BACKGROUND NOTE, 9 May 2012

Alcohol warning labels—do they work?

Matthew Thomas
Social Policy Section

Introduction

In late 2011 the Government released through the Legislative and Governance Forum on Food Regulation its response to the report of the Independent Review of Food Labelling Law and Policy.[1] This Review was a comprehensive examination of food labelling law and policy in Australia and was commissioned by the Council of Australian Governments (COAG) and the Australia and New Zealand Food Regulation Ministerial Council. It was undertaken by a panel chaired by former Australian Health Minister, Dr Neal Blewett. The Review contained a wide range of recommendations.

In its response, the Government agreed with the Review’s recommendation that a warning message about the risks of consuming alcohol while pregnant should be mandated on individual containers of alcoholic beverage. The Government indicated that, given the strong evidence about the risks of consuming alcohol while pregnant, it supported the introduction of health warning labels for pregnant women on all packaged alcoholic beverages.

Noting that the alcohol industry has already taken steps in this direction voluntarily—with pregnancy warnings now being alternated with other generic warning messages on alcoholic beverages—and acting on advice from COAG’s Standing Council on Health, the Government proposed that it would allow the industry two years in which to introduce pregnancy warning labels on all packaged alcohol products voluntarily, before regulating for the change.

At this stage, the Government does not intend to pursue the Review’s recommendation that it should mandate for the inclusion of generic health warning messages on alcohol labels. Instead, state and territory Health Ministers are to seek advice from the Australian Health Ministers’ Advisory Council (AHMAC) on ‘the efficacy of generic alcohol warnings in relation to a comprehensive national campaign on the public health problems of alcohol’.[2]

There are two main related issues that are worth considering in relation to the Government’s response. The first of these is that a number of health researchers have already been critical of the new consumer information messages that are being included by the alcohol industry on the labels of alcohol products sold in Australia. The second is that there is some question as to just how effective alcohol warning labels are in reducing risky or harmful drinking.

This Background Note provides a brief overview of the context for the proposed labelling reforms and a summary of some of the research evidence on the effectiveness of alcohol health warning labels.

Australian Alcohol Guidelines

Before considering the background to the Government’s support for the introduction of alcohol labelling requirements for pregnant women, it is worthwhile clarifying, firstly, what advice on alcohol consumption is currently given to pregnant and breastfeeding women, and, secondly, just how many Australian women do drink alcohol while pregnant or breastfeeding.

Guideline 4 of the National Health and Medical Research Council’s Australian Guidelines to Reduce Health Risks from Drinking Alcohol recommends that pregnant women abstain from drinking alcohol:

Guideline 4

Maternal alcohol consumption can harm the developing fetus or breastfeeding baby.

A For women who are pregnant or planning a pregnancy, not drinking is the safest option.

B For women who are breastfeeding, not drinking is the safest option.[3]

The National Health and Medical Research Council (NHMRC) arrived at this recommendation on the grounds that

a no-effect level has not been established, and limitations in the available evidence make it impossible to set a ‘safe’ or ‘no-risk’ drinking level for women to avoid harm to their unborn children, although the risks to the fetus from low-level drinking (such as one or two drinks per week) during pregnancy are likely to be low.[4]

A similar recommendation was made for children under the age of 15 years on the grounds that, for them, there is no safe level of alcohol consumption, largely due to the vulnerability of their developing brains.

This stance represents a departure from the equivalent recommendation in the previous version of the Guidelines. Under the 2001 Australian Alcohol Guidelines, pregnant women (or those planning on becoming pregnant) were advised to consider abstinence, but the guidelines did not actually recommend abstinence.[5] Where pregnant women did not abstain from drinking alcohol, it was recommended that they should consume no more than two standard drinks a day and no more than seven standard drinks per week. This advice is mirrored in the National Clinical Guidelines for the Management of Drug Use During Pregnancy, Birth and the Early Development Years of the Newborn which were published by the NHMRC in March 2006.[6]

The changed advice to pregnant women is in keeping with the more general approach adopted in the current Guidelines. This approach sees a shift from level of consumption as being the key indicator of alcohol-related problems to an alcohol-related harm focus.[7] The new Guidelines define a level of alcohol consumption to ensure low risk of harm, with any drinking above this level carrying a higher risk than not drinking, and therefore being advised against. As such, the Guidelines support the policy objective of reducing alcohol-related harm, rather than simply reducing alcohol consumption. They attempt to provide consumers with sufficient information on the risks associated with drinking for them to make informed choices about risks posed to themselves through their own drinking.

There have been some criticisms of this changed approach, and of the strict recommendation that women should abstain from drinking alcohol while pregnant and breastfeeding.[8] Such advice, it has been argued, could result in disproportionate anxiety among pregnant women who have (inadvertently or otherwise) consumed alcohol during pregnancy, and in precipitous decisions to terminate a pregnancy.[9] If mishandled, the abstinence message could also cause women to not disclose their drinking during pregnancy and to fail to access antenatal and treatment services that could help to prevent further risk to the fetus from alcohol exposure.[10] It has also been argued that by virtue of their stringent nature, the Guidelines provide no advice to those women who are unable or unwilling to completely abstain from drinking.[11]

How many Australian women drink alcohol while pregnant or breastfeeding?

The National Drug Strategy Household Survey (the NDSH Survey), conducted by the Australian Institute of Health and Welfare (AIHW), is the most comprehensive source of data on the use of licit and illicit drugs in Australia. The results of this survey are released on a three-yearly basis, with the latest survey for which all data are publicly available having been conducted in 2010. While the NDSH Survey contains data on alcohol consumption, because these data are self-reported, they should be treated with caution. These data are likely to under-estimate the amount of alcohol consumed by Australians.[12]

Based on NDSH Survey data, the proportion of pregnant women totally abstaining from drinking alcohol during pregnancy has increased over recent years from 40.0 per cent in 2007 to 52.0 per cent in 2010.[13] The proportion of breastfeeding women abstaining also increased, from 25.1 per cent in 2007 to 33.8 per cent in 2010.[14] While these changes are both consistent with the NHMRC’s Australian Guidelines to Reduce Health Risks from Drinking Alcohol, and statistically significant, it should be noted that of those women who did drink while pregnant or breastfeeding, the proportion that drank less decreased from 2007 to 2010. Women who drank less while pregnant fell from 56.6 per cent in 2007 to 45.5 per cent in 2010, and women who drank less while breastfeeding fell from 70.2 per cent in 2007 to 62.4 per cent in 2010. This finding suggests that increased policy responses that target hard-to-reach or at-risk women might be in order.

