ArticlePDF AvailableLiterature Review

Enhanced labelling on alcoholic drinks: Reviewing the evidence to guide alcohol policy

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Background: Consumer and public health organizations have called for better labelling on alcoholic drinks. However, there is a lack of consensus about the best elements to include. This review summarizes alcohol labelling policy worldwide and examines available evidence to support enhanced labelling. Methods: A literature review was carried out in June-July 2012 on Scopus using the key word 'alcohol' combined with 'allergens', 'labels', 'nutrition information', 'ingredients', 'consumer information' and/or 'warning'. Articles discussing advertising and promotion of alcohol were excluded. A search through Google and the System for Grey Literature in Europe (SIGLE) identified additional sources on alcohol labelling policies, mainly from governmental and organizational websites. Results: Five elements were identified as potentially useful to consumers: (i) a list of ingredients, (ii) nutritional information, (iii) serving size and servings per container, (iv) a definition of 'moderate' intake and (v) a health warning. Alcohol labelling policy with regard to these aspects is quite rudimentary in most countries, with few requiring a list of ingredients or health warnings, and none requiring basic nutritional information. Only one country (Australia) requires serving size and servings per container to be displayed. Our study suggests that there are both potential advantages and disadvantages to providing consumers with more information about alcohol products. Conclusions: Current evidence seems to support prompt inclusion of a list of ingredients, nutritional information (usually only kcal) and health warnings on labels. Standard drink and serving size is useful only when combined with other health education efforts. A definition of 'moderate intake' and recommended drinking guidelines are best suited to other contexts.
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European Journal of Public Health, 1–6
ßThe Author 2013. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
doi:10.1093/eurpub/ckt046
.........................................................................................................
Enhanced labelling on alcoholic drinks: reviewing the
evidence to guide alcohol policy
Jose M. Martin-Moreno
1
, Meggan E. Harris
1
, Joao Breda
2
, Lars Møller
2
, Jose L. Alfonso-Sanchez
1
,
Lydia Gorgojo
3
1 Department of Preventive Medicine and Public Health, Medical School and University Hospital, University of Valencia,
Valencia, Spain
2 WHO Regional Office for Europe, Copenhagen, Denmark
3 European Observatory on Health Systems and Policies, Brussels, Belgium
Correspondence: Jose M. Martin-Moreno, Department of Preventive Medicine and Public Health, Medical School and
University Hospital, University of Valencia, Avenida Blasco Iban
˜ez, 15, 46010-Valencia, Spain, tel: +34 96 386 4997,
fax: +34 96 386 4166, e-mail: jose.maria.martin@uv.es
Background: Consumer and public health organizations have called for better labelling on alcoholic drinks.
However, there is a lack of consensus about the best elements to include. This review summarizes alcohol
labelling policy worldwide and examines available evidence to support enhanced labelling. Methods: A
literature review was carried out in June–July 2012 on Scopus using the key word ‘alcohol’ combined with
‘allergens’, ‘labels’, ‘nutrition information’, ‘ingredients’, ‘consumer information’ and/or ‘warning’. Articles
discussing advertising and promotion of alcohol were excluded. A search through Google and the System for
Grey Literature in Europe (SIGLE) identified additional sources on alcohol labelling policies, mainly from govern-
mental and organizational websites. Results: Five elements were identified as potentially useful to consumers:
(i) a list of ingredients, (ii) nutritional information, (iii) serving size and servings per container, (iv) a definition
of ‘moderate’ intake and (v) a health warning. Alcohol labelling policy with regard to these aspects is quite
rudimentary in most countries, with few requiring a list of ingredients or health warnings, and none requiring
basic nutritional information. Only one country (Australia) requires serving size and servings per container to be
displayed. Our study suggests that there are both potential advantages and disadvantages to providing consumers
with more information about alcohol products. Conclusions: Current evidence seems to support prompt inclusion
of a list of ingredients, nutritional information (usually only kcal) and health warnings on labels. Standard drink
and serving size is useful only when combined with other health education efforts. A definition of ‘moderate
intake’ and recommended drinking guidelines are best suited to other contexts.
.........................................................................................................
Introduction
Every year, citizens in the European Region consume 9.24 l of pure
alcohol per capita—more than in any other WHO Region.
1
A
large, diverse and persuasive body of evidence identifies alcohol as
one of the world’s top three priority public health areas. Even
though only half the world’s population drinks, alcohol is the
world’s third leading cause of ill health and premature death, after
low birth weight and unsafe sex (for which alcohol is also a risk
factor). Harmful use of alcohol is associated with a wide range of
devastating physical pathologies as well as mental illness, traffic
crashes, suicide, violence and other harmful consequences for both
individuals and communities. Indeed, Nutt et al.
2
found that
alcohol’s impact on society is larger and more negative than any
other drug, including heroin, crack cocaine and tobacco. WHO
data confirm that morbidity attributable to alcohol comes second
only to that of tobacco, and 70% of mortality owing to liver disease
is associated with it.
3
These figures are astonishing, given that hazardous and harmful
drinkers only constitute a minority (albeit a significant minority) of
those who drink. In England, hazardous or harmful drinkers
comprised 24% of the adult population in 2007
4
; however, this
sub-population was responsible for consuming three-quarters of
all alcohol sold in the country.
3
On the other hand, studies have
shown that middle-aged and older people who drink lightly or in
moderation are less likely to die from ischaemic events (coronary
heart disease, ischaemic stroke and type 2 diabetes) than abstainers.
Yet, despite the unarguable importance of choosing what, when, and
how much to drink, consumers have less access to health and
nutritional information about these beverages than they do about
a glass of milk, a bowl of cereal or a soft drink.
To address this information gap, several initiatives in Europe,
the USA and the world have called for better labelling of alcoholic
drinks. In June 2012, the European Alcohol Policy Alliance (Eurocare)
released recommendations for a comprehensive European Alcohol
Strategy (currently under consideration by the European
Commission), including better labelling for alcoholic beverages, with
a list of ingredients, allergens with their potential effect, nutritional
information (kcal), alcoholic strength and rotating health warnings.
5
In the US, recommendations from the Center for Science in the Public
Interest (CSPI) date back to 2003, when the coalition of public health
and consumer organizations first called for an ‘Alcohol Facts’ label to
include serving size, servings per container, calories, ingredients,
alcohol content (both percentage of volume and quantity of pure
alcohol per serving) and a definition of ‘moderate consumption’.
