HOUSE OF REPRESENTATIVES STANDING COMMITTEE ON INDIGENOUS AFFAIRS: Harmful use of alcohol in Aboriginal and Torres Strait Islander communities
Department of the Prime Minister and Cabinet response to questions on notice
Hansard Proof Transcript page 6: Referring to income management: is there any evidence that you will be having regard to, an evaluation, that will guide the 'what comes next'?
Response:
Several evaluations of income management have been conducted and the following evaluations are underway: • Place-based Income Management in Greater Shepparton (Victoria), Logan and Rockhampton (Queensland), Playford (South Australia) and Bankstown (New South Wales); • Voluntary Income Management in the Anangu Pitjantjatjara Yankunytjatjara (APY) Lands; and • New Income Management in the Northern Territory.
More information about each evaluation can be found on the Department of Social Services website. It should be noted that due dates of reports are a guide only, and the public release of reports is a decision for Government. The Income Management Evaluation and Review fact sheet is at Attachment A.
The Government will consider the longer-term direction for income management policy guided by the outcomes of the McClure report on Welfare Reform, the Forrest Review of Indigenous Training and Employment Programmes, the evaluations, as well as other relevant data.
There are various measures of income management currently operating in a number of locations. In this year’s Budget the Government provided $101.1 million in 2014-15 to extend income management in existing locations for one year. This will continue income management in the Northern Territory, and in trial sites in Perth and the Kimberley region, Laverton, and Ngaanyatjarra Lands of Western Australia and APY Lands in South Australia. Income management was also expanded to Ceduna and the surrounding region in South Australia from 1 July 2014. Income management in Cape York is funded until 31 December 2015 and in Greater Shepparton, Logan, Rockhampton, Playford, and Bankstown until 30 June 2016.
1
Hansard Proof Transcript pages 6 and 9: Referring to alcohol taxation: On page 8 of your submission you talk about supply, demand and harming strategies, and then a few paras below that it says: 'the Australian Government does not support policies that increase alcohol prices' including excise and price regulation. Does that mean that the federal government is actively working against some of the policies that are in place, such as in the Northern Territory where there have been steps in terms of their supply, demand and harm strategies, and Alice Springs has taken a few steps to control?
Response to alcohol taxation
The statement — that harmful drinkers are generally less responsive than moderate drinkers to alcohol price changes — refers to a point made in the Australian National Preventative Health Agency report, ‘Exploring the Public Interest Case for a Minimum (Floor) Price for Alcohol’.
Contrary to the statement in submission (second sentence, paragraph 5, page 8), the Government has not formed a position on how general alcohol pricing policies might reduce harm.
2
Hansard Proof Transcript page 8: Referring to FASD: Can you tell us whether in fact there are any children or adults who receive disability support pension as a consequence of being diagnosed with FAS or FASD or whether any children under 16 are getting an additional support or care benefit because of the condition?
Response: Social Security Payments The number of people with FASD, or numbers of people caring for people with FASD, and receiving an income support payment, cannot be determined. There is no specific medical code in the payments system for FAS or FASD. Cases would be coded under other more general categories, depending on their particular disability, for example learning disability or congenital malformations, deformations and chromosomal abnormalities. Often a particular condition, such as intellectual disability or behavioural difficulty, is diagnosed well before a link to FASD has been confirmed in a particular case.
The Disability Support Pension (DSP) is designed to give people an adequate means of support if they have a permanent physical, intellectual or psychiatric impairment which attracts at least 20 points under the Impairment Tables. The person must also be assessed as being unable to work for 15 or more hours per week, for at least the next two years, because of their impairment.
The assessment for DSP eligibility involves examining the individual’s ability to function in a work- related environment. As FAS/FASD involves varying degrees of disability and a wide range of behaviours and social skills, these assessments will vary depending on the individual’s level of ability. This process ensures that the system is fair and equitable and is not based on specific disabilities or conditions.
The Impairment Tables cover both intellectual and cognitive impairment. As explained above the Impairment Tables are not diagnosis based so there is no need to have one particular diagnosis to benefit from the application of the tables.
Carers of children or adults with FAS/FASD, may apply to claim Carer Allowance and/or Carer Payment. Their qualification will be determined according to the eligibility criteria, including assessment against the Disability Care Load Assessment (DCLA) (for children) or the Adult Disability Assessment Tool (ADAT) (for adults). In general, access to the payments includes an assessment of the care required rather than focusing on diagnosis of a medical condition. For Carer Allowance (child), a limited list of medical conditions, which are known always to have a high care requirement, provides fast-track qualification. FAS and FASD are not on the list, but that does not preclude carers of people with these conditions from qualifying for payment if the level of care satisfies the criteria.
Response: Carer Support The Government recognises the difficulties experienced by carers and is committed to assisting carers access the support they need.
The National Respite for Carers Programme (NRCP) is targeted to assist carers of:
• All frail older Australians (65 years or over, or 50 years and over if Aboriginal or Torres Strait Islander); • People with dementia; • People with dementia and challenging behaviour;
3
• Younger people (under 65 years or under 50 years if Aboriginal or Torres Strait Islander) with moderate, severe or profound disabilities who are living at home; and • People with a terminal illness in need of palliative care.
The NRCP funds a range of programmes to assist all carers in their caring role. The programmes delivered under the NRCP are expected to ensure that services are responsive to the needs of people who have particular difficulties in accessing services, including carers of people from an Aboriginal or Torres Strait Islander background.
The NRCP provides services to carers through the provision of respite, information, counselling and other support services through:
• The National Carer Counselling Program which provides short term counselling, emotional and psychological support services for carers in need of support. • The Carer Information and Support Programme which provides information and support to carers to assist them to navigate the community care system. • The Commonwealth Respite and Carelink Centres (54 nationally) which provide information and support and assist carers in arranging respite services to meet emergency or short term carer needs; and • Funding for more than 500 respite services across Australia.
From 1 July 2015, the Australian Government will launch the Commonwealth Home Support Programme (CHSP), which will combine the existing Commonwealth HACC Program, the NRCP, the Day Therapy Centres Program and potentially the Assistance with Care and Housing for the Aged Program, under a single streamlined programme to provide basic maintenance, care, support and respite services for older people living in the community, and their carers. Further information about the CHSP is available on the Department of Social Services website at: http://www.dss.gov.au/our-responsibilities/ageing-and-aged-care/aged-care-reform/reforms-by- topic/commonwealth-home-support-programme
4
Hansard Proof Transcript page 8: Referring to FASD: Given that I have just identified, and it is commonly discussed, the problems of the current sets of impairments that do not match FAS-FASD as a disability—for example, it is cognitive not intellectual. A person forgetting to eat and having to be prompted to eat is different from somebody who has to be assisted physically to eat, yet they are both represented as a serious impairment, if you have this condition. Are you aware of anyone in PM&C or a related department actively working to correct these inadequacies of the current impairment criteria, if you like, to deal with the FAS-FASD issues?
Response: NDIS To be eligible for the NDIS, the National Disability Insurance Scheme Act 2013 (NDIS Act) requires that a person has a permanent impairment which results in them having a substantially reduced capacity to undertake activities of daily living.
A person can also access the scheme through a separate early intervention requirement that allows the scheme to provide support to people with a permanent impairment who would benefit from early intervention to reduce their future needs for support.
This means that access to the NDIS is not based on a diagnosis, it is based on the permanence of the disability, the level of a person’s functioning and the need for lifetime support, or need for early intervention.
It is likely that many people, children and adults, who are significantly affected by Foetal Alcohol Spectrum Disorder (FASD) will meet the disability requirements of the NDIS Act. People with FASD who meet the eligibility criteria for the NDIS will receive reasonable and necessary supports under the scheme.
The Operational Guidelines of the National Disability Insurance Agency (NDIA) lists conditions and whether or not additional evidence is required when making an eligibility assessment. Foetal Alcohol Syndrome (FAS) is recognised in List B – ‘Permanent impairment/functional capacity variable – further assessment of functional capacity required’.
FAS is also included in List C – ‘Permanent Impairment/Early Intervention, under 7 years – no further assessment required’ which means that, children aged under seven years old who have been diagnosed with FAS, can automatically access the NDIS through the early intervention provisions.
Under the Australian Government Action Plan – Responding to the Impact of Fetal Alcohol Spectrum Disorders in Australia, the Department of Health has funded the development of a FASD diagnostic tool for specialist clinicians and resources to support diagnosis and early management of FASD.
Further consideration to include FASD in the NDIA’s Operational Guidelines Lists can occur once the diagnostic tool and clinical guidelines being developed have been finalised and approved and once sufficient data in relation to FASD participants has been collected.
5
Hansard Proof Transcript page 9: Referring to the Australian Health Ministers’ recent meeting and labelling: We know that the health ministers recently met and decided to put off the issue of tobacco and alcohol labelling for two years. I would like us to get a brief on why that recommendation was made, if it was made to the ministers. If it was not, what was their rationale for making such a decision? Along with access to alcohol, but also labelling and marketing. I see no discussion in this document about industry responsibilities and what discussions may be taking between the government and industry about their role in changing behaviour. I am wondering if there are any discussions taking place. If there are, who is doing them and how will we get access to them?
Response: Pregnancy warnings on Alcohol Labels Ministers considered the evaluation of the action taken by the alcohol industry in Australia and New Zealand regarding the placement of pregnancy warnings on alcohol products.
Ministers noted that the overall percentage of products with a pregnancy health warning label was encouraging, in particular the wine, beer and cider industries, but that there is a wide band of variability across product types.
In particular Ministers noted and expressed concern about the low uptake in the mixed alcoholic beverages or ready to drink category.
In light of these results the Forum agreed to extend the existing trial on voluntary uptake of pregnancy health warnings on alcohol product labels, and to undertake a review in two years. Ministers agreed to continue to work with industry to ensure increased uptake particularly with companies where the uptake is lower such as the ready to drink industry. This approach recognises the work already undertaken by the industry to place warnings on products and also takes into account the longer turn-over of labels in some areas. Work with industry on consistent and effective messaging in this area will also continue, acknowledging that work to inform and target ‘at risk’ consumers should be part of a broader strategy, including community education and targeted advice to women who are pregnant or planning pregnancy.
The evaluation reports are available on the Food Regulation website http://www.health.gov.au/internet/main/publishing.nsf/Content/foodsecretariat-stakeholder- publications. The Pregnancy Labelling Evaluation report is at Attachment B and the Pregnancy Labelling Evaluation - Appendices is at Attachment C.
6
Hansard Proof Transcript page 10: Referring to the Indigenous Advancement Strategy Program Guidelines: Once you have got the guidelines settled can we get copies provided to the committee?
The Indigenous Advancement Strategy Program Guidelines are available on www.dpmc.gov.au/indigenous_affairs and are at Attachment D.
7
Hansard Proof Transcript page 11: Referring to Children and Family Centres: we have had a lot of concern about those as a committee. We were at Fitzroy Crossing just a week or so ago, for example. They have got a fantastic new centre, but ongoing funding is now a great concern to them. Can you comment on where you are going with those particular programs and if it is possible take it on notice?
Response: Children and Family Centres (CFCs) CFCs were established under the National Partnership Agreement on Indigenous Early Childhood Development (NPA IECD). The six year (2008-2014) NPA IECD had three elements and the NPA expired as expected after six years on 30 June 2014.
Element One: Under this Element the former Commonwealth Government provided funding of $292.62 million to state and territory governments to construct and establish 38 Children and Family Centres (CFCs) across Australia by June 2014. All centres have been built. There was not any funding in the forward estimates for recurrent costs for the CFCs as the Commonwealth investment was provided on the basis that states and territories, who were given the CFCs and established their services, would continue to operate them.
The Commonwealth Government has not withdrawn support to the CFCs and confirmed prior to the expiry of the NP that support would be available through existing Commonwealth programmes and services including the Child Care Rebate and Child Care Benefit. At no time did the Commonwealth indicate that this support would fully cover future operational costs of the CFCs.
In addition to current Commonwealth services and programmes, there may be funding opportunities available to the CFCs in the future under several components of the Indigenous Advancement Strategy. The Indigenous Advancement Strategy seeks to support a new engagement with Indigenous people, allowing more flexibility with funding and to ensure it meets the priorities of communities, rather than a one-size-fits-all approach.
Element Two: Under this Element, the former Commonwealth Government provided $107 million in funding to state and territory governments for the improved access to, and use of antenatal care by young Indigenous mothers. Funding was also directed to sexual and reproductive health programmes and towards the implementation of strategies to address high rates of early pregnancy in Indigenous young women.
The May 2014 Federal Budget announcement included a Commonwealth measure that continues the activities which were funded under Element Two of the NP. The commitment includes funding of $25.9 million over a 12 month agreement (to be negotiated with states and territories).
Element Three: Under this Element, the former Commonwealth Government initially provided $90 million to increase access to, and the use of, Maternal and Child Health Services through the New Directions Mothers and Babies Services program. States and territories also invested $75 million to deliver antenatal, postnatal, child and maternal health services to Indigenous families. The Commonwealth’s initial commitment was extended in the 2011-12 Budget and New Directions is now an ongoing programme.
8
Both the initiative announced in the 2014-15 Budget and the ongoing New Directions programme are managed by the Commonwealth Department of Health.
The Hansard Proof Transcript with changes is at Attachment E.
Income Management Evaluation and Review
Background
Income management is part of the Australian Government’s commitment to reforming the welfare system. It ensures income support payments are spent in the best interests of children and families and helps ease immediate financial stress, allowing individuals to seek education and work opportunities.
Evaluation and review of income management
An evaluation and a review on income management in Western Australia have been completed and the reports are publicly available.
There are three evaluations currently being conducted on New Income Management in the Northern Territory, Place-based Income Management and Voluntary Income Management in the Anangu Pitjantjatjara Yankunytjatjara Lands.
Evaluation of the Child Protection Scheme of Income Management and Voluntary Income Management Measures in Western Australia (2010) In 2010, ORIMA Research conducted an evaluation of income management in Western Australia, testing for impacts and early outcomes.
This evaluation found that income management was having a positive effect on the lives of many individuals, children and families in Western Australia, with a majority of those surveyed in the evaluation believing it had a positive impact overall.
The ORIMA evaluation report is available on the DSS website.
Review of Child Protection Income Management in Western Australia (2014) A review was conducted of Child Protection Income Management in Western Australia, which built on the 2010 ORIMA Study. It drew on different sources of data, including a review of child protection case files and in-depth interviews with child protection clients and their child protection case manager. The department undertook the evaluation in a tri-lateral agreement with the Western Australian Department for Child Protection, and with the Australian Institute of Family Studies acting in an advisory role.
The review found that income management is assisting with managing debt and regular payments on housing and utilities, providing stability and relieving stress, leaving people with an improved capacity to manage other problems.
The report on the review was released in March 2014. New Income Management in the Northern Territory The Australian Government, in partnership with the Northern Territory Department of Children and Families, is undertaking a comprehensive evaluation of income management in the Northern Territory.
The evaluation is being conducted over four years by an independent consortium of experts from the Australian National University, the Australian Institute of Family Studies and the Social Policy Research Centre at the University of New South Wales, in consultation with key stakeholders.
One of the findings from the first report, released in November 2012, was that Indigenous communities perceived an improvement in child wellbeing and ability to afford food.
The final report is due to the department in September 2014*.
Place-based Income Management The department commissioned Deloitte Access Economics to conduct a comprehensive, mixed-method evaluation of Place-based Income Management.
The evaluation of Place-based Income Management in the trial sites involves comparison with communities with similar characteristics where the policy has not been implemented. The evaluation includes a longitudinal client survey; in-depth interviews with clients and family members; interviews, focus groups and on-line surveys with stakeholders; and analysis of administrative data.
This is the first evaluation that will include a baseline to compare people’s experiences before and after going on income management.
The baseline report found that:
• an average of around 60% of people believed income management would change the way they lived, or had already. • improving their money management and payment of bills and rent were the most prominent reasons for volunteering.
The final report is due to the department in May 2015*.
Voluntary Income Management in the Anangu Pitjantjatjara Yankunytjatjara (APY) Lands The Department, in collaboration with the South Australian Department of Premier and Cabinet and the Department of Human Services, has commissioned the Social Policy Research Centre at the University of New South Wales to conduct an evaluation of Voluntary Income Management in the APY lands.
The evaluation will use administrative data, a survey of community members, interviews with community stakeholders, and a participatory research activity with a community reference group.
The final report is due to the department in July 2014*.
*Due dates for reports are a guide only.
Where can I find out more?
To find out more on the evaluations of income management, visit dss.gov.au or email [email protected].
Disclaimer
The information contained in this publication is intended only as a guide. The information is accurate as at June 2014. Evaluation of the voluntary labelling initiative to place pregnancy health warnings on alcohol products
Final Report
23 May 2014
Table of Contents Executive summary iv Acronyms and abbreviations vi Project team, Siggins Miller vii Acknowledgements vii Section 1 Introduction 1 1.1 Background to the labelling initiative 1 1.2 This Evaluation 2 1.2.1 Terms of Reference for the Evaluation 2 1.3 Evaluation approach 3 1.4 This report 3 Section 2 Field study of outlets 4 2.1 Results 6 2.1.2 Aim One sample characteristics (market leading products) 6 2.1.3 Aim One data analyses 6 2.1.4 Aim Two sample characteristics (all products) 7 2.1.5 Aim Two data analysis 7 2.2. Key findings – Aim One 12 2.3 Key findings –Aim Two 12 2.4 Methodological considerations 12 2.5 Conclusions 12 Section 3 Alcohol industry survey of voluntary pregnancy labelling costs 14 3.1 Operation details 14 3.1.1 Adoption of labelling initiative reported by respondents 15 3.2 Cost estimates 16 3.3 Conclusions 18 Section 4 Consumer awareness and understanding of pregnancy health warning labels 20 4.1 Findings 20 4.1.1 Awareness 21 4.1.2 Understanding 21 4.2 Conclusions 21 Section 5 Key contextual factors 22 5.1 International trend to incorporate pregnancy health warning labels on alcohol products 22 5.2 The role of the voluntary pregnancy health warning labelling initiative in raising awareness of risks and harms of alcohol consumption during pregnancy 22 5.3 Evidence based social marketing campaigns 23 5.4 Australian women’s attitudes, knowledge and patterns of behaviour 23 5.5 The role of industry and government parallel initiatives 23
Alcohol and Pregnancy Labelling Evaluation ii
List of Figures Figure 1: Pregnancy health warnings providing opportunity to be associated with responsible consumption of alcohol 17
List of Tables Table 1: Proportion of products with pregnancy health warning by market 6 Table 2: Proportion of products with pregnancy health warning by market 7 Table 3: Proportion of products with pregnancy health warning by year 8 Table 4: Proportion of products with pregnancy health warning by package type 8 Table 5: Proportion of products with a pregnancy health warning by location of manufacture 9 Table 6: Proportion of pregnancy health labels by type and text consistency with NHMRC guidelines 9 Table 7: Proportion of pregnancy health labels by size and location 10 Table 8: Proportion of pregnancy health labels by legibility and prominence 11 Table 9: Types of product package/labels used by companies 14 Table 10: Proportion of product lines with pregnancy health warnings per product package/label type 15 Table 11: Types of pregnancy health warning labels used 15 Table 12: Estimated costs per cost item 16 Table 13: Estimated total cost to industry 18 Table 14: Sensitivity analysis of cost estimates 18 Table 15: Consumer awareness and understanding of pregnancy labels 20
Alcohol and Pregnancy Labelling Evaluation iii
Executive summary Alcohol exposure in pregnancy is a risk factor for poor pregnancy and child outcomes. Labels can contribute to increasing awareness and understanding of the risks of drinking alcohol during pregnancy. Implemented in the context of an integrated strategy, the pregnancy labels on alcohol products might contribute to awareness and understanding because they act as a reminder or prompt a conversation. In December 2011, in its response to the report on the Labelling Logic Review of Food Labelling Law and Policy 2011, the Legislative and Governance Forum on Food Regulation (FoFR) provided the alcohol industry with a two-year period, commencing December 2011, to adopt the voluntary initiative to place pregnancy health labels on alcohol products, before regulating such a change. This Evaluation of the voluntary labelling initiative to place pregnancy health warnings on alcohol products assesses the progress and success of Australian alcohol industry action towards implementing pregnancy health labels on alcohol products. Findings and conclusions Breadth and quantity of alcohol products (primary containers) labelled by market share A sample of 3,020 products was collected with respect to the estimated proportion of products available for sale across each of 12 alcohol product categories. The most appropriate method of assessing the extent to which pregnancy labels have been implemented depends upon which strategy of raising awareness is thought to be most effective: If it is thought to be by targeting the products that are most commonly consumed, then considering those products that represent the greatest market share is the appropriate method, and after adjusting for market share, the proportion of products with a pregnancy health warning label is 62.0%. If it is thought to be by targeting the products that consumers are exposed to, or are potentially exposed to, at the point of purchase, then considering all products that are for sale is appropriate, and 38.2% of products have a pregnancy health warning label. The overall percentage (adjusted for market share) of 62.0% masks a wide band of variability across product types (24.5% to 81.3%). Products with long shelf-life or long lags between the time of manufacture and release to the market post labelling will take some time to work through the retail system. Wines might be benefiting from faster natural replacement for labels, given they tend to change their labels more frequently (for example to update labels with respect to vintage year or for other commercial purposes such as altering tasting notes). The most room for improvement appears to be for straight spirits and Ready To Drinks (RTD), where only 37.5% and 23.1% respectively have a pregnancy health warning label. These issues, combined with the fact that the voluntary scheme has only been in place for two years, suggests that the proportion of alcohol products with a pregnancy health warning label may increase in the immediate future, although the extent to which it may increase is unclear. It is apparent that adoption and implementation of pregnancy health warnings labels has increased over time. For wines with a vintage year before 2011 for example, 17% of the sample carried a pregnancy health warning compared to 66.2% in the 2013 vintage. This is an encouraging sign that the wine sector is shifting towards increasing the proportion of wine labels that have a pregnancy health warning, although only two-thirds of labels had a pregnancy health warning label for 2013 and 2014 vintages, suggesting that there is still room for further improvement. The proportion of alcohol products for sale with a pregnancy health warning label was comparable across Australia, meaning exposure to pregnancy health warning labels is unlikely to differ nationally. In addition, the proportion of all products for sale that had a pregnancy health warning
Alcohol and Pregnancy Labelling Evaluation iv
label and were manufactured in Australia was 38%, compared to 41% of products of international origin. Economic impacts associated with the voluntary pregnancy health warning labelling initiative The industry survey of the costs of the voluntary initiative to place pregnancy health warnings on alcohol products found that the main cost items included: 1) redesign and approval of artwork; 2) production of new print plates; and 3) administration costs associated with those changes. The opportunity cost of the package space that a pregnancy health warning label occupies as well as the potential benefit from improving a company’s reputation (from including a pregnancy health warning label on their products) were identified as potential key indirect costs and benefits, especially for smaller packages (eg 50ml). The estimated average cost to include a pregnancy health warning label per stock keeping unit (SKU) was $1,686.25.1 The total cost to industry for labelling the SKUs available for sale in April 2014 is estimated to be $5,408,188. A sensitivity analysis, using the proportion of SKUs that carry a pregnancy health warning label (59.8%) from those products that comprise the top 75% of market leading products (rather than the proportion of all SKUs available for sale), resulted in an estimated cost to industry of $9,597,773. If updating labels happens in line with other business processes, thus allowing flexibility for producers to incorporate labelling at their own pace, the cost to industry of maintaining the momentum and increasing coverage over time can be kept low. Consistency of the pregnancy warning message across labels and 2009 NHMRC guidelines Producers used either or both the DrinkWise Australia (DWA) green text label ‘it is safest not to drink while pregnant’ and the green pregnancy silhouette pictogram label templates. The templates included a DWA ‘Get the Facts’ badge with a link to the DWA website for more information about alcohol and pregnancy. The most commonly used pregnancy health warning label is the pictogram by itself (79%). Of the 21% of labels that use text, 82% are consistent with the National Health and Medical research Council (NHMRC) recommendation that it is safest not to drink alcohol while pregnant. Visibility and readability of pregnancy health warnings on alcohol products The majority of pregnancy health warnings were visible and readable, being of average or greater size (73%) than the DWA labelling manual and templates, and of average or better legibility or prominence (92% and 90% respectively), both of which are encouraging. The majority of pregnancy health labels were located on the back of the product (81%). Consumer awareness of pregnancy warning labels on alcohol products The consumer awareness survey (n= 5,399) found that 4.3% of women were aware of labels when they were not prompted, although 94% of women respondents understood what they meant when they were shown the labels. Once respondents were shown the labels, the pregnancy pictogram label was superior to the text label in producing higher levels of awareness. When presented with the DWA green pregnancy pictogram label, one third (33.3%) of all respondents and 42.2% of the target group of women reported awareness of the pictogram. 19.9% of the total sample and 26.3% of the target group of women reported awareness of the text label after they were shown the label. When presented with the DWA green pregnancy text message, one third of all respondents (34.9%) and 23.6% of the target group of women understood the text label to mean “don’t drink alcohol when pregnant”.
