Background
Alcohol is one of the most widely consumed drugs, integrated into the fabric of many cultures around the world; but this relationship comes at a price. In the UK alone, it is believed that 9 million adults drink to a level that poses health risks, with over 1.5 million individuals having some degree of alcohol dependence (Public Health
2014). This does not just impact the individual, it has bearings on society, and economics; alcohol-related harm is thought to have cost £21 billion in 2013–2014, with £3.5 billion of that cost related to alcohol issues treated via the National Health Service (NHS; Public Health
2014). Given these statistics, it is therefore imperative that strategies for curbing the excessive consumption of alcohol are considered and research engaged to examine their effectiveness. As part of this process, it is worthwhile learning any lessons from the huge change in public attitudes and behaviour to another widely consumed drug: Nicotine. In England, smoking has decreased from 39 % of adults in 1980 to 20 % in 2010 (HSCIC
2013). The factors responsible for this significant change are a combination that include health-warning labels on packaging, education on the damaging effects of smoking and smoke free legislation (Martin-Moreno et al.
2013). In terms of warning labels, research has shown that they are an important reminder on the danger of smoking and are strongly linked to intentions to stop smoking (Hammond
2006).
The effectiveness of health-warning labels in relation to tobacco have been examined with several factors being identified. Large warning labels are most effective, being large enough to be easily noticed and read (Hammond et al.
2007); Smokers report greater recall for warning labels on the front of packages, and that if the label had a direct and accurate message in conjunction with being simple, a greater impact is found (Hammond
2011); pictorial health-warning labels are more effective than text-only as pictures increase the accessibility to a greater target audience, whilst allowing smokers to visualise problematic scenarios (Hammond et al.
2004); also, colour pictures are more effective than black and white pictures.
In terms of alcohol, research has investigated public acceptability and consumer aspects of alcohol warning messages (e.g. Jarvis and Pettigrew
2013; Martin-Moreno et al.
2013; Thomson et al.
2012), but very little work has examined whether such warning messages can actually change attitudes and virtually none looking at behavioural change. One Internet-based study found that when confronted with choices of which beverage to select with warning messages, young drinkers showed a reduction in choosing the alcoholic beverage (Jarvis and Pettigrew
2013). Work has also demonstrated that advertisements with fear arousing alcohol related visuals (e.g. ambulance at crash scene caused by excess alcohol) led to increases in perceived risks associated to alcohol use (Slater et al.
2002). Theoretically, those findings supported the Extended Parallel Processing Model (EPPM, De Hoog et al.
2007) which predicts that messages accompanied by threatening visuals induce more processing of the accompanying message. Most recently, we conducted an experiment (Wigg and Stafford
2016) where individuals were exposed to alcoholic beverages in three separate conditions (no health warning, text-only, pictorial), and found that participants exposed to the pictorial condition had higher intentions to reduce and quit alcohol consumption; which was related to individuals level of fear arousal.
The aforementioned study provided a useful first step in establishing experimental protocols in this domain; however, it was unclear from that work alone if such health-warning labels can influence other behavioural measures related to alcohol consumption. One such measure is the speed at which alcohol is consumed, which is important since the same quantity of alcohol drunk in a short versus longer period of time will have dramatically different effects and thereby risks associated to individual health and safety (Moskowitz and Burns
1976; Bernosky‐Smith et al.
2012). Episodic drinking rate is driven by a number of factors including the sensory (taste) aspects of the drink that cue the presence of alcohol strength and the perceived behavioural (intoxicating) effects of alcohol (Higgs et al.
2008). It would also seem probable that speed of consumption is related to ‘protective drinking behaviours’ (Ray et al.
2009); the extent to which individuals engage in practices such as pacing the number of drinks consumed in a time period. Work has shown that individuals who score higher in protective drinking behaviours also have fewer negative consequences of alcohol consumption (Ray et al.
2009), which reinforces the point regarding the importance of the rate at which alcohol is consumed.
The current study therefore aimed to examine whether health-warning messages have the ability to influence this important aspect of alcohol behaviour. To test this question, individuals consumed the same alcoholic beverage in one of three separate conditions that varied in the type of health-warning on the bottle: no health-warning label; text-only; pictorial and text health-warning label. We tentatively predict that consumption rate will be fastest in the ‘no health-warning label’ category compared to both text-only and pictorial conditions, with the latter predicted to have the slowest rate.