6
The British government, in collaboration with the alcohol industry,
has also taken some steps to provide drinkers with more consumer
information, developing a label to be included on packaging volun-
tarily, with information on standard units, recommendations on daily
intake and a health warning.
7
In Australia, the Preventative Health
Taskforce called for health warnings on alcoholic drinks to be
modelled after those on tobacco packages, arguing that the small
text-only warning labels on American products have not had a
dissuasive effect on unsafe drinking.
8
All of these recommendations share certain characteristics, but their
heterogeneity raises doubt as to the best elements to include on a
potential label and how to do so. What information would have the
most positive influence on drinking behaviour? How should this be
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presented? What do consumers have the right to know? To independ-
ently contribute to the evidence base that informs national and
European alcohol policy, this literature review will summarize
existing labelling requirements throughout the world (table 1)and
examine the evidence on additional elements to be potentially
included, focusing on two facets of consumer information: dietary
aspects of alcohol intake (ingredients, nutritional information,
calories, serving size) and potentially harmful effects (health
warnings and recommendations on intake). We will then weigh the
known advantages and disadvantages of including each element,
making evidence-based recommendations to guide policy (table 2).
Methods
A literature review was carried out in June–July 2012 on Scopus
using the key word ‘alcohol’ and one or more of the following:
‘allergens’, ‘labels’, ‘nutrition information’, ‘ingredients’, ‘consumer
information’ or ‘warning’. Articles discussing advertising and
promotion of alcohol (including requirements to include health
warnings on these) were excluded. Because alcohol content is
already generally required on labels (although presentation can
vary), we did not investigate this aspect. Additional articles of
interest were identified through examination of the bibliographies
from the identified sources. Nineteen articles were finally included.
There were no peer-reviewed articles synthesizing governmental
requirements for labelling, so a search was subsequently undertaken
on Google and the System for Grey Literature in Europe (SIGLE) to
complement the above and identify grey literature and additional
information on alcohol policies pertaining to labelling. Fifteen
additional references of interest were identified, mainly from gov-
ernmental and organizational websites.
Results
In terms of consumer information, five elements in addition to
alcohol content were identified as potentially useful to drinkers:
(i) a list of ingredients, (ii) nutritional information, (iii) serving
size and servings per container, (iv) a definition of ‘moderate
intake’ and (v) a health warning about the consequences of
unhealthy consumption. While some countries require disclosure
of certain elements on the labelling of alcoholic beverages
(table 1),
9,10
nutritional information on foodstuffs is invariably
more complete, while the kind of health warnings that have
become commonplace on tobacco products are notably absent in
all but a handful of countries.
Ingredients
The most basic element of labelling for consumer goods is a list of
ingredients, including allergens, additives and preservatives.
However, of the 53 countries for which labelling information was
available, just 22 currently require this (only two are European—
Switzerland and the UK) (table 1). Moreover, in the cases of Canada,
Table 1 Selected labelling requirements for alcoholic drinks in 26 countries and the European Union
Alcohol content
as % of total
volume
Mandatory
health warning
List of
ingredients
List of allergens
and/or additives
Calories
per serving
Standard
drinks per
container
Other
nutritional
information
Australia X X X
Belize n/a X
Brazil X X X X
Canada X X
a
Chile X
China X X
Colombia X X
Costa Rica X (spirits) X X
Dominican Republic n/a X X
European Union XX
France X X X
Germany X X (for sweet
alcoholic drinks)
X
Guatemala X X X
Hong Kong n/a X X
India n/a X
Japan X X X
Mexico X X X
a
X (aspartame)
New Zealand X X
a
Peru n/a X X
Phillipines X n/a X X
Russian Federation X X X X X (sugars)
Singapore n/a X
South Africa X X X
South Korea X n/a X X
Sweden X n/a X
b
Switzerland X n/a X X
Taiwan X X
Thailand X X
Turkey X n/a X X
United Kingdom X X
b
X
USA X X X X (selected) X (carbs)
n/a = not available.
a: For mixed or non-standardised drinks only.
b: Regulations in addition to EU standards.
Source
9,10
: International Center for Alcohol Policies: Informing consumers about beverage alcohol. Available at: http://www.fas.usda.gov/
posthome/useu/label.html; International Center for Alcohol Policies: Health Warning Labels. Available at: http://www.icap.org/table/
HealthWarningLabels.
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Mexico and New Zealand, an ingredients list is only required for
mixed or non-standardized drinks.
Yet, common ingredients of even standard alcoholic beverages
include wheat, barley, corn, rye, grapes, hops, histamine, sulphites
and Saccharomyces cerevisiae (brewer’s yeast), substances known to
produce allergic reactions in a minority of individuals, ranging from
a runny nose to anaphylaxis.
11,12
EU legislation requires disclosure
of many common allergens on labels, but people with uncommon
allergens depend on ingredients lists to know whether a product is
safe to ingest. Moreover, food safety authorities have long defended
the basic consumer right to know what is contained in a given
product; it is unclear why this logic has not also been applied to
alcoholic beverages, as there is no apparent downside for consumers
or producers, apart from the initial cost of changing labels (table 2).
Nutritional information
Nutritional information is another aspect to potentially include on
labels. One gram of alcohol contains seven calories, second only to
the number of calories found in a gram of fat, and heavy intake can
significantly contribute to overweight and obesity.
13,14
Given the
considerable public health problem that obesity presents in most
developed, and many developing, countries, caloric information is
extremely relevant to consumers, and so it is striking that no country
in the world currently requires disclosure of this information on
packaging.
Carbohydrate, fat and protein content complete a standard nutri-
tional label for food products, but this is not the case for alcohol.
The Russian Federation and the USA do mandate inclusion of sugar
or carbohydrate content, but the fact that most alcoholic drinks
(with the exception of beers, which have carbohydrates) have no
nutritional value introduces some uncertainty as to the utility of
including this data. Indeed, it could even be counterproductive to
health objectives. Preliminary research from a pilot study with a
sample population of 230 university students found that drinkers
had been consistently overestimating the amount of calories, fat and
carbohydrates contained in all drink types; upon exposure to
accurate nutritional information, their intentions to consume
increased rather than decreased.
15
No studies were identified to
evaluate how consumers of different profiles would interpret this
information.
