Alcohol Consumption during Pregnancy: A Critique on Alcohol Warning Labels – Diana Toledo

Introduction
Alcohol consumption during pregnancy is a major public health concern. According to the Centers for Disease Control and Prevention, data collected from the Behavioral Risk Factor Surveillance System (BRFSS) surveys indicates that there has been no change in alcohol use during pregnancy from 1991 to 2005 (1). This study found that approximately 1 in 8 women (or 12%) drank alcohol during their pregnancy (characterized by having at least one alcoholic beverage in the past 30 days). Approximately 1 in 50 women reported drinking alcohol in a binge-like manner during their pregnancy (characterized by at least one occasion of consuming five or more alcoholic beverages in the past 30 days). This study also found that the sociodemographic factors predicting any amount of alcohol use during pregnancy were: aged 35–44 years (17.7%), college graduates (14.4%), employed (13.7%), and unmarried (13.4%).
Alcohol consumption during pregnancy is strongly associated with a spectrum condition known as Fetal Alcohol Spectrum Disorder (FASD). FASD is an umbrella term that encompasses any of the characteristics seen in infants who have been exposed prenatally to alcohol. These characteristics being any and all of the following: pre- and postnatal growth retardation, central nervous system involvement resulting in neuropsychological impairment (ranging from learning disabilities to more severe mental retardation), seizures, and specific craniofacial anomalies (2). The estimated prevalence of Fetal Alcohol Spectrum Disorders is approximately 1 in 100 (3). This incidence rate is higher than Autism Spectrum Disorders (3-6 in 1,000) and Down syndrome (1 in 733), both of which are not preventable (4). However, this condition can be prevented and more robust interventions need to be implemented.
The current intervention for decreasing alcohol consumption during pregnancy in the United States is the use of alcohol warning labels on beer, wine, and spirits. This intervention was implemented after two decades of controversy, when the Alcohol Beverage Labeling Act of 1988 was passed (5). The current warning label states the following:
GOVERNMENT WARNING: (1) ACCORDING TO THE SURGEON GENERAL, WOMEN SHOULD NOT DRINK ALCOHOLIC BEVERAGES DURING PREGNANCY BECAUSE OF THE RISK OF BIRTH DEFECTS. (2) CONSUMPTION OF ALCOHOLIC BEVERAGES IMPAIRS YOUR ABILITY TO DRIVE A CAR OR OPERATE MACHINERY, AND MAY CAUSE HEALTH PROBLEMS.

Critique Argument #1
My first critique will focus on the public health approach that supports the use of health warnings. Alcohol warning labels were implemented on the basis of the Communication Persuasion Model; a model that was specifically tailored and applied to health warning messages in 1980 by William McGuire. He proposed that the intervention would include input variables and output variables. The input variables include: the source, the message, the channel, the receiver, and the destination. The output variables specifically include 10 processes that facilitate the persuasion effect on the individual level. These 10 processes are: exposure to label, attend to the message, react affectively, understand the information, believe the message, store the information from the message after initial exposure, retrieve information upon moment of action arrives, decides on the action to take, behaves according to the decision, and the behavior should be anchored by the beliefs of the message (3).
The initial input variable is the source of the message, or who it is coming from. For the alcohol warning labels, the message is clearly stated that it is coming from the Surgeon General him/herself. The Surgeon General is unknown to most people, however the idea is that this person has authority over others and has validity in informing pregnant women not to drink. It is not uncommon for people to show resistance when given health advice from an authoritative figure; an example of this being a patient refusing to follow a certain diet advised by their physician.
The message itself is directive and may cause a significant amount of psychological reactance in their audience. Women who read this may instinctively think that their behavioral freedom is being threatened; thus motivating them to avoid any further loss of their freedom. Their extent of motivation is affected by the importance of the free behavior (the importance of drinking alcohol) (6). The channel or vehicle that this message is presented is by a written label on bottles of alcohol that are purchased from a liquor store or vendor. The print, font, and style of the message are often small and disguised by the rest of the label on the alcoholic beverage, almost like the manufacturing company does not want people to see or notice the labels.
As far as the receiver (or intended audience) and the destination of the message, the information is only being presented to the buyer of the alcohol. Once at a venue, the container of the alcohol may be discarded while the contents are put in glasses or the containers may be shared. Also, the intended audience will never see a warning label if they are purchasing their alcohol at a restaurant or bar, where drinks are (mostly) served in glasses.
According to the output variables, the Communication Persuasion Model is assuming too much. They are assuming that a person will have exposure to the label (which is not necessarily true), that they will take in the message, and that they will have a strong emotional reaction to it that will enforce them to discontinue or prevent drinking during pregnancy. They also assume that the emotional affect will cause the individual to have a strong enough belief in the contents of that message and will change behavior. In essence, the theory is assuming that belief or intention directly leads to a behavior change, which is strongly unsupported for drug and alcohol issues. In essence, this model is based on the individual level and assumes that behavior is planned and rational.

