Examining alcohol warning labels as a tool to increase public awareness of alcohol-related health risks and reduce alcohol intake at the population level.

Regions: North Slave Region

Tags: social sciences, public health, alcohol, cancer, public awareness

Principal Investigator: Hobin, Erin P (2)
Licence Number: 16091
Organization: Public Health Ontario
Licenced Year(s): 2018 2017
Issued: May 05, 2017
Project Team: Tim Stockwell (Co-Principal Investigator, Centre for Addictions Research of British Columbia), Kate Vallance (Research Coordinator, Centre for Addictions Research of British Columbia)

Objective(s): To test if labelling alcohol containers with a health message, national drinking guidelines, and standard drink information supports more informed and safer alcohol use.

Project Description: To test, in the real-world, if labelling alcohol containers with a health message, national drinking guidelines, and standard drink information supports more informed and safer alcohol use.
Alcohol Warning Label Intervention – Consistent with evidence for effective warning labels, a full colour alcohol warning label communicating: 1) a health message linking alcohol and cancer, 2) Canada’s national low-risk drinking guidelines, and 3) standard drink information will be posted on alcohol containers sold in the liquor store in Whitehorse for an 8-month period (October 1, 2017 to May 30, 2018). Each of the 3 warning labels will be rotated so that 1 label is posted for a 2-3 week period, then followed by the next warning label. A message cautioning of drinking alcohol when pregnant will also be incorporated into the new label. A parallel social marketing campaign will augment label messages, consistent with evidence for effective labelling. The campaign implemented by the Yukon Liquor Corporation will involve signage in the liquor store, restaurants, and bars in Whitehorse; a toll-free helpline and website in English and French; and local TV, radio, and Whitehorse newspaper advertisements.
STUDY DESIGN AND METHODS: This research will include 2 key data sources: 1) surveys with a total of 2640 liquor store patrons, 1320 patrons in each of the Whitehorse (with the alcohol warning label intervention) and Yellowknife (without the alcohol warning label intervention) liquor stores; and, 2) liquor store sales data from the Whitehorse and Yellowknife liquor stores.
1. SURVEYS - The surveys will be conducted among adult drinkers before (Wave 1) and after (Wave 2) the alcohol warning label is implemented in the Whitehorse liquor store. The Wave 1 survey data collection in both Whitehorse and Yellowknife liquor stores will be conducted over a 4-week period in May - June 2017, 4-months before the labels are implemented in the Whitehorse liquor store. The Wave 2 survey data collection is scheduled over a 4-week period in May - June 2018, 8-months after implementation of the labels in the Whitehorse liquor store.
Study Sample - In Wave 1, 660 liquor store patrons will be recruited in each of Whitehorse and Yellowknife (1320 total). In Wave 2, the 660 liquor store patrons recruited in Wave 1 will be re-contacted via email to participate in a 2nd survey. Estimating that approximately 230 participants will respond to the email and complete the 2nd survey in Wave 2, we will also recruit an additional 430 liquor store patrons in each of Whitehorse and Yellowknife. This process of recruiting new participants at the liquor store in Wave 2 will ensure we have a total of 660 participants in Whitehorse and Yellowknife.
Eligibility Criteria - At time of recruitment, eligible survey respondents will include legal drinkers- adults 19+, who are “current drinkers” (consumed =1 alcoholic drink in past 30-days), who are residents of either Whitehorse or Yellowknife, who have not previously participated in the survey, and who purchased alcohol at the liquor store on the day of recruitment. Quotas will be applied within each city by age (19-39/40+) and gender (50% men/women), with 180 respondents in each of the four age/gender groups. As the intent of the label is to inform drinkers of alcohol-related health risks and safer levels of alcohol intake, the sampling criteria in Wave 1 will exclude never and non-drinkers who are less likely to be exposed to or affected by the label messages. Eligibility will be established through a brief screener at the time of recruitment.

Sampling Protocol and Recruitment – In Wave 1, trained Research Assistants (RAs), hired in Whitehorse and Yellowknife, will be stationed in liquor store lobbies in Whitehorse and Yellowknife between 10am and 8pm on both weekend and weekdays from May 5 – ~June 5, 2017 to recruit customers as they exit the store.
After potential participants verbally confirm their interest in participating in the study, the RAs will provide the participants with a 10-inch tablet to complete a brief screener to establish if the person meets the eligibility criteria. If the participants are eligible, the RAs will review the study details in the information letter with the participants and provide participants with a copy of the letter. Once the participants’ written consent is ascertained and participants’ contact information is collected, the RAs will provide participants with a tablet to complete the survey independently without RA assistance. Data collections will occur simultaneously at study sites in both jurisdictions by different teams of RAs.
For Wave 2, enrolled participants will be sent an email invitation in May 2018, requesting the participants to complete the 2nd survey. The email invitations will include a direct link to a similar online survey, provide a login ID and 8-digit password for the survey, offer a telephone help line and email address to contact the Research Coordinator. Participants can complete the 2nd survey from home, school, or work (i.e., anywhere with a computer/tablet and internet access).
To ensure at least 660 completed surveys in Wave 2 in each of Whitehorse and Yellowknife, participants who do not respond to the email invitation in Wave 2 will be replaced with new participants using an identical sampling design and protocol applied during recruitment in liquor stores in Wave 1.
Survey Measures – The survey collects information about socio-demographic variables (e.g., age, sex, gender, ethnicity, education and income levels) using survey items adapted from Statistics Canada, and health literacy is assessed by the validated 6-item New Vital Sign measure. The survey also collects information about awareness and understanding of alcohol warning label messages, as well as opinions about alcohol warning labels and knowledge of alcohol-related health risks. Alcohol consumption behaviours are assessed using multiple approaches, including 2-items adapted from the validated Quantity/ Frequency method in the 2012 CADUMS (Canadian Alcohol and Drug Use Monitoring Survey) to measure usual consumption: 1) During the past 6-months, how often did you drink alcoholic beverages? (less than once a month, once a month, 2 to 3 times a month, once a week, 2 to 3 times a week, 4 to 6 times a week, every day), and 2) During the past 6-months, on those days when you drank, how many drinks did you usually have? (open-ended). The survey will also assess occasions of heavy drinking (During the PAST 6 MONTHS, how often have you had 5 or more drinks on one occasion?). Participants will be informed that “drink” refers to 341mL of beer, 5oz of wine, and 1.5oz of spirit.
Data Analysis - Similar to previous evaluations of label interventions, awareness and recall of label messages will be assessed as binary outcomes (0=No, 1=Yes) in separate logistic regression models. Volume of alcohol consumption will be calculated as the mean number of drinks consumed per week in the past 6-months as weekly use is associated with long-term health risks. Weekly use will be derived using the formula: (Frequency of alcohol use in past 6-months) x (Usual quantity of drinks on days when drinking)/26 weeks, whereby the response to the frequency of alcohol use in past 6-months is translated to average weekly consumption (e.g., if a participants reports drinking 4 to 5 times per week = 4.5 days x 4 weeks x 6 months).