1 A stock keeping unit (SKU) is a distinct item, such as a product or service, as it is offered for sale, that embodies all attributes associated with the item and that distinguish it from all other items. For a product, these attributes include, but are not limited to: manufacturer, product description, material, size, colour, packaging, and warranty terms http://en.wikipedia.org/wiki/Stock_keeping_unit
Alcohol and Pregnancy Labelling Evaluation v
Acronyms and abbreviations ALSA Australian Liquor Stores Association AMA Australian Medical Association ANCD Australian National Council on Drugs ANPHA Australian National Preventive Health Agency Brewers Brewers Association of Australia and New Zealand BWS Beer, Wine and Spirits CEO Chief Executive Officer COAG Council of Australian Governments CUB Carlton United Breweries DSICA Distilled Spirits Industry Council of Australia DWA DrinkWise Australia EAHF European Alcohol and Health Forum FARE Foundation for Alcohol Research and Education FAS Fetal Alcohol Syndrome FASD Fetal Alcohol Spectrum Disorder FAST Fetal Alcohol Support Trust FoFR Legislative and Governance Forum on Food Regulation FRSC Food Regulation Standing Committee FSANZ Food Standards Australia New Zealand Health Commonwealth Department of Health ICAP International Centre for Alcohol Policies Labelling Logic Labelling Logic: review of food labelling law and policy NAAA National Alliance for Action on Alcohol NABIC National Alcohol Beverage Industries Council NDARC National Drug and Alcohol Research Centre NDRI National Drug Research Institute NDSHS National Drug Strategy Household Survey NHMRC National Health and Medical Research Council NHMRC guidelines NHMRC guidelines to reduce health risks from drinking alcohol NIDAC National Indigenous Drug and Alcohol Committee NOFASD National Organisation for Fetal Alcohol Spectrum Disorders NZIER New Zealand Institute of Economic Research RANZCOG Royal Australian and New Zealand College of Obstetricians and Gynaecologists RG Reference Group SKU Stock Keeping Unit TWE Treasure Wine Estates WFA Winemakers Federation Australia WHO World Health Organisation Wine Australia Wine Australia Corporation
Alcohol and Pregnancy Labelling Evaluation vi
Project team, Siggins Miller
Professor Mary-Ellen (Mel) Miller, Director Dr Ian Siggins, Director and Chief Executive Officer Ms Geraldine Cleary, Associate Director Professor Anthony Shakeshaft, Senior Associate Professor Sharyn Rundle-Thiele, Senior Associate Dr Joshua Byrnes, Senior Associate Ms Lauren Davies, Senior Consultant Ms Meghan Achilles, Senior Consultant Dr Joy Parkinson, Associate Ms Emma Howarth, Consultant Ms Aurelia Connelly, Consultant Mr James Miller, Consultant Five research assistants
Acknowledgements
In undertaking this evaluation project and preparing this report, the Siggins Miller project team is sincerely grateful for the ongoing advice and support of the Department of Health through Ms Colleen Krestensen (Assistant Secretary, Drug Strategy Branch) and Ms Kathy Dennis (Assistant Secretary, Healthy Living and Food Policy Branch), staff of the Drug Strategy Branch, Drug and Alcohol Policy Section including Mr David McNally (Director), Ms Bronwen Dowse (Assistant Director) and Ms Samantha Navin and staff of the Healthy Living and Food Policy Branch, Food Policy Section including Ms Christel Leemhuis (Director) and Ms Michelle Kennedy (Assistant Director); and the member of the Reference Group not yet mentioned, Dr Jo Mitchell (Director of the Centre for Population Health in the NSW Ministry of Health). We are also very grateful to all those who took part in the stakeholder consultations, and whose names are listed in Appendix 1.
Alcohol and Pregnancy Labelling Evaluation vii
Evaluation of the voluntary labelling initiative to place pregnancy health warnings on alcohol products
Final Report
Section 1 Introduction Alcohol exposure in pregnancy is a risk factor for poor pregnancy and child outcomes. High-level or frequent intake of alcohol in pregnancy increases the risk of miscarriage, stillbirth and premature birth, and alcohol related birth defects and neurological problems described in the literature since 1968 under the umbrella of Fetal Alcohol Syndrome (FAS), and more recently Fetal Alcohol Spectrum Disorders (FASD).2 Despite potential dangers to children’s health, drinking by pregnant women is fairly common in Anglo-Saxon countries such as Australia. 3 In Australia, the proportion of women who self-report drinking during pregnancy appears to have decreased over time (60% in 2007 to 51% in 2010). Of those who do drink alcohol during pregnancy, the proportion of women who said that they reduced the amount they drank while pregnant appeared to have decreased over time (57% in 2007 to 49% in 2010).4 1.1 Background to the labelling initiative In 2009, the Australia and New Zealand Food Regulation Ministerial Council (Ministerial Council) announced the review of Food Labelling Law and Policy – the Labelling Logic Review of Food Labelling Law and Policy (the Review). In 2009, in the period leading up to the release of the Review and the Government’s response to it, DrinkWise Australia (DWA) (an independent not for profit organisation established by industry focused on promoting change towards a healthier and safer drinking culture in Australia) took the initiative to research and develop four warning labels for the alcohol industry including pregnancy warnings. The 2009 National Health and Medical Research Council’s (NHMRC) Australian guidelines to reduce health risks from drinking alcohol, Guideline 4A stated that “For women who are pregnant or planning a pregnancy, not drinking is the safest option”. In December 2011, in its response to the Review, the Legislative and Governance Forum on Food Regulation (FoFR) (formerly known as the Ministerial Council) stated its intention to provide the alcohol industry with a two-year period to December 2013 to adopt voluntary initiatives to place pregnancy health labels on alcohol products, before regulating such a change. FoFR acknowledged that industry had already made efforts to introduce warnings on labels voluntarily and committed to working with industry over the voluntary pregnancy health warning labelling period. By the time of the release of the government response to the Review, DWA and industry were already engaged in looking at the issue of consumer advisory information including pregnancy health warning labelling on alcohol products. DWA had conducted market research on behalf of industry peak bodies in 2010/11. In July 2011, DWA launched the alcohol industry initiative to place a range
2 National Health and Medical and Medical Research Council (2009). Australian guidelines to reduce health risks from drinking alcohol. Canberra: Commonwealth of Australia. 3 World Health Organisation (2010). Global strategy to reduce the harmful use of alcohol. Geneva: World Health Organisation (WHO) 4 Australian Institute of Health and Welfare (2011). 2010 National Drug Strategy Household Survey report. Drug statistics series no. 25. Cat. No. PHE 145. Canberra: AIHW
Alcohol and Pregnancy Labelling Evaluation 1
of health information and responsible drinking labels on alcohol products. Industry peak bodies in turn were working to engage as many producers as possible in health labelling initiatives. After a 6 – 9 month set up period aimed at achieving consistency and buy-in about placing pregnancy health warning labels on primary packaging of alcohol products as a minimum, producers commenced labelling products. An agreement between DWA and Winemakers Federation of Australia (WFA) enabled winemakers who were not members of DWA to access the DWA labelling templates via a DWA dedicated winemakers portal in September 2012. 1.2 This Evaluation In January 2014, the Commonwealth of Australia through the Department of Health (Health) engaged Siggins Miller Consultants to undertake the Evaluation of the voluntary labelling initiative to place pregnancy health warnings on alcohol products (Evaluation). The aim of the evaluation was to assess the progress and success of Australian alcohol industry action towards implementing pregnancy health warnings on alcohol product labels at the end of the two year period to December 2013, as measured by market capture, visibility, consistency of message with NHMRC Australian guidelines and consumer awareness.5 1.2.1 Terms of Reference for the Evaluation Objectives and scope of the Evaluation are to: • Analyse and report on the progress and success of the Australian alcohol industry action towards implementing the voluntary labelling initiative as measured by market capture, visibility, consistency of the label message with NHMRC guidelines and consumer awareness • Provide advice on the progress of the alcohol industry action towards implementing pregnancy health warnings on alcohol product labels at the end of the two year period to December 2013 Evaluation Terms of Reference a) The primary focus of the Evaluation is to analyse the progress of alcohol industry action towards implementing voluntary pregnancy health warnings regarding the risks of drinking while pregnant on alcohol product labels, specifically: i. measuring the breadth and quantity of alcohol products and containers that carry the pregnancy warning label and/or the pictogram with respect to the market share of those products ii. analysing economic impacts associated with placing pregnancy health warnings labels on alcohol products iii. assessing how consistent the wording of the pregnancy warning message is across product labels and with the 2009 NHMRC guidelines to reduce health risks from drinking alcohol that ‘it is safest not to drink while pregnant’ iv. assessing the visibility and readability of alcohol warning labels looking at size, font, colour and placement of pregnancy warning messages on labels in the context of broader labelling requirements v. examining consumer awareness of the alcohol warnings on labels and understanding of the message and/or pictograms they contain.
5 The NHMRC guidelines present a review of the evidence on risks associated with alcohol drinking during pregnancy, note the limitations of the studies and that the current evidence does not warrant a “conclusion that drinking alcohol at low- moderate levels during pregnancy is safe.”
Alcohol and Pregnancy Labelling Evaluation 2
b) The Evaluation will give consideration to issues associated with products which are imported or which have an extended shelf-life or cellar released date. The Evaluation will also be mindful of international regulations and evidence. c) In terms of the broader context for the project, the Evaluation will also consider associated industry initiatives designed to supplement and leverage the impact of warning labels on alcohol products. It will also consider the role of activities funded by Government to support these warnings including a point of sale information project, and a project targeting consistent messaging by health professionals about the content of the NHMRC guidelines. The Evaluation was overseen by a small Reference Group of government officials chaired by a representative of Health. An Evaluation Framework was developed in consultations with key stakeholders and the Reference Group. It details methodology and data collection tools. The Evaluation Framework was presented to FoFR in March 2014. 1.3 Evaluation approach The methodology to fulfil the Terms of Reference included: a field study of outlets to assess the proportion of alcohol products with a pregnancy health warning label in terms of market share, products available for sale, and the consistency of the messages on pregnancy labels with the NHMRC guidelines, as well as their size, legibility and prominence (detailed at Appendix 2) an analysis of the estimated cost to industry of placing pregnancy health warning labels on alcohol products (detailed at Appendix 3) a survey to examine consumer awareness and understanding of pregnancy labels on alcohol products (detailed at Appendix 4) interviews with key informants to understand the context within which industry was implementing the initiative, from both industry and public health perspectives (detailed at Appendix 5). literature and document reviews (detailed at Appendix 6) to summarise: - current evidence surrounding alcohol exposure in pregnancy as a risk factor for poor pregnancy and child outcomes - legislation, regulation and guidance on size and legibility of consumer information labelling on alcohol products nationally and internationally - the activities of industry and government being conducted in parallel with the voluntary pregnancy health warning labelling of alcohol products - reviews of evidence for the effectiveness of labelling - reviews of the literature on social marketing best practice. 1.4 This report This report presents the results of each aspect of the methodology and an analysis of data from all sources to address the Terms of Reference.
Alcohol and Pregnancy Labelling Evaluation 3
Section 2 Field study of outlets The field study of outlets (study) was designed to measure the extent to which alcohol products6 carry a pregnancy health warning label (text and/or a pictogram), and an examination of the extent to which the warning labels are consistent with the NHMRC guidelines, are legible and are prominent. Given the over-arching aim of the study is to provide information to help inform judgements about the likely exposure of drinkers to a pregnancy health warning label, and drinkers’ family members and friends, there are two possible methods for measuring exposure. First, identifying those alcohol products that comprise the majority of the alcohol market share in Australia, and checking those products for a pregnancy health warning label. The logic of this approach is that a majority of people will be exposed to the most commonly sold brands of alcohol. Second, identifying a wide-range of alcohol products that are actually for sale in a variety of alcohol outlets, then randomly sampling from these products to check them for a pregnancy health warning label. The logic of this approach is to identify the extent to which purchasers are exposed to warning labels, irrespective of their actual purchasing choices. The second method could also help explore whether manufacturers might have implemented the voluntary code by prioritising the application of warning labels to particular types of products (eg those sold most commonly or those that they market to women). The primary strength of the first approach is that it facilitates an exploration of labelling by market share. The primary strength of the second approach is that it allows greater analysis of whether there are differences in pregnancy health warning labelling between different product types. In line with the methodology in the agreed Evaluation Framework, the specific aims of this study were: 1. To identify the proportion of market-leading alcohol products consumed in Australia that have a pregnancy health warning label and/or a pictogram 2. To identify the proportion of alcohol products for sale in alcohol outlets in Australia that have a pregnancy health warning label and/or a pictogram, and to identify: a. if that proportion differs by product type (eg. beer vs wine vs spirits) b. if that proportion differs by state/territory c. the extent to which warning labels are consistent with NHMRC guidelines d. the size of the warning label with respect to DWA guidelines, and its location e. the extent to which warning labels are legible and prominent with respect to FSANZ legibility requirements. Study Design and sample selection Identification of market leading products (Aim 1) Market leading products were considered with respect to five broad market categories (Beer, Cider, Wine, Spirits, and Ready To Drink products). Within each of these categories, the brands that constitute 75% of each of these broad markets by volume were identified using data provided by
6 Packaged-alcohol products available for sale are defined as those stocked on shelves sold through retail outlets and exclude products that are exclusively for sale direct to consumers, such as via wine clubs, cellar door or other distribution networks. In 2010, store-based retailing accounted for 98.4% of off-site (i.e. not on licensed premises) alcohol expenditure. (Euromonitor International (2011) Wine-Australia in Country Sector Briefing April 2011. Euromonitor International: Australia
Alcohol and Pregnancy Labelling Evaluation 4
Aztek Australia.7 The list of market leading products and their market share by volume (per product category) is provided in Appendix 2.3.
Identification of products for sale in alcohol outlets (Study Aim 2) A cluster, block-randomised, stratified sampling procedure was used. The detailed description of methods is provided in Appendix 2.2.2. Briefly, all alcohol products were divided into 12 categories: Red wine retail price <$11 Red wine retail price > $11 White wine retail price < $11 White wine retail price > $11 Cider Domestic brand full strength beer Domestic brand mid-strength beer Australian craft and / or premium beer International brand beer Dark spirits White spirits RTD. A sample size of 4,039 products was estimated to provide a 95% confidence interval of ±5% with respect to the estimated proportion of products with a pregnancy health warning label for each of the 12 alcohol product categories. The total number of products available within each group was estimated from a large national online alcohol merchant.8 The sample was stratified by state/territory9, based on population size10, and further stratified across five retail chains11, based on the number of retail outlets operated by each retail chain12. To ensure representation across different areas within each capital city, one outlet per retail chain was sampled from each district within each city (generally north, south, east and west districts). 13 To assess the consistency of pregnancy warning labels with respect to NHMRC guidelines, of the pregnancy health warning labels that use text (either alone or in combination with a pictogram) the words were compared to the NHMRC guideline that “it is safest not to drink while pregnant”.
7 Excerpts provided by industry with permission for use in this study 8 Dan Murphy’s: http://danmurphys.com.au/dm/home.jsp; accessed 8 Jan 2014 9 Sampling alcohol products in the NT was omitted from the project brief because of timeframes and budget. Instead, the required sample within each category was stratified by state/territory to ensure proportional representation nationally, based on population size 10 This implicitly assumes that population size is proportional to product availability, and this is constant across Australia. 11 The five organisations included account for approximately 92.8% of the retail outlets in Australia. 12 McKusker Centre for Action on Alcohol and Youth (2014) http://mcaay.org.au/assets/publications/industryindustryindustry-guides/mcaay_majorsalesoutlets_feb2014-final.pdf 13 In Canberra and Hobart, only one outlet was sampled per district.
Alcohol and Pregnancy Labelling Evaluation 5
Field researchers reviewed and evaluated the size of the pregnancy label in relation to the average pictogram and text provided by the DWA guidelines, which our researchers measured as being approximately 0.5cm x 0.7cm. Sizes of labels were classified as being below this standard, standard or above standard size. Given there are no standard recommendations for the location of the pregnancy label, the field researchers noted the location on each alcohol product sampled. The extent to which warning labels are legible and prominent was assessed relative to FSANZ Food Standard 1.2.9: Legibility Requirements (details of assessment criteria used are detailed in Appendix 2.2.3). Labels were classified as ‘low’ if they met only some of the criteria, ‘standard’ if they met all criteria and ‘above’ if they met and exceeded on at least one of the criteria. In addition, the location of manufacture reported on the product label of each sample was recorded. If an Australian location was provided, the Australian state/territory of manufacture was reported; if it was an international location, the country of origin was reported. Data collection (sampling) procedure For both studies, the same lead research officers visited the selected bottle shops in each capital city in each state/territory. The sampling procedure and the sample are described in detail at Appendices 2.1.1 and 2.2. A total of 72 outlets were sampled across Australia. Details of the final number of stores sampled by state/territory and retail chain are presented in Table 3 in Appendix 2.1.1. It highlights relative lack of sampling from independent and Liquor Stores, relative to Wesfarmers, Woolworths and Metcash. While this may present possible selection bias, to exhaust outlet options in the same area the outlet selection methodology was strictly adhered to. 2.1 Results 2.1.2 Aim One sample characteristics (market leading products) Of the 185 identified market leading products for study one, 184 products were sampled, representing 99.5% completion rate. A description of the Aim One sample (by State, package type and vintage year) is provided in Tables 4 and 5 in Appendix 2.2.1. The sample collected for the Aim One study comprised predominantly individually packaged products (97%). The vintage year for wine samples ranges from 2010 to 2014 with the majority of samples labelled as 2013 or 2012 (69%). 2.1.3 Aim One data analyses The number of products that had a pregnancy health warning label for each market is provided in Table 1 below. In order to approximate the proportion of products sold that carry a pregnancy health warning label, samples were weighted corresponding to their market share (Appendix 2.3). That is, those products that represent a larger proportion of the volume of alcohol sold (by product category) were weighted higher than those products that represent a smaller proportion. Table 1: Proportion of products with pregnancy health warning by market Market No pregnancy health Pregnancy Market share adjusted rates warning health warning Spirits 30 (62.5%) 18 (37.5%) 46.0% Wine 26 (26.8%) 71 (73.2%) 78.2% Beer 7 (33.3%) 14 (66.7%) 81.3% RTD 10 (76.9%) 3 (23.1%) 24.5% Cider 1 (20.0%0 4 (80.0%) 79.9% Total 74 (40.2%) 110 (59.8%) 62.0%
Of those products that represent 75% of the alcohol market, between 23.1% and 80% have a pregnancy health warning of some type depending on the product market. Overall, 59.8% of those
Alcohol and Pregnancy Labelling Evaluation 6
products that represent 75% of the alcohol market carry a pregnancy health warning. In total, of the products that represent 75% of the respective alcohol markets, 62.0% of the alcohol products sold carry some type of pregnancy health warning. 2.1.4 Aim Two sample characteristics (all products) Of the estimated 4,039 required sample size, 3,125 samples were achieved. Of the 3,125 samples, 105 samples were identified as duplicates and were removed from the sample leaving 3,020 unique samples or 74.6%. The sample collected for Aim Two is presented in Tables 6 and 7 of Appendix 2.1.1. The distribution of the products sampled reflects the representative sampling strategy (ie across states/territories) and the estimated number of samples required by product group. Of the 3,020 samples, 87.1% were individual packages. For all wine groups the majority of samples collected had a vintage year of 2011 or later. 2.1.5 Aim Two data analysis The results for the proportion of products that had a pregnancy health warning for each product group are provided in Table 2 below. Across all product groups, 38.2% of products sampled carried a pregnancy health warning of some type. This ranged from 15.9% for premium/craft beer to 56.3% for red wine with a retail price of less than $11. Table 2: Proportion of products with pregnancy health warning by market Product Group No pregnancy health Pregnancy health 95% CI* warning warning included Dark Spirits 237 (67.1%) 116 (32.9%) 29.3% : 36.4% White Spirits 105 (62.5%) 63 (37.5%) 33.7% : 41.3% RTD 126 (77.8%) 36 (22.2%) 21.7% : 22.7% Cider 79 (64.8%) 43 (35.3%) 34.5% : 36.0% Int. Beer 110 (71.9%) 43 (28.1%) 24.5% : 31.7% Prem/Craft Beer 190 (84.1%) 36 (15.9%) 13.4% : 18.4% Full Beer 47 (62.7%) 28 (37.3%) 36.1% : 38.6% Mid/Light Beer 28 (66.7%) 14 (33.3%) 29.3% : 36.4% Red Wine < $11 184 (43.7%) 237 (56.3%) 52.4% : 60.2% Red Wine > $11 312 (66.1%) 160 (33.9%) 30.0% : 37.8% White Wine < $11 212 (51.7%) 198 (48.3%) 44.3% : 52.3% White Wine > $11 221 (57.9%) 161 (42.2%) 38.4% : 45.9% Missing 14 (41.2%) 20 (58.8%) n/a Total 1,865 (61.8%) 1,155 (38.2%) CI*: Confidence Interval adjusted for finite population correction.