Data from the Longitudinal Study of Australian Children (LSAC) carried out by the Australian Institute of Family Studies and the Longitudinal Study of Indigenous Children (LSIC) conducted by the Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA) prior to the latest NDSH Survey, bear out the Survey’s finding that a substantial number of Australian women drink while pregnant. However, it should be borne in mind that the more recent National Drug Strategy Household Survey data show signs of improvement, at least in relation to numbers of pregnant women abstaining from drinking.

The LSAC compared the reported alcohol consumption of two groups of respondents, the first of which was made up of women whose children were born in 1999–2000 (K cohort) and the second of which consisted of women whose children were born in 2003–2004 (B cohort). The research found that 27.6 per cent of mothers from the K cohort reported drinking alcohol at some stage during their pregnancy, and that this rate increased to 37.6 per cent among the B cohort.[15]

The LSIC studied 1687 Aboriginal and Torres Strait Islander children, their families and communities in sites across Australia. The first wave of the study commenced in 2007, with interviews being completed in early 2009. Twenty two per cent of parents reported that the birth mother had consumed alcohol while pregnant with the study child.[16] The study did not report on numbers of women drinking alcohol while breastfeeding.

The LSAC study’s authors have speculated that the increase in the rate of women who reported drinking while pregnant may have been influenced by the release of less stringent Australian Alcohol Guidelines in 2001. (It should be noted that the move to less strict guidelines need not necessarily have resulted in more pregnant women drinking; rather, it might have resulted in women being more prepared to report their light drinking during pregnancy.[17]) The study’s manager, Dr Ben Edwards, is reported as having stated that changes in public health warnings about alcohol (which were based on the Guidelines) might have caused confusion among pregnant women about how much alcohol was safe.[18] There is limited evidence of the effects of drinking guidelines on actual drinking behaviour. However, if Edwards is right, then this finding further highlights the importance of getting public alcohol health warning messages right, difficult though this may be.[19]

Alcohol labelling in Australia – current requirements

While alcohol is classified as both a food and a drug under Australian and New Zealand Food Standards legislation, it is treated as a food. Thus, alcohol is subject to the food standards set by the independent statutory agency Food Standards Australia New Zealand (FSANZ) under the Food Standards Australia New Zealand Act 1991.

FSANZ develops uniform food standards and joint codes of practice for the food industry which cover the content and labelling of food sold in Australia and New Zealand. FSANZ also develops Australia-specific food standards that address food safety issues.

In Australia, mandatory labelling requirements for alcoholic beverages and food containing alcohol are specified under Standard 2.7.1 of the Australia New Zealand Food Standards Code.[20] This code is administered by FSANZ. Standard 2.7.1, clause 3 of the Code requires beverages, or foods capable of being consumed as beverages, which contain more than 0.5 per cent alcohol by volume, measured at 20° Celsius, to be labelled with a statement of the approximate number of standard drinks in the package.

While it is mandatory for the labels on alcoholic beverages to indicate the alcoholic strength of the beverage and the number of standard drinks contained therein, there is, at present, no requirement for any form of health warning. Nor is there a requirement—as is the case for non-alcoholic beverages and food—that the labels should display a list of ingredients or nutritional information.[21]

Recent moves to strengthen alcohol labelling requirements

There is growing pressure from a number of sources for the Australian Government to legislate for health warnings on all alcohol products, and not just for pregnant women. Such calls appear to have intensified in recent years, particularly in the light of the 2004 and 2007 National Drug Strategy Household Survey’s findings that around 70 per cent of Australians support information from the National Health and Medical Research Centre’s (NHMRC) Guidelines for Low Risk Drinking being added to alcohol containers.[22] Community polls have consistently shown that a majority of Australians support the inclusion of health information labels on alcohol products.[23]

In 2009, the National Preventative Health Taskforce released the National Preventative Health Strategy, Australia: the Healthiest Country by 2020. One of its recommendations for helping to reduce the harm caused by alcohol in Australia was the inclusion of health advisory information labelling on containers and packaging of all alcohol products.[24]

The latest attempt to introduce mandatory health warnings on alcohol products through legislation was made by former Senator Steve Fielding.

Alcohol Toll Reduction Bill 2007

On 19 September 2007, former Senator Steve Fielding introduced into the Australian Parliament a private Senator’s Bill that, if passed into legislation, would have provided, among other things, for compulsory health information labels for alcohol products.[25] The proposed Act would have amended the Food Standards Australia New Zealand Act 1991[26] to include the requirement that the labelling of alcohol and food containing alcohol provide for the consumption guidelines of the NHMRC, the unsafe use of alcohol, the impact of drinking on populations vulnerable to alcohol and health advice about the medical side- effects of alcohol. It would also have provided for the manner in which the information was to be provided (that is, in text or pictorial form).

On 14 February 2008, the Senate, on the recommendation of the Selection of Bills Committee, referred the Alcohol Toll Reduction Bill 2007 to the Senate Standing Committee on Community Affairs for inquiry and report by 18 June 2008. 

In its report the Committee noted that the alcohol industry had voluntarily introduced both the uniform ‘standard drinks’ logo to alcohol product labels, and responsible consumption messages on wine labels. Nevertheless, the Committee expressed concern about the ‘lack of consistent regulation in relation to the labelling, packaging and naming of alcohol products’.[27] It recommended that the Ministerial Council on Drugs Strategy (MCDS), the Monitoring of Alcohol Advertising Committee (MAAC) and the Alcohol Beverages Advertising Code (ABAC) Scheme Management Committee consider the development of uniform rules in relation to the labelling, packaging and naming of alcohol products to be incorporated into the Alcohol Beverages Advertising Code and ABAC Scheme.[28]

The Committee found that the Australian Government is limited constitutionally in its ability to make changes in relation to food law and to the existing regulatory framework that is established under the Food Standards Agreement (see above description).[29] The Committee argued that a more appropriate pathway for any proposed change to the labelling of alcoholic products is through assessment by FSANZ.