Discussion
The main finding of the study was that alcohol was consumed at a faster rate for those in the control condition compared to both the pictorial health-warning label and text only conditions. This pattern of findings is generally consistent with prediction and extends previous research (Wigg and Stafford
2016) to demonstrate that health-warning labels can also influence episodic drinking behaviour. The mechanism responsible for slower consumption is theorised to be due to higher levels of fear arousal in the two health-warning conditions. It is well established that health-warning messages that elicit fear can be an effective means of informing the public and also instrumental in intentions to quit smoking (Kees et al.
2010). For alcohol, it is also supported by work showing that individuals have less preference for alcohol products with health warnings (Jarvis and Pettigrew
2013). Hence, the lower preference for alcoholic beverages with health warnings may be manifested in the present study as a slower speed of consumption.
The observation that consumption speed did not differ between the pictorial and text-only conditions was surprising and contrary to prediction. In the previous study (Wigg and Stafford
2016), we found higher levels of fear in the pictorial versus text condition which made it seem probable to expect a slower consumption in the pictorial condition. This would also be consistent with the Extended Parallel Processing Model (EPPM, De Hoog et al.
2007) where health messages accompanied by threatening visuals have larger effects, as found in both alcohol (Slater et al.
2002) and tobacco research (Hammond et al.
2004; Schneider et al.
2012). However, it needs to be emphasised that those studies used different outcome measures from the study here, including perception of risk (alcohol) and intentions to reduce or quit (smoking). It could be therefore that the differences between pictorial and text-only health warnings are less important when measuring speed of consumption. Alternatively, it could be that the rate at which alcohol is consumed is not sufficiently sensitive to capture these differences and that adopting a different measure such as volume of consumption might be more appropriate. Connected to this, one study has found that the amount of alcohol consumed is sensitive when assessing the effectiveness of cognitive restraint training (Jones et al.
2011).
Given the aforementioned, the finding that pictorial health-warning labels led to lower acceptability ratings was not surprising; this is also consistent with work demonstrating that a cigarette’s brand appeal can be reduced in the presence of health-warning labels (Thrasher et al.
2007). More interestingly was the finding that despite a clear difference in consumption speed, there were no corresponding difference in acceptability between the text and control conditions, which suggests that many of the advantages of including a health warning are available in the absence of any strong reductions in product acceptability. These findings also extend a previous study where alcohol warnings related to cancer did not provoke overly negative reactions (Pettigrew et al.
2014).
The absence of a relation between protective drinking behaviour and consumption rate is somewhat surprising. Since one of the components of that measure specifically relates to the habitual practice of pacing drinks, it seemed reasonable to assume that this would relate to actual speed of consumption. Previous research using the protective behaviour instrument found it had good accuracy in predicting future alcohol consumption over a given time period (Ray et al.
2009), but we are not aware of any work that examined its possible link with episodic drinking rate. It therefore seems likely that protective behaviours relate more to longer periods of self-reported alcohol consumption.
Considering the wider implications of the present study, since the speed of alcohol consumption influences the level of intoxication and associated health risks (Moskowitz and Burns
1976; Bernosky‐Smith et al.
2012), the findings here have particular resonance; using such health-warning labels can help inform the public and could lead to safer drinking practices. These findings also have implications for wider alcohol work that has examined the drivers of consumption rate in terms of environment (e.g. music, Stafford and Dodd
2013) and sensory/behavioural changes (Higgs et al.
2008). The present study extends those areas of research to show that consumption rate is also sensitive to the information presented on the alcohol product.
In terms of study limitations, due to the fact that this was a female only study, we cannot be sure if the impact of health warnings would be the same for male participants. The rationale to use females was based on the likely confound of consumption rate differences between genders and also the difficulty in finding an alcohol beverage consumed widely by both males and females; the use of one gender is also consistent with previous consumption rate research, (Higgs et al.
2008; Stafford and Dodd
2013). Interestingly, one might speculate that the effects observed in the present study would be weaker for males, based on the fact that work has shown that in response to alcohol health-warning advertisements, females responded more positively than males (Slater et al.
2002).
In summary, we found that individuals consumed alcohol more slowly when it was presented with pictorial or text-only health warnings. This is the first study to demonstrate this outcome measure in the context of health-warning messages similar to those used in the tobacco industry. The findings here suggest that using health warnings on alcoholic beverages could be an effective strategy in changing attitudes and behaviour to one of our favourite but harmful drugs.
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