health warning labels for alcoholic beverages in canada

Health Warning Labels for Alcoholic Beverages in CanadaAuthor(s): REGINALD G. SMARTSource: Canadian Journal of Public Health / Revue Canadienne de Sante'e Publique, Vol. 81, No.4 (July / August 1990), pp. 280-284Published by: Canadian Public Health AssociationStable URL: http://www.jstor.org/stable/41989907 .

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Health Warning Labels for

Alcoholic Beverages in Canada

REGINALD G. SMART, Ph D1

After legislation a long fight,

(October the United

21, 1988) States

that Congress

would adopted require legislation (October 21, 1988) that would require

warning labels by November 1989 on any alcoholic beverages sold in the country. The new label will read "Government Warning: 1) According to the Surgeon General, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects. 2) Consumption of alcoholic beverages impairs your ability to drive a car or operate machinery and may cause other health problems". They are to be reviewed in two years to see whether other warnings are required. The need for warning labels has been discussed in Canada, but no serious legislative or regulatory steps have been taken to require

1. Director, Prevention Studies Department, Addiction Research Foundation. The views expressed in this paper are those of the author and do not necessarily reflect those of the Addiction Research Foundation. Please send reprint requests to: Dr. R.G. Smart, Director, Prevention Studies Department, Addiction Research Foundation, 33 Russell Street, Toronto, Ontario, M5S 2S1.

them. Of course, the alcohol beverage industry1 2 3 4 opposes warning labels in both Canada and the U.S.A. Others may view them as unnecessary or ineffective, but in general, health authorities in both countries have favoured them. The Canadian Medical Association5 and the Standing Committee on National Health and Welfare6 recommend them. No one seems to expect that labels would eradicate drinking problems, only that they would contribute to an overall alcohol education program and slightly reduce levels of drinking.

Warning labels on U.S. alcoholic beverages will affect Canadians indirectly, as Canadian manufacturers must prepare labels for the U.S. market and some Canadians buy alcoholic beverages in the U.S. However, more Canadians would benefit if Canada, too, required warning labels on alcoholic beverages. This paper examines the rationale for warning labels on alcoholic beverages, their likely impact, the opposition to them, and the special problems of such labels in Canada.

280 Canadian Journal of Public Health Vol. 81, July/ August 1990

This paper reviews the background and rationale for health warning labels for alcoholic beverages. They have been recently approved for the United States . Mexico and Colombia already have such labels. However, Canadian health officials seem reluctant to require them unless the alcohol industry agrees. Arguments against labels (i.e. that they detract from other efforts , are misguided or ineffective) are not convincing. Evidence from research on health warnings on cigarettes and prescription and non-prescription drugs shows that labels can be effective if well designed. Special problems in having bilingual labels may exist but could be overcome. Canada should have health warning labels on alcoholic beverages as soon as possible.

Dans cet article on discute de la raison d'être pour les étiquettes sur les bouteilles de boissons alcooliques , qui avertissent des risques à la santé. De telles étiquettes ont été approuvées récemment aux Etats-Unis. Au Mexique et à la Colombie on les a déjà. Cependant les personnages officiels dans le domaine de la santé publique au Canada ne veulent pas les demander si l'industrie des boissons alcooliques n'est pas d'accord. Les arguments contre les étiquettes sont spécieux , par exemple, qu'elles diminuent l'efficacité d'autres efforts, qu'elles sont peu judicieuses ou inefficaces elles-mêmes. Les recherches sur les étiquettes d'avertissement aux paquets des cigarettes et des drogues d'ordonnance indiquent par contre que les étiquettes peuvent être efficaces si elles sont bien dessinées. Les problèmes spéciaux dus à la nécessité d'avoir les étiquettes bilingues peuvent être surmontés. Le Canada devrait mettre des étiquettes d'avertissement sur les bouteilles de boissons alcooliques aussitôt que possible.



A Short History of Warning Labels on Alcoholic Beverages

Although many countries have had warning labels on cigarettes since the early 1970s, few have such labels for alcoholic beverages. Colombia introduced a law in 1974 requiring the statement "Alcohol is harmful to health" in a conspicuous position.7 In 1985, Mexico required that alcoholic beverages, other than beer, carry the message "The abuse of this product is harmful to your health". No research has been done on the effectiveness of these labels or their impact on drinking levels.