Food Standards Australia New Zealand warning label reviews

In May 2008, the Australia and New Zealand Food Regulation Ministerial Council (ANZFRMC)[30] requested that FSANZ consider mandatory health warnings on packaged alcohol[31], and the Senate Committee indicated that it also supported this action.[32] FSANZ was to conduct a review of the effectiveness of labelling in relation to high-risk drinking and to present this evaluation to the Ministerial Council.

FSANZ is also considering a request from the Alcohol Advisory Council of New Zealand to amend the Australia New Zealand Food Standards Code to require a health advisory label on alcoholic beverage containers, advising of the risks of consuming alcohol when planning to become pregnant and during pregnancy.[33] FSANZ released an initial assessment report for labelling of alcoholic beverages with a pregnancy health advisory label on 12 December 2007.[34] It has commissioned two independent reports, one of which is to review evidence related to the effectiveness of the strategy, and the other to review the cost-effectiveness of mandatory labelling compared with further strategies to reduce alcohol consumption among pregnant women.

FSANZ deferred further consideration of the Alcohol Advisory Council of New Zealand’s application until Ministers and COAG had had a chance to consider the findings and recommendations of the Independent Review of Food Labelling Law and Policy.

Independent Review of Food Labelling Law and Policy

The Independent Review of Food Labelling Law and Policy, which was commissioned by the Australia and New Zealand Food Regulation Ministerial Council in October 2009, considered, among other matters, alcohol health warning labels. The Review’s final report was released in January 2011. It found that ‘there are compelling reasons for applying labelling changes to alcohol in the light of the growing evidence relating to the short- and long-term adverse health effects of alcohol consumption’.[35] The Review recommended:

•        generic alcohol warning messages be placed on alcohol labels but only as an element of a comprehensive multifaceted national campaign targeting the public health problems of alcohol in society (Recommendation 24)

•        a suitably worded warning message about the risks of consuming alcohol while pregnant be mandated on individual containers of alcoholic beverages and at the point of sale for unpackaged alcoholic beverages, as support for ongoing broader community education (Recommendation 25)

•        energy content be displayed on the labels of all alcoholic beverages, consistent with the requirements for other food products (Recommendation 26) and

•        drinks that are mixtures of alcohol and other beverages comply with all general nutrition labelling requirements, including disclosure of a mandatory Nutrition Information Panel (Recommendation 27).[36]

The Australian Government, in its response:

•        agreed to Recommendation 25

•        decided to seek further advice and research in relation to Recommendations 24 and 26. As noted above, Health Ministers are to seek advice from AHMAC on the efficacy of generic alcohol health warnings. Further research will be sought from FSANZ on the impact of requiring that energy content be displayed on the labels of all alcoholic beverages and

•        decided not to pursue Recommendation 27. The Government has done so on the grounds that requiring a Nutrition Information Panel on mixed alcoholic beverages could have unintended health consequences, international trade considerations and impose additional costs on the alcohol industry.

Recent developments

DrinkWise Australia is an organisation that was established by the alcohol industry in 2005 as a means to contribute to the development of a safer drinking culture in Australia.[37] This alcohol industry-funded body aims to achieve this goal primarily through sustained education and campaign activities. Around half of the DrinkWise Board is made up of industry representatives, with the remaining representatives drawn from the community and health, law enforcement, communications and public policy fields.

On 12 July 2011 DrinkWise Australia announced that as a part of its ongoing community education activities it would be incorporating new consumer information messages on the labels of alcohol products sold in Australia.[38] Labels will include an encouragement for consumers to ‘Get the Facts’ from the DrinkWise website, which ‘provides evidence based information on alcohol to help people make informed choices when drinking’. This message will either be used alone or in tandem with one of three other messages:

•        Kids and alcohol don’t mix

•        Is your drinking harming yourself or others? or

•        It is safest not to drink while pregnant (or an alternative pictogram, see below)

In recognition of the fact that labels alone will not change consumer behaviour, DrinkWise emphasises that the initiative is just one part of its broader consumer information and education campaign.

While a number of public health organisations have welcomed the fact that DrinkWise has accepted the need for warning labels, they argue that the warnings do not go nearly far enough. Mike Daube, Public Health Association of Australia spokesperson and Director of the McCusker Centre for Action on Alcohol and Youth insists that if the warnings are to have a real impact, then they need to be strong and factual:

There is good research showing that warnings need to be forceful, with new and specific health information. These warnings give us such phrases as ‘Kids and alcohol don’t mix’ or ‘Is your alcohol use harming yourself or others?’, which will hardly stop any drinkers in their tracks. There appears to be nothing about some of the most serious consequences of alcohol, from brain damage to road crashes or cancer. There is nothing that will give a moment’s pause for thought to kids who are binge-drinking.[39]

Similarly, Sondra Davoren, Senior Legal Policy Advisor at Cancer Council Victoria has argued:

... the labels proposed by DrinkWise fail to address the wide range of harms caused by alcohol, and instead, focus on narrow sectors of society, namely pregnant women and underage drinkers. Cancer Council Victoria would like to see labels featuring warnings about health risks associated with alcohol use, including specific messages about the link between alcohol consumption and cancer.

Community awareness of alcohol as a carcinogen is relatively low. For example, few people are aware that one in five breast cancers is caused by alcohol. Indeed recent research by Cancer Council Victoria found that just 9% of Victorians could name alcohol as a risk factor for cancer.

Cancer Council Victoria acknowledges the link between alcohol and cancer is not a palatable one, but we have a responsibility to give people the information they need to make informed choices about reducing their own cancer risk. Labelling provides an opportunity to reach consumers at the point of consumption and has the potential to strongly influence individual choice.

We believe that the alcohol industry has a collective responsibility to ensure its customers are fully informed about the risks associated with their product, and if the industry doesn’t deliver on this, then Governments should act.[40]

Alcohol Education and Rehabilitation Foundation Chief Executive, Michael Thorn has insisted that the campaign-style messages proposed by DrinkWise are ambiguous and lack clarity. Like Daube and Davoren, he has called for a suite of labels with clear facts about specific alcohol-related harms. These labels, he maintains, should be specific and unambiguous, informing people of the short- and long-term effects of drinking. They should reflect the current NHMRC Guidelines for Low Risk Drinking and include a range of rotating messages:

There are around 60 different types of disease and injury linked to alcohol including oesophageal cancer, heart disease, stroke, mouth and throat cancer, and breast cancer. The Australian public know too little about these effects and it’s our collective responsibility to inform them.

