Impact of health warning labels communicating the risk of cancer on alcohol selection: An online randomised experimental study

Natasha Clarke, Emily Pechey, Eleni Mantzari, Anna K M Blackwell, Katie J De-Loyde, Richard W Morris, Marcus R Munafo, Theresa M Marteau, Gareth J Hollands

Research output: Contribution to journalArticle (Academic Journal)peer-review

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Background and Aims
Evidence from tobacco research suggests that health warning labels (HWLs) depicting the adverse consequences of consumption change smoking behaviours, with image‐and‐text (also known as ‘pictorial’ or ‘graphic’) HWLs most effective. There is an absence of evidence concerning the potential impact of HWLs placed on alcohol products on selection of those products. This study aimed to obtain a preliminary assessment of the possible impact of (a) image‐and‐text (b) text‐only and (c) image‐only HWLs on selection of alcoholic versus non‐alcoholic drinks.

A between‐subjects randomised experiment with a 2 (image: present vs absent) x 2 (text: present vs absent) factorial design.

The study was conducted on the online survey platform Qualtrics.

Participants (n=6024) were adults over the age of 18 who consumed beer or wine regularly (i.e., at least once a week), recruited through a market research agency.

Participants were randomised to one of four groups varying in the HWL displayed on the packaging of alcoholic drinks: i. image‐and‐text HWL; ii. text‐only HWL; iii. image‐only HWL; iv. no HWL. HWLs depicted bowel cancer, breast cancer and liver cancer, which were each displayed twice across six alcoholic drinks. Each group viewed six alcoholic and six non‐alcoholic drinks and selected one drink that they would like to consume.

The primary outcome was the proportion of participants selecting an alcoholic versus a non‐alcoholic drink.

Alcoholic drink selection was lower for all HWL types compared with no HWL (image‐and‐text: 56%; image‐only: 49%; text‐only: 61%; no HWL: 77%), with selection lowest for HWLs that included an image. Image‐and‐text HWLs reduced the odds of selecting an alcoholic drink compared with text‐only HWLs (OR = 0.80, 95% CI = 0.69, 0.92), but increased the odds of selecting an alcoholic drink compared with image‐only HWLs (OR = 1.34, 95% CI = 1.16, 1.55).

Health warning labels communicating the increased risk of cancers associated with alcohol consumption reduced selection of alcoholic versus non‐alcoholic drinks in a hypothetical choice task in an online setting; labels displaying images had the largest effect. Their impact in laboratory and real‐world field settings using physical products awaits investigation.
Original languageEnglish
Early online date8 Apr 2020
Publication statusE-pub ahead of print - 8 Apr 2020


  • health warning label
  • pictorial health warning label
  • alcohol
  • graphic warnings
  • choice architecture
  • cancer

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