation coupled with minimum unit pricing to both reduce impacts on health‐care services and provide much‐needed revenues for governments at this critical time.

News Media and the Influence of the Alcohol Industry: An Analysis of Media Coverage of Alcohol Warning Labels With a Cancer Message in Canada and Ireland

OBJECTIVE

Media coverage of alcohol-related policy measures can influence public debate and is often more aligned with interests of the alcohol industry than public health. The purpose of this study was to examine the framing of news coverage of alcohol warning label (AWL) initiatives that included a cancer message on alcohol containers in two different countries. Policy contexts and industry perspectives were also evaluated.

METHOD

We identified and systematically reviewed news articles published between 2017-2019 covering an AWL academic study in Yukon, Canada, and labeling provisions in a Public Health (Alcohol) Bill in Ireland. Both included a cancer message. News stories were coded for media type and topic slant; inclusion of alcohol industry perspectives was examined using content analysis.

RESULTS

Overall, 68.4% of media articles covering the Yukon Study (n = 38) and 18.9% covering the Ireland Bill (n = 37) were supportive of AWLs with a cancer message. The majority of articles in both sites presented alcohol industry perspectives (Yukon, 65.8%; Ireland, 86.5%), and industry arguments opposing AWLs were similar across both contexts. In articles with statements from industry representatives, the label message was frequently disputed by distorting or denying the evidence that alcohol causes cancer (n = 33/43).

CONCLUSIONS

News coverage of AWLs with a cancer message was more supportive in Canada than Ireland, where alcohol industry perspectives were consistently foregrounded. Industry arguments opposing the cancer label bore similarities across contexts, often distorting or denying the evidence. Increasing awareness of industry messaging strategies may generate more critical coverage of industry lobbying activities and increase public support for alcohol policies.