The proportion of products within a product group that carries a pregnancy health warning label varies by state/territory, however this study was not designed to test whether these differences are statistically significant or an artefact of the sampling frame.
For those states where a substantial sample was collected (NSW = 951; VIC = 819; QLD = 505; WA = 346), rates across all product groups were relatively consistent (34.9% - 39.3%).
Alcohol and Pregnancy Labelling Evaluation 7
Adoption and implementation of pregnancy health warning labels over time The proportion of products with a pregnancy label by product and year is presented in Table 3 below. Over time adoption and implementation of pregnancy health warnings has increased. For wines with a vintage year before 2011, for example, 17% of the sample carried a pregnancy health warning compared to 66.2% in 2013. Table 3: Proportion of products with pregnancy health warning by year <2010 2011 2012 2013 2014 Total Product group 2010 2011 2012 2013 2014 Total Red Wine < 11 (23.4%) 26 (44.1%) 92 (67.6%) 62 (82.7%) 0 (0%) 191 (60.1%) $11 Red Wine > 19 (14.7%) 44 (37.3%) 57 (46%) 9 (40.9%) 129 (32.8%) $11 White Wine < 1 (4.8%) 3 (9.7%) 59 (50.4%) 78 (70.9%) 2 (100%) 143 (50.9%) $11 White Wine > 13 (21%) 13 (29.5%) 48 (43.6%) 51 (53.7%) 125 (40.2%) $11 Total 44 (17%) 86 (34.1%) 256 (52.6%) 200 (66.2%) 2 (66.7%) 588 (45.1%)
Comparison of the proportion of products with a pregnancy health warning across differing product package types is provided in Table 4 below. The proportion of products that carry a pregnancy health warning varies by package type. Individual packaged products have a much higher proportion of products with a pregnancy health warning (41.8%) compared to multi-packs (ie 3 - 12 packs: 12%). Table 4: Proportion of products with pregnancy health warning by package type Individual 3-12 pack 20+ pack Keg Product Group Individual package 3-12 pack 20+ pack Keg Dark Spirits 115 (33.3%) 1 (50%) White Spirits 63 (38.7%) RTD 20 (23.8%) 15 (20.5%) Cider 37 (44%) 4 (13.8%) Int. Beer 35 (36.5%) 5 (13.2%) 2 (13.3%) Prem/Craft Beer 24 (21.2%) 5 (5.6%) 5 (29.4%) 2 (100%) Full Beer 26 (66.7%) 1 (7.7%) 1 (100%) Mid/Light Beer 237 (58.4%) Red Wine < $11 160 (33.9%) Red Wine > $11 197 (49.7%) White Wine < $11 160 (42.1%) 1 (50%) White Wine > $11 12 (70.6%) 1 (9.1%) 1 (100%) Total 1,086 (41.8%) 32 (12%) 8 (11.6%) 4 (80%)
Domestic and international comparisons
Alcohol and Pregnancy Labelling Evaluation 8
The proportion of Australian manufactured products that carry a pregnancy health warning was compared to the proportion of products of international origin, as shown in Table 5 below. In line with the evidence for an international trend towards implementing pregnancy health warnings on alcohol products, the proportion of Australian manufactured products is similar to the proportion of those products imported for sale in Australia (38% vs. 41%). For both red and white wines with a retail price of $11 or below as well as international branded beers, Australian manufactured products have a higher proportion of products with a pregnancy health warning label compared to international products (59% vs. 55%; 51% vs. 47% and 33% vs. 26% respectively). On the other hand, Australian produced RTDs, spirits (white and dark) and cider had comparatively lower proportions of products with a pregnancy health warning label. Table 5: Proportion of products with a pregnancy health warning by location of manufacture Product group Manufacturer Manufacturer located Manufacturer location Total located in Aus internationally information missing Dark Spirits 16/103 (16%) 97/245 (40%) 3/5 (60%) 116/353 (33%) White Spirits 15/47 (32%%) 48/117 (41%) 0/4 (0%) 63/168 (38%) RTD 26/140 (19%) 9/19 (47%) 1/3 (33%) 36/162 (22%) Cider 18/79 (23%) 24/41 (59%) ½ (50%) 43/122 (35%) Int. Beer 9/27 (33%) 33/125 (26%) 1/1 (100%) 43/153 (28%) Red Wine < $11 199/337 (59%) 37/67 (55%) 1/17 (6%) 237/421 (56%) Red Wine > $11 135/406 (33%) 25/63 (40%) 0/3 (0%) 160/472 (34%) White Wine < $11 164/324 (51%) 33/70 (47%) 1/16 (6%) 198/410 (48%) White Wine > $11 107/255 (42%) 54/126 (43%) 0/1 (0%) 161/382 (42%) Total 783/2,081 (38%) 363/880 (41%) 9/59 (15%) 1,155/3,020 (38%)
Comparison by state/territory of manufacture Of the three Australian states that represented the majority of Australian products (NSW, Victoria and South Australia) the proportion of products that carried a pregnancy health warning label was relatively consistent (34%, 33% and 48% respectively) (Table 8 of Appendix 2.1.1). Type of labels and text consistency with NHMRC guidelines A comparison of the proportion of pregnancy health warning labels that are pictogram only, vs text only vs pictogram and text is provided in Table 6 below. The majority of pregnancy health warning labels use a pictogram only (79%). Additionally, of those pregnancy health warning labels that use text, an estimated 82% of labels are consistent with NHMRC recommendations, ranging from 29% to 100%. Table 6: Proportion of pregnancy health labels by label type and text consistency with NHMRC guidelines Product Group No Pictogram Text pregnancy Text and Consistency with pregnancy pregnancy health warning pictogram NHMRC health health guidelines warning warning Dark Spirits 237 71 (63%) 40 (36%) 1 (1%) 23 (56%) White Spirits 105 31 (49%) 31 (49%) 1 (2%) 19 (59%)
Alcohol and Pregnancy Labelling Evaluation 9
Product Group No Pictogram Text pregnancy Text and Consistency with pregnancy pregnancy health warning pictogram NHMRC health health guidelines warning warning RTD 126 15 (44%) 19 (56%) 16 (84%) Cider 79 30 (71%) 10 (24%) 2 (5%) 10 (83%) Int. Beer 110 27 (66%) 13 (32%) 1 (2%) 4 (29%) Prem/Craft Beer 190 19 (54%) 16 (46%) 14 (88%) Full Beer 47 16 (57%) 11 (39%) 1 (4%) 7 (58%) Mid/Light Beer 28 10 (71%) 4 (29%) 4 (100%) Red Wine < $11 184 217 (92%) 18 (8%) 2 (1%) 15 (75%) Red Wine > $11 312 136 (85%) 24 (15%) 24 (100%) White Wine < $11 212 176 (89%) 21 (11%) 1 (1%) 22 (100%) White Wine > $11 221 125 (78%) 35 (22%) 25 (71%) Missing 14 17 (85%) 3 (15%) 3 (100%) Total 1,865 890 (79%) 221 (20%) 9 (1%) 189 (82%)
Comparison of the proportion of pregnancy health labels that were smaller or larger than the average is provided in Table 7 below. Additionally, a comparison of the location of health warning labels is also provided. The majority of pregnancy health labels (73%) are of an average14 or larger size and 81% are placed on the back of the product. Table 7: Proportion of pregnancy health labels by size and location Product Smaller Average Larger Front of Back of Side of Neck of Top/Bottom group size size size package package package package of package Dark 33 (28%) 72 (62%) 11 (9%) 2 (2%) 103 7 (6%) 0 0 Spirits (92%) White 12 (19%) 42 (67%) 9 (14%) 0 53 (84%) 10 (16%) 0 0 Spirits RTD 11 (31%) 24 (67%) 1 (2.8%) 0 12 (36%) 3 (9%) 2 (6%) 16 (48%) Cider 19 (44%) 20 (47%) 4 (9%) 3 (7%) 33 (80%) 3 (7%) 1 (2%) 1 (2%) Int. Beer 18 (42%) 17 (40%) 8 (19%) 2 (5%) 24 (57%) 8 (19%) 3 (7%) 5 (12%) Prem/Craft 6 (17%) 28 (78%) 2 (6%) 0 13 (42%) 7 (23%) 5 (16%) 6 (19%) Beer Full Beer 7 (25%) 20 (71%) 1 (4%) 2 (7%) 5 (19%) 15(56%) 4 (15%) 1 (4%) Mid/Light 5 (36%) 9 (64%) 0 0 4 (29%) 6 (43%) 3 (21%) 1 (7%) Beer Red Wine 53 (22%) 160 (68%) 24 (10%) 23 (10%) 204 10 (4%) 0 0 < $11 (86%) Red Wine 40 (25%) 97 (61%) 23 (14%) 4 (3%0 132 20 13%) 0 0
14 Field researchers reviewed and evaluated the size of the pregnancy label in relation to the average pictogram and text provided by the DWA guidelines, which was approximately 0.5cm x 0.7cm.
Alcohol and Pregnancy Labelling Evaluation 10
Product Smaller Average Larger Front of Back of Side of Neck of Top/Bottom group size size size package package package package of package > $11 (85%) White 50 (25%) 117 31 (16%) 4 (2%) 170 16 (8%) 0 0 Wine < (59%0 (86%) $11 White 48 (30%) 88 (55%) 25 (16%) 6 (4%) 140 9 (6%) 0 0 Wine > (88%) $11 Missing 10 (50%) 10 (50%) 0 0 18 (90%) 2 (10%) 0 0 Total 312 (27%) 704 (61%) 139 46 (4%) 911 116 18 (2%) 30 (3%) (12%) (81%) (10%)
Legibility and Prominence The legibility and prominence of pregnancy health labels with respect to the FSANZ legibility requirements are summarised in Table 8 below. The majority of pregnancy health labels across all product types (ie the total) were assessed as standard or above in terms of both legibility (92%) and prominence (90%).
Table 8: Proportion of pregnancy health labels by legibility and prominence Product Low Standard Above Low Standard Above group legibility legibility standard prominence prominence standard legibility prominence Dark Spirits 4 (4%) 83 (87%) 8 (8%) 4 (7%) 84 (78%) 17 (16%) White 7 (12%) 44 (77%) 6 (11%) 8 (13%0 39 (63%) 15 (24%) Spirits RTD 1 (4%) 22 (88%) 2 (8%) 5 (16%) 24 (75%) 3 (9%) Cider 1 (4%) 27 (93%) 1 (4%) 9 (23%) 22 (56%) 8 (21%) Int. Beer 5 (15%) 26 (76%0 3 (9%) 14 (36%) 14 (36%) 11 (28%) Prem/Craft 0 26 (87%) 4 (13%) 3 (9%) 30 (86%) 2 (6%) Beer Full Beer 2 (8%) 22 (92%) 0 3 (11%) 21 (78%) 3 (11%) Mid/Light 2 (15%) 10 (77%) 1 (8%) 3 (21%) 9 (64%) 2 (14%) Beer Red Wine < 2 (3%) 74 (97%) 0 14 (6%) 188 (81%) 31 (13%) $11 Red Wine > 3 (5%) 52 (95%) 0 8 (5%) 111 (71%) 36 (23%) $11 White Wine 15 (14%) 82 (75%0 14 (15%) 14 (7%) 125 (64%) 56 (23%) < $11 White Wine 9 (10%) 70 (75%) 14 (15%) 22 (14%) 89 (57%) 46 (29%) > $11 Missing 0 0 0 0 6 (100%) 0 Total 51 (8%) 538 (84%) 53 (8%) 107 (10%) 762 (69%) 230 (21%)
Alcohol and Pregnancy Labelling Evaluation 11
2.2. Key findings – Aim One Overall, an estimated 59.8% of those products that comprise 75% of market share carry a pregnancy health label. After adjusting for market share, the proportion of products with a pregnancy health label is 62.0%. The proportion of market leading products (adjusted by market share) that have a pregnancy health warning differs considerably by product: our estimates range from 24.5% to 81.3%. 2.3 Key findings –Aim Two The proportion of all alcohol products for sale that have a pregnancy label varies between 15.9% and 58.8% by product type, with 38.2% of all products carrying a pregnancy health warning label. Individually packaged products and wines with a later vintage have higher proportions of products with a pregnancy health warning label: wines with a year of 2013 have between 40.9% and 82.7% of products with a pregnancy health warning compared to 4.8% and 23.4% in samples prior to 2011. Only two-thirds of labels had a pregnancy health warning for 2013 and 2014, and for straight spirits and RTDs, only 37.5% and 23.1% respectively have a pregnancy health warning label. The analysis of the extent to which warning labels are consistent with NHMRC guidelines, and are legible and prominent, was conducted only in the context of the study that examined the range of alcohol products that are actually for sale in a variety of alcohol outlets, as opposed to those products that comprise the majority market share. This means that the findings about consistency, legibility and prominence of pregnancy health warning labels do not necessarily reflect those products that are consumed by the majority of drinkers in Australia, they do represent a much greater range of label types (n=3,020), compared to the relatively small number of label types that comprise 75% of market share (n=148 labels). The most commonly used pregnancy label is the pictogram by itself (79%). Of the 21% of labels that use text, 82% are consistent with the NHMRC recommendation. The majority of pregnancy health warnings are on the back of the product (81%) and are of average or greater size (73%). 92% of pregnancy health warnings were considered of standard or better with respect to legibility and 90% were of standard or better prominence. 2.4 Methodological considerations It is important to recognise that the results from both Aim One and Aim Two are with respect to those products that were on the shelf in retail outlets at the time the data were collected. It is plausible that this may represent an underestimate of the proportion of all products that are currently manufactured with a pregnancy health warning (eg because of the natural time lag between production and appearance at retail outlets). 2.5 Conclusions After adjusting for market share, the proportion of products with a pregnancy health label is 62.0%. In contrast to the market leading products, only 38.2% of all alcohol products available for sale had a pregnancy health warning label. A reasonable interpretation of these results is that the most appropriate method of assessing the extent to which pregnancy labels have been implemented depends upon which strategy of raising awareness is thought to be most effective: If it is thought to be by targeting the products that are most commonly consumed, then considering the products that represent the greatest market share is appropriate, and 59.8% of products have a pregnancy health warning label with a range across product types of 24.5% to 81.3%. If it is thought to be by targeting the products that consumers are exposed to, or are potentially exposed to, at the point of purchase, then considering all products that are for sale is appropriate, and 38.2% of products have a pregnancy health warning label.
Alcohol and Pregnancy Labelling Evaluation 12
The overall percentage of 62.0% (adjusted by market share) masks a wide band of variability across product types (24.5 to 81.3%). The substantial difference in pregnancy warning labels by product category is potentially of concern. Overall, differentiation in the time lag between production and appearing within retail outlets may explain the variance in the proportion of pregnancy health warning labels between product categories observed in the current study. Another contributing factor may be parallel importing – an issue identified by the industry which may affect product markets differently (see Appendix 5 for a summary of the results of the key informant interviews). Products with long shelf-life or long lags between the time of manufacture and release to the market post labelling will take some time to work through the retail system. Wines might also benefit from faster natural replacement for labels, given they tend to change their labels more frequently (for example to update labels with respect to vintage year or for other commercial purposes such as altering tasting notes). The most room for improvement appears to be for straight spirits and RTDs, where only 37.5% and 23.1% respectively have a pregnancy health warning label. It is apparent that adoption and implementation of the pregnancy health warnings labels has increased over time. For wines with a vintage year before 2011, for example, 17% of the sample carried a pregnancy health warning compared to 66.2% in 2013. This is an encouraging sign that the wine sector is shifting towards increasing the proportion of wine labels that have a pregnancy health warning, although only two-thirds of labels had a pregnancy health warning for 2013 and 2014, suggesting that there is room for further improvement. In general, the time lag issues, combined with the fact that the voluntary scheme has only been in place for two years, suggests that the proportion of alcohol products with a pregnancy label may increase in the immediate future, although the extent to which it may increase is unclear. Parallel importing by some retailers, for example, currently facilitates the sale of alcohol products in Australia that are not manufactured in Australia and so may not be subject to the same voluntary agreements about pregnancy warning labels. Assessing the proportion of alcohol products sold in Australia through parallel importing, and the extent to which those products have pregnancy warning labels that comply with the requirements of their source country and with the current voluntary code in Australia, however, was beyond the scope of this Evaluation. Producers used either or both the DWA green text label ‘it is safest not to drink while pregnant’ and the green pregnancy silhouette pictogram label templates. The templates included a DWA ‘Get the Facts’ badge with a link to the DWA website for more information about alcohol and pregnancy. The most commonly used pregnancy health warning label is the pictogram by itself (79%). Of the 21% of labels that use text, 82% are consistent with the NHMRC recommendation. The majority of the pregnancy health warning labels were visible and readable, being of average or greater size (73%) than the DWA labelling manual and template, and of average or better legibility or prominence (92% and 90% respectively), both of which are encouraging. 92% of pregnancy health warnings were considered of standard or better with respect to legibility and 90% were of standard or better prominence. The majority of pregnancy health labels were located on the back (81%).
Alcohol and Pregnancy Labelling Evaluation 13
Section 3 Alcohol industry survey of voluntary pregnancy labelling costs The online alcohol industry survey of voluntary pregnancy labelling costs was designed to determine the costs associated with actions taken by industry members to implement the voluntary pregnancy labelling initiative. In total, 14 responses to the survey were received which included small, medium and large companies. The majority of respondents were from companies where the main activity was manufacturing, the other two respondents represented an importer/distributor company and an industry representative group. The percentages reported are presented as proportions of total respondents who answered each question, as opposed to the total number of respondents who completed the entire survey. The profile of respondents to the survey is detailed in Appendix 3. 3.1 Operation details Types of package/labels used All respondents indicated the types of product package/labels used across their company’s product range, as well as the number of their products which use each package/label (see Table 9). The most commonly reported type of product package/label was a “glass bottle approx. 750ml,” which was used by 12 of the 14 companies (85.71%). The least commonly used package/label type was “multiple (shrink-wrapped),” only used by two companies (14.29%); and no respondents used “beer mini-kegs.” “Glass bottle approx. 750ml” had the highest range and average number of company product lines with any type of package/label, followed by “wine cask.” Table 9: Types of product package/labels used by companies Product package/label Number of Range of number of Average number of companies using company products company products package/label type using package/label using package/label in range type type Glass bottle approx. 750ml 12 (85.71%) 8 to 780 236.70 Glass bottle (wine) approx. 375ml 8 (57.14%) 1 to 38 8.57 Glass bottle approx. 187ml 5 (35.71%) 2 to 12 6.00 Wine cask 5 (35.71%) 20 to 77 38.00 Glass bottle (beer) approx. 375ml 8 (57.14) 1 to 8 3.80 Metal can approx. 375ml 4 (28.57%) 1 to 13 5.67 Multiple (cardboard) 6 (42.86%) 1 to 24 9.80 Multiple (shrink-wrapped) 2 (14.29%) 1 1 Carton approx. 30 5 (35.71%) 1 to 17 17 Beer mini keg 0 - - Half of all respondents (n=7, 50%) indicated that their company uses a product package/label other than those listed in Table 11. Units sold per year The number of units (across all product lines and SKUs) sold by respondent companies ranged from 100,000 to 1.57 billion, with a median of 8.5 million.15
15 A stock keeping unit (SKU) is a distinct item, such as a product or service, as it is offered for sale that embodies all attributes associated with the item and that distinguish it from all other items. For a product, these attributes include, but are not limited to, manufacturer, product description, material, size, color, packaging, and warranty terms http://en.wikipedia.org/wiki/Stock_keeping_unit
Alcohol and Pregnancy Labelling Evaluation 14
3.1.1 Adoption of labelling initiative reported by respondents Reported proportion of product lines with a pregnancy label The estimated average proportion of company product lines with a pregnancy health label was 71%; with proportions ranging from 0 to 100%. Reported use of pregnancy health warning labels across product package/label types Respondents reported on the number of product lines across each of the product package/label types for which they had incorporated a pregnancy health warning on the label (refer Table 10). Table 10: Proportion of product lines with pregnancy health warning labels per product package/label type Product package/label Number of product Average proportion Range lines with a pregnancy label Glass bottle approx. 750ml 1,835 85.1% 11% - 100% Glass bottle approx. 375ml 52 54.3% 0% - 100% Glass bottle approx. 187ml 22 88.9% 75% - 100% Wine cask 94 78.6% 0% - 100% Glass bottle (beer) approx. 14 71.4% 20% - 100% 375ml Metal can approx. 375ml 16 71.2% 33% - 100% Multiple (cardboard) 45 27.1% 0% - 50% Multiple (shrink-wrapped) 1 100% 100% Carton approx. 30 28 21.3% 0% - 35% Other 79 53.9% 35% - 98% Introduction of pregnancy labels/package Respondents indicated that pregnancy health warnings had been introduced on their company’s product labels/packages between November 2011 and June 2013 (n = 9). Type of pregnancy health warning labels used Respondents were asked to select the different types of pregnancy health warning labels incorporated on their SKUs. Nine of the 11 respondents who answered indicated that their products display the pregnancy pictogram label (82%). Approximately half of the respondent used a pregnancy text label (n=6, 55%), and only one used the NHMRC pregnancy text label (refer to Table 11). Four respondents indicated that their company had incorporated more than one type of label; the majority of which used both the pictogram label and pregnancy text (n=3). Table 11: Types of pregnancy health warning labels used Type of pregnancy health label n (9) %* Pictogram label 9 82% Pregnancy text label 6 55% Pictogram and text 3 27% *Percentages are presented as the proportion of all respondents to this question who have implemented each label type, therefore percentages do not add up to 100 The three respondents who indicated that their company uses an “other” label provided details about non-pregnancy related DWA logos (eg “get the facts” and “is your drinking harming yourself or others?”).