Serving size and servings per container
Serving size (understood as a standard drink) and servings per
container are also absent on beer, wine and spirits labels in all
countries except Australia. In part, this may be because the
standard drink concept is somewhat problematic: The definition
varies across countries worldwide, from 8 g of ethanol in the UK
to nearly 20 in Japan
16
(the European Commission defines it as
10 g), and objective pour sizes both at home and in drinking estab-
lishments usually exceed standard measurements, especially for
Table 2 Summary of evidence regarding inclusion of dietary information and health warnings on alcohol labels, with recommendations
Pros Cons Recommendations
List of ingredients Protects consumer right to
information
Consumers with allergies can better
choose products
Producers must assume costs Should be included on drinks labelling
without delay
Nutritional
information
Facilitates health decisions through
accurate caloric and nutritional
content
Could influence drinking behaviour
of populations concerned with
overweight
Consumers who had over-
estimated caloric, fat or carbo-
hydrate content could increase
consumption
Producers could propound health
claims such as ‘fat free’ or ‘no/low
carbs’
Kilocalories should be included on all
labels. Fat, carbohydrate and protein
content should not be included unless
present. More research should be
carried out to determine how nutri-
tional information is interpreted
among different groups
Standard drink size
and servings per
container
Consumers can accurately track
alcohol intake
Allows better interpretation of
drinking guidelines
Need for some harmonization
among countries
Container and pour size often
do not correspond to standard
drink size
Consumers may decide to buy
drinks based on strongest
alcohol content for the money
Lack of awareness among
consumers about the signifi-
cance of a standard drink
Inclusion of standard drink size and
servings per container should be
coupled with measures to counteract
negative consequences, such as health
education and regulations to tie
pricing with standard drink sizes.
Drinking guidelines/
definition of
‘moderate intake’
Consumers would be more know-
ledgeable about generally safe
levels of consumption
Difficult to define; safe consump-
tion levels depend on individual
risk profiles
Recommendations would vary
according to drinking patterns
‘Moderation’ is a subjective, not
scientific term
Uniform guidelines cannot easily
influence large populations
No uniform guideline should be included
on labels, but tailored health commu-
nication should be undertaken outside
of a drinking context
Health warnings Effective way to inform all
consumers of risks associated with
alcohol
Could potentially reduce dangerous
drinking behaviour
Consumers overwhelmingly support
health warnings on alcoholic
products
Warnings will face strong
resistance from industry
Little existing evidence or policy
experience
Messages must be tailored to
drink type and audience
Health warnings should be included and
modelled after those that have
worked against tobacco (i.e., large-
print, simple, rotating warnings
occupying a large area of label and
including graphic images)
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spirits drinks.
17
Although containers are generally the same size (for
example, 33 cl for a bottled beer in many countries), alcohol content
can differ greatly, both between the three beverage groups (beer,
wine, spirits) as well as among different brands of the same
beverage—vodka alone can have an alcohol content ranging from
35 to 50% of its volume. Thus, it is unsurprising that drinkers have
little notion of how much alcohol they consume; self-reported
alcohol intake is significantly and consistently underestimated.
17
In
Australia, where the government has launched a public health
initiative to rectify this lack of awareness by educating consumers
about standard drink size, young drinkers are more knowledgeable
about their intake. However, they did not use the information to
comply with health recommendations, but rather to buy the
strongest drinks at the lowest cost.
18
Moreover, standard drink
labelling is of limited use unless combined with measures to
educate consumers on what it means. A European study using
focus groups in six EU Member States found that there was little
understanding of what a standard drink was nor what it meant;
participants speculated that it was aimed to help people know
how much they could drink before driving, that it was only
applicable to beer drinkers or that it was useful as a scale to know
how many drinks it took to get drunk.
19
Recommendations on ‘moderate intake’
Complementary to standard drink size, a definition of ‘moderate
intake’ was also identified as of potential interest to consumers, as
defended by the American CSPI
6
and the British government.
7
No
country currently requires this; however, the concept runs into some
of the same pitfalls as that of standard drink size: inconsistency
between countries and health organizations, lack of correlation
with serving sizes and poor understanding among consumers.
Although international recommendations on what constitutes
‘moderate’ consumption usually set the bar at one daily drink for
women and two for men, British guidelines allow up to four daily
drinks for men and three for women.
20
Likewise, serving size may
vary greatly; in Spain, beer is often sold in bottles of just 20 cl, while
in the UK or Ireland it is generally consumed in Imperial pints,
nearly 57 cl. Consumer awareness is low as well; an NHS survey
showed that although most drinkers are aware of the existence of
recommended units, over a third are incapable of defining them.
21
However, even if these obstacles could somehow be overcome (for
example, through a broad international public health campaign that
harmonized terminology while educating consumers), the idea of
‘moderate intake’, like ‘responsible drinking’, remains extremely
problematic because it is inherently subjective. Harding and
Stockley explore these problems,
22
signalling that optimal drinking
guidelines would have to be tailored not only to the specific risk
profiles of individuals (age, ethnicity, family history, body mass
index, mental and physical health, use of medications), but also to
target audiences. After all, health recommendations attempt to use
behavioural psychology to change behaviours (usually of those at
higher risk), and these vary tremendously between, for example, a
healthy university student who drinks excessively on weekends and a
middle-aged woman with high blood pressure who rarely drinks at
all. The former should be encouraged to reduce intake on weekends
and abstain on weekdays, while the latter could benefit from
increasing intake to one drink a day with meals.
With these complexities in mind, current evidence does not
support inclusion of this sort of health advice on labels (table 2).
Health warnings
With regard to health warnings, and despite the effectiveness of
prominent and graphic warnings on tobacco products,
23
this tool
has remained relatively unused on alcoholic beverages, with only
12 countries requiring some kind of health message. Countries in
the Americas (both north and south) tend to mandate these more
than European countries, while South Africa and Thailand stand out
for the strength of the required messages (e.g., ‘Alcohol abuse is
dangerous to your health’ in South Africa or ‘Liquor drinking is
harmful to you and destroys your family’ in Thailand) and the
prominence that these messages have on packaging. The EU does
not require any health warning (or even weakly worded advice) on
the possible consequences of alcoholic intake, and among Member
States, only France and Germany have taken some kind of measure
in this direction; the former requires either a message or pictogram
directed towards pregnant women, and the latter simply requires
sweet alcoholic drinks to include a warning against consumption
by minors.
Some soft measures have been taken in cooperation with industry
to provide consumers with more information. The UK attempted to
improve labelling through voluntary agreements with producers in
2007, including serving size and health warnings related to unsafe
consumption but not nutritional information. However, 3 years
later, the first report evaluating the voluntary programme was
published, finding that just 15% of commercially available drinks
were properly labelled.