Critique Argument #2
My second critique will focus on the label itself. The alcohol warning label that has been placed on every domestic and imported alcoholic container since 1988 is nothing short of inconspicuous. Typically, the message is written in fine print and illegible on bottles and cans. The location of the message tends to be on an obscure place of the container, such as the back or side of the bottle. Since alcoholic beverages are typically served cold, condensation that accumulates on these containers has the potential to rub the paper label off, making paper a poor choice in material for such an important message.
Public opinion supports my thoughts on the label itself. According to a national survey that was conducted by the Center for Science in the Public Interest (CSPI) in 2001, most Americans do not notice or read the alcohol warning labels. Three out of four alcohol consumers agree that the labels “sometimes appear in the least prominent place on containers, making them difficult to notice or read”. According to the survey: 63% of alcohol consumers say that they never notice the warning label; only 21% say that they are familiar with the information on the warning message; close to 90% say that placing the warning label in a more prominent spot on the front of alcohol containers and/or having labels printed in red or black print on a white background surrounded by a lined border would make them more noticeable and readable (7).
The design and implementation of these warning labels could hardly be worse. In a way, the labels seem to be designed to go unnoticed and ultimately fail.
The labels are also not reaching many alcohol consumers. Those who only purchase their alcohol at bars or restaurants are not coming into any contact with the message on alcohol containers. This is because most drinks at these establishments are served in glasses and not in their original bottle or can. This is also true for events, such as holiday parties, where alcohol is typically served in something other than the original container, an example being drink from a punch bowl (with unknown amounts of alcohol).
The content of the message itself is very strong and directive. The wording is forward and has an accusatory tone. People are typically not persuaded by strong, directive language because many like to feel like they have control over their own decisions and do not need advice from a higher authority, such as the Surgeon General. The strength of the language on the message is likely creating a counter-intuitive effect on alcohol consumption.

Critique Argument #3
My third critique will focus on effects of the label and attenuation of it over time. These warning labels have not changed since their implementation in the late 1980s. They have the same message (word for word); they essentially have the same font, as well as the same style. For a habitual alcohol drinker, these labels have become commonplace and attenuation of them has led to the message being overlooked.
Research has suggested that general awareness of adverse effects being associated with alcohol consumption during pregnancy has increased. However, this general awareness has attenuated over time and has not proven to be completely effective on reducing alcohol consumption during pregnancy (8).
Another study focused on researching whether multiple exposures to health messages influenced behavior change around drinking during pregnancy. They found that those who were exposed multiple times (1, 2, & 3 times) to three different messages with distinct approach around alcohol consumption during pregnancy were more likely with each exposure to converse about the issue with someone. Also, actual reduction in the amount of alcohol consumed during pregnancy was only observed after two or more messages were exposed (9). This research reinforces the idea that one exposure to the same message strategically located where few ever see it is not enough to instill any changes to behavior.
Findings have also suggested that warning labels in general have induced counter-productive influences. One study found that alcohol warning labels actually caused a boomerang effect in that alcohol consumers perceived greater benefits from having alcohol due to the presence of a warning label (10). Another study found that warning labels surrounding violence preceding a television show produced a counter-productive effect, adding to the suggestion that warning labels may do more harm than good (11).
Another study found that health messages with strong arguments and directive language may not be persuasive or change attitudes surrounding the content of the message. They found that messages with strong statements are less likely to be seen as believable or credible, and are more likely to be viewed as implausible (17). Also, the believability of the message does not necessarily change if the message is coming from an authoritative figure, such as the Surgeon General.

