Effect of alcohol health warning labels on knowledge related to the ill effects of alcohol on cancer risk and their public perceptions in 14 European countries: an online survey experiment

Background: Alcohol health-warning labels are a policy option that can contribute to the reduction of alcohol-related harms, but their effects and public perception depend on their content and format. Our study aimed to investigate the effect of health warnings on knowledge that alcohol causes cancer, the perceptions of three different message topics (responsible drinking, general health harm of alcohol, and alcohol causing cancer), and the role of images included with the cancer message. Methods: In this online survey experiment, distributed in 14 European countries and targeting adults of the legal alcohol-purchase age who consumed alcohol, participants were randomly allocated to one of six label conditions using a pseudorandom number generator stratified by survey language before completing a questionnaire with items measuring knowledge and label perceptions. Effect on knowledge was assessed as a primary outcome by comparing participants who had increased knowledge after exposure to labels with the rest of the sample, for the six label conditions. Label perceptions were compared between label conditions as secondary outcomes. Findings: 19 110 participants completed the survey and were eligible for analysis. Our results showed that a third of the participants exposed to the cancer message increased their knowledge of alcohol causing cancer (increase for 1131 [32·5%, 95% CI 29·8 to 35·2] of 3409 participants [weighted percentage] for text-only message; increase for 1096 [33·3%, 30·4 to 36·2] of 3198 [weighted percentage] for message inlcuding pictogram; and increase for 1030 [32·5%, 29·6 to 35·4] of 3242 [weighted percentage] for message including graphic image), compared with an increase for 76 (2·4%, –1·2 to 6·0) of 3018 participants who viewed the control message. Logistic regression showed that cancer messages increased knowledge compared with the control label (odds ratio [OR]text only 20·20, 95% CI 15·88 to 26·12; ORpictogram 21·16, 16·62 to 27·38; ORgraphic-image 20·61, 16·19 to 26·68). Cancer messages had the highest perceived impact and relevance, followed by general health harm and responsibility messages. Text-only and pictogram cancer messages were seen as clear, comprehensive, and acceptable, whereas those including an image of a patient with cancer had lower acceptability and the highest avoidance rating of all the labels. The only identified interaction between perceptions and experimental conditions (with gender) indicated higher comprehensibility and acceptability ratings of cancer labels than responsibility messages and control labels by women, with the results reversed in men. Interpretation: Health warnings are an effective policy option to increase knowledge of alcohol causing cancer, with a generalisable effect across several countries. Europeans consider alcohol health-warning labels to be comprehensible and acceptable, with cancer-specific health warnings having the highest perceived impact and relevance. Funding: EU4Health. © 2024 World Health OrganizationThe research leading to these results or outcomes has received funding from EU4Health under contribution agreement SANTE/2022/SI2.883729 (addressing alcohol harm: capacity building, raising awareness, and implementation of best practices in the Union). The contents of this manuscript are the sole responsibility of the authors and do not necessarily reflect the views of the EU. We would like to express our gratitude to the members of the WHO Technical Advisory Group for Alcohol Labelling (Nathan Crichtlow, Gloria Dossou, Olivier Droulers, Eugenia Fadeeva, Karine Gallopel Morvan, Nikhil Gokani, David Hammond, Erin Hobin, Frank Houghton, Inge Kersbergen, Eunan McKinney, Simone Pettigrew, Maria Renström, Tim Stockwell, and Orratai Waleewong) for their advice on the implementation and interpretation of this study and specifically to Karine Gallopel Morvan and Gloria Dossou for their support with the French translation of the survey. Additionally, we extend our gratitude to the following individuals for their support in translating and distributing the survey across the 14 countries: Nicky Dirkx, Gloria Dossou, Herdis Dugstad, Paula Ericson, Sheila Gilheany, Torleif Halkjelsvik, Soledad Justo, Ines Zuza, Paula Leonard, Brigitta Õunmaa, Sandra Radoš-Krnel, Claudia Rafling, Lidia Segura Garcia, Joan Colom, Mindaugas Štelemėkas, Anne Swaluë, Jelena Talačkienė, Anna Raninen, and Elēna Zviedre. We would also like to thank Carolin Kilian for her valuable contributions in establishing the web-based survey, and potential weighting. Furthermore, we are grateful to Jakob Manthey for his valuable support with the interpretation and discussion of the survey design and intermediate results, and to Benn McGrady and Elisabet Ruiz Cairó for their support in developing and constructing the survey. We would also like to express our gratitude to Astrid Otto for support with language editing and referencing

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

Background: Although the detrimental health effects of alcohol are well established, consumption levels are high in many high-income countries such as Germany. Improving alcohol health literacy presents an integrated approach to alcohol prevention and an important complement to alcohol policy. Our aim was to identify and prioritize measures to enhance alcohol health literacy and hence to reduce alcohol consumption, using Germany as an example.Methods: A series of recommendations for improving alcohol health literacy were derived from a review of the literature and subsequently rated by five experts. Recommendations were rated according to their likely impact on enhancing (a) alcohol health literacy and (b) reducing alcohol consumption. Inter-rater agreement was assessed using a two-way intra-class correlation coefficient (ICC).Results: Eleven recommendations were established for three areas of action: (1) education and information, (2) health care system, and (3) alcohol control policy. Education and information measures were rated high to increase alcohol health literacy but low to their impact on alcohol consumption, while this pattern was reversed for alcohol control policies. The ratings showed good agreement (ICC: 0.85-0.88).Conclusions: Improving alcohol health literacy and reducing alcohol consumption should be considered complementary and become part of a comprehensive alcohol strategy to curb the health, social, and economic burden of alcohol