24
Upon the report’s publication, the
incoming Tory government pledged to mandate inclusion of
clearer labelling on alcoholic products, decrying the units system
as ‘confusing’ and also proposing to include caloric information.
Since then, a public consultation, including population surveys,
has been carried out, and the Department of Health affirms that
specific policies to revamp the voluntary programme are under
development.
25
Voluntary labelling by producers has also taken place to some
extent.
26
These messages are often couched around the somewhat
amorphous concept of ‘responsible drinking’, which is basically
portrayed by drinks manufacturers to mean abstaining if driving,
pregnant, or underage. Importantly, however, the primary aim is not
to reduce alcohol consumption or binge drinking in other collect-
ives, nor to educate consumers about the health risks associated with
alcohol intake.
27
Indeed, industry efforts to ‘help’ governments in
shaping alcohol education and policies have been repeatedly
criticized as quite cynical attempts to placate public health
advocates without actually hurting sales.
28,29
Despite the effectiveness of prominent and graphic warnings on
tobacco products,
23
this tool is relatively undeveloped for alcoholic
drinks. The long small-print health warning required on alcohol
labels in the US since 1989—upon which most studies of the effec-
tiveness of warning labels on alcohol products are based––has not
been updated or enhanced in the same way that health warnings on
tobacco products have, leading to the rather unfair conclusion that
labels on alcoholic drinks are inherently ineffective.
30
In fact, these
text-only warnings have been shown to raise awareness of the
dangers of alcohol consumption during pregnancy and to reduce
drunk driving.
31,32
Several studies have been carried out to explore consumer
reactions to alternative formats. An Australian study used focus
groups to gauge reactions to varying tones, presentations and infor-
mational messages on warning prototypes; researchers found that
messages should be serious in tone and matched to target
audiences and beverage types.
33
Another study compared the
American warning to pregnant women and drivers with a shorter
(but more impactful) New Zealand warning (‘Alcohol is a drug’),
finding that risk perception among all drinkers—including risks
associated with driving and pregnancy—were higher after being
exposed to the second message.
34
The Protect study found that
pictures had more impact than words, that messages viewed as
relevant were better received than those that did not immediately
pertain to the consumer, and that rotating messages were more likely
to retain the attention of drinkers.
19
All studies called for labelling to
be part of a broader alcohol policy.
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Discussion
As public health professionals search for effective policies to address
alcohol misuse and abuse, labels stand out as an underused and
undertried way to empower consumers to make healthy decisions
about alcohol intake. This is true both globally and in Europe. The
European Union establishes certain minimums for labelling but
stops short of requiring full disclosure of ingredients and nutritional
information; labels must only display alcoholic strength and the
presence of any common allergens, such as sulphites in wine. No
EU country has, thus far, complemented these regulations with any
other mandatory requirements on standard drink size, calories or
nutrition, and just two require any kind of health warning. This
dearth of consumer information on alcohol packaging puts
Europe behind other countries, although it is also true that few
countries stand out as having taken rigorous action in this respect,
and none require full nutritional disclosure. Upon even a perfunc-
tory objective reflection on the matter, it is surprising that just one
country (Australia) requires information on serving size, and
baffling that none currently require disclosure of the number of
calories.
Given the potential benefits and relatively low cost of such
measures, the scarcity of existing research and policy on the topic
is noteworthy, constituting an inevitable limitation to the policy
recommendations made in this article. The area of alcohol
labelling merits more work, particularly through studies using
focus groups, to understand how labelling information is inter-
preted. Our study identified a few noteworthy examples focusing
on young people,
18,19,33,34
but none dealing with other populations
or risk groups. In particular, there is ample synergy to be developed
between the fields of addiction and nutrition, with overweight and
obese populations standing out as among the specific groups with
the most to benefit from more nutritional information on labels.
Likewise, health warnings similar to those found on cigarette
products (and combined with other policy and health education
measures) have the potential to replicate the success achieved in
the public health campaign against tobacco; given the harmful
impact that alcohol exerts on society as a whole, this area of work
is critical.
Based on existing evidence, labels that borrow elements from both
foodstuffs (nutritional information) and tobacco (health warnings)
seem to constitute the best approach to deal with the dual nature of
alcohol, which is both a dietary element and a drug. These types of
labels enjoy wide support from drinkers and non-drinkers alike.
35–37
However, specific considerations based on evidence should be made
before implementing any policy (table 2).
This literature review has found that some consumers, instead
of using labelling to make healthy choices, would use it to buy the
strongest drinks at the lowest price, and others who had previously
overestimated fat, carbohydrate and caloric content could feel
empowered to increase their intake. Should health professionals
desist from advocating for accurate content labelling on alcoholic
drinks because consumers may use the information to facilitate or
justify unsafe drinking behaviour?
History and policy have tended to favour consumers’ right to
information over health authority concerns regarding how that
information is used. An illustrative case comes from the USA,
where until 1995, beer manufacturers were forbidden from
displaying alcohol content on labels in an attempt to protect
consumers from themselves, by averting ‘strength wars’ between
competitors. The Supreme Court overturned the law on the basis
of free speech, denouncing the ‘supposed state interests that seek to
keep people in the dark for what the government believes to be their
own good.’
38
In Europe, debate around so-called ‘nudge’ policies
touch on the same themes; individual freedom of choice is consist-
ently defended even when this may be detrimental to health.
39
Thus, from an ethical standpoint, the potential harm that may
arise from displaying content information on alcohol labels is not
enough to preclude the provision of that information to consumers.
However, it does constitute a strong argument in favour of also
including a health warning, and of integrating alcohol labelling
into a comprehensive set of policies—including strengthened
alcohol education—to protect consumers from the health risks
of unsafe intake. Furthermore, the large body of research available
on the decades-long public health campaign against smoking
confirms that each measure undertaken (warning labels, smoke-
free legislation, health education, advertising bans, price
controls ...) reinforces the effectiveness of the others. Labelling
alone, even with a health warning, would likely be of limited use
in absence of a comprehensive programme targeting harmful alcohol
intake.
Health warnings on labels must consider the target audience,
drink type, possible drinking venue and patterns of consumption.
Although this endeavour presents certain methodological challenges,
rotating prominent warnings, adjusted for beverage type, could
ensure that relevant messages reach all consumer profiles. On the
other hand, drinking guidelines or recommendations on what con-
stitutes ‘moderate consumption’ must be tailored to individual risk
profiles, which is mostly independent of drink type; this type of
message may be more suited to a health education context rather
than a product label.