Alcohol and Pregnancy Labelling Evaluation 15
3.2 Cost estimates Additional cost items Respondents were asked whether there were any cost items in addition to: a) Redesign and approval of artwork b) Production of new print plates c) Administration costs associated with those changes. Of the 12 who responded, four indicated that additional cost items needed to be considered; three respondents said that additional costs were “material write-offs”, and one stated that it was the cost associated with “relabelling of imported products”. Total cost estimates per item Estimates were provided by eight respondents for the total costs associated with implementing pregnancy health warning labels across each of the identified cost items. Average estimated total costs outlined in Table 12 show that the most costly item associated with the labelling was production of new print plates. No estimated total costs were provided for any additional cost items (ie material write offs and relabelling of imported products). Where a respondent only provided a range of values, the midpoint was used. The estimated average cost to include a pregnancy health warning label per SKU was $1,686.25. This is lower than that estimated for a minor labelling change to a glass bottle ($3,967) reported by PricewaterhouseCoopers in its 2008 report to FSANZ.16 Table 12: Estimated costs per cost item Range of estimated total Cost item Average estimated cost cost Redesign and approval of artwork $638.75 $55 - $2,500 Production of new print plates $675.63 $0 - $2,000 Administration costs $363.75 $0 - $2,000 Total Cost $1,686.25 $310 - $5,500
Indirect costs and benefits The opportunity cost of the package space that a pregnancy health warning occupies as well as the potential benefit from improving a company’s reputation (from including a pregnancy health warning on their products) were identified as potential key indirect costs and benefits. Three out of nine respondents reported that their company considered the inclusion of a pregnancy health warning on their product labels or packaging as a reduction in the capacity or scope to provide alternative information (33%). One respondent from a company that manufactures spirits and RTD alcoholic beverages commented that this was particularly relevant for smaller packages (eg 50ml), where it is very difficult to accommodate the labels and all the mandatory labels on the back and side labels. Another company reported having removed the statement “is your drinking harming yourself or others” in order to include a pregnancy health warning message. Another respondent believed that the inclusion of additional information presented a challenge to consumer comprehension, dependent on whether a labelling requirement is mandated by format or left to the company to decide on placement and comprehensibility. They noted that had they
16 PricewaterhouseCoopers (2008). Cost schedule for food labelling changes: Final report. Food Standards Australia and New Zealand p 3
Alcohol and Pregnancy Labelling Evaluation 16
needed to increase the size of a label to accommodate for additional warnings there would have been an impact on the integrity of application and adhesion of the labels, therefore requiring significant machine changes affecting the cost of production. Zero cost estimates Due to the two year period for implementing the pregnancy health warning, some manufacturers were able to incorporate the pregnancy health warning as part of an otherwise scheduled change in the product label. This resulted in some manufacturers reporting that no marginal costs to the company were incurred due to the timeframe available as part of the voluntary pregnancy health warning initiative. It was reported that management of costs was also facilitated because the companies could maintain some flexibility with respect to the pregnancy health warning design and location. Two participants (one beer and one wine producer) indicated that there was no additional cost. In the final cost estimates, the proportion of products that these companies produce were set to zero. This is a conservative approach as this does not consider the likelihood of additional producers also reporting a zero cost. One respondent indicated that their remaining stock would be labelled to achieve 100% as new container deposit labelling requirements were introduced in July 2014. Responsible consumption of alcohol Respondents were asked to what extent they agreed with the statement “my company considers the inclusion of a pregnancy health warning as an opportunity to be associated with the responsible consumption of alcohol.” As demonstrated in Figure 1, the most common response was “neither agree nor disagree” (n=5, 45%) with 5 respondents (45%) either agree or strongly agree. No respondents strongly disagreed. Figure 1: Pregnancy health warnings providing opportunity to be associated with responsible consumption of alcohol
100.00% 90.00%
80.00% 70.00% 60.00% 50.00% n=5 n=4 40.00% 30.00% %respondents of 20.00% n=1 n=1 10.00% n=0 0.00% Strongly agree Agree Neither agree nor Disagree Strongly disagree disagree
The indirect costs and benefits associated with including a pregnancy health warning, whilst potentially not insignificant, were not included in the final estimated cost to industry. Total cost to industry The total cost to industry is estimated as the number of SKUs that have adopted the pregnancy health warning multiplied by the proportion of manufacturers that incurred a cost associated with implementing the pregnancy health warning multiplied by the total cost per SKU implementing the change to labels. Table 13 shows the proportion of SKUs with a pregnancy health warning was taken from the estimate of all products that carry a health label (detailed in Section 3 above).
Alcohol and Pregnancy Labelling Evaluation 17
Table 13: Estimated total cost to industry Proportion with Proportion Total Cost to Market SKUs warning without cost industry Beer 636 24.4% 2.2% $255,922 Cider 120 35.2% 0.0% $71,227 Wine 6,076 44.9% 3.1% $4,457,690 Spirits 972 34.4% 0.0% $563,828 Ready To Drink 159 22.2% 0.0% $59,521 TOTAL 7,963 $5,408,188 The total estimated cost to industry of adopting the voluntary initiative is estimated at $5.4 million. This is significantly dependent on the estimated number of SKUs within the industry, the proportion of those SKUs that have a pregnancy health warning and the per SKU cost of implementing the pregnancy health warning. A series of one-way sensitivity analyses were conducted to test the sensitivity of the estimated cost figure with alternative parameter estimates. These are presented in Table 14 below. The results from the sensitivity analyses indicate that the total cost figure is particularly sensitive to the estimated cost per SKU to apply a pregnancy health warning label. If the cost estimate from Pricewaterhouse Coopers is used instead of the cost derived from the industry survey, the total cost is estimated as $12,723,074. The estimates are also sensitive to estimates regarding proportion of products with a pregnancy health label. If the estimates from the market leaders study (Aim One in Section 3 above) the cost is estimated as $9,597,773. Table 14: Sensitivity analysis of cost estimates Total Cost to Sensitivity Analysis industry Base Case $5,408,188 Increase in number of SKUs by 10% (total of 8,759 vs 7,963 ) $5,949,007 Increase in Proportion of SKUs (estimates based on market leaders vs all products) $9,597,773 Increase in cost per SKU to include pregnancy health label( PwC estimate) $12,723,074 3.3 Conclusions The estimated average cost per stock keeping unit was $1,686.25.17 The total cost to industry for labelling the SKUs available for sale in April 2014 is estimated to be $5,408,188. In a sensitivity analysis, the proportion of SKUs that carry a pregnancy health warning from those products that comprise the top 75% of market leading products (59.8%) was used instead; the resultant cost to industry was estimated as $9,597,773. The opportunity cost of the package space that a pregnancy health warning occupies as well as the potential benefit from improving a company’s reputation (from including a pregnancy health warning on their products) were identified as potential key indirect costs and benefits. This could be particularly relevant for smaller packages (eg 50ml), where it is very difficult to accommodate the labels as well as the mandatory contents labels on the back and side labels. If updating labels happens in line with other business processes thus allowing flexibility for producers to incorporate
17 A stock keeping unit (SKU) is a distinct item, such as a product or service, as it is offered for sale that embodies all attributes associated with the item and that distinguish it from all other items. For a product, these attributes include, but are not limited to, manufacturer, product description, material, size, color, packaging, and warranty terms http://en.wikipedia.org/wiki/Stock_keeping_unit
Alcohol and Pregnancy Labelling Evaluation 18
labelling at their own pace, the cost to industry of maintaining the momentum and increasing coverage over time can be kept low.
Alcohol and Pregnancy Labelling Evaluation 19
Section 4 Consumer awareness and understanding of pregnancy health warning labels The consumer awareness online survey was designed specifically to gather and analyse data to understand the extent and nature of consumer awareness of the pregnancy health warnings on alcohol product labels and their understanding of the message and/or pictograms they include. In line with evidence summarised in Section 5 below and in more detail in Appendix 6, that labelling on its own will only affect awareness and/or prompt further information seeking, the survey did not seek to measure effects of labels on attitude change, changes in behavioural intentions, or behaviour change. The survey asked respondents about their awareness of pregnancy-related messages and campaigns. Unprompted approaches rely solely on a respondent’s recall of an alcohol warning message on alcohol products in the absence of prompts. Use of prompts (in this case the DWA pictorial and text alcohol warning messages provided to the Australian alcohol industry as part of the voluntary initiative) were used to further examine consumer awareness. Establishing consumer understanding of the pictogram and text, alcohol warning label messages involved the use of open- ended questions to capture verbatim respondent comments. The survey was conducted 19 March – 14 April 2014. In total, 5,399 complete responses were obtained. The sample provided the desired population representativeness across target groups, geographies and socio economic status (see sample framework and detailed demographic information in Table 6 in Appendix 4.2). We compared responses of total sample with those of the target group of women (comprising women who were currently pregnant, were planning to become pregnant in the next two years, or had a child under 18 months of age). The online survey design is detailed in Appendix 4.3. The statistical analyses used are detailed in Appendix 4.4. The survey instrument is presented at Appendix 4.5 and the results of the data analyses including detailed demographic group differences are at Appendix 4.6. 4.1 Findings Comparisons of unprompted and prompted awareness and consumer understanding of the pictogram and the text label and their messages are summarised in Table 15. Table 15: Consumer awareness and understanding of pregnancy labels Construct Response Total sample n= (%) Women*n= (%) Unprompted campaign or Yes 3,386 (62.4%) 2,100 (67.7%) message awareness No 2,040 (37.6%) 1,002 (32.3%) Unprompted campaign or Pregnant lady symbol on 183 (5.8%) 134 (4.3%) message recall description alcohol products Messages on alcohol products 231 (7.3%) 176 (5.7%) Prompted (recall) Have seen label 1807 (33.3%) 1309 (42.2%) pictogram awareness Prompted (recall) text Have seen label 1078 (19.9%) 816 (26.3%) label awareness Pictogram understanding Don’t drink alcohol when 4576 (92.5%) 2627 (84.7%) pregnant Alcohol causes harm to unborn 113 (2.3%) 65 (2.1%) child or mother Text label understanding Don’t drink alcohol when 1478 (34.9%) 732 (23.6%) pregnant Alcohol causes harm to unborn 1288 (30.4%) 798 (25.7%) child or mother *Target group = women who were currently pregnant, were planning to become pregnant in the next two years, or have a child under 18 months of age.
Alcohol and Pregnancy Labelling Evaluation 20
4.1.1 Awareness Unprompted recall In the absence of direct prompts, very few respondents were aware of any campaigns or messages. Only 5.8% of all respondents and 4.3% of the target group of women recalled the pictogram which was described by respondents as the “pregnant lady symbol on alcoholic products.” Slightly more (7.3% of all respondents and 5.7% of the target group of women) reported a nondescript alcohol warning label using words such as “messages on bottles” or “messages on bottles of alcohol with warnings.” Overall, results revealed 62.4% of all respondents and 67.7% of the target group of women reported seeing campaigns or messages about pregnant women and alcohol consumption. Prompted recall When presented with the DWA green pregnancy pictogram label, one third (33.3%) of all respondents and 42.2% of the target group of women reported awareness of the pictogram, showing that levels of awareness of the pictogram were similar in the target group and the total sample. 19.9% of the total sample and 26.3% of the target group of women reported awareness of the text label after they were exposed to the label. 4.1.2 Understanding Pictogram label In total, 92.5% of all respondents and 94% of the target group of women understood the pictogram to mean “do not drink alcohol when pregnant”. Only 2.3% of all respondents (and the target group of women) understood the pictogram to mean “alcohol causes harm to the unborn child.” Forty-three (2%) of the responses to open-ended questions indicated that using the colour green for the pictogram the use of the colour red would be more effective because the colour red in and of itself signals that it is a warning. Three respondents indicated that the green meant they should drink alcohol. These findings indicate that the pictogram in red rather than green may help to avoid consumer confusion about the message. Respondents who reported awareness (unprompted) of the pictogram were more likely to understand the label to mean do not drink alcohol when pregnant or alcohol causes harm to the unborn child than those who were not aware of the label until prompted. Text label One third of all respondents (34.9%) and 23.6% of the target group of women understood the text label to mean “don’t drink alcohol when pregnant.” While 30.4% of all respondents and 25.7% of the target group of women understood the text label to mean “alcohol causes harm to the unborn child.” 4.2 Conclusions The consumer awareness survey found that awareness of pregnancy warning labels was low 4.3% when women were not prompted, however, once shown the labels (prompted) 94% of women understood what they meant. Results indicate that the pictogram is superior to the text label in producing both higher levels of awareness and understanding that are consistent with NHMRC guidelines, but the use of the green pictogram can confuse the message by suggesting that alcohol should be consumed.
Alcohol and Pregnancy Labelling Evaluation 21
Section 5 Key contextual factors 5.1 International trend to incorporate pregnancy health warning labels on alcohol products Alcohol labelling regulation nationally and internationally is expressed though one or a combination of mechanisms including food standards laws and codes, industry initiatives to promote healthy use of alcohol through labelling or point-of-sale advertising, or voluntary agreements reached between industry and government in relation to alcohol and labelling.18 Our review of the literature in relation to requirements for, or the adoption of, health warning labelling and specifically pregnancy health warning labelling of alcohol products, internationally, revealed that in the period 2009 to 2014, the number of countries with pregnancy health labelling of alcohol products increased from six to 33 (see Appendix 6.3). Of the 33 countries with pregnancy health warning labels, 29 are implementing voluntary pregnancy warning labelling initiatives. South Africa, the Russian Federation and the United States are the only countries with both mandatory health warning labels and prescribed pregnancy health warning labels. The only other country to have mandatory pregnancy health warning labels is France, where it is the only mandatory health warning label. Twenty five of the 29 countries with voluntary pregnancy labelling initiatives currently use the red pregnant lady pictogram mandated in France (see Table 4 in Appendix 6.5). Since 1995 in Australia, the FSANZ Code has required labels on alcoholic beverage containers to legibly display consumer information about volume, standard drinks and ingredients. While the FSANZ Code does not require that alcohol product labels display directional information about safe consumption or warnings about health risks associated with drinking alcohol, it does provide guidance about legibility and prominence (contrast and size). Both industry and public health sectors support a minimum standard set by government for consistent content, size, and placement to be applied to the pregnancy health warning labels. DWA developed a manual and label templates for use by industry members to guide consistent labelling. 5.2 The role of the labelling initiative in raising awareness Both public health and industry key informants to this Evaluation reported that there is confusion about the potential role of pregnancy health warning labelling of alcohol products in changing the drinking patterns of women who are pregnant or planning to become pregnant (see Appendix 5). There is strong evidence that a comprehensive, integrated approach, sustained over time and emphasising the need to address the sensitive issues around alcohol consumption during pregnancy through interpersonal communication and relationship with a trusted health professional, is required to achieve changes in awareness, attitudes and behaviour (see Appendix 6.6). Implemented in the context of an integrated strategy, the pregnancy health warning labels on alcohol products might contribute to awareness and understanding because they act as a reminder or prompt a conversation. Reflecting on the experience of the voluntary initiative to date, key informants agreed that: Australians have a right to know that alcohol should not be consumed by women who are pregnant in order to make better decisions about alcohol consumption and this right should be respected. Labels are one way of contributing to awareness of the issue but of themselves pregnancy health warning labels do not change drinking behaviours
18 Stockwell T (2006). A review of research into the impacts of alcohol warning labels on attitudes and behaviour. British Columbia, Canada: University of Victoria, Centre for Addictions Research of BC
Alcohol and Pregnancy Labelling Evaluation 22
Pregnancy health warnings on alcohol products are one mechanism intended to improve the awareness of the community of the potential for alcohol-related harms from drinking whilst pregnant. The main impact of the labels is to remind and prompt further information seeking or some interpersonal communication if people see it and are prompted to wonder what it means. 5.3 Evidence based social marketing campaigns There is strong evidence for what works in awareness, attitude and behaviour change – a comprehensive integrated approach sustained over time and emphasising the need to address the sensitive issues around alcohol consumption during pregnancy through interpersonal communication and relationship with a trusted health professional. 5.4 Australian women’s attitudes, knowledge and patterns of behaviour A 2010 study of Australian women’s knowledge and attitudes regarding drinking alcohol while pregnant found that most of the 1,103 women surveyed agreed that pregnant women should not drink alcohol (80.2%) and 97% agreed that alcohol can affect the unborn child. However, awareness of the specific risks to the unborn child arising from drinking alcohol during pregnancy was poor in the Australian female childbearing population.19 Since 2011, the Foundation for Alcohol Research and Education (FARE) has conducted annual polling on awareness of the harms caused by drinking alcohol, including drinking while pregnant or breastfeeding. For its 2014 poll FARE used a Galaxy Research questionnaire online to survey 1,545 respondents over the age of 18 years across Australia.20 The survey results showed that: 78% (65% in 2013) of Australians believed that pregnant women should not consume any alcohol in order to avoid harm to the fetus 50% (47% in 2013) were aware of Fetal Alcohol Syndrome and related disorders 15% (15% in 2013) believed that pregnant women can drink in moderation (safely drink small amounts of alcohol without harming their baby). 5.5 The role of industry and government parallel initiatives The DWA point of sale project (2011-12 to 2012-13) incorporated the DWA pregnancy text and pictogram labels, and engaged alcohol retailers and producers in providing responsible messages to consumers about reducing harmful drinking, particularly during pregnancy and to promote and explain new labels through a media campaign involving dissemination of resources and website material. The materials integrated the pregnancy health warning labels, promoted the DWA “Get the Facts” badge and provided expert opinion and factual information and guidance in line with the NHMRC guidelines about alcohol and pregnancy. Industry key informants believed that the labelling initiative and the point of sale project served to increase DWA’s profile as a provider of credible online health information. These initiatives are presented in greater detail in Appendix 6.2. During the two year period of the voluntary pregnancy health warning labelling initiative, governments invested in a range of FASD research, advocacy, policy/guidelines health workforce and community capacity as well as surveillance and management activities (see Appendix 6.2). While these were not integrated with the labelling initiative, key informants believed they provided a foundation and impetus for discussion about labelling and how to better integrate it into broader public health campaigns designed to reduce the risks of alcohol-related harms during pregnancy.
