School of Public Health, The University of Adelaide, South Australia, Australia.
Cancer is the second most common cause of alcohol-related death in both men and women in Australia. In view of this and other health risks, mandatory health warnings on alcoholic beverages have been proposed in Australia and introduced elsewhere. This paper reviews academic literature and statements from selected advocacy groups to identify the ethical justifications that are used in relation to mandatory health warnings on alcoholic beverages. The paper then analyses how these justifications relate to the ethics of public health interventions in the context of cancer prevention. This involves examining the potential tension between the utilitarian nature of public health interventions and the liberalism characteristic of many of the societies in which those interventions occur.
Public health is the systematic attempt to improve the health and well-being of a population by creating conditions in which good health may flourish. For an intervention to be justified as a public health intervention, there must be good reason to believe that it will in some way contribute to a net positive effect in regards to the health of the population of interest. In this respect, public health is often regarded as utilitarian,* since its main concern is not individual outcomes, but the net effect across a population. By contrast, the prevailing political philosophy of western democracies is liberalism, which encompasses the principle that an individual who is autonomous (that is, capable of making free decisions) ought to be allowed to do as he or she pleases, except where this causes harm to another. The tension between the goals of public health interventions, namely the good of populations, and the political context in which public health interventions often take place, with its emphasis on individual freedom, is addressed in the field of public health ethics. This tension can be observed in discourses around mandatory health warning labels on alcohol beverages, as demonstrated below.
In Australia, cancer is the second most common cause of alcohol-related death in both men (25%) and women (31%).1 Given that alcohol consumption is a modifiable risk factor for cancer and other health issues, government intervention may be justified. One possible intervention is to mandate health warning labels on alcoholic beverages. This intervention has been proposed in Australia and introduced elsewhere.2,3 For this reason, it is important to understand the grounds on which the intervention may be justified, together with how it is viewed by stakeholders, including alcohol producers. This understanding can be advanced by answering the following questions: What justificatory language is used in academic and policy circles regarding health warning labels on alcoholic beverages? Are the justifications given appropriate to the public health context? What implications do these justifications have for proposals to mandate labels on alcoholic beverages specific to cancer risks? This paper answers these questions, principally by reviewing the justifications used in the academic literature and in some advocacy statements made by public health and industry stakeholders.
We searched the Scopus database with a search string designed to identify academic literature on warning or communicating risk by means of labels on alcoholic beverages:
TITLE-ABS-KEY (alcohol AND ((warning OR (risk w/2 communicat*)) AND label*)
The initial return of 172 documents was culled for relevance by title and abstract where possible, giving a remainder of 93 documents. At this stage, two criteria were used to determine relevance: (1) was the document a publication, in English, in a peer-reviewed journal in a relevant academic area; and (2) did the document feature discussion of alcohol warning labelling. To be included in the review, a document did not need to focus solely on alcohol or labelling interventions. The 93 documents were then further culled for relevance using a third criterion: (3) does the document feature justificatory language referring to mandatory warning labels, where the justification may be explicit or implicit. This gave a remainder of 65 documents. The same three criteria were applied to a separate collection of documents assembled for a forthcoming systematic review relating to alcohol warning labels. This resulted in the inclusion of 41 new documents, giving a total of 106 scholarly publications (see appendix 1).
To review some advocacy literature, we selected statements from four groups who have made public statements on the topic of alcohol warning labels. The Foundation for Alcohol Research and Education (FARE) was selected as representing a public health position on alcohol.4 Cancer Council Australia was selected because it specialises in cancer research and prevention.5 DrinkWise Australia was selected as a prominent example of an Australian alcohol industry health initiative.6 Finally, the combined response from the Australian alcoholic beverage industry to the Blewett Labelling Review was selected as representative of the views of alcohol producers in Australia.7
After selecting these advocacy statements and identifying the 106 scholarly publications, an initial reading of each text was carried out to identify patterns in the ethical justifications being used, whether these justifications were explicit or implicit. When patterns became apparent, texts were re-read in greater detail to clarify the nature of the identified patterns and any relationships between them.