DrinkWise says the core message on the labels is to encourage people to ‘Get the Facts’ on its website. But consumers should be able to get the facts from the product label itself, in the same way they can on food labels. What’s the point of having ‘consumer information messages’, as the industry is calling them, if they don’t contain any information?

Instead, they’re diverting consumers’ attention away from the product in their hands and onto a website. This convoluted mechanism makes it difficult for people to access information and also allows alcohol brands to avoid any negative associations with alcohol-related diseases.[41]

Mike Daube has described the alcohol industry organisation’s initiative as being ‘more like public relations than public health’. As Daube and other public health advocates see it, for these reasons and others, ‘decisions about health and health warnings should not be left to the industry’.[42]

Alcohol warning labelling overseas

Countries with general health warning labels on alcoholic beverages

As at February 2010, 15 countries had national laws mandating health warning labels on alcohol beverage containers.[43] These were Argentina, Brazil, Colombia, Costa Rica, Ecuador, El Salvador, France, Germany, Guatemala, Mexico, the Russian Federation, South Africa, Taiwan, Thailand and the United States (US). A number of other countries had labels that were provided voluntarily by the alcohol industry. Most states in India have health warning label policies, but there is no comprehensive national law. Two Canadian provinces (Yukon and the North West Territories) mandate labels and an Ontario Liberal member of parliament has introduced a private member’s Bill to the Canadian Parliament that would have required alcohol health warning labels across all the provinces.[44]

The nature of the warnings varies. Most provide reminders about the general health risks associated with alcohol consumption, of drinking during pregnancy and of the dangers of drinking while driving. Very few are specific about the potential adverse effects of alcohol.

Pregnancy health warning labels

In 1989, the US became the first country to mandate alcohol warning labels in relation to drinking during pregnancy. While a number of countries require general health warning labels on alcoholic beverages, few demand warnings specifically in relation to pregnancy.

Other countries that prescribe warning labels for alcoholic beverages regarding pregnancy include Russia, Colombia, South Korea, France and South Africa. Canada and Finland considered making advisory statements regarding the risks of consuming alcohol during pregnancy mandatory, but have decided not to do so.[45] In Canada’s case a 2006 private member’s Bill that required mandatory warnings never made it past the committee stage. This would appear to have been on the grounds that there was insufficient empirical evidence to indicate that warning labels would reduce the incidence of Fetal Alcohol Spectrum Disorders (FASD).[46] In Finland, a law requiring both pregnancy and general health warnings on alcohol labels was withdrawn for what appear to be largely political reasons.[47] Since 2007, France has required that all containers of alcoholic beverage contain one of two health messages. These are either a statement indicating that consuming alcoholic beverages during pregnancy, even in small amounts, can have serious effects on the health of the child, or a pictogram similar to the one to be introduced by DrinkWise (see above).

Some countries (such as the United Kingdom) have not mandated warning labels regarding pregnancy on alcoholic beverages, but are actively encouraging the alcohol industry to include sensible drinking information for pregnant women on labels.[48] Various alcohol companies are including such health information voluntarily. For example, some brewers in Japan willingly include messages about not drinking during pregnancy on their products. Pernod Ricard, one of the world’s largest wine and spirits companies, intends to progressively introduce a warning regarding the health risks for pregnant women to all its wine and spirit brands sold across the European Union.[49]

Evidence for the effectiveness of alcohol health warning labels

The following is a brief overview of the most significant studies of the effectiveness of alcohol warning labels.

In 2007, the World Health Organisation (WHO) Expert Committee on Problems Related to Alcohol Consumption published the findings of a meta-analysis (or systematic review) of evidence-based strategies and interventions to reduce alcohol-related harm. The WHO found that results of evaluation research on mandated health warnings on alcohol product containers do not demonstrate that exposure produces a change in drinking behaviour per se. While alcohol health warnings do not have a direct impact on behaviour (as do tobacco warning labels), they do influence intervening variables[50], such as intention to change drinking patterns that could heighten risk, having conversations about drinking and willingness to intervene with people who are seen as hazardous drinkers.[51]

In 2005, Professor Tim Stockwell, Director of the Centre for Addictions Research at the University of Victoria, British Columbia, Canada, conducted a meta-analysis of research into the impacts of alcohol warning labels on attitudes and behaviour for Health Canada. Stockwell reached similar conclusions to those of the WHO. Based on his analysis of reviews and primary studies of the impact of warning labels, he found that most had concluded that there is little or no measurable change in drinking behaviour and related harms as a result of the introduction of alcohol warning labels.

Stockwell focused in particular on a number of primary baseline studies that evaluated the impact of the US alcohol warning labels mandated in 1989. The advantage of these studies was that they did not deal with responses to hypothetical warning labels and they evaluated the situation before and after the introduction of the warning labels. Generally speaking, the studies found that the impacts of the labels on drinking behaviour were either nonexistent or minimal, but that the labels did result in greater awareness of the messages they contained.

Stockwell went on to observe:

Health researchers commenting on the studies have almost universally suggested that warning labels have the potential to contribute to positive outcomes as part of a larger range of more proven strategies, and especially if they are enhanced so as to be more noticeable, impactful and varied. These researchers have also been more likely to highlight (i) the high and increasing levels of public support for alcohol warning labels in the US since their introduction; (ii) evidence that the highest risk groups of drinkers (including young people, pregnant women, and heavy drinkers) are particularly likely to recall the messages; (iii) evidence that, especially early after their introduction, the labels prompted drinkers and high-risk drinkers to engage in more discussion about the risks of drinking alcohol; and (iv) evidence that recall of warning labels was associated with being less likely to report having engaged in drunk driving.[52]

An extensive study of the evidence for alcohol warning labels in the US, conducted in 2000, found that while a significant proportion of the population is exposed to these warning labels, this exposure alone produces no change in drinking behaviour. Rather, warning labels can serve as a first step in the move toward behavioural change; they can have an impact on the cognitive and behavioural steps that are necessary for behavioural change. It should be noted that the study’s authors observed that the labels used in the US were relatively small and there was a lack of variation in the messages they contained. This, they argued, contributed to the lack of demonstrated effects.[53]