In conclusion, both public health organizations and consumers
worldwide strongly support enhanced labelling of alcoholic drinks,
but from a public health perspective, it is imperative that consumer
information be coupled with health education and other policy tools
to reduce harmful drinking behaviours.
Conflicts of interest: None declared.
Key points
Public health and consumer organizations support better
labelling for alcohol, but heterogeneous recommendations
reveal a lack of consensus on what elements to include.
Consumers may benefit from labels that include a list of
ingredients, nutritional information, serving size and
health warnings.
Alcohol labels stand out as a potentially effective strategy to
inform all consumer risk groups about the risks of drinking,
but they are insufficient (and possibly even counterproduct-
ive) in achieving health objectives unless combined with a
comprehensive alcohol strategy.
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at Universidad de Valencia on June 4, 2013http://eurpub.oxfordjournals.org/Downloaded from
... Despite the risks to health from drinking alcohol, when making purchasing choices, consumers are provided with little information about alcoholic beverages on product labels; less 'than they do about a glass of milk, a bowl of cereal or a soft drink' (Martin-Moreno et al., 2013, p. 1082. The UK government imposes no legal requirements for health information on alcoholic drinks labelling but, as part of the 2011 Public Health Responsibility Deal with alcohol producers, best practice guidelines were established recommending that industry voluntarily display alcohol content in units, the Chief Medical Officers' (CMO) low-risk drinking guidelines and a pregnancy warning as minimum information on at least 80% of alcoholic drinks labels by 2013 (Cramer, 2018). ...
... Although it is widely recognised that policy changes, such as minimum unit pricing, would be the most effective means of changing alcohol consumption at a population level (Anderson et al., 2009;Babor, 2010;Burton et al., 2016), enabling individual informed choice has wide public support (Blackwell et al., 2018;Cramer, 2018;Martin-Moreno et al., 2013;Stautz & Marteau, 2016). Despite there being scant evidence for the provision of information being sufficient for altering drinking behaviour, these findings are likely to have been affected by the way in which health messages have been implemented (Cramer, 2018;Pettigrew et al., 2014). ...
... Interventions that have focused on providing information about alcohol unit guidelines and the health risks of drinking alcohol have been effective in increasing knowledge and awareness of the unit guidelines (Blackwell et al., 2018;de Visser et al., 2017;Martin-Moreno et al., 2013). Additionally, research suggests that alcohol health messages can alter attitudes and intentions towards drinking alcohol (Glock et al., 2015;Miller et al., 2016;Moss et al., 2017;Wakefield et al., 2018). ...
Article
Full-text available
Objective: Research shows that personal relevance may affect the impact of alcohol-related health information. This study explored alcohol consumption during the UK Covid-19 lockdown, and whether a message emphasising the effect of alcohol on the immune system was more effective in altering intentions to follow low-risk drinking guidelines than other messages about the effects of alcohol on health. Methods & Measures: From April to June 2020, 953 drinkers completed an online questionnaire, and were randomly allocated to exposure to a control condition or one of three messages emphasising the impact of alcohol on: the immune system; mental health; or physical health. Outcome variables were: concern about alcohol intake, and intention to adhere to low-risk drinking guidelines. Results: Pre-post ANCOVAs revealed that participants in the immunity message group had significantly stronger intention to adhere to low-risk guidelines than the control group (after controlling for initial intention). Concern for the effect of alcohol on health was not significantly affected. Conclusion: During Covid-19 lockdown, a message emphasising the impact of alcohol on the immune-system had a greater effect on intention to observe low-risk drinking guidelines than other messages. Contextually relevant messages could be used for alcohol health campaigns and for improving alcohol labelling.
... In a few more countries (e.g. China and Japan), such health warnings are voluntary (Wilkinson and Room 2009;Martin-Moreno et al. 2013). The content of warning labels varies among countries. ...
... Wilkinson and Room 2009;Martin-Moreno et al. 2013). The transnational alcohol corporations have moved to include in international trade agreements restrictions on national requirements for warning labels on containers, seeing such requirements as restricting their use of the valuable 'real estate' on the label for their promotional material; see Chapter 15). ...
Book
Full-text available
This book is about alcohol policy: why it is needed, how it is made, and the impact it has on health and well-being. It is written for both policymakers and alcohol scientists, as well as the many other people interested in bridging the gap between research and policy. It begins with a global review of epidemiological evidence showing why alcohol is not an ordinary commodity, and it ends with the conclusion that alcohol policies implemented within a public health agenda are needed to reduce the enormous burden of harm it causes. The core of the book is a critical review of the cumulative scientific evidence in seven general areas of alcohol policy: pricing and taxation; regulating the physical availability of alcohol; modifying the environment in which drinking occurs; drink-driving countermeasures; marketing restrictions; primary prevention programmes in schools and other settings; and treatment and early intervention services. The final chapters discuss the current state of alcohol policy in different parts of the world, the detrimental role of the alcohol industry, and the need for both national and global alcohol policies that are evidence-based, effective, and coordinated. This book shows that opportunities for evidence-based alcohol policies that better serve the public good are clearer than ever before, as a result of accumulating knowledge on which strategies work best.
... In a few more countries (e.g. China and Japan), such health warnings are voluntary (Wilkinson and Room 2009;Martin-Moreno et al. 2013). The content of warning labels varies among countries. ...
... The content of warning labels varies among countries. In France and Australia, the emphasis is solely on risks from drinking during pregnancy, while in South Africa, warning labels must contain at least one of seven health messages (including risks of personal injuries and addiction) (Wilkinson and Room 2009;Martin-Moreno et al. 2013). The transnational alcohol corporations have moved to include in international trade agreements restrictions on national requirements for warning labels on containers, seeing such requirements as restricting their use of the valuable 'real estate' on the label for their promotional material (O'Brien et al. 2018;see Chapter 15). ...
Chapter
Full-text available
This book is about alcohol policy: why it is needed, how it is made, and the impact it has on health and well-being. It is written for both policymakers and alcohol scientists, as well as the many other people interested in bridging the gap between research and policy. It begins with a global review of epidemiological evidence showing why alcohol is not an ordinary commodity, and it ends with the conclusion that alcohol policies implemented within a public health agenda are needed to reduce the enormous burden of harm it causes. The core of the book is a critical review of the cumulative scientific evidence in seven general areas of alcohol policy: pricing and taxation; regulating the physical availability of alcohol; modifying the environment in which drinking occurs; drink-driving countermeasures; marketing restrictions; primary prevention programmes in schools and other settings; and treatment and early intervention services. The final chapters discuss the current state of alcohol policy in different parts of the world, the detrimental role of the alcohol industry, and the need for both national and global alcohol policies that are evidence-based, effective, and coordinated. This book shows that opportunities for evidence-based alcohol policies that better serve the public good are clearer than ever before, as a result of accumulating knowledge on which strategies work best.
