Voluntary Pregnancy Warning Labels on Alcohol Presentation for the Australasian Drug and Alcohol Strategy Conference, 2-5 May 2017

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Strategy Conference, 2-5 May 2017 Dr Fiona Imlach,

1 Voluntary Pregnancy Warning Labels on Alcohol Presentation for the Australasian Drug and Alcohol Strategy Conference, 2-5 May 2017 Dr Fiona Imlach, Team Lead Research Susan Cook, Senior Researcher

2 Outline Why bother with labelling? Labelling in NZ Consumer awareness in NZ What next?

3 Why bother with labelling? Alcohol is a known teratogen Fetal Alcohol Spectrum Disorder (FASD) Permanent damage to developing body and brain of a fetus Leading cause of non-genetic intellectual disability Affected children/adults are at increased risk of poor outcomes

4 Drinking and pregnancy in NZ At least one in two pregnancies are exposed to alcohol in NZ One in ten exposed at high-risk levels ~30% of women don t drink before pregnancy 44% of pregnancies unplanned Almost 60% of women stop drinking once aware of pregnancy (not always immediately) ~10-20% continue to drink (may reduce)

estimated that one in every 67 women who consume alcohol

5 FASD in NZ NZ prevalence of FASD unknown Estimated between 600-3,000 babies born per year with FASD in NZ Worldwide, estimated that one in every 67 women who consume alcohol during pregnancy will deliver a child with FAS (fetal alcohol syndrome)

lifelong disability in the child Listeria 1/10,000 pregnant women

6 Alcohol vs Listeria Alcohol 1/67 women who drink while pregnant have a child with FAS (1-5% of all births) FAS and FASD causes lifelong disability in the child Listeria 1/10,000 pregnant women contract listeriosis 24% of pregnant women with listeriosis will lose the baby

8 Some myths One or two drinks are ok in pregnancy Heavy drinking (four or more drinks at a time) most likely to harm the fetus but even lower levels of drinking can be damaging Is ok to drink later in pregnancy No amount is safe No time is safe First trimester (including time before pregnancy awareness) is a critical period but fetal brain development occurs throughout pregnancy

10 Other myths The placenta protects the baby The placenta is no barrier alcohol goes straight through to the fetus I drank in my last pregnancy so this one will be ok Some babies are more susceptible than others (twin studies) Can t predict which babies will be affected or how Guiness/stout is good for the baby No type of alcohol is safe

11 Attitudes in NZ Most women know stopping alcohol use in pregnancy is important for a healthy baby?specific harms to the baby?risks of low levels of alcohol?harms from different types of alcohol?consumption in different trimesters Moderate-heavy drinkers drinking in pregnancy safe Pacific Island women and non-drinkers drinking in pregnancy not safe

12 Health professionals 68% of pregnant women who had ever drunk alcohol were advised not to drink Around half who received advice - by a GP Others - by other health professionals (nurse, midwife, O&G), spouse/partner, relative or friend

13 Summary Many women in NZ drink at some point during pregnancy Drinking during pregnancy can harm a developing baby Consistent information about the risks of drinking in pregnancy is needed

14 EVIDENCE FOR LABELLING

15 What is the evidence for pregnancy warning labels on alcohol? Based on review of research in 2009 (mostly US): Majority could recall drinking in pregnancy warning labels Around half remembered the message Messages have an impact on judgments about risks of drinking Limited evidence for impact on behaviour (except for discussing the message)

Clear about consequences Clear simple language Frequently

16 What is an effective warning label? Depict health risks in vivid and emotionally arousing manner Clear about consequences Clear simple language Frequently updated and rotated Include pictures not solely text Large and prominent On the front of packaging

17 Other research Australia 2011 Comparison of different pregnancy warning labels 2015 Poor recall of any warning labels on alcohol

18 New Zealand 2005 warning labels on alcohol given a high rating by 53% of women as a source of information about drinking in pregnancy UK 2015 survey of alcohol labelling (evaluation of voluntary agreement) 95% of products had a pregnancy warning (usually logo without text) but smaller than average (especially on wine) 6mm 8mm

19 Summary Labelling can reinforce messages/norms about not drinking in pregnancy Needs to be part of a programme of work to raise awareness and change attitudes FASD Action Plan HPA s Don t know? Don t drink campaign and other work

21 LABELLING IN NEW ZEALAND

22 Alcohol pregnancy warning labelling NZ history 2006 ALAC lodged application with Food Safety Australia NZ for mandatory labelling 2009 Comprehensive independent review of food labelling law and policy (agreed to by the Food Regulation Ministers) 2011 (Jan) Final report (Labelling Logic) publicly released Included a recommendation for mandatory warning labels around drinking in pregnancy (Rec 25) 2011 (Dec) Ministerial Forum responded to the review

23 2011 Trial of voluntary labelling 2014 Voluntary labelling in NZ and Australia evaluated Uptake ~50% in NZ Expected 80-90% uptake by 2016 Trial extended for another two years 2016 Further evaluation 2017 Forum to reconsider voluntary/ mandatory labelling in late 2017

24 What s on the labels in NZ?

27 AWARENESS OF LABELLING IN NZ

28 How to assess the effectiveness of a warning label? Ability to attract the consumer s attention Reading and comprehension Recall of message Judgment of the product s risks and hazards Behavioural compliance with the message

29 Consumer awareness study Online survey of 1,488 consumers in June 2016 testing 3 warning labels (Colmar Brunton) Attention - How many consumers have seen the alcohol pregnancy warning labels? Recall How many people remember the message? Comprehension - What message do these labels convey? How do people interpret the message?

30 Key findings - 1 Overall, 3% recalled pregnancy warning labels 10% when specifically asked With visual prompting: 29% recalled the DrinkWise text 25% recalled the pictogram 44% recalled at least one of 3 labels Pictogram viewed as most effective in conveying the key messages

31 Key findings - 2 Respondents thought combining text with pictogram made the message clearer Red pictogram looked most like a warning Respondents thought labels likely to prompt people not to drink while pregnant and promote discussion DrinkWise text may convey message that you can drink while pregnant Report available at

34 WHAT NEXT?

35 Mandatory or self-regulation? Lessons from other industries Need for robust monitoring whatever option is taken (eg, the Volkswagen saga)

36 Conclusion Stop drinking if you could be pregnant, are pregnant or are trying to get pregnant. There is no known safe level of alcohol consumption during pregnancy. Ministry of Health/Health Promotion Agency key message, endorsed by many other health providers and agencies

Attitudes to and awareness of alcohol pregnancy warning labels

Attitudes to and awareness of alcohol pregnancy warning labels Attitudes and Behaviour towards Alcohol Survey 2015/16 June 2017. ISBN: 978-0-478-4490-8 Citation: Health Promotion Agency. (2017). Attitudes