A meta-analysis of research evaluating the effectiveness of alcohol warning labels, conducted by US research scientists Gina Agostinelli and Joel Grube found that warning labels have the potential to influence drinking behaviour. However, this potential is heavily influenced by label design (which influences whether warning labels are actually noticed), the content of warning labels (which impacts on whether or not warnings evoke visceral avoidance responses) and how well the messages are targeted at their intended audience.[54]

A review of the early evidence relating to the US alcohol warning label experience conducted by John Andrews in the mid 1990s found that the warning labels increased the awareness of risks among frequent and heavy drinkers. However, these drinkers were likely to discount the information and were resistant to changing their drinking behaviour.[55]

In 2000, David MacKinnon published a summary of substantial research on the effects of US alcohol warning labels on adolescents. The research involved repeated cross-sectional samples of tenth and twelfth graders each year, starting before the warning was introduced in 1989 and finishing in 1995. The warning labels were found to have had some effect on young people’s awareness and memory of the content of the label, but these effects diminished over time. Based on the research results, MacKinnon suggested that the alcohol warning label is informing and reminding people of the risks associated with alcohol use, and modification of the warning may enhance its effects. As was the case for adults, the warning did not appear to significantly impact on alcohol-related behaviours.[56]

A study of the long-term impacts of US alcohol warning labels was conducted in the US and Ontario (the control site) from 1989 to 1994. The study employed a baseline survey of the drinking behaviour, beliefs about alcohol, and awareness of warning labels among the adult populations of the US and Ontario. Surveys were then undertaken on an annual basis to determine whether or not the warning labels had had any impact. While the results were modest, the study’s lead author nevertheless saw some merit in alcohol warning labels:

... the potential value of this policy intervention is that it is relatively ubiquitous, with a delivery mechanism assuring (as evidenced) that it will reach its intended targets, heavier, younger drinkers, at virtually no cost to the government and little to the industry. Furthermore, small positive influences, when applied on a population level, can have major importance given the magnitude of costs to the nation from acute and chronic alcohol problems... From a consumer information standpoint, this policy measure, so long as it does no harm, represents a benefit. Although results are mixed, we believe that the pattern of evidence, taken as a whole, suggests that Congressional intent to remind is being met to a modest extent.[57]

A time-series analysis of the impact of US alcohol warning labels on in-pregnancy drinking by 21 127 African-American pregnant women was conducted between 1986 and 1995. Having controlled for patient characteristics and unemployment rate, the study found that warning labels had a differential impact on risky drinkers and lighter drinkers. While there was some evidence that the warning label had reduced reported alcohol consumption by lighter drinkers, it had not decreased the alcohol consumption of the heaviest drinkers.[58]

In an Australian context, health economists David Collins and Helen Lapsley argue that there is insufficient quantified evidence of the effects of alcohol warning labels to be able to estimate their potential for reducing the social costs of alcohol abuse. Nevertheless, they do note that the latest NHMRC Guidelines for Low Risk Drinking would enhance the effectiveness of any health warnings that were to be introduced.[59]

Conclusion

Generally speaking, the research evidence indicates that while warning labels may increase awareness of the risks associated with excess alcohol consumption, the increased awareness does not necessarily translate to behavioural changes in at-risk groups. If alcohol health warning labels are to have any chance of spurring positive changes in drinking behaviours, then the messages they convey need to be, firstly, arresting (similar to tobacco warning labels) and, secondly, varied reasonably frequently. It is debateable whether the DrinkWise Australia consumer information messages meet the first of these criteria. If they do not do so, then it does not matter how frequently they are varied, they are unlikely to contribute in a significant way to reducing alcohol-related harms.

Warning labels could provide information necessary for consumers to make informed choices about their drinking. However, it is important to note that drinking takes place in a particular social context and environment, one in which alcohol is readily available. If alcohol-related mortality and morbidity is to be significantly reduced then many public health experts suggest that it is this setting that needs to be changed.[60] This would appear to require an increased policy focus on interventions that reduce the accessibility and affordability of alcohol. 

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[1].               Legislative and Governance Forum on Food Regulation (convening as the Australia and New Zealand Food Regulation Ministerial Council), Response to the recommendations of Labelling logic: Review of Food Labelling Law and Policy (2011), viewed 11 April 2012, http://www.foodlabellingreview.gov.au/internet/foodlabelling/publishing.nsf/content/ADC308D3982EBB24CA2576D20078EB41/$File/FoFR%20response%20to%20the%20Food%20Labelling%20Law%20and%20Policy%20Review%209%20December%202011.pdf

[2].               Ibid., p. 29.

[3].               National Health and Medical Research Council (NHMRC), Australian Guidelines to Reduce Health Risks from Drinking Alcohol, NHMRC, 2009, p. 67, viewed 5 December 2011, http://www.nhmrc.gov.au/publications/synopses/ds10syn.htm

[4].               Ibid., p. 68.

[5].               For a critique of the 2001 Guidelines in advance of the release of the 2009 Guidelines, see J Whitehall, ‘National guidelines on alcohol use during pregnancy: a dissenting opinion’, Medical Journal of Australia, vol. 186, no. 1, January 2007, viewed 5 May 2012, http://parlinfo/parlInfo/download/library/jrnart/6K9M6/upload_binary/6k9m62.pdf;fileType=application/pdf#search=%22foetal%20alcohol%20syndrome%20attention%20deficit%20hyperactivity%20disorder%22

[6].               New South Wales Health, National clinical guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn, NSW Department of Health, Sydney, 2006, viewed 5 December 2011, http://www.health.nsw.gov.au/pubs/2006/pdf/ncg_druguse.pdf

[7].               For a discussion of some of the issues associated with developing policies for Fetal Alcohol Spectrum Disorders (FASD), see C O’Leary, L Heuzenroeder, E Elliott and C Bower, ‘A review of policies on alcohol use during pregnancy in Australia and other English-speaking countries’, Medical Journal of Australia, vol. 186, no. 9, 2006, pp. 466–471, viewed 5 December 2011, http://www.mja.com.au/public/issues/186_09_070507/ole11155_fm.html

[8].               See, for example, National Alcohol Beverage Industries Council, Submission to the National Health and Medical Research Council on the Australian Alcohol Guidelines for Low Risk Drinking, December 2007, http://www.wfa.org.au/files/reports/2007_Lo_Risk_Drinking.pdf and P O’Brien, ‘Is it all right for women to drink small amounts of alcohol in pregnancy? Yes’, British Medical Journal, vol. 35, 2007, pp. 856–857, viewed 5 May 2012, http://www.bmj.com/content/335/7625/856.full

[9].               New South Wales Health, op. cit., p. 26. It should be noted that the Guidelines do stress that ‘efforts should be made [by health professionals] not to induce unnecessary anxiety for isolated episodes of [pregnant women’s] drinking. Women who drank alcohol before they knew they were pregnant or during pregnancy should be reassured that the risk to the fetus is likely to be low if they had drunk at low risk levels’. NHMRC, op. cit., p. 77.