Interest in alcohol warning labels began in 1972 when the Center for Science in the Public Interest in Washington discovered that alcohol labelling was the responsibility of the U.S. Food and Drug Administration.8 Formerly, it was believed that jurisdiction rested with the Bureau of Alcohol, Tobacco and Firearms (BATF), which did not take action on labels. In 1972, the CSPI formally petitioned8 9 both agencies to list ingredients on alcoholic beverages as with other foods and beverages. After this, a series of congressional hearings were held which created interest in the topic. Congressional hearings were held by the Senate Subcommittee on Alcoholism and Drug Abuse in 1978. Various legal amendments and recommendations requiring alcoholic beverage labels were proposed by Senator Strom Thurmond and others. However, all were defeated, partly because of pressure from wine growers in California, whiskey makers in Kentucky, and beer manufacturers in various states.8 9

About 1979, interest changed from having a general warning about alcohol such as those in Mexico and Colombia to one focussed on fetal effects and drinking- driving issues. Research on the fetal effects of alcohol began in the early 1970s, but the results were not well known to the public or politicians for several years. This new research on fetal effects was one of the main factors in having warning labels accepted in the U.S.A., and such effects are clearly mentioned on the label. However, research on drinking- driving was also important although much of it was not new.

The alcohol labelling change in 1988 had the support of more than 100 medical, nursing, parent and community groups, including the American Medical Association and the American Public Health Association.9 This consortium was organized largely by the Center for Science in the Public Interest, a non-profit health-oriented group centred in Washington. Seldom has such a small regulatory change required such an enormous effort to get it passed, especially when it appeared to serve the public health interest at little cost. Much of the success in the United States is due to a single senator and a few colleagues and to the efforts of the CSPI, not government officials who often seemed to delay the process. Surprisingly, the warning label requirement in 1988 was made part of the Omnibus Drug Bill, most of which deals with the control of illicit drugs.

In Canada, the Canadian Medical Association called for alcohol warning labels in 1985. 5 A committee of Parliament,

The Standing Committee on Health and Welfare, recommended them in 1987. 6 However, the Minister of Health and Health and Welfare10 officials seem to oppose them unless they are agreed to voluntarily by the alcohol beverage industry and the provincial alcohol commissions. A private members' bill is being prepared by an NDP member which would require warning labels,2 but such bills rarely pass.

A Contribution to the Prevention of Adverse Reactions Certainly, there is no reason to think that alcohol

problems are less in Canada than in the United States, or that Canada does not need warning labels. Traditionally, Canada has had slightly higher levels of per capita consumption11 compared to the U.S. and a larger proportion of the population who drink. Excessive alcohol consumption in Canada is not merely a private matter but has serious public health consequences. Traditionally, governments have warned the public about potentially dangerous products and alcohol is the exception to this public health position. The authority for warning labels comes under the Food and Drug Act, but provinces could probably also require them under liquor control legislation.

Alcoholic beverages are among the most poorly labelled foods available in Canada. Most foods and beverages require a statement of contents but alcoholic beverages do not, except for a statement about alcohol content. Alcoholic beverages do, at times, contain dangerous elements. A U.S. study estimated that up to 1 .7 million Americans are allergic to the ingredients commonly used in wine, and that 4,000 could be fatally allergic.8 In the 1960s, cobalt products which caused cardiomyopathy appeared in Canadian beer, especially in Quebec.14 Numerous potentially dangerous products do carry warning labels, e.g. tobacco, some over- the-counter drugs and many prescription drugs. Better labelling of alcoholic beverages as to both contents and adverse effects is long overdue.

Even social drinking, averaging two drinks per day, increases the frequency of low birthweight and other undesirable pregnancy outcomes.1214 Heavy drinking during pregnancy (6 drinks a day or more) can result in a 50% rate of adverse outcomes (miscarriages, birth defects, etc.). It has been estimated that about 4,000 children in the U.S.A. are born with fetal alcohol syndrome and that 10 times that number have less severe defects.12 Probably the proportions in Canada would be similar and about 400 children with the fetal alcohol syndrome would be expected each year.

Knowledge of the risks of alcohol to pregnant women seems to be poor. A study in the U.S.A. showed that only 5.7% of Americans had heard of the fetal alcohol syndrome despite millions of pieces of information on the topic having been distributed to physicians and the general public. Less than 46% of respondents with less than a high school education were aware of the danger of drinking during

July/August 1990 281



pregnancy.12 Only about 28% said drinking should be avoided during pregnancy.