2. LIQUOR STORE SALES DATA - Liquor store sales data, provided by the Yukon and Northwest Territories government alcohol monopolies, will include all purchases in the Whitehorse liquor store and the 2 liquor stores in Yellowknife from October 1, 2012 to December 31, 2018, representing pre- and post-intervention points. These are powerful population-level data that include the date and time of purchase, store location, and the type, volume (litres), price, and quantity of each product purchased. Data will be aggregated by beverage category (beer, wine, spirits, coolers, cider, and cocktails), percent alcohol/volume, site, and week. Liquor store sales data provide data at the store-level, and does not include individual-level customer data or financial information. Overall, this provides 260-week baseline and 60-week follow-up data, enabling estimation of seasonal effects and secular sales trends for control in analyses. Previous analyses of Canadian provincial sales show marked seasonal variations, with almost two times more beer purchased in summer than winter months. Data will be stored on a secure network. Please note that these data will not include any personally identifying data, but only store-level information and details of alcohol purchased.
Outcome Measures - Consistent with previous studies, per capita alcohol intake will be assessed as a function of beverage type, strength, and total volume purchased, and will be estimated for both cities for each week between October 1, 2012 and December 31, 2018. Transaction data will be expressed in terms of dollars, litres of beverage, and litres of ethanol. For each city and time point, total litres of ethanol sold will be divided by the population age 15+, per standard practice in alcohol epidemiology. Respective population size will be obtained from Statistics Canada. Dollar values will be Consumer Price Index adjusted to 2012 values using territory specific data from Statistics Canada. The same approach will be used to estimate per capital alcohol consumption separately for each beverage category.
Data Analysis - Multilevel regression models using weekly time periods nested within cities will be used to examine the effect of alcohol warning labels on per capita alcohol intake (total and by beverage type and strength), adjusting for covariates and temporal autocorrelation.
In preparation for the research proposed in the current application, our team has held 3 teleconferences and numerous emails with the Government of NWT, specifically the Liquor Commission Board. Partners in NWT also provided letters of support that were included in the grant application funded by Health Canada.
One of the key research activities is to conduct a 10-minute survey with customers in the liquor stores in Whitehorse and Yellowknife, starting May 2017. We have hired local Research Assistants in Whitehorse and Yellowknife to conduct these surveys in the liquor stores.
This is the first study in Canada, and one of the few internationally, to test the impact of alcohol warning labels in a real-world setting. Results will inform options for alcohol labelling practices and policies in Yukon and could set the stage for wider implementation in other jurisdictions across Canada, including the NWT.
Going forward, our research team will continue to collaborate with key partners through regular teleconference meetings at key milestones and a face-to-face meeting (in which GNWT will be invited to attend) to discuss progress and next steps, and review the results, interpret the findings, discuss key learnings, as well as outline challenges and enablers, and potential next steps and adaptations for sustaining the intervention after project funding ends.
The aims of this study are to increase knowledge and awareness of key research findings to inform policy and practice in Yukon as well as other jurisdictions across Canada, including Northwest Territories. Therefore, at the end of the study, several knowledge translation activities will be implemented to share the research findings, including:
• A summary briefing produced in plain language to communicate key findings to stakeholders, and posted on a project website for the public to access.
• A policy brief summarizing the state of the evidence, key findings of the proposed research, and implications for provincial, territorial and national alcohol-prevention efforts. This briefing will be shared at the Pan-Canadian Public Health Network and the Canadian Council of Chief Medical Officers of Health meetings as well as with provincial/territorial liquor control boards.
• A conference symposium at Canadian Centre for Substance Abuse's national conference, Issues of Substance, in Ottawa in November 2019. The panel will consist of investigators and key partners from the proposed research and the purpose will be to highlight key findings and to discuss barriers and supports to applying or adapting alcohol warning labels to other jurisdictions in Canada. A special invitation to attend this panel will be sent to all provincial/territorial liquor control boards.
• The media is among the most effective dissemination channels for evidence on alcohol, and we anticipate this research to a highly publicized study. Drs. Hobin and Stockwell have conducted several media interviews and often serve as a resource for alcohol policy-related stories for national news outlets.
However, please note that all research findings will be shared with the GNWT and other key partners to review and provide feedback at least 30-days prior to being released to outside sources, including media or the public.
The fieldwork for this study will be conducted from May 5, 2017 to June 30, 2017.