[10].               C O’Leary and C Bower, ‘Guidelines for pregnancy: what’s an acceptable risk, and how is the evidence (finally) shaping up?’, Drug and Alcohol Review, vol. 31, no. 2, p. 178, viewed 5 May 2012, http://parlinfo/parlInfo/download/library/jrnart/1610205/upload_binary/1610205.pdf;fileType=application/pdf#search=%22Guidelines%20for%20pregnancy%20whats%20an%20acceptable%20risk%20and%20how%20is%20the%20evidence%20finally%20shaping%20up%22. Having examined the evidence from systematic reviews and meta-analyses of the risk from low and moderate levels of prenatal alcohol exposure, O’Leary and Bower support the advice that women should abstain from drinking alcohol during pregnancy. They do so on the grounds that while there is not a strong relationship between low levels of maternal alcohol consumption and fetal harm, there is a relatively low threshold for fetal harm from prenatal alcohol exposure. However, O’Leary and Bower emphasise that the abstinence message must be handled carefully by health professionals if the message is to do more good than harm.

[11].               National Alcohol Beverage Industries Council, op. cit.; Australian Medical Association, Draft Australian alcohol guidelines for low-risk drinking: submission by the Australian Medical Association, 2007, viewed 11 April 2012, http://ama.com.au/node/4190.

[12].               T Stockwell and others, ‘Under-reporting of alcohol consumption in household surveys: a comparison of quantity-frequency, graduated-frequency and recent recall’, Addiction, vol. 99, no. 8, August 2004, pp. 1024–33.

[13].               Australian Institute of Health and Welfare (AIHW), 2010 National Drug Strategy household survey report, AIHW, Canberra, 2011, p. 73, viewed 5 May 2012, http://www.aihw.gov.au/publication-detail/?id=32212254712&tab=2

[14].               Ibid.

[15].               The study also found that there were significant differences in the number of women reporting drinking during pregnancy, based on the age of the mother when the child was born. Mothers who were 40 years or older when their child was born were more than twice as likely as mothers under 25 years to report drinking.

[16].               Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA), Footprints in Time: The Longitudinal Study of Indigenous Children—Key Summary Report from Wave 1, FaHCSIA, Canberra, 2009, p. 31, viewed 5 May 2012, http://www.fahcsia.gov.au/sa/indigenous/progserv/famchild/lsic/Pages/default.aspx

[17].               T Stockwell and R Room, ‘Constructing and responding to low-risk drinking guidelines: conceptualisation, evidence and reception’, Drug and Alcohol Review, vol. 31, 2012, pp. 123–4.

[18].               See P Karvelas, ‘Women still drink and smoke while pregnant’, The Australian, 15 November 2011, viewed 5 May 2012, http://parlinfo/parlInfo/download/media/pressclp/1226135/upload_binary/1226135.pdf;fileType=application/pdf#search=%22women%20still%20drink%20and%20smoke%20while%20pregnant%22

[19].               Almost all of the international evidence on Fetal Alcohol Spectrum indicates that is concentrated in disadvantaged communities. This suggests that any serious attempt to prevent women from drinking whilst pregnant would require a broad response to the problem and one that went beyond a focus on alcohol use and pregnancy alone. This would entail helping disadvantaged women out of poverty and identifying and addressing a range of other factors that contribute to their alcohol abuse.

[20].               Australia New Zealand Food Standards Code – Standard 2.7.1 – Labelling of alcoholic beverages and food containing alcohol, viewed 5 December 2011, http://www.comlaw.gov.au/Details/F2011C00588

[21].               In response to the results of a survey conducted with 13 000 Australian university students in April 2007, K Kypri and others propose that while warning labels on alcoholic beverages appear to have no immediate measurable effects on drinking behaviour, nutrition labels might help to reduce the alcohol consumption of young people, and especially young women. They argue that, given the preoccupation with weight gain in many developed countries, including Australia, consumers (particularly weight-conscious young women) might be less inclined to drink as much alcohol if they knew the calorie count of what they were drinking. See K Kypri and others, ‘Ingredient and nutrition information labelling of alcoholic beverages: do consumers want it?’, Medical Journal of Australia, vol. 187, nos. 11–12, 17 December 2007, pp. 426–35, viewed 5 May 2012, http://parlinfo/parlInfo/download/library/jrnart/3Y4U6/upload_binary/3y4u60.pdf;fileType=application/pdf#search=%22Ingredient%20and%20nutrition%20information%20labelling%20of%20alcoholic%20beverages%20do%20consumers%20want%20it%22. The Independent Review of Food Labelling Law and Policy has recommended that the energy content of alcoholic beverages be displayed on the labels of these products. While the Government has indicated that it supports this recommendation in principle, it is to request that Food Standards Australia New Zealand (FSANZ) conduct further research into the impact of its implementation. The Government observed that including the energy content on alcohol labels could have unintended consequences in relation to young women’s eating and drinking behaviour. The concern is that young women could skip means as a means to reduce their energy intake and allow them to drink more alcohol without putting on weight. Legislative and Governance Forum on Food Regulation (convening as the Australia and New Zealand Food Regulation Ministerial Council), op. cit., p. 31.