Surveys of pregnant women show that 20-25% have high risk drinking practices.12 A little more than half have never discussed drinking during pregnancy with their doctor. Other studies show that many doctors do not counsel pregnant women about drinking and only about 50% recommend abstinence during pregnancy.

Warning labels could provide information to women who do not have a physician, to those pregnant women who do not see a physician until very late in pregnancy, or whose physician does not discuss the risks of drinking.

It is more difficult to argue for warning labels against drinking and driving. Most citizens are aware of the risks and favour strict enforcement laws. For example, a recent Canada Health Promotion Survey15 indicated that only 16.1% drove after drinking in the past month. About 76% intervened on the last occasions when friends or relatives were about to drink and drive. Also, drinking-driving accidents are declining in Canada. Of course, drinking- driving is still an important problem and placing the issue on a warning label would reinforce the existing attitudes and establish the importance which the government places on it.

In addition to the specific information they carry, warning labels could have some symbolic value. As a strong statement of concern by the government, they would initiate a new level of interest in alcohol problems in general. Something of this sort seemed to happen when cigarette warning labels were introduced. They were among the first tangible steps taken by government to warn about the dangers of cigarettes. In Canada, as in the U.S.A., warning labels preceded the many steps followed later such as the tar and nicotine level warnings, price increases, workplace restrictions, etc.

The Opposition to Warning Labels Some experts and representatives of the alcohol industry

have doubted the preventive effects of warning labels. The main arguments seem to be that (i) sufficient alcohol education is already taking place and that labels could destroy or limit other co-operative efforts between the industry and health officials,134 (ii) they would create unnecessary fear or concern for the public, especially those who are light drinkers,13 (iii) they "let legislators and bureaucrats off the hook" and lead to a feeling of complacency,13 (iv) they miss the main problem to be attacked, i.e. problem or alcoholic drinking, not drinking in moderation,13 (v) there is, now, regulation overload and people get so much product information it is ineffective,1 (vi) there is no evidence that warning labels would increase awareness or decrease drinking.12'3

None of the arguments against warning labels as a preventive device are very convincing. There is no intention to stop other educational efforts because of warning labels or to allow educators or others to become complacent.

Perhaps special efforts will be needed to see that this does not happen. It is not the case that only excessive drinking or alcoholism causes problems. Low levels of alcohol consumption can lead to allergic reactions, alcohol-related accidents, and adverse pregnancy outcomes. Some products may be over-regulated and contain too many warnings. However, that is not yet the case for alcoholic beverages for which there is almost no consumer protection at all via labels. The issue of the effectiveness of warning labels requires special consideration.

The Effectiveness of Alcohol Warning Labels A common argument against warning labels, especially

by alcohol industry representatives, is that they are ineffective or not known to be effective. The two countries, Colombia and Mexico, with warning labels on alcoholic beverages have done no research to support or deny their effectiveness. The warnings in those countries are more vague and general than those to appear in the U.S. A. Since they will not be introduced until late 1989, research on their impact could not be available for some time.

Assessing the effect of such labels will be very difficult. They are being introduced at a time when many other regulatory changes are occurring and in a country with many educational and mass media messages for and against alcohol. We may never be certain just what contribution labels make separated from all of the other influences on peoples' drinking. In addition, the unique contribution of any single change in alcohol controls is likely to be small. It is unfortunate that there was no plan to introduce warning labels on an experimental basis, for example, in some states and not in others.

Although research on alcohol warning labels has not been done, research on other health warning labels shows very positive outcomes. This research was reviewed for the United States Congress in 1987 and covers tobacco product warnings, food labelling, over-the-counter and prescription drug labelling, and labels for hazardous consumer products.16 In this review, all available empirical studies were critically examined, including both published and unpublished studies and those in foreign languages. In addition, the review itself was carefully examined by a number of experts in the field for its accuracy and completeness. The review is too extensive to repeat here; however, the main conclusions are important. For example, i) Health warning labels do have an impact on the

consumer if they are designed to be credible, useful, specific, and easy to read and understand.

ii) Health warning labels have a greater impact if they are designed to be prominent, printed in large letters and contrasting colours, and do not contain too much information.

iii) Well-designed studies of health warning labels show a significant, moderate impact, e.g. studies of tobacco warnings and those for saccharin in diet beverages.