Proposed Intervention
There is no question that other interventions need to be implemented to reduce or eliminate alcohol use during pregnancy; the greater effect being to reduce the incidence rate of Fetal Alcohol Spectrum Disorder. My proposed intervention consists of an elaborate media campaign that sells the core value of control to women of child-bearing age. The campaign will involve multiple types of media: television commercials, magazine ads and articles, billboard ads, and radio public service announcements. This concept is supported by the idea that multiple message exposures and the use of different strategies increase the likelihood of awareness and behavior change (9). The idea of using the concept of control is because it is a core value to many people. Once that control is perceived as lost, then an individual will be motivated to restore that sense of control (6). According to the Illusion of Control, people tend to think that they have more control in situations and over certain life events than they actually do (12). By advertising the stories of those who thought they had control over their alcohol consumption during pregnancy and lost control over their chance at having a healthy baby will impact individuals who believe moderate alcohol intake is not harmful during pregnancy.
A typical campaign television commercial will involve no statistics or numbers on the incidence of Fetal Alcohol Spectrum Disorder or the rate of alcohol consumption during pregnancy (although both are alarmingly high). These commercials will give the picture of a real family with a real story and issues that they face around the diagnosis FASD in a child. The main focus of the campaign will be on mothers who drank light to moderate amounts of alcohol without contemplating or realizing that those alcohol levels could still present long term effects for their child.
The typical story will start with the mother talking about the complications at birth and the differential diagnoses that were suggested by a number of specialists; discussing the loss that the family experienced when they learned that their newborn was not healthy. At this point, the mother can talk about how she thought she had taken proper precautions and done everything right by taking prenatal vitamins, eating healthy, and exercising. Then, the story will lead into the actual diagnosis of FASD and hearing the news that alcohol during the pregnancy caused these issues at birth and will continue to cause issues for the developing child and adult. Toward the end of the commercial, the mother will talk about the light drinking she had done (an example being two glasses of wine per week) during her pregnancy and how she thought she was in control of the situation. In this part, it will be important for the mother to elaborate on her lack of knowledge that such low levels of alcohol can still have serious repercussions and implications for the fetus, for example “I just didn’t know that a few glasses of wine per week could cause these problems for my baby” or “I thought I was in control of my alcohol intake during my pregnancy, but I just didn’t know the risk I was taking”. Although the commercial should not be heavy on the guilt that the mother may be feeling, it can allude to some of those ideas with phrases like “My child will now have challenges during development because of something I could have easily prevented.”
Similar quotes (like the ending quote from my “commercial”) can be used to make a magazine ad very powerful. The campaign can be advertised in women’s health magazines, motherhood and parenting magazines, black health magazines, Spanish language magazines, etc. These magazines will specifically target the intended population, increasing awareness, increasing exposure, and promoting behavior changes. Similarly, billboards will be placed in busy, well populated areas, while radio public service announcements can be played on all radio stations that reach women of child-bearing age from all ethnic backgrounds.

Defense of Intervention Section #1
My first defense will focus on the core value of control and the use of one emotionally charged story. Advertising theory relies on the concept of a promise, typically the promise that a core value will be met. In the marketing paradigm, the needs and wants of the audience are met by the core value that is at the root of the promise that is made through the advertisement. Marketing does not actually change the needs and wants of the audience, however it convinces them that their needs and wants will be met by the achievement of the core value (13).
In this campaign, the needs and wants of the audience are to have a healthy baby with long term wellbeing. The way to achieve this need is to promote the idea of control. If a woman controls her alcohol consumption during pregnancy and brings the volume to zero, then her control over having a healthy pregnancy and baby is significantly increased compared to before.
A good method of promoting the core value of control and giving that “jolt” to women who are pregnant or thinking about becoming pregnant is the telling of one story or case. The law of small numbers suggests that people have a distorted perception of statistics and tend to overestimate small sample sizes (12). One real story with one real affected child that discusses the implications of alcohol intake during pregnancy can have a jolting impact on the population. The story should not include numbers or statistics, as that would cloud the actual message. Although numbers like “1 in 12 women drink alcohol during pregnancy” and “Fetal Alcohol Spectrum Disorder occurs in 1 in 100 live births” are powerful, they are not as influential of one story with one name and face. Also, pregnancy can be a good time for a “jolt” because there is a heightened sense of emotion around the pregnancy and more chance of quitting cold turkey.

Defense of Intervention Section #2
My second critique will focus on women’s response to emotional advertisement. The intended population for this campaign is women of child-bearing age. Although the multi-media approach will likely reach both genders and all age groups, the targeted audience is women 18 to 40 years of age. This is because women are in control of what they consume during their pregnancies. Women tend to have stronger responses to emotional advertisement; this may be especially true during pregnancy when emotional states are higher.
In general, women tend to be more attuned with their emotions and put their insights at higher value (14). Studies have found that women self-report having more frequent and more intense emotional responses and experiences than men (15).
Women also have a strong response to the sense of guilt. The guilt that women feel after an event is focused on a specific behavior or action. Feelings of tension, remorse, and regret over one event are characteristics of guilt (16). Demonstrating the feelings of parental guilt surrounding Fetal Alcohol Spectrum Disorder in the proposed campaign has the potential to instill behavior change in women to control for future sense of guilt.
Defense of Intervention Section #3
My third defense will focus on the impact of presenting more realistic information throughout the campaign. Alcohol warning labels are not informative enough to gain the acknowledgement that they should have. The only comment of fetal alcohol effects is the mention of the too general term “birth defects”. What are these birth defects? Are there any long term effects? If there are no physical birth defects, are we in the clear? These questions are important in fully understanding the issues that surround Fetal Alcohol Spectrum Disorder.
Describing the birth history in the commercials, from having birth defects (like postnatal growth retardation, low birth weight, small head size, and heart problems) to not having any signs at birth will be important in educating the public on what FASD actually is. Detailing the possible seizures in childhood, as well as the learning difficulties and disabilities that arise once a child is in a school and learning setting will be essential in driving the point that FASD does not need to be present at birth for it to impact the rest of the child’s life (2).
In a way, the alcohol warning labels are misleading the public by mentioning the term “birth defects” since many issues do not arise until later in childhood. A campaign showcasing these effects will educate people on the actual risks that alcohol during pregnancy causes.