19 Peadon E, Payne J, Henley N, D’Antoine H, Bartu A, O’leary C, Bower C, Elliot EJ (2010). Women's knowledge and attitudes regarding alcohol consumption in pregnancy: a national survey. BMC Public Health. 10: 510. DOI: 10.1186/1471-2458-10-510 20 Foundation for Alcohol Research and Education (2014). Annual Alcohol Poll: Attitudes and behaviours. Canberra: FARE
Alcohol and Pregnancy Labelling Evaluation 23
Evaluation of the voluntary labelling initiative to place pregnancy warnings on alcohol products
Appendices
23 May 2014
Alcohol and Pregnancy Labelling Evaluation - Appendices ii
Contents Appendix 1: Stakeholders consulted by group and consultation activity 5 Appendix 2: Outlet study 8 2.1 Methods 8 2.1.1 Study design and sample selection 8 2.2 Detailed description of the outlet study sampling procedure 15 2.2.1 Aim one 15 2.2.2 Aim two 15 2.2.3 Pregnancy warning label legibility and prominence 16 2.3 List of market leading products by market and percentage of market by volume 17 Appendix 3: An estimated cost to industry of placing pregnancy health warning labels on alcohol products 20 3.1 Average cost estimates 21 3.2 Estimating the total cost to industry 21 Appendix 4: Consumer awareness online survey detailed methods and data analyses 22 4.1 Data collection methodology 22 4.2 Online survey design 24 4.3 Data analyses 25 4.4 Survey protocol 26 Appendix 5: Key informant interviews 54 5.1 Summary 54 5.2 Detailed data analysis 55 Appendix 6: Literature and document review 62 6.1 Context 63 6.2 Implementation of the pregnancy labelling voluntary initiative 67 6.3 National and international pregnancy labelling context 74 6.4 Rationales for health warning labelling of alcohol products 75 6.5 Voluntary vs mandatory pregnancy health warning labelling arrangements 78 6.6 Evidence for the effectiveness of health warnings on alcohol products 91 6.7 Bibliography 94
Alcohol and Pregnancy Labelling Evaluation - Appendices iii
List of Figures Figure 1: Number of countries with mandatory or voluntary general health and pregnancy specific health warning labelling policies (2014) 77
List of Tables Table 1: Estimated required sample size by product category 9 Table 2: Estimated sample size by state 10 Table 3: Number of stores sampled by state/territory and retail chain 11 Table 4: Aim one sample by market and state/territory 12 Table 5: Aim one sample by market and product description 12 Table 6: Aim two number of products sampled with a pregnancy health warning by market and state/territory 13 Table 7: Aim two sample by market and product description, and wine by vintage year 14 Table 8: Aim two sample of products with a pregnancy health warning by state/territory location of manufacture 15 Table 9: Nature of respondent company’s activities 20 Table 10: Markets respondent company products sold in 20 Table 11: Consumer awareness survey sample framework 24 Table 12: Detailed analyses by target group, of awareness and understanding of pregnancy health warning labels on alcohol products 34 Table 13: Key informant data analysis summary by group and interview topic 56 Table 14: Pregnant Women who drank more, less or the same amount of alcohol compared with when they were neither pregnant nor breastfeeding, 2007 and 2010 (per cent) 63 Table 15: Activities of four large companies and DWA 68 Table 16: Countries with alcohol product information and health warning labelling policy other than pregnancy, grouped as mandatory (blue) or voluntary (white) 80 Table 17: Countries with a specific pregnancy warning labelling policy, grouped as mandatory (blue) or voluntary (white) 85
Alcohol and Pregnancy Labelling Evaluation - Appendices iv
Appendix 1: Stakeholders consulted by group and consultation activity
Name Name Position/s Unit/branch, organisation Location Consultation Activity RG Teleconferences; Framework workshop; Industry survey; key informant interview 1 Colleen Krestensen Assistant Secretary Drug Strategy Branch (Reference Group Chair) Canberra RG Teleconferences; Framework workshop 2 Kathy Dennis Assistant Secretary Healthy Living and Food Policy Branch (Reference Group Member) Canberra RG Teleconferences; Framework workshop 3 Jo Mitchell Director Centre for Population Health, NSW Ministry of Health (Reference Sydney RG Teleconferences Group Member) 4 Dave McNally Director Drug and Alcohol Policy Section, Drug Strategy Branch (Reference Canberra RG Teleconferences; Framework workshop Group Member) 5 Bronwen Dowse Assistant Director Drug and Alcohol Policy Section, Population Health Division Canberra Framework Workshop 6 Trevor Webb Manager and Principal Social Food Standards Australia New Zealand Canberra Framework Workshop Scientist Behaviour Regulatory Analysis Section (on behalf of Dean Stockwell, General Manager Food Standards) 7 Jenny Hazelton Manager, Labelling And Information Food Standards Australia New Zealand Canberra Framework Workshop Standards 8 Catrina McStay Senior Policy Officer Department of Health, Western Australia Perth Framework Workshop; Key informant interview 9 Dr Cecile McKeown Senior Consultant Department of Health, Tasmania Hobart Framework Workshop; Key informant interview 10 David Cusack Manager Strategic Policy and NSW Food Authority Sydney Framework Workshop; Projects Key informant interview 11 Dr Sarah Wright Policy Advisor, Health Promotion NZ Wellingto Key informant interview Agency n 12 Rosie Pears Senior Policy Advisor Health Promotion Agency Wellingto Key informant interview n
Alcohol and Pregnancy Labelling Evaluation - Appendices 5
Name Name Position/s Unit/branch, organisation Location Consultation Activity RG Teleconferences; Framework workshop; Industry survey; key informant interview 11 John Scott CEO DrinkWise Australia Canberra Framework Workshop; Key informant interview 12 Madi Jacobs Manager Corporate Affairs DrinkWise Australia Canberra Framework Workshop; Key informant interview; associated initiatives data 13 Denita Wawn CEO Brewers Association of Australia and New Zealand Canberra Framework Workshop; Key informant interview; 14 Gordon Broderick Executive Director Distilled Spirits Industry Council of Australia (DSICA) Melbourn Framework Workshop e 15 Stephen Riden Research and Communications Distilled Spirits Industry Council of Australia (DSICA) Melbourn Framework Workshop; Key informant e interview; Industry survey 16 Terry Mott CEO Australian Liquor Stores Association Sydney Framework Workshop 17 Ailish Hanley Head of Corporate Diageo TBA Framework Workshop; Key informant interview; Industry survey 18 Bryan Mundy Research and Policy Analyst Brewers Association of Australia and New Zealand Canberra Framework Workshop; Key informant interview; Industry survey 19 Peter Gniel General Manager, Government Winemakers Federation of Australia Canberra Framework Workshop; Key informant Affairs interview; Industry survey 20 Anita Poddar Global External Affairs Accolade Wines Reynella, Framework Workshop; Industry survey SA 21 Jonathan Chew National Manager Clubs Australia Sydney Framework Workshop 22 James Brindley CEO National Alcohol Beverage Industries Council Incorporated (NABIC) TBA Framework Workshop; Key informant interview 23 Kate Thompson Legal and Corporate Affairs Director Pernod Ricard Winemakers Pty Ltd (Board Member of both Sydney Key Informant interview; Industry survey DrinkWise Australia and Wine Australia Corporation) 24 Mitchell Taylor Managing Director Taylors Wines (Board Member Winemakers Federation of Auburn Key informant interview Australia) 25 Roger Sharp Director, Group Corporate Affairs Treasury Wine Estates (TWE) Global Melbourn Key informant interview and Vintrepreneur e
Alcohol and Pregnancy Labelling Evaluation - Appendices 6
Name Name Position/s Unit/branch, organisation Location Consultation Activity RG Teleconferences; Framework workshop; Industry survey; key informant interview 26 Caterina Giorgi Director Policy and Research Foundation for Alcohol Research and Education (FARE) Canberra Framework Workshop; Key informant interview 27 Melanie Walker Deputy CEO Public Health Association of Australia Canberra Framework Workshop; Key informant interview 28 Brian Vandenberg CEO National Alliance for Action on Alcohol (NAAA) Melbourn Framework Workshop; Key informant e interview 29 Vicki Russell CEO National Organisation on Fetal Alcohol Syndrome (NOFASD) Adelaide Framework Workshop; Key informant interview 30 Prof Michael Farrell Director National Drug and Alcohol Research Centre (NDARC) Sydney Key informant interview 31 Prof Mike Daube Director of the Public Health Health Sciences Curtin University Perth Key informant interview advocacy Institute and the McCusker Centre for Action on Alcohol 32 Prof Steve Allsop Director National Drug Research Institute (NDRI) Perth Key informant interview 33 Prof Margaret Hamilton OA Monash University Australian National Council on Drugs, (Chair Alcohol Expert Melbourn Key informant interview Committee of the Australian National Preventive Health Agency) e 34 A/Prof Ted Wilkes Chairman National Indigenous Drug and Alcohol Council (NIDAC) Perth Key informant interview 35 Dr Dennis Gray Deputy Director and Project Leader National Indigenous Drug and Alcohol Council (NIDAC)/ National Perth Key informant interview Substance Use Among Indigenous Drug Research Institute (NDRI) Australians 36 Anna Stearne Researcher National Indigenous Drug and Alcohol Council (NIDAC) Perth Key informant interview 37 Sondra Davaron Senior Legal Policy Advisor Cancer Council of Victoria and Member ANPHA Alcohol Committee Melbourn Key informant interview e
Alcohol and Pregnancy Labelling Evaluation - Appendices 7
Appendix 2: Outlet study This study was designed to measure the extent to which alcohol products and containers carry a pregnancy health warning label and/or a pictogram. In line with the methodology in the agreed Evaluation Framework, the specific aims of this study are: 1. To identify the proportion of market-leading alcohol products consumed in Australia that have a pregnancy health warning label and/or a pictogram. 2. To identify the proportion of alcohol products for sale in alcohol outlets in Australia that have a pregnancy health warning label and/or a pictogram, and to identify: a. if that proportion differs by product type (eg. beer vs wine vs spirits) b. if that proportion differs by state/territory c. the extent to which warning labels are consistent with NHMRC guidelines d. the extent to which warning labels are legible and visible. 2.1 Methods Definition of an alcohol product available for sale Packaged-alcohol products available for sale are defined as those stocked on shelves sold through retail outlets and exclude products that are exclusively for sale direct to consumers, such as via wine clubs, cellar door or other distribution networks (It is assumed that the majority of products sold through these networks are also available for retail sale in alcohol outlets). In 2010, store-based retailing accounted for 98.4% of off-site (ie not on licensed premises) alcohol expenditure.1 A product is categorised by alcohol type, brand, variety, package size and type. In the case of wine, the vintage year is also used to differentiate each product. For example, Carlton mid-strength individual 375ml glass bottle is different from Carlton mid-strength six pack of 375ml glass bottles or a 24 case of 375ml glass bottles or an individual Carlton mid-strength 375ml metal can. Similarly, Wolf Blass Yellow label cabernet sauvignon 2011 750ml bottle is considered a different product from Wolf Blass Yellow label cabernet sauvignon 2011 187ml bottle, from Wolf Blass red label cabernet sauvignon 2011 750ml bottle, and again from Wolf Blass Yellow label cabernet sauvignon 2012 750ml bottle. 2.1.1 Study design and sample selection Identification of market leading products (aim one) Market leading products were restricted to five categories (Beer, Cider, Wine, Spirits, and Ready To Drink [RTDs] because these five broadly comprise 100% of the available alcohol products in Australia. Within each of these categories, the brands that constitute 75% of the market share by volume were identified using data provided by Aztek Australia.2 The sample size that equated to 75% of market share within each product category is provided in Table 1 below. The selection of market leading products per outlet is described below. Identification of products for sale in alcohol outlets (aim 2) A cluster, block-randomised, stratified sampling procedure was used. First, the five product categories identified for aim one were further divided into 12 categories, as detailed in Table 1 below.
1 Euromonitor International (2011) Wine-Australia in Country Sector Briefing April 2011. Euromonitor International: Australia 2 Excerpts provided by industry with permission for use in this study
Alcohol and Pregnancy Labelling Evaluation - Appendices 8
i. Wine was separated by both product and price characteristics. First, wine was separated into either red or white wine, reflecting a primary characteristic of wine. Here, red wine includes fortified wines, where champagne, sparkling wine and dessert wines were included as white wine.3 Secondly, wine was divided by products with a retail price of more or less than $11. This reflects a natural market segmentation (~50% off-trade wine sold is less than $11 per product4 as well as potential differences in product manufacturing cost structures and target consumers: that is, production runs for lower priced wine may be larger than for higher priced wine which in turn may influence the decision to carry a label. Additionally, higher priced wine may target a more affluent consumer who may have alternative preferences regarding health warnings. ii. Beer was divided into four categories: international beers, Australian craft or premium beer, full strength domestic beer and mid or light strength domestic beer. International beers were separated from national beers because it is possible that suppliers of domestic brand products may be more willing to adopt Australian specific labelling initiatives than international branded products. National brand beers are separated into craft/premium, full strength or low/mid strength beers due to potential differences in target audience and production costs. Craft/premium beers are potentially more likely to target more affluent consumers whereas low/mid strength beers are potentially more likely to target more health conscious consumers. iii. Spirits were divided into clear and dark spirits to reflect a natural product separation and the possibility that target audiences may differ across clear and dark spirit consumers. It is hypothesised that clear spirits are drunk more frequently by young females than dark spirits. Clear spirits include: rum, vodka, tequila, gin, schnapps, ouzo, sake and absinthe. Alternatively dark spirits include: whisky, liqueurs, brandy, cognac and aperitifs. iv. Ready to drink (RTD) or alcopops are products that contain a portion of alcohol (typically spirits) and a non-alcoholic beverage within the same container. v. Cider includes both apple, pear and other fruit ciders. Secondly, the total number of products available within each group was estimated from a large national online alcohol merchant.5 It is assumed that this represents close to the total number of alcohol products available for sale in Australia. There is, however, a potential bias towards increased availability of higher priced items, for example wine over $500, relative to retail outlets. Thirdly, sample size calculation for the random selection was based on achieving an estimate of the proportion of sampled products with a label with a 95% confidence interval of ±5%. It was assumed that 50% of products have a pregnancy health warning label. Given the clustering by product category and potential correlation for labelling within each product category cluster and by manufacturer sample sizes are adjusted by a factor of 2.0 or set equal to the entire known population in the case of product categories with small population. Sample sizes per product category are summarised in Table 1. Table 1: Estimated required sample size by product category Product category Estimated total Sample size to achieve Sample size adjusted number of products 95% CI of ± 5% for cluster sampling Red wine <$11 1,318 298 596
3 Some sparkling wines are red, for example a sparkling shiraz, and some fortified wines are white, for example white port. However, these represent a very small proportion of these categories. 4 Op cit 148 Euromonitor International (2011) 5 Dan Murphy’s: http://danmurphys.com.au/dm/home.jsp; accessed 8 Jan 2014
Alcohol and Pregnancy Labelling Evaluation - Appendices 9
Product category Estimated total Sample size to achieve Sample size adjusted number of products 95% CI of ± 5% for cluster sampling Red wine >$11 2,617 335 670 White wine <$11 1,240 293 586 White wine >$11 901 270 540 Dark spirits 742 253 506 White spirits 230 144 230 RTD 159 113 159 Cider 120 92 120 International beer 205 134 205 Aust craft/premium beer 311 172 311 Full strength domestic beer 71 60 71 Mid/light strength domestic beer 45 40 45 Total 7,959 2,204 4,039 Aust.: Australia; CI: confidence interval; Mid: mid strength; RTD: Ready to Drink Fourthly, the required sample within each category was then stratified by state/territory6 to ensure proportional representation nationally, based on population size.7 The required sample size per state/territory is shown in Table 2. The data collection was limited to capital cities because of logistics and because those cities account for the majority of the population in each state/territory. Table 2: Estimated sample size by state Product category NSW Vic Qld SA WA Tas ACT Total Red wine <$20 187 170 88 51 76 9 15 596 Red wine >$20 210 191 99 58 86 9 17 670 White wine <$20 184 167 86 50 75 9 15 586 White wine >$20 170 154 80 46 69 8 13 540 Dark spirits 159 144 75 43 65 7 13 506 White spirits 72 66 34 20 29 3 6 230 RTD 50 45 23 14 20 2 4 158 Cider 38 34 18 10 15 2 3 120 International beer 64 59 30 18 26 3 5 205 Aust craft/premium beer 98 89 46 27 40 5 7 312 Full strength domestic beer 22 20 9 6 9 1 2 70 Mid/light strength domestic 14 13 7 4 6 1 1 46 beer Total 4,039
In order to ensure the sample was taken from representative retail outlets, the sample was further stratified by retail chain. The number of labels to be sampled by retail chain was proportional to their share of retail outlets. In 2012, there were approximately 6,880 alcohol retail outlets in
6 Northern Territory is excluded from this study 7 This implicitly assumes that population size is proportional to product availability, and this is constant across Australia.
Alcohol and Pregnancy Labelling Evaluation - Appendices 10
Australia. Woolworths accounted for 18.2%, Wesfarmers 11.4%, Metcash 35.6%, Independent Liquor Group 17.4%, and Liquor Marketing 10.2%.8 These five organisations account for approximately 92.8% of the retail outlets in Australia. This estimate includes bottle shops and takeaway outlets associated with on-site licensed premises including hotels and clubs. Independent Liquor Group Co-operative members must have a financial share in a NSW liquor licence. As such, Independent Liquor Group outlets were assumed to exist only in NSW.9 Outlet selection To ensure representation across different suburbs or areas within each capital city, one outlet per retail chain was sampled for each of four districts of Sydney, Melbourne, Brisbane, Adelaide and Perth (ie 5 retailers x 4 districts in Sydney, 4 retailers x 4 districts in Melbourne/Brisbane/ Adelaide/Perth). In Canberra and Hobart, only one outlet per retail chain was sampled per district. Canberra is divided into four districts and one retailer randomly selected per district. Hobart is divided into three districts with each retailer randomly assigned a district. Data collection (sampling) procedure For both studies, the same lead research officers visited the selected bottle shops in each capital city in each state/territory. The same lead researchers were used to optimise standardisation in the data collection process and maximise inter-rater reliability. A total of 72 outlets were sampled across Australia. Details of the final number of stores sampled by location and retail chain are presented in Table 3. It highlights that relative lack of sampling from independent and Liquor Stores, relative to Wesfarmers, Woolworths and Metcash. While this may present possible selection bias, to exhaust outlet options in the same area the outlet selection methodology was strictly adhered to. There were fewer stores from Metcash and Independent Liquor Group Stores, relative to Wesfarmers and Woolworths retail stores. This was partly due to the sampling design, which was based on the proportion of retail outlet numbers, and partly because a greater proportion of these stores refused to participate in the study. In total, 54 stores declined across the 5 week sampling period. If declined, an alternative was selected from a list of randomly selected replacement retailers in the same region and within the same retailer group. If the alternative selected from the replacement list also declined to participate then the process of selecting alternatives was repeated. If the second alternative store declined (ie: the third store approached) then the sample was not replaced. In total 18 stores were unaccounted for out of the identified sample of 90. The stores that declined were generally smaller outlets. Those who declined most commonly said that they had not received communication from management or that they did not understand the project objective. Table 3: Number of stores sampled by state/territory and retail chain
State WES WOW MET LIQ IND OTH Total NSW 4 4 2 2 3 0 15 VIC 4 4 2 2 0 0 12 QLD 5 5 3 2 0 0 15
8 McKusker Centre for Action on Alcohol and Youth (2014) http://mcaay.org.au/assets/publications/industry- guides/mcaay_majorsalesoutlets_feb2014-final.pdf 9 Some outlets are likely to be spread over the country. However, no clubmart, pubmart or little bottler outlets were identified in Queensland where they also hold offices. It is likely that co-operative members trade under independent names. No such list of co-operative members is available. As such all outlets are assumed to be in NSW were little bottler, club and pubmarts were located.
Alcohol and Pregnancy Labelling Evaluation - Appendices 11
State WES WOW MET LIQ IND OTH Total WA 4 2 3 3 0 0 12 SA 4 4 2 1 0 0 11 Tas 0 1 1 0 0 2 4 Act 1 2 0 0 0 0 3 Total 22 22 13 10 3 72 WES: Wesfarmers, WOW: Woolworths; MET: Metcash; LIQ: Liquor IND: Independent In total 18 outlets declined to allow the researchers to sample alcohol products in their stores. The stores that declined were generally smaller independent retailers. Those who declined most commonly said that they had not received communication from management or did not understand the project objective. These outlets were replaced with an alternative outlet drawn from a pool of randomly selected alternative outlets generated for this purpose as per the outlet selection protocol.10 Aim one sample Of the identified 185 market leading products for study one, 184 products were sampled representing 99.5% completion rate. The one missing product was a wine (“Super Value”) that was unable to be located during the data collection process. The sample for Study One by State is provided in Table 4 below. Table 4: Aim one sample by market and state/territory State/territory Spirit market Wine market Beer market RTD market Cider market total NSW 17 52 17 6 2 94 VIC 15 13 1 0 1 30 QLD 4 9 2 4 0 19 WA 2 2 0 1 0 5 SA 1 2 1 2 1 7 Tas 2 1 0 0 0 3 ACT 7 18 0 0 1 26 Total 48 97 21 13 5 184
Samples for Aim One were predominantly individually packaged products (Table 5). For wine, the sample with the latest vintage was included in this analysis, however the actual year for the wine samples ranges from 2010 to 2014 with the majority of samples labelled as 2013 or 2012 (Table 5). Table 5: Aim one sample by market and product description SKU Market SKU Individual SKU 6/10 pack SKU >10 pack SKU Total Spirits 48 0 0 48 Wine (total) 76 0 0 76 2010 2 0 0 2
10 Approximately 54 stores declined across the 5 week sampling period from 18 March 2014. If declined, an alternative was selected from an alternative list of other retailers in the same region and of the same retailer group – if declined from that alternative, the process of selecting an alternative was repeated and, if that alternative store declined, seeking an alternative for that store was finally closed off. This is what resulted in 18 stores being unaccounted for out of the sample of 90.