282 Canadian Journal of Public Health Vol. 81



In general, the authors of the review concluded that alcohol warning labels could be designed to be effective. Based on research with other types of label warnings, those for alcohol might reduce drinking by about 4% to 10% over time.16 Of course, their impact might be lessened if they were vague, difficult to read, or poorly designed in other ways. However, considerable research may be required to design effective alcohol warning labels, and lessons from other types of warnings may not be applicable.

Special Considerations in Canada Since alcohol warning labels have been introduced in the

U.S.A., there will be increased pressure to have them in Canada. Canadian manufacturers of spirits and beer will be printing labels carrying the U.S.A. warning. Since bilingual labels are required in some provinces, the U.S.A. labels cannot be used here. If there are complex French and English warnings, that could lead to allegations that the labels are cluttered, difficult to read or confusing. However, many alcohol labels have empty space available and could accommodate the two messages. Others may require some re-design. Some additional cost to beverage manufacturers is likely, and this appears at a time when alcohol consumption and profits are declining. These costs could be offset by small reductions in the taxes on alcohol, although such reductions did not occur when tobacco warnings were introduced.

Warning labels could ultimately be beneficial to the alcohol beverage industry as well as consumers. Legal claims for damage to fetuses from alcohol have started in the U.S.A., and one of the arguments is that no warnings of possible harm from alcohol were given. Health warning labels on FAS or drinking-driving may reduce legal liability in the future. However, if Canadian alcohol manufacturers warned of the dangers of drinking their beverage in the U.S.A., but not for the same beverage in Canada, that might be taken as neglect in future court cases.

An additional set of problems is seen in Canada but not in the U.S.A. Canadian Health and Welfare Canada officials took the position that warning labels should be introduced with the voluntary participation of the alcohol beverage industry.10 As expected, no agreement could be obtained for warning labels.610 Although the voluntary approach was used successfully with tobacco warnings, it was done with the threat of enforcing legislation. Such a solution may be necessary for alcohol warning labels.

Health and Welfare was also advised10 that there could be problems under the General Agreement on Tariffs and Trade (GATT) as labels would be required on imported beverages. This consideration does not appear in the debates in the U.S.A., nor did it prevent the law being enacted there. Manufacturers who wish to sell alcoholic beverages in the U.S.A. must comply, whether domestic or foreign. Canada requires bilingual labels and a statement of alcohol content, and it is difficult to see that health warnings

would be a major departure. Some alcohol beverage manufacturers in other countries may decide not to sell in the U.S.A. or Canada. However, there is a world over- supply of most alcoholic beverages, and Canadians will likely not go thirsty.

CONCLUSION

Warning labels for alcoholic beverages would probably have a limited impact on drinking levels in Canada. The best labels are probably very specific and warn consumers of special risks from alcohol (e.g. abortion, accidents, allergies), as well as establish the general health concern about excessive drinking. They probably could contribute to prevention of drinking problems, especially if combined with other educational efforts. Proponents do not see them as a panacea. The best argument against them is that they would entail additional costs.

Warning labels could be introduced in Canada. An intergovernmental task force of health and consumer experts should prepare guidelines for warning labels in Canada and should set out the political and practical steps in having them introduced. The political will to introduce alcohol warning labels in Canada would be increased if a consortium of public interest and professional groups were formed to support them, as happened in the United States. A consumers' association or one of the provincial alcohol agencies is perhaps the most likely starting point for such a movement.

In order to make labels acceptable to the alcohol industry, it may be necessary for the Federal or Provincial governments to reduce the tax levels on alcoholic beverages. After labels are introduced, research programs should be mounted to see whether the labels are noticed by consumers and whether they have any effect on drinking habits.

Acknowledgement The author thanks Dr. Eric Single for comments on this manuscript.

