Waxing and Waning on Warnings

By Guest Columnist Christine Rogan, Health Promotion Advisor for Alcohol Healthwatch who has advocated for alcohol health advisory statements for pregnant women since 1996.

The other day I came across a premix vodka beverage with an alcohol content of 7% that was sporting a health advisory statement which said, “NOT RECOMMENDED FOR CHILDREN, PREGNANT OR LACTATING WOMEN AND INDIVIDUALS SENSITIVE TO CAFFEINE.  Caffeine?  The message about the significant risk that alcohol posed to such consumers was simply absent.

How could such a situation come about?  In 2001, the Food Standards Australia New Zealand or FSANZ mandated what it called “rigorous labelling” for caffeinated drinks.  A FSANZ spokesperson interviewed at the time by the New Zealand Herald (01/08/01) said, “We are sure that this will protect the health and safety of people who drink these products”.  There had at that point been three deaths linked internationally to the consumption of caffeinated drinks, two ironically where the caffeine had been mixed with alcohol. 

Despite the fact no caffeine-associated deaths to my knowledge were reported in New Zealand and Australia, FSANZ moved quickly to regulate with this health warning. However, just one year prior, the food standards organisation, summarily dismissed such a move for alcohol, an altogether more significant and proven risk to human health.  Why?  Among the number of questionable arguments put forward at that time, was that a health warnings on alcohol containers would be ineffective at achieving desirable behaviour change and could even increase undesirable behaviour in some ‘at risk’ groups. 

Why then would a health warning label be effective for caffeine one year hence?  There is no rational explanation as to why a level of proof of effectiveness should be so different for alcohol. 

Alcohol is categorised as a food under Government regulations because it is ingested like other types of manufactured food.  However unlike other food products, alcohol has never been required to display nutritional or other health information even though consumption can pose a significant risk to health, beverages can contain preservatives and alcohol produces calories. 

Alcohol manufacturers are required by law to display the alcohol content of every beverage as well as the number of standard drinks this represents.  For instance the 250ml caffeinated vodka product I referred to earlier bears a label stating that it contains 1.4 standard alcohol drinks. In essence that means that a pregnant woman could ascertain the quantity of alcohol she consumes, but not know that it may pose a risk to her unborn child.  That important information she is obliged to seek from sources elsewhere.  Irrespective of the ‘effectiveness’ argument, leaving alcohol without such a health advisory statements severely limits the consumer’s ability to make an informed consumer choice. 

Ascertaining effectiveness is a bit like asking ‘how long is a piece of string’.  The answer is as always, it depends.  It depends what it is that you require an advisory statement to achieve all on its own. It depends on its visibility and legibility and it depends on whether it exists in isolation of other measures to prevent harm.  Arguments that warning labels are ineffective are not convincing.  They are a cost-effective means of raising awareness, the first step needed for behaviour change to occur. They are and never should be seen as the whole behaviour change package.

Advisory statements like all educational information are passive – designed to inform or instruct.  With any passive information the onus is on the person to engage with its message.  There is clear evidence based on the introduction of alcohol advisory statements initiated in the USA in 1989 that the Government warning increased public awareness – effectively doing the job that was intended and even reached ‘at risk’ populations. 

There is no doubt that their effectiveness as a public health measure would be amplified if product health warnings were supported by a comprehensive package of measures. Those for example used for smoking e.g. social marketing, health advice and resources, quit programmes, tax increases have all played a part in bringing down the rate of smoking alongside health warnings on packets.  It would be a foolish argument to suggest that warnings on packets played no part in that overall strategy. Increasing awareness of and desirable behaviour change to reduce the risk of drinking during pregnancy is likely to require a similar package of measures. 

For ‘high risk’ drinkers this clearly will be more difficult to achieve, as it is with every public health issue, but why would you set out to attempt that without the key platform - information on the actual product?

Front line health professionals often express their incredulity over the current situation.  They tell me that an advisory statement on alcohol would strengthen their ability to provide advice to women of reproductive age about alcohol.  As it stands they hear the argument that if there was any real harm from drinking alcohol during pregnancy then the Government would say so on the product!  In other words, not having this basic foundational information displayed on the product sends a signal to women that alcohol mustn’t be that much of a problem during pregnancy – a message contrary to Government aims and official Ministry of Health advice to avoid alcohol during that time.

The status quo on this subject may be about to change.  A public petition submitted to the New Zealand Parliament in 2000 met with Government support in 2003 resulting in a further application to FSANZ this time submitted by the Alcohol Advisory Council.  Application A576 - Labelling of Alcoholic Beverages with a Pregnancy Health Advisory Label – was submitted in 2006. 

Earlier this year, FSANZ advised that the release of their Initial Assessment Report on this application would be delayed pending the review of the National Health & Medical Research Council’s review of the Australian Alcohol Guidelines. The NHMRC have since reviewed and altered their advice on alcohol and pregnancy to now advise women to avoid consuming any alcohol during pregnancy. Previously the guidelines were ambivalent suggesting that one standard drink a day was acceptable.  Also gone is the suggestion that alcohol conveys a health benefit, something that FSANZ relied on heavily to dismiss the case for a warning label previously.

The NHMRC released the revised draft Australian Alcohol Guidelines in October and FSANZ advises that their Initial Assessment Report will be released for public consultation in December 2007. These stronger and much clearer guidelines, pave the way to having a pregnancy warning accepted for alcohol products in Australia and New Zealand in the near future. 

Also supporting the case for this to finally happen here is that, since rejecting this in 2000, other western nations such as France, Ireland and South Africa have mandated pregnancy health advisory statements for alcohol.  Even some European-based manufactures such as Heineken see this as inevitable and to avoid the risk of litigation have already moved to voluntarily label their products accordingly. 

To their credit, the manufacturer of the particular RTD‘Ready to drink’ alcohol drinks, combining a spirit with a carbonated soft drink. discussed in this article Diageo, voluntarily label the product with the message, “Drink responsibly” and even back that up with a further reinforcing message, “Drink intelligently”. However, industry groups have generally fought hard to resist regulation requiring them to display the very information that consumers needs in order to be responsible.

Here’s hoping that such opposition will soon be a thing of the past and we can all get on with the business of reducing alcohol related harm by as many means as we can possibly achieve.  The ongoing nature and the level of alcohol related harm together with the vulnerability of children requires this of us all.

If you would like further information about this topic you can download a Briefing Paper entitled “Health and Safety Advisory Statements for Alcohol” from the Alcohol Healthwatch website www.ahw.co.nz or by contacting 09 520 7037 or email christine@ahw.co.nz.

This article first appeared in the December 2007 edition of alcohol.org.nz