... 3 Although the prevalence of alcohol use during pregnancy in the World Health Organisation (WHO) European region is estimated to be the highest among the six WHO regions, European Union legislation does not oblige the alcohol industry to include any health warning labels on alcohol packaging or advertisements. 2,4 However, since 2007, French law requires a warning label to be placed on all alcoholic beverages sold on French territory. The official French pregnancy warning label (PWL) consists of a pictogram representing the silhouette of a pregnant woman in a circle crossed by an oblique line or the sentence 'Drinking alcoholic beverages during pregnancy, even in small amounts, can have serious consequences on the health of the child'. ...
Article
Purpose - Upstream social marketers advocate implementing effective public policies to protect vulnerable populations from the impacts of advertising harmful products. This research explores how alcohol ad content restrictions (as practised in some countries where ads may only convey factual information and objective properties of alcohol products) versus non-regulated advertising affect consumers’ product perceptions, attitude towards the ad, and desire to drink. It also examines how such restrictions influence the noticeability of text health warnings in ads (signalling alcohol-related risks) depending on their prominence. Design/methodology - A multi-method study was used to increase the validity of results. An online quantitative survey (n = 348) and an eye-tracking study (n = 184) were conducted on young French people (15–30). The eye-tracking method is particularly relevant for objectively measuring visual attention. Findings - Results show that content restrictions on alcohol advertising reduce ad appeal and desire to drink. A more prominent format enhanced attentional processing of the text warning, whereas none of the tested ad contents influenced its noticeability. Originality - To the best of the authors’ knowledge, this is the first multi-method study that assesses the effect of regulated vs. non-regulated alcohol ads in terms of persuasion and of text warning visibility. Practical implications - This study assesses scientific evidence of the effect on alcohol ad content regulations adopted by some countries and provides arguments for upstream social marketers to inform and influence policy makers.
... 3 Although the prevalence of alcohol use during pregnancy in the World Health Organisation (WHO) European region is estimated to be the highest among the six WHO regions, European Union legislation does not oblige the alcohol industry to include any health warning labels on alcohol packaging or advertisements. 2,4 However, since 2007, French law requires a warning label to be placed on all alcoholic beverages sold on French territory. The official French pregnancy warning label (PWL) consists of a pictogram representing the silhouette of a pregnant woman in a circle crossed by an oblique line or the sentence 'Drinking alcoholic beverages during pregnancy, even in small amounts, can have serious consequences on the health of the child'. ...
Article
Objectives Every year, foetal alcohol spectrum disorders impact 1 in 100 live births in France. France is one of the few countries with mandated labelling that must include a pregnancy warning. However, as the regulation passed with minimal specifications regarding the size and colour of the ensuing pictogram, the current pregnancy warning labels (PWLs) is often barely visible. This study investigated the potential influence of the PWL design on women's attention and alcohol product choice. Study design The study used a within-subject experiment, with participants exposed to four PWL conditions. Methods An eye-tracking method was adopted. Eye movement was used as a proxy for measuring visual attention. In total, 4752 observations were collected (99 participants × 48 wine bottles) among women of childbearing age. Results The results show that almost none of the participants paid attention to the current French PWL. However, the findings also indicate that a larger colourful PWL, with a combined text and pictogram, attracts far more attention, and that participants chose the bottles of wine displaying this type of PWL less frequently. Conclusions The study indicates that the current French PWL is insufficient to draw women's attention and suggests improvements to the PWL design to help increase its effectiveness.
... 92 It has also been argued that nutritional labelling could theoretically result in alcohol being more likely to be considered or treated as a food product, as opposed to being a psychoactive substance that can cause addiction and serious harm. 93 It is important to note that not all potential compensatory behaviours in response to alcohol observed in studies are unhealthy, with some young people reporting drinking water or eating healthier foods to account for calories consumed from alcohol. 94 Nonetheless, given that some young adults report engaging in unhealthy compensatory behaviours in response to the number of calories in alcoholic drinks, it will be important to determine whether widespread energy labelling of alcoholic drinks would increase the proportion of the general population exhibiting these types of behaviours. ...
Article
Full-text available
Alcohol is calorie dense, but unlike food products, alcoholic drinks tend to be exempt from nutritional labelling laws that require energy content information to be displayed on packaging or at point of purchase. This review provides a perspective on the likely efficacy of alcoholic drink energy labelling as a public health policy to reduce obesity and discusses key questions to be addressed by future research. First, the contribution that alcohol makes to population level daily energy intake and obesity is outlined. Next, consumer need for alcohol energy labelling and the potential impacts on both consumer and industry behaviour are discussed. Pathways and mechanisms by which energy labelling of alcoholic drinks could reduce obesity are considered, as well as possible unintended consequences of alcoholic drink energy labelling. Would widespread energy labelling of alcoholic drinks reduce obesity? The unclear effect that alcohol has on population level obesity, the modest contribution calories from alcohol make to daily energy intake and limited impact nutritional labelling policies tend to have on behaviour, suggest alcohol energy labelling alone may have limited impact on population obesity prevalence as a standalone policy. However, there are a number of questions that will need to be answered by future research to make definitive conclusions on the potential for alcohol energy labelling policies to reduce obesity. This article is protected by copyright. All rights reserved. Would widespread energy labelling of alcoholic drinks reduce obesity? We provide a perspective on the potential of this obesity policy" cd_value_code="text
... On the other hand, research on indirect measures have suggested that increasing alcohol sales hours was associated with an increase in traffic collisions in both Australia and Canada, and paradoxically with a decrease in the United Kingdom (Sanchez-Ramirez and Voaklander, 2018;Popova et al., 2009). Reviews regarding health warning labels suggest that this policy could be associated with mild reductions in DUIA in Canada and the United States (Greenfield et al., 1999;Martin-Moreno et al., 2013). ...