REFERENCES 1. American Business Men's Research Foundation. The Great Debate:

Health Warnings for Alcoholic Beverages Bottom Line 1980; 3: 3-35. 2. Alcohol producers oppose rising pressure for warning labels. Toronto:

Globe and Mail, December 16, 1988. 3. Health Issues Challenge Alcohol Industry Impact 1988; 18: 1-5. 4. Canadian Medical Association. Alcohol Beverage Makers Disagree

about Warning Labels Can Med Assoc J 1987; 12: 1117. 5. Canadian Medical Association. Drinking and Driving Can Med Assoc

J 1985; 133: 806A. 6. Standing Committee on National Health and Welfare. Booze, Pills,

and Dope: Reducing Substance Abuse in Canada. Ottawa: House of Commons 1987.

7. Fluss S. Legal Protection of Minors from Alcohol-Related Problems, in: Jeannert O, Ed., Alcohol and Youth. Basel, Switzerland: S. Kroger 1983.

8. Alcoholic Beverage Warning Labels - An Idea Whose Time Has Come Bull Alcohol Policy 1987; 5: 8-10.

9. Taylor P. Health and Safety Warning Labels on Alcohol Beverage Containers. Statement to Committee on Government Affairs, U.S. Senate, Center for Science in the Public Interest 1988.

10. Government Response to the Report of Standing Committee on "Booze, Pills and Dope: Reducing Substance Abuse in Canada". Ottawa: Ministry of National Health and Welfare 1988.

July/ August 1990 283



11. Adrian M. Statistics on Alcohol and Drug Use in Canada and Other Countries. Toronto: Addiction Research Foundation 1988.

12. Abel EL. Fetal Alcohol Syndrome and Fetal Alcohol Effects. New York: Plenum Press 1984.

13. Morin Y, Daniel P. Quebec Beer-Drinkers Cardiomyopathy: Etiological Considerations Can Med Assoc J 1967; October 7: 927.

14. Morrissey ER. Of women, By Women or For Women: Selected Issues in the Primary Prevention of Drinking Problems. Women and Alcohol: Health Related Issues, Washington, D.C.: U.S. Government Printing Office 1986; Research Monograph No. 16.

15. Canada's Health Promotion Survey. Ottawa: Health and Welfare Canada 1988.

16. Richardson P, Reinhart E, Rosenthal H, Hayes C, Silva R. Reviews of the Research Literature on the Effects of Health Warning Labels: A Report to the United States Congress. Department of Health and Human Services 1987.

Received: February 17, 1989 Accepted: June 16, 1989

DALL FOR ABSTRACTS 16th National Primary Care Nurse Practitioner Symposium

The 16th National Primary Care Nurse Practitioner Symposium is accepting abstracts on research, innovative clinical practice/models and roles, and other professional papers relating to primary care nursing. Abstracts are being accepted for presentations or poster sessions. This Symposium, sponsored by the University of Colorado School of Nursing, will be held July 12-15, 1991 in Colorado. Send 3 typed copies (300 words or less). Format includes title, brief statement of purpose, methods, conclusions and clinical application(s) or brief summary of project/ paper if not research. Include author vita and indicate interest in presentation or poster session. Preference will be given to abstracts with strong clinical applicability, innovative role development models and papers with future-oriented perspective. Presenters are provided tuition waiver for registration the day of their presentation but are responsible for own travel and expenses. Deadline is October 2, 1990. Contact Ellen Lemberg, RN, C, MS, Extended Studies, Box C288, School of Nursing, University of Colorado Health Sciences Center, 4200 East 9th Avenue, Denver, Colorado 80262; Tel. (303) 270-8691.

284 Canadian Journal of Public Health Vol. 81

International Lactation Consultant Association Announces

1991 Manuscript Competition The International Lactation Consultant Association is sponsoring a competition designed to identify outstand- ing manuscripts relating to human lactation or breastfeeding in 1991. Authors may enter one of two categories: a Literature Review competition or a Research Paper competition. The winner in each category will receive $500. (U.S.); winning manuscripts will be published in the Journal of Human Lactation. Competition is open; entrants need not be members of the International Lactation Consultant Association. Students are encour- aged to enter.

Competition in the Research Paper competition is open only to currently unpublished authors; authors entering the Literature Review competition may be published or unpublished. The deadline for entry in the 1991 competition is February 1, 1991. To obtain information detailing competition manuscript form and length limitations, send a stamped (U.S.) self- addressed envelope to:

K.G. Auerbach, Ph.D., IBCLC, Editor-in-Chief Journal of Human Lactation

Dept. PH 2240 Willow Road

Homewood, IL 60430-3221 USA



health warning labels for alcoholic beverages in canada

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