[22].               AIHW, 2004 National Drug Strategy Household Survey: detailed findings, AIHW, Canberra, 2005, p. 91, viewed 5 May 2012, http://www.aihw.gov.au/publication-detail/?id=6442467781, AIHW, 2007 National Drug Strategy Household Survey: detailed findings, AIHW, Canberra, 2008, p. 94, viewed 5 May 2012, http://www.aihw.gov.au/publication-detail/?id=6442468195&tab=2

[23].               A population survey conducted in Victoria in 2009 found that there was overwhelming support or strong support for the inclusion of health warnings and advice on alcohol beverage labels. L Thomson, B Vandenberg and J Fitzgerald, ‘An exploratory study of drinkers views of health information and warning labels on alcohol containers’, Drug and Alcohol Review, vol. 31, no. 2, 2012, p. 245, viewed 5 May 2012, http://parlinfo/parlInfo/download/library/jrnart/1610218/upload_binary/1610218.pdf;fileType=application/pdf#search=%22An%20exploratory%20study%20of%20drinkers%20views%20of%20health%20information%20and%20warning%20labels%20on%20alcohol%20containers%22

[24].               Australia. National Preventative Health Taskforce, Australia: the healthiest country by 2020 – National Preventative Health Strategy – the roadmap for action, National Preventative Health Taskforce, Canberra, 2009, p. 252, viewed 5 May 2012, http://www.health.gov.au/internet/preventativehealth/publishing.nsf/Content/nphs-roadmap

[25].               Alcohol Toll Reduction Bill 2007 [2008], viewed 5 May 2012, http://parlinfo/parlInfo/search/display/display.w3p;adv=yes;orderBy=customrank;page=0;query=%22alcohol%20toll%20reduction%20bill%202007%22%20Dataset%3Abillslst,billsPrevParl,billsCurBef,billsCurNotBef,tariffs,billsdgs,webdisinsts,webdisinstr;rec=0;resCount=Default

[26].               Food Standards Australia New Zealand Act 1991 (Cth), viewed 5 May 2012, http://www.comlaw.gov.au/Details/C2011C00743

[27].               Senate Standing Committee on Community Affairs, Alcohol Toll Reduction Bill 2007[2008], The Senate, Canberra, June 2008, viewed 5 May 2012, http://www.aph.gov.au/Parliamentary_Business/Committees/Senate_Committees?url=clac_ctte/alcohol_reduction/report/index.htm. Until very recently, alcohol industry groups have consistently been opposed to the introduction of health warnings on alcohol products. They preferred the voluntary system that is currently in place. See L. Wilson, ‘Booze labels aimed at mothers’, The Australian, 14 December 2007, p. 7, viewed 5 May 2012, http://parlinfo/parlInfo/download/media/pressclp/QF8P6/upload_binary/qf8p62.pdf;fileType=application/pdf#search=%22booze%20labels%20aimed%20at%20mothers%22 and Senate Standing Committee on Community Affairs, op. cit., p. 25. The Distilled Spirits Industry Council has in the past argued that there is no need for further regulation or warning labels, and that ‘people should be responsible for their own behaviour’. See B Packham and F Burstin, ‘Cork it, Rudd urged’, Herald Sun, 8 December 2007, p. 7, viewed 5 May 2012, http://parlinfo/parlInfo/download/media/pressclp/6M6P6/upload_binary/6m6p64.pdf;fileType=application/pdf#search=%22cork%20it%20rudd%20urged%22

[28].               Senate Standing Committee on Community Affairs, op. cit., p. 32.

[29].               These constitutional limitations are outlined on page 30 of the Committee report.

[30].               On 13 February 2011, the Council of Australian Governments (COAG) agreed to establish a new council system and, as a part of the new system, the Australia New Zealand Food Regulation Ministerial Council became the Legislative and Governance Forum on Food Regulation. The Forum was launched on 17 September 2011. See, ‘Legislative and Governance Forum on Food Regulation’, Department of Health and Ageing website, viewed 11 April 2012, http://www.health.gov.au/internet/main/publishing.nsf/Content/foodsecretariat-anz.htm

[31].               In doing so, Food Standards Australian New Zealand (FSANZ) has been asked to take into account the work of the (now dissolved) Ministerial Council on Drug Strategy and any other relevant ministerial councils, any relevant guidelines in New Zealand, the recommendations from the NHMRC’s Australian Alcohol Guidelines for Low Risk Drinking; and to consider the broader community and population-wide context of the misuse of alcohol. FSANZ will also conduct a cost-benefit analysis of an alcohol information labelling system through a regulatory impact statement.

[32].               In the view of the Committee, alcohol products should be treated the same as other food and beverages where it comes to the requirement that they display a nutritional information label. This, the Committee argued, would enable consumers to ‘make informed choices about a particular alcoholic product’.

[33].               See Food Standards Australia New Zealand, ‘Health advisory labels on alcoholic beverages’, http://www.foodstandards.gov.au/scienceandeducation/factsheets/factsheets/healthadvisorylabels5226.cfm. This was in response to research which suggests that, despite media attention given to Fetal Alcohol Spectrum Disorder, some 34 per cent of pregnant women consumed alcohol during their most recent pregnancy. See L. Wilson, ‘Booze labels aimed at mothers’, The Australian, 14 December 2007, p. 7, http://parlinfo/parlInfo/download/media/pressclp/QF8P6/upload_binary/qf8p62.pdf;fileType=application/pdf#search=%22booze%20labels%20aimed%20at%20mothers%22

[34].               FSANZ, Initial assessment report: Application A576, Labelling of alcoholic beverages with a pregnancy health advisory label, FSANZ, 2007, viewed 5 May 2012, http://www.foodstandards.gov.au/_srcfiles/A576_IAR_Alcohol_labelling_FINAL.pdf

[35].               N Blewett, N Goddard, S Pettigrew, C Reynolds and H Yeatman, Labelling logic: Review of Food Labelling Law and Policy, Department of Health and Ageing, Canberra, 2011, p. 5, viewed 5 May 2012, http://www.foodlabellingreview.gov.au/internet/foodlabelling/publishing.nsf/content/home

[36].               Ibid., pp. 78–83.

[37].               See Drinkwise Australia, viewed 5 May 2012, http://drinkwise.org.au/

[38].               DrinkWise Australia, New consumer messages on alcohol products: latest initiative in ongoing Community Education and Awareness Campaign, media release, 12 July 2011, viewed 5 May 2012, http://drinkwise.org.au/2011/07/new-consumer-messages-on-alcohol-products/

[39].               Public Health Association Australia and McCusker Centre for Action on Alcohol and Youth, New alcohol warning labels need strengthening, media release, 12 July 2011, viewed 5 May 2012, http://www.phaa.net.au/documents/MediaReleaseNEWALCOHOLWARNINGLABELSNEEDSTRENGTHENING.pdf

[40].               Cancer Council Victoria, Cancer Council warns proposed alcohol labels do not go far enough, media release, 12 July 2011.