Article
Full-text available
Background: In June 2013, an alcohol-related traffic law took effect in Turkey. The law 6487 introduced administrative fines for not respecting blood alcohol concentration limits, health warning messages on alcohol containers (bottles, cans), and prohibited the sale of alcohol beverages in retail facilities between 10 p.m. and 6 a.m.. This article examines how this law is associated with traffic fatality variation. Methods: Data from the Turkish Statistical Institute for the 2008-2019 period were analyzed. Outcomes were traffic fatality rates per 100,000 population and 10,000 motor vehicles. Exposure variable was the presence of law 6487. Alcohol, tobacco, and related beverages' household expenditure, unemployment rate, number of health professionals, number of crashes, and lags of the outcomes represented control variables. A time-series cross-regional fixed effect model was applied. Results: Empirical estimates suggest that the law 6487 was associated with a reduction of 15% (Incidence Rate Ratio (IRR) 0.85, 95% Confidence Interval (CI): 082, 0.94) in the traffic fatality per population rate and with a reduction of 14% (IRR: 0.86 (95% CI: 0.78, 0.92) in the traffic fatality per motor-vehicle rate. After 6 years of its implementation, this intervention was associated with an absolute reduction of 1519 (95% reduction interval: 1177, 1810) traffic fatalities. Conclusions: Our research emphasizes that legislation with direct and indirect measures targeting driving under the influence of alcohol (DUIA) may be related to traffic fatalities reduction. Practical applications: This finding has important implications for policy and future research in contexts in which alcohol consumption is low such is in Turkey. Future research should seek to identify mechanisms that explain how laws are ultimately associated with DUIA variation.
Article
Purpose The purpose of the research is to evaluate the visibility and effectiveness of responsible drinking campaigns used for the sale of the product “beer” (on labels and commercials) on a sample of university students at the University of Pisa to verify whether a preventive “education” on the issue of the effects of alcohol consumption is suitable to improve the perception of responsible communication. Design/methodology/approach A focus group methodology was used. Three interviews were conducted with 21 university students. The interview protocol was divided into three sections and ten guiding questions were prepared to conduct the focus groups. Findings The study shows the weak effectiveness of responsible communication promoted by brewers, even though the sample knew aspects related to responsible communication and the adverse health effects of alcohol. Most respondents failed to remember the existence of responsibility messages placed on beverage labels, except as a result of visual stimuli, a sign that preventive education can play a role in message recognition. Commercials seem to have a more significant impact when associated with the dangers of drunk driving. However, promoting consumer awareness campaigns continues to be perceived as contradictory. Originality/value This study presents the results of qualitative research that focuses on university students' perceptions of the effectiveness of the most recent responsible communication campaigns conducted by brewers. The research is significant in assessing the effectiveness of communication tools, providing theoretical and industrial implications for improving the understanding of the phenomenon and the effectiveness of responsible messages.
Article
Full-text available
Objectives: This study aimed to explore (a) how people interpret responsible drinking messages on alcohol product labels, and (b) the acceptability of including health information on labels. Design: Qualitative interviews. Methods: Face-to-face semi-structured interviews were conducted with 20 people aged 21-63; 18 were classified risky drinkers using AUDIT-C. They were shown three sets of alcohol product labels: one including three responsible drinking messages (drink responsibly), one with three positively worded health messages (drinking less reduces risks) and one with three negatively worded health messages (drinking more increases risks). Health messages included information about cancer, liver and heart disease. Results: Thematic analysis identified three themes: ambiguity about alcohol labelling; identifying oneself as responsible; and acceptability of enhanced product labelling. Participants were critical of responsible drinking messages and wary of conflicting health information in the media. They positioned themselves as responsible, knowledgeable drinkers and distanced themselves from problem drinkers. They did not appear to support the inclusion of health information on labels; however, novel information was considered more impactful. Conclusions: Responsible drinking messages were seen by our sample as an alcohol industry ploy. Although health messages about cancer were seen as potentially impactful, the ability of consumers to position themselves as unproblematic drinkers means that they may not see the information on the label as relevant to themselves. Understanding factors that increase the personal relevance of messages is needed, alongside an exploration of a wider range of methods for alcohol health communication.
Article
Full-text available
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.
Article
Full-text available
Proper assessment of the harms caused by the misuse of drugs can inform policy makers in health, policing, and social care. We aimed to apply multicriteria decision analysis (MCDA) modelling to a range of drug harms in the UK. Method Members of the Independent Scientific Committee on Drugs, including two invited specialists, met in a 1-day interactive workshop to score 20 drugs on 16 criteria: nine related to the harms that a drug produces in the individual and seven to the harms to others. Drugs were scored out of 100 points, and the criteria were weighted to indicate their relative importance. Findings MCDA modelling showed that heroin, crack cocaine, and metamfetamine were the most harmful drugs to individuals (part scores 34, 37, and 32, respectively), whereas alcohol, heroin, and crack cocaine were the most harmful to others (46, 21, and 17, respectively). Overall, alcohol was the most harmful drug (overall harm score 72), with heroin (55) and crack cocaine (54) in second and third places. Interpretation These findings lend support to previous work assessing drug harms, and show how the improved scoring and weighting approach of MCDA increases the differentiation between the most and least harmful drugs. However, the findings correlate poorly with present UK drug classification, which is not based simply on considerations of harm.
Conference Paper
Since 1989 the U.S. federal government has required warnings on alcohol containers. Findings are presented from telephone surveys conducted between 1990 and 1994 in the U.S. and Ontario, Canada, the no-treatment reference site. In the U.S., penetration peaked in 1993-94, with 43% of the lifetime drinkers reporting label awareness. Label exposure was weaker (< 20%) for all years in the reference site. The proportion reporting conversations about drinking during pregnancy was higher among label seers in both sites. Those seeing labels in the U.S. were more likely to engage in conversations about drinking and driving than those not seeing. Reports of limiting drinking for health reasons showed a positive association with label exposure increasing with time. In the U.S. only, across all years, controlling for age, gender, education, and alcohol consumption, label seers were more likely to drive after drinking too much, but also to say they had deliberately not driven after drinking during the last year. Findings from this quasi-experiment cannot establish causal relationships, but the pattern of results, though mixed, suggests modest effects on conversations and several precautionary behaviors related to risks of drinking. The label's effects may partially offset an overall trend toward lower public concern about health risks of alcohol. Results are interpreted as consistent with Congressional intent to remind people of certain hazards of drinking, especially during pregnancy or before driving vehicles. (C) 1999 John Wiley & Sons, Inc.