Alcohol and Pregnancy Labelling Evaluation - Appendices 12
SKU Market SKU Individual SKU 6/10 pack SKU >10 pack SKU Total 2011 5 0 0 5 2012 21 0 0 21 2013 46 0 0 46 2014 2 0 0 2 Missing Year 21 0 0 21 Beer 18 1 2 21 RTD 10 3 0 13 Cider 5 0 0 5 Total 178 4 2 184
After adjusting for market share, it is estimated that of those products that represent 75% of the respective alcohol markets, between 24.5% and 81.3% of products sold have a pregnancy health warning of some type depending on the product market. In total, of the products that represent 75% of the respective alcohol markets, 62.0% of the alcohol products sold carry some pregnancy health warning. Aim two sample Of the estimated 4,039 required sample size 3,125 samples were achieved. Of the 3,125 samples, 105 samples were identified as duplicates and were removed from the sample leaving 3,020 unique samples or 74.6%. Data collection was terminated early owing to: difficulty identifying products that had not already been sampled an interim analysis of the data that identified the primary end point of the study (95% confidence interval of less than 5%) had been achieved. The original sample size was based on assumptions regarding the level of correlation between the likelihood the sample had a pregnancy health warning and the state, retail chain and product category. Whilst some level of correlation is likely with respect to product brand (ie products within the same product branding are likely to be correlated with respect to having a health pregnancy warning), after analysis of the interim data it appeared that sufficient data had been collected to achieve the pre-specified error margins for the primary outcome result. The sample collected for Aim Two is presented with respect to more detailed market segmentation and State from where the sample was collected in Table 6 below. A total of 3,020 samples were achieved across 12 product groups from 7 states. The distribution of the samples is reflective of the representative sampling strategy (ie across states) and estimated number of samples required by product group. Table 6: Aim two number of products sampled with a pregnancy health warning by market and state/territory Product group NSW VIC Qld WA SA Tas ACT Total Dark Spirits 100 101 64 45 25 6 12 353 White Spirits 49 45 31 17 16 4 6 168 RTD 66 36 27 17 11 2 3 162 Cider 55 28 13 12 9 2 3 122 Int. Beer 46 48 21 17 11 4 6 153 Prem/Craft Beer 64 65 42 28 17 4 6 226 Full Beer 37 18 11 5 1 0 3 75
Alcohol and Pregnancy Labelling Evaluation - Appendices 13
Product group NSW VIC Qld WA SA Tas ACT Total Mid/lght Beer 27 9 6 0 0 0 0 421 Red Wine < $11 125 115 71 49 37 9 15 472 Red Wine > $11 141 132 84 60 41 9 5 410 White Wine < $11 127 111 72 51 36 9 4 382 White Wine > $11 114 111 63 45 31 7 11 42 Missing 1 13 0 0 0 0 20 34 Total 952 832 505 346 235 56 94 3,020
Samples within Aim Two are described with respect to product group and packaging (and year for wine) in Table 7. Of the 3,020 samples, 87.1% were individual packages. For all wine groups the majority of samples collected had a vintage year of 2011 or later. Table 7: Aim two sample by market and product description, and wine by vintage year a) Aim two sample by market and product description SKU Market SKU SKU 3-12 SKU >12 SKU SKU SKU Total Individual pack pack Keg Missing Dark Spirits 345 2 0 0 6 353 White Spirits 163 0 0 0 5 168 RTD 84 73 4 0 1 162 Cider 84 29 7 0 2 122 Int. Beer 96 38 15 1 3 153 Prem/Craft 113 90 17 2 4 226 Beer Full Beer 39 22 13 1 0 75 Mid/lght Beer 17 11 13 1 0 42 Red Wine < 406 0 0 0 15 421 $11 Red Wine > 472 0 0 0 0 472 $11 White Wine < 396 0 0 0 14 410 $11 White Wine > 380 2 0 0 0 382 $11 Missing 34 34 Total 2,629 267 69 5 50 3,020
b) Study two product sample: wines 2010 2011 2012 2013 2014 Missing Total
Red Wine < 47 59 136 75 1 103 421 $11 Red Wine > 129 118 124 22 0 79 472 $11 White Wine 21 31 117 110 2 129 410 < $11
Alcohol and Pregnancy Labelling Evaluation - Appendices 14
2010 2011 2012 2013 2014 Missing Total
White Wine 62 44 110 95 71 382 > $11
Table 8: Aim two sample of products with a pregnancy health warning by state/territory location of manufacture Product NSW Vic Qld WA SA Tas Aust group manufacturer manufacturer manufacturer manufacture manufacturer manufacturer Dark 10/45 1/35 0/3 0/1 5/16 0/3 16/103 Spirits (22%) (3%) (0%) (0%) (31%) (0%) (16%) White 7/17 2/12 6/13 0/2 0/3 - 15/47 Spirits (41%) (17%) (46%) (0%) (0%) (32%) RTD 14/72 2/43 3/14 - 7/11 - 26/140 (19%) (5%) (21%) (64%) (19%) Cider 12/26 1/26 - 0/4 4/20 1/3 18/79 (46%) (4%) (0%) (20%) (33%) (23%) Int. Beer 4/13 3/7 1/1 - 1/6 - 9/27 (31%) (43%) (100%) (17%) (33%) Red Wine 45/86 46/82 0/1 7/16 101/152 - 199/337 < $11 (52%) (56%) (0%) (44%) (66%) (59%) Red Wine 22/64 14/66 0/1 14/50 83/220 2/5 135/406 > $11 (35%) (21%) (0%) 28%) (38%) (40%) (33%) White 35/87 40/72 - 8/22 80/142 1/1 164/324 Wine < (40%) (56%) (37%) (56%) (100%) (51%) $11 White 17/49 24/50 - 17/59 43/88 6/9 107/255 Wine > (35%) (48%) (29%) (49%) (67%) (42%) $11 Total 194/566 173/524 12/50 54/203 336/700 14/38 783/2,081 (34%) (33%) (24%) (27%) (48%) (37%) (38%)
2.2 Detailed description of the outlet study sampling procedure 2.2.1 Aim one For each store data collectors sampled a number of market leading products from a randomly generated list. The number of market leading products sampled per store was equal to the total number of market leading products to be sampled divided by the number of outlets included in the study. Data collectors sampled a product corresponding to the top of the randomly ordered list of market leading products. If that product was not available at that store, the next product on the list was sampled. If a product on the list had already been sampled it was not resampled. This process continued until all market leading brands had been sampled. Of the identified 185 market leading products for study one, 184 products were sampled representing 99.5% completion rate. The missing product was a wine (“Super Value”) that was unable to be located during the data collection process. 2.2.2 Aim two In each store, data collectors located the appropriate product category section and selected a product at random. In the first store, this meant that the first number (n) of products for that category was selected and checked until the quota for that product category for that store was
Alcohol and Pregnancy Labelling Evaluation - Appendices 15
reached. In the next store, the same process occurred, unless that product had already been checked, in which case it was not re-examined but the adjacent product was checked instead. Data were entered electronically to facilitate easy verification that each sample was a unique product. Pregnancy health warnings were checked to consider if the warning was a picture, text or a combination of the two. If it was text, then the wording was assessed for consistency with the 2009 NHMRC Australian guidelines regarding alcohol consumption during pregnancy, in order to address Aim Two. Where uncertainty with respect to consistency arose, a photograph of the label was taken for further verification. Legibility and prominence data were collected to answer Aim Two Question d. Both were recorded with respect to the legibility requirements for food labels in Standard 1.2.9 Food Standards Australia New Zealand Code. The user guide to this standard was read by all data collectors. Where a data collector was unsure of a label, it was presented to an alternative data collector for verification. Where uncertainty or inconsistency between investigators arose, a photograph of the label was taken for further verification. 2.2.3 Pregnancy warning label legibility and prominence Pregnancy warning label legibility and prominence was assessed to the Food Standards Australia New Zealand standard 1.2.9 on Legibility Requirements. Using these guidelines field researchers reviewed and evaluated each pregnancy warning label and provided an assessment of below, average or above average. Legibility assessment requirements involved researchers evaluating the labels size, distinction against other stimuli, message complexity, exclusion area/bordering, spacing, font type and text casing (if applicable). Prominence assessment requirements involved researchers evaluating the labels size, location and position on packaging or label or labels, the noticeable nature of the text or picture, colour and image contrast, bordering, font differences, spacing and segmenting from other label stimuli. It should be noted that external factors affecting legibility and prominence of how easily a consumer can read food labels at point of sale were not taken into consideration for this study. Labels which presented the assessment factors in a suitable manner were evaluated and noted as standard for both legibility and prominence. Those which utilised only some factors or were considered too difficult to distinguish or see amongst the labels logo, product title text, product description and overall location of the warning on packaging or label were evaluated and noted as below standard. Labels assessed as above standard featured assessment factors but tended to be larger in size, have greater contrast in both colour, font type (if applicable) and be positioned in a more accessible site on the label or package. These factor in turn create a warning which is far more dominant and visible on the label or packaging warranting the above standard evaluation.
Alcohol and Pregnancy Labelling Evaluation - Appendices 16
2.3 List of market leading products by market and percentage of market by volume
Beer % (Vol) Cider % (Vol) XXXX Gold 12.7% Strongbow 29.6% Victoria Bitter 11.9% Somersby 15.2% Carlton Draught 5.8% Rekorderlig 13.1% Corona Extra 5.5% Tooheys 5seeds 12.5% Carlton Dry 4.9% Mercury 5.4% Tooheys New 4.9% Tooheys X-dry 4.2% Carlton Mid Str 3.9% Crown Lager 2.7% Coopers Pale Ale 2.5% Hahn Super Dry 2.2% Pure Blonde Premium 2.2% Heineken Lager 1.6% Hahn Prm Lgt 1.6% Boags Premium 1.5% West End Draught 1.4% XXXX Summer Bright Lager 1.4% Cascade Prm Light 1.2% Hahn Super Dry 3.5% 1.2% Cold 1.1% XXXX Bitter 1.1%
Alcohol and Pregnancy Labelling Evaluation - Appendices 17
Wine % (Vol) Wine % (Vol) Wine % (Vol) Wine % (Vol) Jacobs Creek Classic 3.4 De Bortoli Sacrd Hl 0.9 Brancott Est Classic 0.5 Penfolds Bin 0.3 Yellowglen Everyday 3.0 Bowlers Run 0.9 Stanley Fortified 0.5 R/Mount Dmnd Blends 0.3 Gossips 2.9 Jacobs Creek Reserve 0.8 Grant Burge Other 0.5 Killawarra 0.3 Brown Brothers 2.6 Rosemount Dmnd Lbl 0.8 Baily & Baily Slhtt 0.5 Overstone 0.3 Cleanskin 2.4 Crittenden & Co 0.8 Rumours 0.5 Cradle 0.3 Wolf Blass Red Lbl 2.1 Villa Maria Pb 0.8 Wynns Coonawrra 0.5 Devil's Lair Hidden Cave 0.3 Wolf Blass Eaglehawk 2.1 Hardys R&R 0.8 Counting Sheep 0.5 De Bortoli 0.3 Mcguigan Blk LB 1.9 McWilliams Inheritance 0.7 Amiri 0.5 Ingoldby 0.2 Yellow Tail 1.7 Jamiesons Run 0.7 Jacobs Creek Cool Harvest 0.5 Zonin 0.2 Jacobs Creek Spklg 1.6 Yellowglen Vintage 0.7 Tangaroa 0.4 Story Bay 0.2 Oyster Bay 1.6 Renmano Fortifieds 0.7 McWilliams Hanwood Estate 0.4 The Emerald 0.2 Banrock Station Val 1.5 Whispers 0.7 Wither Hills 0.4 Jansz 0.2 Lindeman's Bin Series 1.5 Yellowglen Jewel 0.7 Brookland Valley V1 0.4 Vasse Felix 0.2 Penfolds Koonunga Hill 1.4 Yalumba Y Series 0.7 Jacobs Creek Trilogy 0.4 Hidden Gem 0.2 Houghton Other 1.3 Wolf Blass Yllw Lbl 0.6 Pleasant Valley 0.4 Super Value 0.2 Fifth Leg 1.2 Hardys Stamp 0.6 Riccadonna 0.4 Zilzie Est 0.2 Penfolds Rawsons Ret 1.1 Passion Pop 0.6 Shingle Peak 0.4 Omni Nv 0.2 Annie's Lane 1.1 Taylors Promise Land 0.6 Moet & Chandon Imperial 0.4 De Bortoli Premium 1.1 Seaview 0.6 Wirra Wirra 0.4 Giesen 1.0 Chandon 0.6 De Bortoli Accomplice 0.3 Taylors Estate 1.0 Matua Marlborough 0.6 Obikwa 0.3 Lindeman's Early Harvest 1.0 Pepperjack 0.6 St Andrews Est 0.3 Stoneleigh Core 0.9 McWilliams Royal Reserve 0.6 Cleanskin T/Choice 0.3 Evans & Tate Classic 0.9 South Island 0.6 Secret Stone Marlb 0.3 Wyndham Est Bin 0.9 McWilliams Fortifieds 0.5 Stones Ginger 0.3 Arrogant Frog 0.3 Peter Lehmann 0.5 Hardys Nottage Hill 0.3 Goundrey Hmstd 0.3 Golden Oak 0.5 St Hallett 0.3
Alcohol and Pregnancy Labelling Evaluation - Appendices 18
Spirits % (L) RTD % (L) Jim Beam White 7.7% Jim Beam White 16.0% Smirnoff Red 7.4% Jack Daniels 13.0% Bundaberg Up 7.3% Bundaberg Up 10.0% Johnnie W Red 7.3% Woodstock Black 5.7% Jack Daniels 4.6% Canadian Club 4.8% Baileys 3.0% UDL 4.8% Grants 2.0% Cruiser Core 4.0% Wild Turkey 86.8 1.8% Smirnoff Ice Dbl Bk 3.7% ABSOLUT Core 1.7% Johnnie W Red 3.6% Bacardi Superior 1.7% Wild Turkey 2.8% Gordons 1.6% Wild Turkey 101 2.0% Canadian Club 1.6% Bundaberg Red 1.8% Chivas Regal 1.5% Cougar 1.4% Johnnie W Black 1.3% Mcallister 1.3% Black Douglas 1.3% Jameson 1.2% Dewars White Label 1.1% Southern Comfort 1.1% Captain Morgan 1.0% Ballantines 0.9% Kahlua 0.9% St Agnes 0.9% Bundaberg Red 0.9%
Alcohol and Pregnancy Labelling Evaluation - Appendices 19
Appendix 3: An estimated cost to industry of voluntary initiative Siggins Miller sent an invitation letter and survey link to peak alcohol industry associations to distribute to their members. The peak alcohol industry associations involved Brewers, DSICA, Diageo, WFA and Accolade Wines. The survey was open from the 11th to 30th of April. Survey completion rates were monitored to determine whether small, medium and large producers from all alcohol markets were represented in the survey responses. Follow ups with peak associations were followed-up in cases where markets were poorly represented. The majority of respondents to the industry survey of labelling costs were from companies where the main activity was manufacturing (n=10, 83.33%). As seen in Table 9: below, the other two respondents were an importer/distributor company and an industry representative. Table 9: Nature of respondent company’s activities Company activities n (12) % Manufacturer 10 83.33 Importer/distributor 1 8.33 Industry representative 1 8.33
Product markets Respondents represented companies from all alcohol markets: beer, cider, wine, spirits and RTD alcohol beverages (refer Table 10). The most common market in which respondent’s products were sold was the wine market (n=8, 66.67%), whereas the least represented market was cider (n=2, 16.67%). A third of respondents (n=4, 33.33%) had products in more than one market (eg beer, cider and spirits), whereas the remaining respondents sold products in only one market. Table 10: Markets respondent company products sold in Market n (12) %* Wine 8 66.67 Spirit 5 41.67 Ready to Drink (RTD) alcoholic beverages 5 41.67 Beer 3 25.00 Cider 2 16.67 *Percentages are presented as the proportion of all respondents to this question who have product in each market, therefore percentages do not add up to 100 In total, 14 responses to the survey were received which included small, medium and large companies. This is inclusive of both complete and incomplete responses, as several respondents did not provide responses to some questions. Percentages reported are presented as proportions of total respondents who answered each question, as opposed to the total number of respondents who completed the entire survey. Industry participant details Role in company 11 respondents indicated their role in their company. These included: CEO Government Relations Manager Group supply chain manager
Alcohol and Pregnancy Labelling Evaluation - Appendices 20
Head of Global Regulatory Affairs Insights Director Australia, New Zealand and South East Asia Logistics & Supply Director Marketing Co-Ordinator Marketing Manager Purchasing Packaging and Senior Management Winemaker and Director 3.1 Average cost estimates Estimates were provided by eight respondents for the total costs associated with implementing pregnancy health labels across each of the identified cost items. No estimated total costs were provided for any additional cost items (ie material write offs and relabelling of imported products). Where a respondent only provided a range of values, the midpoint was calculated as an estimate the average cost. The opportunity cost of the package space that a pregnancy health warning occupies as well as the potential benefit from improving a company’s reputation (from including a pregnancy health warning on their products) were identified as potential key indirect costs and benefits. However, the indirect costs and benefits associated with including a pregnancy health warning, whilst potentially not insignificant, were not included in the final estimated cost to industry. 3.2 Estimating the total cost to industry The total cost to industry is estimated as the number of SKUs that have adopted the pregnancy health warning multiplied by the proportion of manufacturers that incurred a cost associated with implementing the pregnancy health warning multiplied by the total cost per SKU implementing the change to labels.
Alcohol and Pregnancy Labelling Evaluation - Appendices 21
Appendix 4: Consumer awareness online survey detailed methods and data analyses Consumer awareness online survey The overarching aims of the consumer awareness online survey component of the evaluation are: 1. Examining consumer awareness of the alcohol warnings on labels 2. Understanding of the message and/or pictograms they contain. Identification and recall of messages and/pictograms is an important element of evaluation. An examination of awareness requires asking respondents if they have seen any pregnancy-related warning labels on alcohol containers. Establishing whether they understand the messages seen involves questions about recall of messages and how they understand them. Attention will be given to reaching Aboriginal and Torres Islander communities to minimize any bias resulting from online survey method as far as possible The survey must stay within scope and not seek to measure changes in behavioural intentions, attitude change or behaviour change as the evaluation is an implementation evaluation only, and the labels are expected to affect awareness but in and of themselves, they are not expected to change attitudes or behaviour. 4.1 Data collection methodology Full ethical clearance for the online survey under protocol number MKT.06/14/HREC was obtained on 6 March 2014 from Griffith University Human Research Ethics Committee. An online approach was selected due to its ability to reach a broad range of respondents quickly and cost effectively. Furthermore, an online methodology minimises response biases, such as social desirability response, that are commonly observed for sensitive topics. The reach of the survey included: A whole of community survey to reach people around women Attention will be given to reaching Aboriginal and Torres Islander people to minimise any bias resulting from online survey method. The survey comprised closed questions, Likert type scale responses (eg strongly agree to strongly disagree) and open-ended questions. The survey will be conducted online through Griffith University’s Lime Survey Software. A judgment and snowball sampling design will be used for this project to enable widespread contact with the target community. A targeted online campaign was be used to reach women who are planning to become pregnant, are currently pregnant or have recently had a child. Banner advertisements and invitations were posted on sites such as: pregnancy planning websites and blogs maternity hospital and obstetrician websites fertility clinics parenting websites and blogs – Mamma Mia, BubHub, Hoopla, Essential Baby, Raising Children Network, Raising Baby online social media websites ninemsn Facebook Twitter
Alcohol and Pregnancy Labelling Evaluation - Appendices 22
Griffith University web site Social media pages. The survey was announced via social media and through a coordinated press release ensuring maximum uptake. Snowball sampling involved asking respondents to refer friends and family members to the survey. The survey was set to capture the referrer URL used by respondents. A commercial online survey recruitment provider was also used to assist with obtaining an adequate response nationally. They were provided with the following sampling framework and target response rates: Sample size: 3, 600 (600 per target group) Six groups: 1. Pregnant women (18 - 50 years, mean age expected to be 31 years) 2. Women planning to have a child in the next 18 months (18 - 50 years, mean age expected to be 31 years) 3. Women with a child under 18 months of age (18 - 50 years, mean age expected to be 31 years) 4. Males whose partner is one of the following: currently pregnant, planning to become pregnant within 18 months or has a child under 18 months of age (18+ years) 5. People with an adult child who is one of the following: currently pregnant, planning to become pregnant within 18 months or has a child under 18 months of age (18+ years) 6. Adults over 18 Aged 18 and over with representation from: both university educated and non-university educated low-income earners, mid-income earners and high-income earners 2.5% indigenous representation nationally Geographic spread for each group: each state and territory should be represented (approximate breakdown across states): NSW-25% Vic-25% Qld-20% SA-10% WA-5% Tas-5% NT-5% ACT-5%
Alcohol and Pregnancy Labelling Evaluation - Appendices 23
Table 11: Consumer awareness survey sample framework Target Group Target Actual Pregnant 600 848 Planning 600 648 Child under 18 months 600 1,606 Partner 600 281 Parents of adult child 600 1,188 Other over 18 600 855 NSW 25% 1,657 (30.7%) 32.0% Vic 25% 1,252 (23.2%) 24.8% Qld 20% 1,395 (25.8%) 20.1% SA 10% 450 (8.3%) 7.2% WA 5% 485 (9.0%) 10.9% Tas 5% 325 (6.0%) 2.2% NT 5% 33 (0.6%) 1.0% ACT 5% Included in NSW 1.6% Australian Bureau of Statistics11
4.2 Online survey design A key aim of this survey is to evaluate unprompted awareness of alcohol warnings on labels. To ensure unprompted awareness is gained the purpose of the survey cannot be revealed until after exposure to the labels in the online survey. Any indication the survey is about warning labels prior to exposure in the survey will bias awareness results upwards and a true estimate of unprompted awareness is a necessary component in this methodology to evaluate label awareness. A statement prior to submission for completion of the survey will be made to ensure respondents are comfortable with submitting their responses as follows: This study is funded by the Department of Health. Your feedback is assisting the Department’s evaluation of the voluntary labelling initiative to place pregnancy warning labels on alcohol products. Thank you for assisting this research. The survey submission button was placed after this statement to ensure respondents are fully aware of the purpose of the survey.
11 Australian Bureau of Statistics (2013). Australian Demographic Statistics, Catalogue 3101.0. Accessed 27 May 2013 from http://www.abs.gov.au/ausstats/[email protected]/mf/3101.0
Alcohol and Pregnancy Labelling Evaluation - Appendices 24
Key constructs and measures were:
Key constructs Key demographic items Label awareness Gender Message understanding Age Employment status Educational attainment Ethnicity Postcode Pregnancy details Household size Number of children Incentives To achieve a good response rate from the public for an online survey, we offered incentives of $50 VISA vouchers to complete the questionnaire. This is standard in market research. The Survey Protocol at 4.4 below shows the draft email invitation and banner advertising copy. The incentive of an equal chance to win one of fifteen $50 Visa Pre Paid cards will be offered to encourage participation in the research. A link in the online survey to the terms and conditions was included for the prize draw (see the Survey Protocol below at Appendix 4.4). Participants were asked to enter a valid email address to qualify for the competition. This email address was stored separately to responses. Participants were also invited to refer others to participate in the research (see Appendix 4.4). Participants who entered valid email addresses of their friends (who subsequently completed the survey) were eligible to enter the prize draw. Email invitations were issued to the email addresses by Dr Joy Parkinson. Subsequent completion of the survey was assessed by identifying linked email addresses and the completed survey. An incentive of an equal chance to win one of five $50 Visa Pre Paid cards was offered to respondents who recommended others for the study. The survey questions are presented at 4.4 below. Participant Consent The full participant information sheet was provided to the participants via a link on the first page of the survey. The front page of the survey protocol informed participants that the survey was voluntary and confidential and that they could withdraw at any time without penalty, up until they submitted the survey. It also informed participants that submitting the online questionnaire was accepted as their consent to participate in the project. All participants had to actively self-select to participate in the research by clicking on the survey link and then by clicking on the submit button at the end of the survey. 4.3 Data analyses Bivariate and multivariate analysis will be undertaken with all data and we will analyse the data based on the total sample and by groups. We will compare results between each of the four target groups, women who are planning to become pregnant, women who are currently pregnant, women who have recently had a baby (child aged under 18 months) and partners. We will undertake detailed analysis and description of the findings, including frequencies and cross-tabulations, tables and charts to illustrate the results where appropriate, and commentary on the results including summaries for key sections of the draft final report.