The academic literature featured three main justifications for including health warning labels on alcoholic beverages. The labels: (1) inform consumers; (2) reduce harm to consumers by generating behavioural change; and (3) reduce the wider social and economic burdens of alcohol. These justifications generally built upon one another, producing arguments of increasing complexity – the improved decision making of informed consumers generates behavioural change (in the form of reduced alcohol consumption), and this behavioural change then reduces the wider social and economic burdens of alcohol. The academic literature rarely used explicitly ethical language, instead only implying ethical justifications, generally as background information to a particular research project. Only 11 of the 106 papers used explicitly ethical language in discussion of warning labels, and of those 11 papers, four were direct responses to an ethics paper on the topic.2,3,8-16
Over half of the articles either quoted or referred to the warning label made mandatory in the United States, especially its stated purpose: “The purpose of the alcohol labelling regulation, according to the federal government, was to inform the American public of health risks, including birth defects, associated with the consumption and abuse of alcohol, and to serve as a reminder of health hazards”.17 Most of the academic literature featured the strong assumption that informing the public generates behavioural change, and this was evident in the language used. For example, one study of warning label awareness justified their interest in “federally mandated warning messages on alcoholic beverages … because the consumption of alcohol and cigarettes leads to a high prevalence of health problems among Hispanics in the United States”.18 A study of adolescent exposure to and awareness of warning labels in the United States chose this population of interest because “it is during adolescence that health behaviors are being established and experimentation with alcohol and other drugs first occurs”.19 Laughery et al argued that “the user has both a need and a right to understand the potential hazards associated with a product,”16 specifically to facilitate decision making. This ‘right’ makes explicit that justifications for warning labels are not simply a practical concern, but also an ethical one. Martin-Moreno et al also raised the question of what consumers have a right to know, making explicit an ethical element to labelling.3
Whether or not warning labels are actually effective at generating behavioural change is debated in the academic literature, with warning label composition and placement being raised as issues to be addressed in implementation.20,21 In the reviewed academic literature, comparisons were made to tobacco, where warning labels have been shown to be effective,22-25 with the caveat that tobacco presents greater health risks than alcohol, so one cannot assume that alcohol warning labels will have a substantially similar effect.15,20,21
The least common (and most complex) of the arguments put forth was that the reduction of harm resulting from behavioural change would reduce the wider social and economic burdens of alcohol. This argument was presented both explicitly and implicitly.3,26-30 Pettigrew et al described the financial burden of alcohol-related harms and explicitly stated that “calls for warning labels also reflect a growing evidence base relating to the relationship between alcohol consumption and a range of health problems, including cancer, diabetes, cardiovascular disease, overweight and obesity, liver disease, fetal abnormalities, cognitive impairment, mental health problems, and accidental injury”.30 Four years after the introduction of warning labels in the United States, Malouff et al described the “100,000 deaths a year in the United States, as well as untold illness, lost productivity and misery for both drinkers and others,” and described warning labels as an effort to reduce alcohol abuse.29 Martin-Moreno et al described an array of “harmful consequences for both individuals and communities,” and described the labelling of alcoholic beverages as an opportunity to address the information gap between what consumers know and what is required to make informed decisions about alcohol consumption. Other authors touched upon the heavy social and economic burdens of alcohol consumption, but did not explicitly link these to warning labels.26-28
FARE and Cancer Council Australia put forward justifications similar to those of the academic literature, but in greater detail. Both FARE and Cancer Council Australia used language about informing consumers and reducing harm. Cancer Council’s statement supported mandatory warning labels to inform, asserting that people ought to be informed “that the product they are purchasing and/or consuming can have a serious impact on their health and wellbeing”, and that “access to information on how to use alcohol … should accompany the sale and supply of all alcohol products as a public health promotion message and disease prevention measure.”5 FARE recommended that warning labels should “alert the consumer to particular harms associated with alcohol consumption” and that they “can contribute greatly to improving health by increasing awareness of harms.”4
Position statements from both FARE and Cancer Council make explicit that labels alone are insufficient to change behaviour and should be implemented as part of a wider scheme of interventions. In this way, they introduce nuance into the justification that informing consumers about health risks changes health-related behaviour. Rather than draw a direct causal link between informing consumers and changing behaviour, they argue that numerous determinants of behaviour can and should be targets of intervention. Cancer Council recommends that labels be “part of a wider alcohol control strategy”,5 and FARE recommends changes to “industry practices that impact on the access and availability of alcohol”, particularly practices that appeal to young drinkers.4 Both organisations single out drinking while pregnant for inclusion on warning labels, with Cancer Council also recommending warnings about other risks associated with alcohol such as medical side-effects, drinking and driving/operating machinery, physical violence and social/health/injury problems.5
DrinkWise, the Australian alcohol industry’s voluntary program of alcohol warning labels, does not directly refer to harm that labels might reduce and describes their labels as intended to “inform and educate”. In this way, they evoke the argument that a label’s purpose is to inform consumers. The only harm-related language can be found in a statement of the intention of DrinkWise labels: to “help consumers enjoy alcohol with more responsibility and care”.6 In contrast to the nuanced statements from FARE and Cancer Council, this implicitly draws a direct causal link between informing consumers and improving health behaviour. The Australian alcohol beverage industries’ submission to government regarding mandatory labelling emphatically rejects calls for warning labels, also appealing to harm reduction (or a lack thereof) by arguing that “the overwhelming evidence clearly shows that warning labels have no impact on drinking behaviour, especially among at-risk groups.”7
Public health interventions use population-level tools to achieve population-level gains. However, these interventions have often been implemented in a society that supports the right of the individual to act as they please, unless this puts others at risk. For example, the British Public Health Act of 1848 brought water and sewerage under government control. While such arrangements are now commonly accepted, it was said in a newspaper at the time that “a little dirt and freedom” was “more desirable than no dirt at all and slavery.”31 This extreme attitude is no longer common, with government interference being seen as normal and even expected in such areas. Public utilities, road rules, food safety standards, product safety standards and occupational health and safety standards are an everyday part of life in Australia and elsewhere. So even in liberal societies, restrictions on liberty are often accepted and seen as justified, especially when they are needed to protect others.