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A comparison of worldwide recommendations on alcohol consumption reveals wide disparity among coun- tries. This could imply that many of the recommendations do not adequately accommodate the science, given that the science is equally valid worldwide. Such a view, however, would be an oversimplification of the problem that those who formulate such guidelines face. The objective of guidelines is to influence and change behavior among target populations. It follows, therefore, that several factors then become rel- evant: behavior that is thought to be in need of change, the culture and mindset of the target populations, and the kind of message that islikely to be effective. There are some tensions between advice intended only to reduce the prevalence of misuseand that which also seeks to reflect the evidence on the beneficial health effects of moderate consumption.
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This article examines public opinion in US alcohol policies during the 1990s and their correlates in 2000, using five national telephone surveys. Trend analyses of public opinion on 11 common alcohol policies is presented and factor‐based policy scales, based on 14 items in 2000, are used to examine demographic correlates of support for various policy areas, using bivariate, linear (OLS) and logistic regression analyses. With the exception of the alcohol warning label policy, national support for alcohol policies declined (eight policies) or was unchanged in the 1990s for 11 measured policies. In 2000, four meaningful policy opinion factors were found with adequate reliabilities (αs 0.65–0.75) for three of four derived scales. In 2000, support for specific policies varies. Warnings on labels and advertisements have highest support (>90%), then interventions like prevention, treatment, and responsible beverage service at 70% (with similar levels seen for improving access to treatment). Alcohol controls show varied, but lower support from 25% (raising minimum drinking age further), to above 60% for banning sales in corner stores; only about a third favor higher alcohol taxes (35%) and more restrictive hours of sale (32%). In general, women and those with lower socio‐economic status show higher alcohol policy support. Multivariate results show heavier drinkers are least supportive of alcohol policy, while ethnic minorities, especially Hispanics are more favorable to alcohol controls and raising alcohol taxes. Since evidence‐based alcohol control policies show mixed, but lower public support than treatment, prevention and consumer warnings, there is a need for community‐based strategies to increase awareness of environmentally orientated alcohol policies and their public health benefits.
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Excessive alcohol consumption is associated with numerous adverse health conditions and is the third leading cause of preventable death in the United States. Unlike manufacturers of most other packaged food and beverage products, alcohol beverage producers are not required to disclose product nutrition information. This situation may soon change. On July 31, 2007, the Alcohol and Tobacco Tax and Trade Bureau proposed a rule that will require a Serving Facts panel containing a statement that includes levels of calories, carbohydrates, fat, and alcohol content on all alcohol beverage containers. The primary purpose of this research was to test predictions and provide insight regarding consumers’ potential responses to the provision of Serving Facts information on alcohol beverage labels. Implications of the results for public policy makers and consumer welfare are offered.
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Since 1989 the U.S. federal government has required warnings on alcohol containers. Findings are presented from telephone surveys conducted between 1990 and 1994 in the U.S. and Ontario, Canada, the no-treatment reference site. In the U.S., penetration peaked in 1993–94, with 43% of the lifetime drinkers reporting label awareness. Label exposure was weaker (<20%) for all years in the reference site. The proportion reporting conversations about drinking during pregnancy was higher among label seers in both sites. Those seeing labels in the U.S. were more likely to engage in conversations about drinking and driving than those not seeing. Reports of limiting drinking for health reasons showed a positive association with label exposure increasing with time. In the U.S. only, across all years, controlling for age, gender, education, and alcohol consumption, label seers were more likely to drive after drinking too much, but also to say they had deliberately not driven after drinking during the last year. Findings from this quasi-experiment cannot establish causal relationships, but the pattern of results, though mixed, suggests modest effects on conversations and several precautionary behaviors related to risks of drinking. The label's effects may partially offset an overall trend toward lower public concern about health risks of alcohol. Results are interpreted as consistent with Congressional intent to remind people of certain hazards of drinking, especially during pregnancy or before driving vehicles. © 1999 John Wiley & Sons, Inc.
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In recent years, alcohol-related problems on college campuses have been well documented. This research examines how two different alcoholic beverage health warnings placed on the label of a fictitious brand of beer influence alcohol-related risk perceptions, attitudes and intentions, and characterizations of problem-drinking behaviors of binge and non-binge drinkers in Australia and the United States. The consumer welfare implications of our findings, which show that the dependent measures are influenced by both main and interaction effects, are discussed.
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In 2008 the Australian government increased the excise rate on ready-to-drink premixed spirits or 'alcopops' by 70% to reduce their attraction to young people. A campaign against the decision was led by the Distilled Spirits Industry Council of Australia, whose members include representatives of the world's largest spirits producers and which aspires to partner the government in making alcohol policy. Distilled Spirits Industry Council of Australia's central thesis appeared to lack substance and sincerity: first, it promoted industry data that were evidently premature and misleading; second, it claimed ready-to-drinks were a safer alternative to the consumption of full-strength spirits because spirits pose a threat to drinkers due to their higher alcoholic content. For spirits producers to concede that drinking spirits is generically hazardous may be unprecedented and contradicts the spirits industry's long-standing opposition to the introduction of health warnings on product labels. Although that admission did not survive the resolution of the case, the effect may be profound, as it might justify the demand for greater control of the labelling and marketing of spirits, and reduce the credibility of spirits producers, and the broader alcohol industry, on matters of policy.
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Nudging, or libertarian paternalism, is presented as a new and ethically justified way of improving people's health. It has proved influential and is currently taken up by the governments in the US, the UK and France. One may question the claim that the approach is new, in any case it has many similarities with the idea of "making healthy choices easier". Whether the approach is better from an ethical perspective depends on the ethical principles one holds. From a paternalistic perspective there could be no objections, but from a libertarian, there are several. Contrary to what the authors state, libertarian paternalism is an oxymoron.
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For consumers to follow drinking guidelines and limit their risk of negative consequences they need to track their ethanol consumption. This paper reviews published research on the ability of consumers to utilise information about the alcohol content of beverages when expressed in different forms, for example in standard drinks or units versus percentage alcohol content. A review of the literature on standard drink definitions and consumer understanding of these, actual drink pouring, use of standard drinks in guidelines and consumer understanding and use of these. Standard drink definitions vary across countries and typically contain less alcohol than actual drinks. Drinkers have difficulty defining and pouring standard drinks with over-pouring being the norm such that intake volume is typically underestimated. Drinkers have difficulty using percentage alcohol by volume and pour size information in calculating intake but can effectively utilise standard drink labelling to track intake. Standard drink labelling is an effective but little used strategy for enabling drinkers to track their alcohol intake and potentially conform to safe or low-risk drinking guidelines.