Alcohol and Pregnancy Labelling Evaluation - Appendices 25
4.4 Survey protocol
Consumer awareness online survey Griffith University and Siggins Miller Social want to understand your thoughts and opinions about alcohol labelling. For a chance to win one of fifteen $50 Visa Pre paid cards, adults over the age of 18 are invited to complete this 10 minute survey. Your participation in this survey is completely voluntary and confidential. You are free to withdraw from the survey, without penalty, at any time up until you submit the survey. By submitting the survey you are providing your consent to participate in the research. For further information please click here. There are 34 questions in this survey Some people drink more or less than others, depending on their lifestyle and individual choices. How long ago did you last have an alcoholic drink? Please choose only one of the following: 1 week or less More than 1 week, less than 2 weeks 2 weeks to less than 1 month 1 month to less than 3 months 3 months to less than 12 months 12 months More than 12 months Never Don't remember Message awareness Are you aware of any messages or campaigns about drinking alcohol when pregnant? Please choose only one of the following: Yes No Please describe any messages or campaigns you have seen: Only answer this question if the following conditions are met: Answer was 'Yes' at question '2 [UNPromAW]' ( Are you aware of any messages or campaigns about drinking alcohol when pregnant? ) Please write your answer here:
Alcohol and Pregnancy Labelling Evaluation - Appendices 26
Consumer awareness online survey Where have you seen or heard the messages to encourage pregnant women not to drink alcohol while pregnant? Only answer this question if the following conditions are met: ° Answer was 'Yes' at question '2 [UNPromAW]' ( Are you aware of any messages or campaigns about drinking alcohol when pregnant? ) Please choose all that apply: On alcohol products
In licensed retail outlets Other licensed outlets such as services clubs, sports clubs or pubs Medical practitioner offices Other: Please specify On which alcohol products (e.g. cans, bottles, casks) did you see the warnings? Only answer this question if the following conditions are met: ° Answer was 'Yes' at question '2 [UNPromAW]' ( Are you aware of any messages or campaigns about drinking alcohol when pregnant? ) and Answer was at question '4 [UNPromAW2]' ( Where have you seen or heard the messages to encourage pregnant women not to drink alcohol while pregnant? ) Please choose all that apply: Wine Beer Spirits Cider Premixers e.g. Cruisers, UDLs Other. Please specify Labelling
Have you seen the above label? Please choose only one of the following: Yes No
Alcohol and Pregnancy Labelling Evaluation - Appendices 27
Consumer awareness online survey
What does this label mean to you? Please write your answer here:
Labelling continued Have you seen the above warning label? Please choose only one of the following: Yes No
What does this label mean to you? Please write your answer here: Another label
Have you seen the above warning label? Please choose only one of the following: Yes No What does this label mean to you? Please write your answer here:
Labelling cont'd
Alcohol and Pregnancy Labelling Evaluation - Appendices 28
Consumer awareness online survey
Have you seen the above label? Please choose only one of the following: Yes No What does this label mean to you? Please write your answer here:
About you Which of the following statements best describes you? Please choose only one of the following: I'm pregnant I'm planning to become pregnant in the next two years I'm a mum to a child under 18 months of age My partner is pregnant My partner is planning to become pregnant in the next two years I'm a dad to a child under 18 months of age My adult child (or their partner) is pregnant My adult child (or their partner) is planning to become pregnant in the next to years My adult child has a child under 18 months of age None of the above How many weeks pregnant Please choose only one of the following: 1 Numbered options through to 40 weeks 40 What is your gender? Please choose only one of the following: Female Male What was your age at your last birthday? Please choose only one of the following:
Alcohol and Pregnancy Labelling Evaluation - Appendices 29
Consumer awareness online survey
18 Numbered options through to 100 years 100 What is your current relationship status? Please choose only one of the following: Single Married/De facto relationship Separated Divorced Widowed What is the highest level of education you have completed? Please choose only one of the following: Never attended school Some primary school Completed primary school Some high school Completed high school (i.e. Year 12, Form 6, HSC) TAFE or Trade Certificate or Diploma Undergraduate degree Postgraduate degree Other: Please specify Are you of Aboriginal or Torres Strait Islander origin? Please choose only one of the following: No Yes, Aboriginal Yes, Torres Strait Islander Yes, both Aboriginal and Torres Strait Islander
What is the post code where you live? Please write your answer here:
Which one of the following best describes your situation? Please choose only one of the following: Employed (Fulltime/part-time/casual/contract) Employed, currently on maternity leave Retired Unemployed Engaged in home duties Student Other
Alcohol and Pregnancy Labelling Evaluation - Appendices 30
Consumer awareness online survey
Before tax is taken out, which of the following ranges best describes your household's approximate income, from all sources, over the last 12 months? Please choose only one of the following: Less than $10 000 $10 000 - less than $20 000 $20 000 - less than $40 000 $40 000 - less than $60 000 $60 000 - less than $80 000 $80 000 - less than $100 000 $100 000 - less than $120 000 $120 000 and over No answer In which country were you born? Please choose only one of the following: Australia China Germany Greece Hong Kong India Ireland Italy Lebanon Malaysia Malta Netherlands New Zealand Philippines Poland South Africa Turkey United Kingdom (England, Northern Ireland, Scotland, Wales) USA Vietnam Yugoslavia (the former republic) Other What language do you mainly speak at home? Please choose only one of the following: English Arabic Cantonese/Mandarin Greek Italian
Alcohol and Pregnancy Labelling Evaluation - Appendices 31
Consumer awareness online survey
Serbian/Croatian/Bosnian Spanish Tagalog Vietnamese Other How many people live in your household? Please choose only one of the following: 1 Numbered options through to 20 people 20 Do you have any children? Please choose only one of the following: Yes No How many children do you have? Only answer this question if the following conditions are met: ° Answer was 'Yes' at question '27 [children1]' ( Do you have any children? ) Please choose only one of the following: 1 Numbered options through to 20 20 Is your youngest child under 18 months of age? Only answer this question if the following conditions are met: ° Answer was 'Yes' at question '27 [children1]' ( Do you have any children? ) Please choose only one of the following: Yes No How old is your youngest child in months? Only answer this question if the following conditions are met: ° Answer was 'Yes' at question '27 [children1]' ( Do you have any children? ) and Answer was 'Yes' at question '29 [children2]' ( Is your youngest child under 18 months of age? ) Please choose only one of the following: 1 Numbered options through to 18 months 18 Prize draw Terms and conditions To thank you for your participation in our survey we would like to invite you to enter a draw to win one (1) of 15 $50 VISA Pre-paid cards. Would you like to be entered into the prize draw to win one of fifteen $50 VISA Pre-paid cards for completing the survey? Please choose only one of the following: Yes No
Alcohol and Pregnancy Labelling Evaluation - Appendices 32
Consumer awareness online survey
Email Please provide your email address to be entered into the prize draw Only answer this question if the following conditions are met: ° Answer was 'Yes' at question '31 [prize_draw1]' ( Terms and conditions: To thank you for your participation in our survey we would like to invite you to enter a draw to win one (1) of 15 $50 VISA Pre- paid cards. Would you like to be entered into the prize draw to win one of fifteen $50 VISA Pre-paid cards for completing the survey? ) Please write your answer here:
Terms and conditions Do you know other people who are over 18 years of age who would like to complete the survey? Would you like to be entered into the prize draw to win one (1) of 5 $50 VISA Pre-paid cards for referring other people to complete the survey? You will need to provide both your email address and the email address/es for the person/people you are referring. Please choose only one of the following: Yes No Would you like to be entered into the prize draw to win one of five $50 VISA cards for referring other people to complete the survey? Only answer this question if the following conditions are met: ° Answer was 'Yes' at question '33 [prize_draw_referral]' ( Terms and conditions Do you know other people who are over 18 years of age who would like to complete the survey? Would you like to be entered into the prize draw to win one (1) of 5 $50 VISA Pre-paid cards for referring other people to complete the survey? You will need to provide both your email address and the email address/es for the person/people you are referring. ) Please write your answer(s) here: Yes, please provide your email address Yes, please provide the email addresses for the people you are referring Thank you for your time. 01.01.1970 – 10:00 Submit your survey. Thank you for completing this survey.
Alcohol and Pregnancy Labelling Evaluation - Appendices 33
Table 12: Detailed analyses by target group, of awareness and understanding of pregnancy health warning labels on alcohol products Question Response Pregnant Planning Mother Pregnant Planning Father Adult child Adult child Adult child Other/ Total categories Female Female Male Male is is planning has child None of pregnant pregnant under 18 the above months Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Or Or Or Or Or Or Or Or Or Or Or Freq. (%) Freq. (%) Freq. (%) Freq. (%) Freq. (%) Freq. (%) Freq. (%) Freq. (%) Freq. (%) Freq. (%) Freq. (%12)
Pregnant? N/A 21.9 (10.4) N/A N/A 20.4 (10.5) N/A N/A 22.4 (10.1) N/A N/A N/A 22..1 How many N=848 N=64 N=281 (10.2) weeks N=1024 pregnant?
Age N/A 29.1 (4.7) 29.9 (5.7) 29.7 (4.6) 34.3 (6.3) 35 (6.5) 36.6 (6.8) 58.2 (8.1) 58.9 (8.2) 59.4 (8.1) 49.4 (15.5) 39.5 (15.0) What was your N=848 N=648 N=1606 N=64 N=105 N=112 N=281 N=284 N=622 N=855 N=5429 age at your last birthday?
Household N/A 3.1 (1.3) 2.9 (1.3) 3.9 (1.1) 3.4 (2.1) 2.9 (1.2) 4.0 (1.3) 2.5 (1.5) 2.3 (1.0) 2.2 (1.1) 2.6 (1.3) 3.1 (1.4) How many N=843 N=646 N=1590 N=64 N=112 N=112 N=281 N=284 N=621 N=853 N=5399 people live in your household? Children 2 N/A 1.6 (1.2) 1.6 (1.1) 1.8 (1.0) 1.7 (1.0) 1.6 (1.0) 2.1 (1.2) 3.0 (1.3) 2.8 (1.6) 2.9 (1.3) 2.6 (1.2) 2.2 (1.3) How many N=521 N=300 N=1575 N=38 N=49 N=112 N=268 N=278 N=605 N=649 N=4396 children do you have?
12 Percentages reported in the table are percentages of the whole sample
Alcohol and Pregnancy Labelling Evaluation - Appendices 34
Question Response Pregnant Planning Mother Pregnant Planning Father Adult child Adult child Adult child Other/ Total categories Female Female Male Male is is planning has child None of pregnant pregnant under 18 the above months Children 4 How N/A 13.1 (4.6) 10.5 (6.2) 8.8 (5.2) 7.5 (6.3) 7.8 (4.3) 9.6 (5.2) N=0 11.5 (5.0) 8.8 (5.9) 10.1 (6.3) 9.2 (5.3) old is your N=129 N=57 N=1531 N=8 N=12 N=103 N=2 N=8 N=12 N=1862 youngest child in months? Relationship Single 32 (0.6%) 43 (0.8%) 66 (1.2%) 3 (0.1%) 2 (0.0%) 3 (0.1%) 11 (0.2%) 6 (0.1%) 16 (0.3%) 121 (2.2%) 303 (5.6%) Status Relationship Married/ 807 598 1507 60 (1.1%) 103 (1.9%) 109 (2.0%) 222 (4.1%) 217 (4.0%) 485 (8.9%) 600 (11%) 4708 Status De Facto (14.9%) (11.0%) (27.8%) (86.8%) Relationship Separated 6 (0.1%) 4 (0.1%) 29 (0.5%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 6 (0.1%) 11 (0.2%) 13 (0.2%) 27 (0.5%) 96 (1.8%) Status Relationship Divorced 3 (0.1%) 3 (0.1%) 4 (0.1%) 1 (0.0%) 0 (0.0%) 0 (0.0%) 29 (0.5%) 31 (0.6%) 71 (1.3%) 71 (1.3%) 213 (3.9%) Status Relationship Widowed 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 13 (0.2%) 19 (0.4%) 37 (0.7%) 36 (0.7%) 105 (1.9%) Status Relationship Total 848 648 1606 64 (1.2%) 105 (1.9%) 112 (2.1%) 281 (5.2%) 284 (5.2% 622 855 5425 Status (15.6%) (11.9%) (29.6%) (11.5%) (15.8%) (100%) Education Level Never 1 (0.0%) 1 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 2 (0.0%) Attended Education Level Some 3 (0.1%) 1 (0.0%) 1 (0.0%) 1 (0.0%) 0 (0.0%) 1 (0.0%) 1 (0.0%) 0 (0.0%) 1 (0.0%) 4 (0.1%) 13 (0.2%) Primary Education Level Completed 1 (0.0%) 2 (0.0%) 1 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 2 (0.0%) 3 (0.1%) 3 (0.1%) 3 (0.1%) 15 (0.3%) Primary Education Level Some High 52 (1.0%) 43 (0.8%) 147 (2.7%) 5 (0.1%) 3 (0.1%) 8 (0.1%) 48 (0.9%) 38 (0.7%) 129 (2.4%) 122 (2.3%) 595 School (11.1%) Education Level Completed 140 (2.6%) 100 (1.9%) 222 (4.1%) 8 (0.1%) 10 (0.2%) 10 (0.2%) 48 (0.9%) 37 (0.7%) 134 (2.5%) 154 (2.9%) 863 High (16.1%) School
Alcohol and Pregnancy Labelling Evaluation - Appendices 35
Question Response Pregnant Planning Mother Pregnant Planning Father Adult child Adult child Adult child Other/ Total categories Female Female Male Male is is planning has child None of pregnant pregnant under 18 the above months Education Level TAFE or 316 (5.9%) 233 (4.3%) 541 17 (0.3%) 19 (0.4%) 46 (0.9%) 98 (5.2%) 127 (2.4%) 212 (3.9%) 291 (5.4%) 1900 Trade Cert (10.1%) (35.4%) Education Level Undergrad 207 (3.9%) 182 (3.4%) 439 (8.2%) 23 (0.4%) 46 (0.9%) 20 (0.4%) 51 (1.0%) 36 (0.7%) 85 (1.6%) 163 (3.0%) 1251 Degree (23.3%) Education Level Postgrad 115 (2.1%) 83 (1.5%) 239 (4.5%) 10 (0.2%) 27 (0.5%) 26 (0.5%) 32 (0.6%) 38 (0.7%) 49 (0.9%) 109 (2.0%) 728 Degree (13.6%) Education Level Total 835 645 1590 64 (1.2%) 105 (2.0%) 111 (2.1%) 280 (5.2%) 279 (5.2%) 613 846 5368 (15.6%) (12.0%) (29.6%) (11.4%) (15.8%) (100%) Indigenous No 822 622 1565 61 (1.1%) 100 (1.9%) 109 (2.0%) 275 (5.1%) 281 (5.2%) 614 6810 5259 Status (15.2%) (11.5%) (29.0%) (11.4%) (15.0%) (97.4%) Indigenous Yes 23 (0.4%) 18 (0.3%) 38 (0.7%) 0 (0.0%) 4 (0.1%) 2 (0.0%) 4 (0.1%) 2 (0.0%) 7 (0.1%) 33 (0.6%) 131 (2.4%) Status Aboriginal Indigenous Yes 1 (0.0%) 1 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 2 (0.0%) 4 (0.1%) Status Torres Strait Islander Indigenous Yes Both 0 (0.0%) 3 (0.1%) 1 (0.0%) 2 (0.0%) 0 (0.0%) 0 (0.0%) 1 (0.0%) 0 (0.0%) 0 (0.0%) 1 (0.0%) 8 (0.1%) Status A & TSI Indigenous Total 846 644 1604 63 (1.2%) 104 (1.9%) 111 (2.1%) 280 (5.2%) 283 (5.2%) 621 846 5402 Status (15.7%) (11.9%) (29.7%) (11.5%) (15.7%) (100%) Employment Employed 476 (9.1%) 473 (9.0%) 504 (9.6%) 60 (1.1%) 96 (1.8%) 100 (1.9%) 139 (2.6%) 131 (2.5%) 256 (4.9%) 423 (8.1%) 2658 Status (50.6%) Employment Full Time 81 (1.5%) 7 (0.1%) 409 (7.8%) 2 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (0.0%) 4 (0.1%) 504 (9.6%) Status currently Maternity leave Employment Retired 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (0.0%) 3 (0.1%) 95 (1.8%) 99 (1.9%) 254 (4.8%) 218 (4.2%) 670 Status (12.8%)
Alcohol and Pregnancy Labelling Evaluation - Appendices 36
Question Response Pregnant Planning Mother Pregnant Planning Father Adult child Adult child Adult child Other/ Total categories Female Female Male Male is is planning has child None of pregnant pregnant under 18 the above months Employment Unemploy 26 (0.5%) 26 (0.5%) 44 (0.8%) 1 (0.0%) 3 (0.1%) 1 (0.0%) 11 (0.2%) 9 (0.2%) 15 (0.3%) 47 (0.9%) 183 (3.5%) Status ed Employment Home 207 (3.9%) 96 (1.8%) 557 1 (0.0%) 2 (0.0%) 5 (0.1%) 28 (0.5%) 31 (0.6%) 71 (1.4%) 90 (1.7%) 1088 Status Duties (10.6%) (20.7%) Employment Student 35 (0.7%) 31 (0.6%) 43 (0.8%) 0 (0.0%) 1 (0.0%) 1 (0.0%) 0 (0.0%) 2 (0.0%) 2 (0.0%) 34 (0.6%) 149 (2.8%) Status Employment Total 825 633 1557 64 (1.2%) 103 (2.0%) 110 (2.1%) 273 (5.2%) 272 (5.2%) 599 816 5252 Status (15.7%) (12.1%) (29.6%) (11.4%) (15.5%) (100%) Language English 809 604 1525 54 (1.0%) 94 (1.8%) 97 (1.8%) 275 (5.2%) 278 (5.3%) 612 815 5163 (15.4%) (11.5%) (29.0%) (11.6%) (15.5%) (98%) Language Other 13 (0.2%) 18 (0.3%) 30 (0.5%) 3 (0.1%) 4 (0.1%) 7 (0.2%) 3 (0.1%) 2 (0.0%) 4 (0.1%) 20 (0.4%) 104 (2.0%) Languages Language Total 822 622 1555 57 (1.1%) 98 (1.9%) 104 (2.0%) 278 (5.3%) 280 (5.3%) 616 835 5267 (15.6%) (11.8%) (29.5%) (11.7%) (15.9%) (100%) Before Tax Less than 8 (0.2%) 11 (0.2%) 18 (0.3%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 2 (0.0%) 3 (0.1%) 15 (0.3%) 29 (0.6%) 86 (1.7%) Income $10 000 Before Tax $10 000 - 21 (0.4%) 22 (0.4%) 55 (1.1%) 3 (0.1%) 0 (0.0%) 4 (0.1%) 15 (0.3%) 18 (0.3%) 37 (0.7%) 63 (1.2%) 238 (4.6%) Income less than $20 000 Before Tax $20 000 - 74 (1.4%) 59 (1.1%) 132 (2.5%) 5 (0.1%) 13 (0.3%) 9 (0.2%) 64 (1.2%) 46 (0.9%) 149 (2.9%) 141 (2.7%) 692 Income less than (13.3%) $40 000 Before Tax $40 000 - 123 (2.4%) 87 (1.7%) 216 (4.2%) 6 (0.1%) 13 (0.3%) 14 (0.3%) 46 (0.9%) 50 (1.0%) 127 (2.4%) 167 (3.2%) 849 Income less than (16.3%) $60 000 Before Tax $60 000 - 116 (2.2%) 104 (2.0%) 296 (5.7%) 13 (0.3%) 16 (0.3%) 19 (0.4%) 43 (0.8%) 49 (0.9%) 97 (1.9%) 119 (2.3%) 872 Income less than (16.8%) $80 000
Alcohol and Pregnancy Labelling Evaluation - Appendices 37
Question Response Pregnant Planning Mother Pregnant Planning Father Adult child Adult child Adult child Other/ Total categories Female Female Male Male is is planning has child None of pregnant pregnant under 18 the above months Before Tax $80 000 - 153 (2.9%) 105 (2.0%) 299 (5.8%) 13 (0.3%) 21 (0.4%) 18 (0.3%) 36 (0.7%) 36 (0.7%) 64 (1.2%) 109 (2.1%) 854 Income less than (16.4%) $100 000 Before Tax $100 000 - 133 (2.6%) 112 (2.2%) 255 (4.9%) 9 (0.2%) 17 (0.3%) 18 (0.3%) 23 (0.4%) 28 (0.5%) 39 (0.8%) 73 (1.4%) 707 Income less than (13.6%) $120 000 Before Tax $120 000 198 (3.8%) 121 (2.3%) 299 (5.8%) 15 (0.3%) 22 (0.4%) 27 (0.5%) 34 (0.7%) 29 (0.6%) 57 (1.1%) 95 (1.8%) 897 Income and over (17.3%) Total 826 621 1570 64 (1.2%) 102 (2.0%) 109 (2.1%) 263 (5.1%) 259 (5.0%) 585 796 5195 (15.9%) (12.0%) (30.2%) (11.3%) (15.3%) (100%) Do you have Yes 521 (9.7%) 300 (5.6%) 1575 38 (0.7%) 49 (0.9%) 112 (2.1%) 268 (5.0%) 278 (5.2%) 605 649 4395 children? (29.3%) (11.2%) (12.1%) (81.7%) Do you have No 318 (5.9%) 343 (6.4%) 5 (0.1%) 26 (0.5%) 56 (1.0%) 0 (0.0%) 13 (0.2%) 6 (0.1%) 14 (0.3%) 202 (3.8%) 983 children? (18.3%) Do you have Total 839 643 1580 64 (1.2%) 105 (2.0%) 112 (2.1%) 281 (5.2%) 284 (5.3%) 619 851 5378 children? (15.6%) (12.0%) (29.4%) (11.5%) (15.8%) (100%) Is your Yes 129 (2.9%) 57 (1.3%) 1532 8 (0.2%) 12 (0.3%) 103 (2.3%) 0 (0.0%) 2 (0.0%) 8 (0.2%) 12 (0.3%) 1863 youngest child (34.9%) (42.4%) under 18 months? Is your No 392 (8.9%) 243 (5.5%) 43 (1.0%) 30 (0.7%) 37 (0.8%) 9 (0.2%) 268 (6.1%) 276 (6.3%) 597 637 2532 youngest child (13.6%) (14.5%) (57.6%) under 18 months? Is your Total 521 300 (6.8%) 1580 38 (0.9%) 49 (1.1%) 112 (2.5%) 268 (6.1%) 278 (6.3%) 605 649 4395 youngest child (11.9%) (35.8%) (13.8%) (14.8%) (100%) under 18 months?