[41].               Alcohol Education and Rehabilitation Foundation, Alcohol labels must contain the facts, media release, 12 July 2011.

[42].               Numerous public health researchers have observed that the alcohol industry faces something of a conflict of interest when it comes to meeting their duties to shareholders and customers. It is in the industry’s interests to couch its health and safety messages in terms of ‘moderation’ or ‘responsible drinking’ so as to better sell their products and maximise profits for shareholders. However, such messages, it is argued, fall short of the specific information on the potential risks associated with drinking alcohol that is required. See, for example, M Carr-Gregg and N Lennox, ‘“According to the Surgeon General ...” Is there a case for warnings on alcohol advertisements in Australia?’, Health Promotion Journal of Australia, vol. 4, no. 1, 1994, pp. 22–25, viewed 5 May 2012, http://parlinfo/parlInfo/download/library/jrnart/7JNR6/upload_binary/7jnr61.pdf;fileType=application/pdf#search=%22According%20to%20the%20Surgeon%20General%20is%20there%20a%20case%20for%20warnings%20on%20alcohol%20advertisements%20in%20Australia%22

[43].               See International Centre for Alcohol Policies (ICAP), Health Warning Labels, ICAP website, viewed 22 December 2011, http://www.icap.org/table/HealthWarningLabels

[44].               See Parliament of Canada, Private Member’s Bill C-251, Parliament of Canada LEGISinfo website, viewed 5 May 2012, http://www.parl.gc.ca/LegisInfo/BillDetails.aspx?Language=E&Mode=1&Bill=C251&Parl=39&Ses=2

[45].               See FSANZ, Initial assessment report: Application A576: Labelling of alcoholic beverages with a pregnancy health advisory label, FSANZ, 2007, viewed 5 May 2012, http://www.foodstandards.gov.au/_srcfiles/A576_IAR_Alcohol_labelling_FINAL.pdf

[46].               M Rabson, ‘Warning label “such a simple thing”’, Winnipeg Free Press, 18 June 2011, viewed 2 May 2012,  http://www.winnipegfreepress.com/opinion/fyi/warning-label-such-a-simple-thing-124123739.html

[47].               W Farke, Health warnings and responsibility messages on alcoholic beverages – a review of practices in Europe, Catholic University of Applied Sciences, Koln, 2011, p. 18, viewed 2 May 2012, http://protect-project.eu/wp-content/uploads/2011/03/WP5-Alcohol-labelling-practices-in-Europe-23-03-11.pdf

[48].               See Department of Health, Safe. Sensible. Social: the next steps in the National Alcohol Strategy, Department of Health and Anti-Social Behaviour and Alcohol Unit, Alcohol Harm Reduction Programme Office, Home Office, 2007, pp. 43–4, viewed 12 April 2012, http://news.bbc.co.uk/2/shared/bsp/hi/pdfs/5_6_07_alcoholsurvey.pdf

[49].               See Pernod Ricard, ‘Raising awareness about risks to pregnant women’, Pernod Ricard website, viewed 12 April 2012, http://www.pernod-ricard.com/en/pages/2844/pernod/Corporate-responsibility/Responsible-consumption/Raising-awareness-about-risks-to-pregnant-women.html

[50].               An intervening variable explains the relationship or provides a causal link between dependent and independent variables. In this case the independent variable is alcohol warning labels and the dependent variable changes in drinking behaviour.

[51].               World Health Organization (WHO), Expert Committee on Problems Related to Alcohol Consumption Second report, WHO, Geneva, 2007, viewed 22 December 2011, http://www.who.int/substance_abuse/expert_committee_alcohol/en/index.html

[52].               T Stockwell, A Review of Research into the Impacts of Alcohol Warning Labels on Attitudes and Behaviour, Centre for Addictions research of BC, University of Victoria, Canada, 2006, viewed 5 May 2012, http://carbc.ca/Portals/0/PropertyAgent/558/Files/7/AlcWarningLabels.pdf

[53].               T Babor, R Caetano, S Casswell, G Edwards, N Giesbrecht, K Graham, J Grube, P Grunewald, L Hill, H Holder, R Homel, E Osterberg, J Rehm, R Room and I Rossow, Alcohol: no ordinary commodity – research and public policy, Oxford University Press, Oxford, 2003.

[54].               G Agostinelli and J Grube, ‘Alcohol Counter-Advertising and the Media: a review of recent research’, Alcohol Research and Health, vol. 26, no. 1, 2002.

[55].               J Andrews, ‘The effectiveness of alcohol warning labels: a review and extension’, American Behavioural Scientist, vol. 38, no. 4, 1995, pp. 622–32.

[56].               D MacKinnon, ‘Effects of the United States alcohol warning label on adolescents’, paper presented to the Human Factors and Ergonomics Society Annual Meeting, July 2000, vol. 44, no. 28, p. 806.

[57].               T Greenfield and K Graves, ‘Long-term effects of alcohol warning labels: findings from a comparison of the United States and Ontario, Canada’, Psychology and Marketing, vol. 16, no. 3, 1999, p. 261.

[58].               J Hankin, ‘The modest impact of the alcohol beverage warning label on drinking during pregnancy among a sample of African-American women’, Journal of Public Policy and Marketing, vol. 17, no. 1, 1998, pp. 61–9.

[59].               D Collins and H Lapsley, The avoidable costs of alcohol abuse in Australia and the potential benefits of effective policies to reduce the social costs of alcohol, Monograph series, no. 70, National Drug Strategy, Department of Health and Ageing, 2008, p. 32, viewed 22 December 2011, http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/Content/0A14D387E42AA201CA2574B3000028A8/$File/mono70.pdf

[60].               See for example Australia. National Preventative Health Taskforce, Australia: the healthiest country by 2020: Technical Report No 3: preventing alcohol-related harm in Australia: a window of opportunity, National Preventative Health Taskforce, Canberra, 2009, http://www.health.gov.au/internet/preventativehealth/publishing.nsf/Content/09C94C0F1B9799F5CA2574DD0081E770/$File/alcohol-jul09.pdf