The experience of health warnings dedicated to tobacco could benefit those of alcoholic products

In Canada, a reflection on health warnings proposes to allow alcoholic products to benefit from the experience and expertise developed with tobacco products.

Since it was formally established in 1964 that smoking tobacco causes cancer, Canada has been engaged in a constant effort to limit and discourage its consumption. This has led, among many other measures adopted, to the development of health warnings on cigarette packages, so that no smoker can ignore the risks they incur by smoking. These health warnings are also intended to raise awareness among those around smokers of the dangers of smoking, as well as among young non-smokers to dissuade them from starting to smoke.

It has since been scientifically proven that not only does alcohol consumption also produce cancers, with the incidence starting from the first drink[1], but also that these cancers are the first pathologies attributable to alcohol consumption. Although this medical reality has been known for several decades, it is only today that some voices in the medical world are being raised to demand such warnings on alcoholic products, drawing inspiration from the experience and model developed for tobacco products[2].

Warnings about the dangers of tobacco are beginning to sound timidly

Initiated in 1966 in the United States, these health warnings were initially left to the discretion of tobacco manufacturers. Some manufacturers even included statements such as "avoid inhaling", but there were no rules governing this practice. The warnings were then placed on the side of the packets and did not mention any specific illness. In 1973, Australia placed these warnings on the front of the packets, while in 1977, Sweden introduced a rotation of 16 health messages with specific information on tobacco-related pathologies, in black characters on a white background or dark characters on a light background.[3].

In Canada, in the late 1980s, four warnings ("smoking reduces life expectancy", "smoking is a major source of cancer", "smoking is a major cause of cardiovascular disease" and "smoking during pregnancy harms your child") were imposed on tobacco manufacturers, but these were still text warnings without photos. These messages were then "camouflaged" by the manufacturers, in colours that blended in with those of the package.

In 1993, a Canadian law placed the words "smoking can kill you" on the top of the front of packages, in white letters on a black background, framed by a white border. Tobacco companies called the legislation "harassment," saying the words did not work, and they challenged the law in court, with the Supreme Court of Canada ruling in their favor in 1995.

Extension and illustration of health warnings

With the Canadian Tobacco Act in 1997, Parliament reintroduced and imposed health warnings on cigarette packages. These warnings were accompanied, in 2001, by illustrations or photos representing the various pathologies, which significantly reinforced the effectiveness of the health messages. At that time, these warnings covered at least 50% of the main surface of the packages. A study of ex-smokers showed that 27% of them indicated that these messages had helped them in their efforts to quit, and 38% stated that the anti-smoking policy had helped them not to resume their consumption.[4].

Throughout the 2000s, illustrated health warnings spread on the planet, particularly among countries that have ratified the Framework Convention on Tobacco Control (FCTC), whose Article 11 requires the establishment of this type of measure in the years following this ratification. Guidelines were adopted at the 2008 Conference of the Parties, providing countries with concrete recommendations in the field of health warnings based on good practices. In 2021, health warnings were mandatory in 134 countries, 122 of which required them to represent at least 50 % of the surface area of the packages. Today, Canada is considering declining these health messages on cigarettes themselves, this location being perceived as more striking than a warning on the product packaging.

Teachings for alcoholic products or other substances

After being used for e-cigarettes, health warnings are now being considered, as is standardization of packaging, for cannabis products in the few countries and states where it is legalized. Analysis of the marketing of these cannabis products shows that colorful, illustrated packaging highlighting different flavors is more appealing to young consumers.[5]. There therefore seems to be no reason why alcoholic products should escape these health warnings.

In France, Article L.3322-2 of the Public Health Code has required, since February 12, 2005, the presence on each container of alcohol of a health message aimed at pregnant women and intended to prevent fetal alcohol syndrome (FAS, 15,000 cases per year according to the SAF France association). This message can be presented either in the form of a pictogram or a statement indicating "The consumption of alcoholic beverages during pregnancy, even in small quantities, can have serious consequences on the health of the child", the choice being left to the producer. These producers systematically opt for the pictogram, the dimensions and colors of which are not defined, but endeavor to reproduce it in a reduced size and in a color that blends in with the colors of the packaging, thus making it almost invisible to almost all consumers. The definition of criteria for enlarging and improving the visibility of this pictogram is constantly being postponed[6] under the action of the alcohol industry lobbies, and in particular the wine industry. In March 2017, the senator for Marne, Yves Détraigne (UDI/Union Centriste), spoke out against the widening and colouring of this pictogram, arguing that "the labels on the bottles are not intended to convey health messages but are above all a marketing medium produced at the producers' expense."[7].

Several recommendations are put forward by Garfield Mahood, former executive director of the association Non Smokers' Rights, in order to deploy health warnings on products - whether alcohol or other substances:

• First, it is advisable to prefer punchy phrases to overly polite formulas, which some public health organizations often tend to adopt. If a substance causes cancer, it is therefore preferable to indicate "causes cancer" rather than "may cause cancer".
• These warnings must include photos or illustrations that make an impression and significantly reinforce the impact of the health messages.
• The severity of pathologies (cancers, cardiovascular diseases, etc.) and the specificity of the indications, when the messages are aimed at a specific audience, are also indicators of the effectiveness of health messages.
• Overly long blocks of text messages should be avoided, as punchy phrases have a better influence.
• Messages and illustrations tend to become commonplace over time, so they need to be updated regularly.[8].
• Finally, it is important to be patient and develop extremely persuasive pleas, because the alcohol industry will not let itself be controlled any more than the tobacco industry, and they know perfectly well how to address political decision-makers most directly. The case of the United States, where legislation on health warnings for tobacco is constantly pushed back, is a notorious example of the potential difficulties.

The experience gained by advocates of a tobacco-free world should therefore be of benefit to those in favour of limited alcohol consumption.

Keywords: health warnings, tobacco, alcohol, Canada.

©Tobacco Free Generation

M.F.

[1] Cancers: risks from the first drink, Alcohol-Info-Service.

[2] Mazerolle J, The long struggle for cigarette warnings has lessons for alcohol labels, experts say, CBC News, published January 19, 2023, accessed January 24, 2023.

[3] Cunningham R, Tobacco package health warnings: a global success storyy, Tob Control 2022;31:272–283.

[4] Hammond D, Fong GT, Brown S, Cameron R, The Impact of Cigarette Warning Labels and Smoke-free Bylaws on Smoking Cessation, Can J Public Health. 2004 May; 95(3): 201–204.

[5] Leos-Toro C, Fong GT, Hammond D, The efficacy of health warnings and package branding on perceptions of cannabis products among youth and young adults, Drugs and alcohol. 2021 May; 40(4): 637-646.

[6] Cancer Plan: Open letter to the President of the Republic, Addictions France, published February 11, 2021, consulted January 25, 2023.

[7] Pictogram recommending the absence of alcohol consumption by pregnant women

14^e legislature, Written Question No. 24782 from Mr. Yves Détraigne (Marne – UDI-UC), JO Senate of January 26, 2017.

[8] Hitchman S,, Pete Driezen P, Logel C, Hammond D, Fong GT, Changes in Effectiveness of Cigarette Health Warnings Over Time in Canada and the United States, 2002–2011, Nicotine Tob Res. 2014 May; 16(5): 536–543.