Historically, public health interventions have tended to proceed on the basis that the liberties of some can justifiably be curtailed for the benefit of many, especially when benefits are substantial and the liberties curtailed are comparatively minor. Requiring alcohol producers to place warning labels on their product in order to reduce alcohol-related harm seems to align with this tradition – one group (the producers) have a limit placed on their liberty (their choice in labelling) in order to protect many (the consumers) from harm. While this is true, the assumption inherent in this case is that an individual will make the ‘right’ (healthy) choice when given the relevant information. This is not necessarily the case, and as noted, the question of the effectiveness of labelling in generating behavioural change is debated in the literature. In this way, the justification centred on generating behavioural change through informing is strongly aligned with the liberal notion of the autonomous individual – informing consumers gives them the information necessary to make an autonomous (free and informed) decision.
This idea of the drinker as an enlightened individual who will make the ‘right’ decision when given the relevant information is problematic because we know that there are many factors that impact drinking behaviour, with the most influential being pricing.32 Additionally, in many Anglo-centric cultures, alcohol is deeply embedded in the social fabric to the point where choosing not to drink sometimes requires subterfuge or the provision of a socially acceptable excuse.33 The drinker is not tabula rasa, but instead makes their decision within a pre-existing framework of normalised and acceptable drinking practices. To drink in spite of the health risks may also be perfectly consistent with an individual’s priorities or view of the good life.
A recent paper discusses some of these issues, with a specific focus on cancer warning labels.2 Its authors argue that autonomy (the capacity for self-government) can be compromised by factors such as one’s culture or lack of knowledge, and so mandated warning labels might be a justifiable means of achieving harm reduction, namely by improving consumers’ ability to make autonomous choices and by changing the cultural environment in preparation for other interventions. The authors argue that warning labels ought not to be considered a standalone intervention but rather part of a suite of wider alcohol controls, and that although labels by themselves may not have a measurable impact on health behaviours (e.g. a reduction of alcohol consumption), they pave the way for future interventions. This means that labels could instead be considered part of a suite of interventions that, when considered as a whole, produce behavioural changes and thereby avert harms.
The academic literature and policy statements reviewed proposed three hierarchically structured justifications for the use of alcohol warning labels: (1) to inform consumers, so they might (2) improve their health outcomes through behavioural change, thereby (3) reducing wider social and economic burdens. We argue that the first two justifications amount to an argument which understates the importance of social, economic and cultural factors in influencing alcohol consumption. While it is laudable to try to ensure that people know the risks that they run in consuming alcohol, a public health intervention can only be justified if there is good reason to believe that it will contribute to improving health in some way, and we cannot assume that knowledge of risks alone is enough to change health-related behaviours and thereby improve health across the population.
Despite this, many accounts in the academic literature and industry statements use precisely this argument for warning labels on alcohol. This fits with the prevailing political climate of liberalism, which assumes that knowledge usually leads to right action and places both the right to choose and the responsibility for any consequences squarely with the individual. The pro-label advocacy literature presents a more nuanced justification for warning labels. It acknowledges that a range of modifiable factors impact on one one’s drinking choices and behaviour, and that labels must be considered as part of a suite of interventions collectively aimed at effecting change at a population-level.
With thanks to Natalie May (School of Public Health, The University of Adelaide) for allowing the use of her systematic review search results in the preparation of this article.
* Utilitarianism is the ethical theory according to which population-wide utility (which may be understood as welfare) is the measure by which an action is right or wrong.
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