Conclusion
Experiences in the prenatal genetic counseling clinic have taught me that many women think that light to moderate drinking (one-two glasses of wine per sitting) is reasonable to do during a pregnancy. The thought among many of these women is that Fetal Alcohol Spectrum Disorder only occurs in babies that are exposed to very high levels of alcohol in utero. Although we give them a disclaimer that there is no safe level of alcohol consumption during a pregnancy, they tend to be set in their ways and thoughts by the time we see them in clinic. In my opinion, the issue of light to moderate alcohol intake during pregnancy needs to be addressed before women even become pregnant or enter child-bearing years. By having a campaign that is multi-media and targeting the core value of control, many more women would have a more concrete ideology that any alcohol intake equates to the possibility of FASD effects in their child.

Resources
(1) CDC. Alcohol Use Among Pregnant and Nonpregnant Women of Childbearing Age --- United States, 1991--2005. MMWR 58(19); 529-532.

(2) Hankin, Janet R., (1993), The Impact of the Alcohol Warning Label on Drinking during Pregnancy, Journal of Public Policy & Marketing, Volume 12, Issue No 1, Pages 10-18.

(3) O’Connor, Mary J., (2007), Brief Intervention for Alcohol Use by Pregnant Women, American Journal of Public Health, Volume 97, Issue No 2, Pages 252-258.

(4) Rutter, M., (2005), Incidence of autism spectrum disorders: changes over time and their meaning, Acta Paediatrica, Volume 94, Issue No 1, Pages 2-15.

(5) Graves, Karen L., (1993), An Evaluation of the Alcohol Warning Label: A Comparison of the United States and Ontario, Canada in 1990 and 1991, Journal of Public Policy & Marketing, Volume 12, Issue No 1, Pages 19-29.

(6) Brehm, Jack, W., (1966), A Theory of Psychological Reactance. Academic Press.

(7) Center for Science in the Public Interest. Alcohol Labels Go Unnoticed, Poll Finds. Washington, DC. http://www.cspinet.org/booze/batf_labels2001_press.htm

(8) MacKinnon, DP., (1995), Review of the effects of the alcohol warning label, Alcohol, Cocaine, and Accidents: Drug and Alcohol Abuse Reviews 7. Totowa, NJ: Humana Press, Pages 131-161.

(9) Kaskutas, LA., (1994), Relationship between cumulative exposure to health messages and awareness and behavior-related drinking during pregnancy, American Journal of Health Promotion, Volume 9, Issue No 2, Pages 115-124.

(10) Snyder, LB., (1992), Caution: Alcohol Advertising and the Surgeon General’s Warning may have Adverse Effects on Young Adults, Journal of Applied Communication Research, Volume 20, Pages 37-53.

(11) Bushman, BJ., (1996), Forbidden Fruit Versus Tainted Fruit: Effects of Warning Labels on Attraction to Television Violence, Journal of Experimental Psychology: Applied, Volume 2, Pages 207-226.

(12) Siegel, M., Social and Behavioral Sciences for Public Health Lecture, November 18, 2010.

(13) Siegel, M., Social and Behavioral Sciences for Public Health Lecture, October 28, 2010.

(14) Feldman Barrett, Lisa, (1998), “Are Women the ‘More Emotional’ Sex?” evidence form Emotional Experiences in Social Context, Cognition and Emotion, Volume 14, Pages 555-578.

(15) Dube, Laurette, (1998), Capturing the Dynamics of In-Process Consumption Emotions and Satisfaction in Extended Service Transactions, International Journal of Research in Marketing, Volume 15, Pages 309-320.

(16) Niedenthal, PM., (1994), If only I weren't" versus "If only I hadn't": Distinguishing shame and guilt in counterfactual thinking, Journal of Personality and Social Psychology, Volume 67, Pages 585-595.

(17) Petty, RE., (1986), The elaboration likelihood model of persuasion, Advances in Experimental Social Psychology, Volume 19, Pages 123-205.