Alcohol and Pregnancy Labelling Evaluation - Appendices 38
Question Response Pregnant Planning Mother Pregnant Planning Father Adult child Adult child Adult child Other/ Total categories Female Female Male Male is is planning has child None of pregnant pregnant under 18 the above months SEIFA 1-3 183 (3.4%) 163 (3.0%) 353 (6.6%) 13 (0.2%) 15 (0.3%) 18 (0.3%) 60 (1.1%) 70 (1.3%) 164 (3.1%) 187 (3.5%) 1226 Score Category (22.9%) SEIFA 4-6 264 (4.9%) 176 (3.3%) 528 (9.9%) 22 (0.4%) 38 (0.7%) 30 (0.6%) 88 (1.6%) 88 (1.6%) 185 (3.5%) 235 (4.4%) 1654 Score Category (30.8%) SEIFA 7-10 394 (7.4%) 300 (5.6%) 708 27 (0.5%) 50 (0.9%) 60 (1.1%) 131 (2.4%) 125 (2.3%) 267 (5.0%) 415 (7.7%) 2477 Score Category (13.2%) (46.2%) SEIFA Total 841 639 1589 62 (1.2%) 103 (1.9%) 108 (2.0%) 279 (5.2%) 283 (5.3%) 616 837 5357 Score Category (15.7%) (11.9%) (29.7%) (11.5%) (15.6%) (100%) How long since 1 week or 65 (1.2%) 326 (6.0%) 650 35 (0.6%) 66 (1.2%) 82 (1.5%) 180 (3.3%) 190 (3.5%) 399 (7.4%) 514 (9.5%) 2507 last alcoholic less (12.0%) (46.2%) drink? How long since More than 22 (0.4%) 62 (1.1%) 172 (3.2%) 8 (0.1%) 16 (0.3%) 6 (0.1%) 21 (0.4%) 17 (0.3%) 38 (0.7%) 69 (1.3%) 431 (7.9%) last alcoholic 1 week drink? less than 2 How long since 2 weeks to 32 (0.6%) 55 (1.0%) 153 (2.8%) 6 (0.1%) 8 (0.1%) 5 (0.1%) 18 (0.3%) 27 (0.5%) 43 (0.8%) 55 (1.0%) 402 (7.4%) last alcoholic less than 1 drink? month How long since 1 month to 114 (2.1%) 63 (1.2%) 139 (2.6%) 1 (0.0%) 5 (0.1%) 7 (0.1%) 17 (0.3%) 21 (0.4%) 31 (0.6%) 57 (1.1%) 455 (8.4%) last alcoholic less than 3 drink? months How long since 3 months 466 (8.6%) 64 (1.2%) 136 (2.5%) 2 (0.0%) 2 (0.0%) 4 (0.1%) 13 (0.2%) 10 (0.2%) 34 (0.6%) 52 (1.0%) 783 last alcoholic to less (14.4%) drink? than 12 months How long since 12 months 58 (1.1%) 8 (0.1%) 42 (0.8%) 0 (0.0%) 0 (0.0%) 1 (0.0%) 1 (0.0%) 1 (0.0%) 3 (0.1%) 9 (0.2%) 123 (2.3%) last alcoholic drink? How long since More than 68 (1.3%) 43 (0.8%) 254 (4.7%) 2 (0.0%) 8 (0.1%) 4 (0.1%) 18 (0.3%) 11 (0.2%) 43 (0.8%) 52 (1.0%) 503 (9.3%) last alcoholic 12 months
Alcohol and Pregnancy Labelling Evaluation - Appendices 39
Question Response Pregnant Planning Mother Pregnant Planning Father Adult child Adult child Adult child Other/ Total categories Female Female Male Male is is planning has child None of pregnant pregnant under 18 the above months drink?
How long since Never 15 (0.3%) 24 (0.4%) 46 (0.8%) 10 (0.2%) 0 (0.0%) 3 (0.1%) 11 (0.2%) 6 (0.1%) 26 (0.5%) 34 (0.6%) 175 (3.2%) last alcoholic drink? How long since Don't 8 (0.1%) 3 (0.1%) 14 (0.3%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 2 (0.0%) 2 (0.0%) 5 (0.1%) 13 (0.2%) 47 (0.9%) last alcoholic remember drink? How long since Total 848 648 1606 64 (1.2%) 105 (1.9%) 112 (2.1%) 281 (5.2%) 285 (5.3%) 622 855 5426 last alcoholic (15.6%) (11.9%) (29.6%) (11.5%) (15.8%) (100%) drink? Unprompted Yes 584 378 (7.0%) 1138 31 (0.6%) 50 (0.9%) 57 (1.1%) 154 (2.8%) 177 (3.3%) 360 (6.6%) 457 (8.4%) 3386 awareness (10.8%) (21.0%) (62.4%)
Aware of any messages or campaigns about drinking alcohol when pregnant? Unprompted No 264 (4.9%) 270 (5.0%) 468 (8.6%) 33 (0.6%) 55 (1.0%) 55 (1.0%) 127 (2.3%) 108 (2.0%) 262 (4.8%) 398 (7.3%) 2040 awareness (37.6%)
Aware of any messages or campaigns about drinking alcohol when pregnant? Unprompted Total 848 648 1606 64 (1.2%) 105 (1.9%) 112 (2.1%) 281 (5.2%) 285(5.3%) 622 855 5426 awareness (15.6%) (11.9%) (29.6%) (11.5%) (15.8%) (100%)
Alcohol and Pregnancy Labelling Evaluation - Appendices 40
Question Response Pregnant Planning Mother Pregnant Planning Father Adult child Adult child Adult child Other/ Total categories Female Female Male Male is is planning has child None of pregnant pregnant under 18 the above months
Aware of any messages or campaigns about drinking alcohol when pregnant? Where have Not 597 469 (8.6%) 1125 48 (0.9%) 86 (1.6%) 91 (1.7%) 256 (4.7%) 256 (4.7%) 569 733 4230 you seen these Selected (11.0%) (20.7%) (10.5%) (13.5%) (78.0%) messages or campaigns? (on alcohol products) Where have Yes 251 (4.6%) 179 (3.3%) 481 (8.9%) 16 (0.3%) 19 (0.4%) 21 0.4%) 25 (0.5%) 29 (0.5%) 53 (1.0%) 122 (2.2%) 1196 you seen these (22.0%) messages or campaigns? (on alcohol products) Where have Total 848 648 1606 64 (1.2%) 105 (1.9%) 112 (2.1%) 281 (5.2%) 285 (5.3%) 622 855 5426 you seen these (15.6%) (11.9%) (29.6%) (11.5%) (15.8%) (100%) messages or campaigns? (on alcohol products) Where have Not 792 586 1475 58 (1.1%) 92 (1.7%) 100 (1.8%) 274 (5.0%) 277 (5.1%) 598 804 5056 you seen these Selected (14.6%) (10.8%) (27.2%) (11.0%) (14.8%) (93.2%) messages or campaigns? (in licensed retail outlets)
Alcohol and Pregnancy Labelling Evaluation - Appendices 41
Question Response Pregnant Planning Mother Pregnant Planning Father Adult child Adult child Adult child Other/ Total categories Female Female Male Male is is planning has child None of pregnant pregnant under 18 the above months Where have Yes 56 (1.0%) 62 (1.1%) 131 (2.4%) 6 (0.1%) 13 (0.2%) 12 (0.2%) 7 (0.1%) 8 (0.1%) 24 (0.4%) 51 (0.9%) 370 (6.8%) you seen these messages or campaigns? (in licensed retail outlets) Where have Total 848 648 1606 64 (1.2%) 105 (1.9%) 112 (2.1%) 281 (5.2%) 285 (5.3%) 622 855 5426 you seen these (15.6%) (11.9%) (29.6%) (11.5%) (15.8%) (100%) messages or campaigns? (in licensed retail outlets) Where have Not 802 599 1502 60 (1.1%) 96 (1.8%) 101 (1.9%) 271 (5.0%) 271 (5.0%) 598 816 5116 you seen these Selected (14.8%) (11.0%) (27.7%) (11.0%) (15.0%) (94.3%) messages or campaigns? (Other licensed outlets such as services clubs, sports clubs etc.) Where have Yes 46 (0.8%) 49 (0.9%) 104 (1.9%) 4 (0.1%) 9 0.2%) 11 (0.2%) 10 (0.2%) 14 (0.3%) 24 (0.4%) 39 (0.7%) 310 (5.7%) you seen these messages or campaigns? (Other licensed outlets such as services clubs, sports clubs etc.)
Alcohol and Pregnancy Labelling Evaluation - Appendices 42
Question Response Pregnant Planning Mother Pregnant Planning Father Adult child Adult child Adult child Other/ Total categories Female Female Male Male is is planning has child None of pregnant pregnant under 18 the above months Where have Total 848 648 1606 64 (1.2%) 105 (1.9%) 112 (2.1%) 281 (5.2%) 285 (5.3%) 622 855 5426 you seen these (15.6%) (11.9%) (29.6%) (11.5%) (15.8%) (100%) messages or campaigns? (Other licensed outlets such as services clubs, sports clubs etc.) Where have Not 433 (8.0%) 403 (7.4%) 729 52 (1.0%) 84 (1.5%) 90 (1.7%) 188 (3.5%) 180 (3.3%) 426 (7.9%) 612 3197 you seen these Selected (13.4%) (11.3%) (58.9%) messages or campaigns? (Medical Practitioner Offices) Where have Yes 415 (7.6%) 245 (4.5%) 877 12 (0.2%) 21 (0.4%) 22 (0.4%) 93 (1.7%) 105 (1.9%) 196 (3.6%) 243 (4.5%) 2229 you seen these (16.2%) (41.1%) messages or campaigns? (Medical Practitioner Offices) Where have Total 848 648 1606 64 (1.2%) 105 (1.9%) 112 (2.1%) 281 (5.2%) 285 (5.3%) 622 855 you seen these (15.6%) (11.9%) (29.6%) (11.5%) (15.8%) messages or 5426 campaigns? (100%) (Medical Practitioner Offices)
Alcohol and Pregnancy Labelling Evaluation - Appendices 43
Question Response Pregnant Planning Mother Pregnant Planning Father Adult child Adult child Adult child Other/ Total categories Female Female Male Male is is planning has child None of pregnant pregnant under 18 the above months On which Not 692 529 (9.7%) 1311 59 (1.1%) 95 (1.8%) 97 (1.8%) 263 (4.8%) 269 (5.0%) 587 775 4677 alcohol Selected (12.8%) (24.2%) (10.8%) (14.3%) (86.2%) containers have you seen these messages or campaigns? (Wine) On which Yes 156 (2.9%) 119 (2.2%) 295 (5.4%) 5 (0.1%) 10 (0.2%) 15 (0.3%) 18 (0.3%) 16 (0.3%) 35 (0.6%) 80 (1.5%) 749 alcohol (13.8%) containers have you seen these messages or campaigns? (Wine) On which Total 848 648 1606 64 (1.2%) 105 (1.9%) 112 (2.1%) 281 (5.2%) 285 (5.3%) 622 855 5426 alcohol (15.6%) (11.9%) (29.6%) (11.5%) (15.8%) (100%) containers have you seen these messages or campaigns? (Wine) On which Not 773 586 1490 56 (1.0%) 95 (1.8%) 104 (1.9%) 277 (5.1%) 279 (5.1%) 609 825 5094 alcohol Selected (14.2%) (10.8%) (27.5%) (11.2%) (15.2%) (93.9%) containers have you seen these messages or campaigns? (Beer) On which Yes 75 (1.4%) 62 (1.1%) 116 (2.1%) 8 (0.1%) 10 (0.2%) 8 (0.1%) 4 0.1%) 6 (0.1%) 13 (0.2%) 30 (0.6%) 332 (6.1%) alcohol containers have
Alcohol and Pregnancy Labelling Evaluation - Appendices 44
Question Response Pregnant Planning Mother Pregnant Planning Father Adult child Adult child Adult child Other/ Total categories Female Female Male Male is is planning has child None of pregnant pregnant under 18 the above months you seen these messages or campaigns? (Beer) On which Total 848 648 1606 64 (1.2%) 105 (1.9%) 112 (2.1%) 281 (5.2%) 285 (5.3%) 622 855 5426 alcohol (15.6%) (11.9%) (29.6%) (11.5%) (15.8%) (100%) containers have you seen these messages or campaigns? (Beer) On which Not 773 586 1490 56 (1.0%) 95 (1.8%) 104 (1.9%) 277 (5.1%) 279 (5.1%) 609 825 5094 alcohol Selected (14.2%) (10.8%) (27.5%) (11.2%) (15.2%) (93.9%) containers have you seen these messages or campaigns? (Spirits) On which Yes 75 (1.4%) 62 (1.1%) 116 (2.1%) 8 (0.1%) 10 (0.2%) 8 (0.1%) 4 (0.1%) 6 (0.1%) 13 (0.2%) 30 (0.6%) 332 (6.1%) alcohol containers have you seen these messages or campaigns? (Spirits) On which Total 848 648 1606 64 (1.2%) 105 (1.9%) 112 (2.1%) 281 (5.2%) 285 (5.3%) 622 855 5426 alcohol (15.6%) (11.9%) (29.6%) (11.5%) (15.8%) (100.0%) containers have you seen these messages or campaigns?
Alcohol and Pregnancy Labelling Evaluation - Appendices 45
Question Response Pregnant Planning Mother Pregnant Planning Father Adult child Adult child Adult child Other/ Total categories Female Female Male Male is is planning has child None of pregnant pregnant under 18 the above months (Spirits)
On which Not 776 584 1456 61 (1.1%) 101 (1.9%) 101 (1.9%) 279 (5.1%) 282 (5.2%) 618 835 5093 alcohol Selected (14.3%) (10.8%) (26.8%) (11.4%) (15.4%) (93.9%) containers have you seen these messages or campaigns? (Cider) On which Yes 72 (1.3%) 64 (1.2%) 150 3 4 11 2 3 4 20 333 alcohol (2.8%) (0.1%) (0.1%) (0.2%) (0.0%) (0.1%) (0.1%) (0.4%) (6.1%) containers have you seen these messages or campaigns? (Cider) On which Total 848 648 1606 64 105 112 281 285 622 855 5426 alcohol (15.6%) (11.9%) (29.6%) (1.2%) (1.9%) (2.1%) (5.2%) (5.3%) (11.5%) (15.8%) (100.0%) containers have you seen these messages or campaigns? (Cider) On which Not 777 579 1462 60 98 109 277 280 609 828 5079 alcohol Selected (14.3%) (10.7%) (26.9%) (1.1%) (1.8%) (2.0%) (5.1%) (5.2%) (11.2%) (15.3%) (93.6%) containers have you seen these messages or campaigns? (Premixes)
Alcohol and Pregnancy Labelling Evaluation - Appendices 46
Question Response Pregnant Planning Mother Pregnant Planning Father Adult child Adult child Adult child Other/ Total categories Female Female Male Male is is planning has child None of pregnant pregnant under 18 the above months On which Yes 71 69 144 4 7 3 4 5 13 27 347 alcohol (1.3%) (1.3%) (2.7%) (0.1%) (0.1%) (0.1%) (0.1%) (0.1%) (0.2%) (0.5%) (6.4%) containers have you seen these messages or campaigns? (Premixes) On which Total 848 648 1606 64 105 112 281 285 622 855 5426 alcohol (15.6%) (11.9%) (29.6%) (1.2%) (1.9%) (2.1%) (5.2%) (5.3%) (11.5%) (15.8%) (100.0%) containers have you seen these messages or campaigns? (Premixes) Pictogram label Yes 375 (6.9%) 241 (4.4%) 693 21 (0.4%) 32 (0.6%) 39 (0.7%) 51 (0.9%) 52 (1.0%) 103 (1.9%) 200 (3.7%) 1807 awareness (12.8%) (33.3%)
Have you seen the above label? Pictogram label No 473 (8.7%) 407 (7.5%) 913 43 (0.8%) 73 (1.3%) 73 (1.3%) 230 (4.2%) 233 (4.3%) 519 (9.6%) 655 3619 awareness (16.8%) (12.1%) (66.7%)
Alcohol and Pregnancy Labelling Evaluation - Appendices 47
Question Response Pregnant Planning Mother Pregnant Planning Father Adult child Adult child Adult child Other/ Total categories Female Female Male Male is is planning has child None of pregnant pregnant under 18 the above months Have you seen the above label? Pictogram label Total 848 648 1606 64 (1.2%) 105 (1.9%) 112 (2.1%) 281 (5.2%) 285 (5.3%) 622 855 5426 awareness (15.6%) (11.9%) (29.6%) (11.5%) (15.8%) (100.0%)
Have you seen the above label? Pictogram label Don't 702 543 1382 49 (1.0%) 85 (1.7%) 98 (2.0%) 237 (4.8%) 243 (4.9%) 554 683 4576 understanding (11.0%) (27.9%) (11.2%) (13.8%) (92.5%) drink (14.2%) alcohol when pregnant Pictogram label Alcohol 1 (0.0% 4 (0.1%) 1(0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 3 (0.1%) 1 (0.0%) 1 (0.0%) 1 (0.0%) 12 (0.2%) understanding and pregnanc y don't mix Pictogram label Alcohol 18 (0.4%) 14 (0.3%) 33 (0.7%) 1 (0.0%) 1 (0.0%) 1 (0.0%) 11 (0.2%) 9 (0.2%) 13 (0.3%) 12 (0.2%) 113 (2.3%) understanding causes harm to
Alcohol and Pregnancy Labelling Evaluation - Appendices 48
Question Response Pregnant Planning Mother Pregnant Planning Father Adult child Adult child Adult child Other/ Total categories Female Female Male Male is is planning has child None of pregnant pregnant under 18 the above months unborn child or mother Pictogram label No 2 (0.0%) 0 (0.0%) 2 (0.0%) 1 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (0.0%) 4 (0.1%) 10 (0.2%) understanding alcohol served to pregnant patrons Pictogram label Don’t 16 (0.3%) 17 (0.3%) 23 (0.5%) 5 (0.1%) 5 (0.1%) 7 (0.1%) 19 (0.4%) 11 (0.2%) 23 (0.5%) 56 (1.1%) 182 (3.7%) understanding know or other comment s Pictogram label Don't 0 (0.0%) 0 (0.0%) 1 (0.0%) 0 (0.0%) 0 (0.0%) 1 (0.0%) 1 (0.0%) 1 (0.0%) 1 (0.0%) 4 (0.1%) 9 (0.2%) understanding drink in advanced stages of pregnanc y Pictogram label Drinking 8 (0.2%) 3 (0.1%) 22 (0.4%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (0.0%) 1 (0.0%) 3 (0.1%) 5 (0.1%) 43 (0.9%) understanding when pregnant is banned
Alcohol and Pregnancy Labelling Evaluation - Appendices 49
Question Response Pregnant Planning Mother Pregnant Planning Father Adult child Adult child Adult child Other/ Total categories Female Female Male Male is is planning has child None of pregnant pregnant under 18 the above months or illegal
Pictogram label Total 747 581 1464 56 (1.1%) 91 (1.8%) 107 (2.2%) 272 (5.5%) 266 (5.4%) 596 765 4945 understanding (15.1%) (11.7%) (29.6%) (12.1%) (15.5%) (100.0%) Pictogram label Red 43 (2%) understanding suggests danger to drinking in pregnanc y
Total 1803 (100%) Text only label Yes 216 (4.0%) 170 (3.1%) 430 (7.9%) 15 (0.3%) 21 (0.4%) 28 (0.5%) 18 (0.3%) 26 (0.5%) 49 (0.9%) 105 (1.9%) 1078 awareness (19.9%)
Have you seen the above warning label?
Text only label No 632 478 (8.8%) 1176 49 (0.9%) 84 (1.5%) 84 (1.5%) 263 (4.8%) 259 (4.8%) 573 750 4348 awareness (11.6%) (21.7%) (10.6%) (13.8%) (80.1%)
Alcohol and Pregnancy Labelling Evaluation - Appendices 50
Question Response Pregnant Planning Mother Pregnant Planning Father Adult child Adult child Adult child Other/ Total categories Female Female Male Male is is planning has child None of pregnant pregnant under 18 the above months
Have you seen the above warning label?
Total 848 648 1606 64 (1.2%) 105 (1.9%) 112 (2.1%) 281 (5.2%) 285 (5.3%) 622 855 5426 (15.6%) (11.9%) (29.6%) (11.5%) (15.8%) (100.0%) Text only label Don't 187 (4.4%) 157 (3.7%) 388 (9.2%) 18 (0.4%) 36 (0.9%) 41 (1.0%) 104 (2.5%) 83 (2.0%) 219 (5.2%) 245 (5.8%) 1478 understanding (34.9%) drink alcohol when pregnant Text only label Alcohol 226 (5.3%) 174 (4.1%) 398 (9.4%) 15 (0.4%) 18 (0.4%) 27 (0.6%) 62 (1.5%) 70 (1.7%) 123 (2.9%) 175 (4.1%) 1288 understanding (30.4%) causes harm to unborn child or mother Text only label Don’t 19 (0.4%) 25 (0.6%) 37 (0.9%) 7 (0.2%) 9 (0.2%) 7 (0.2%) 17 (0.4%) 9 (0.2%) 32 (0.8%) 82 (1.9%) 244 (5.8%) understanding know or Other comment s Text only label Website 30 (0.7%) 44 (1.0%) 92 (2.2%) 2 (0.0%) 4 (0.1%) 9 (0.2%) 19 (0.4%) 18 (0.4%) 47 (1.1%) 55 (1.3%) 320 (7.6%) understanding
Alcohol and Pregnancy Labelling Evaluation - Appendices 51
Question Response Pregnant Planning Mother Pregnant Planning Father Adult child Adult child Adult child Other/ Total categories Female Female Male Male is is planning has child None of pregnant pregnant under 18 the above months informati on or facts Text only label Drinkwis 77 (1.8%) 74 (1.7%) 189 (4.5%) 5 (0.1%) 10 (0.2%) 8 (0.2%) 35 (0.8%) 48 (1.1%) 82 (1.9%) 80 (1.9%) 608 understanding (14.4%) e recomme ndations informati on suggestio n or warnings Text only label Literal 39 (0.9%) 17 (0.4%) 57 (1.3%) 2 (0.0%) 6 (0.1%) 7 (0.2%) 12 (0.3%) 20 (0.5%) 42 (1.0%) 46 (1.1%) 248 (5.9%) understanding meaning, as it says “it is safest not to drink alcohol when pregnant ”
Alcohol and Pregnancy Labelling Evaluation - Appendices 52
Question Response Pregnant Planning Mother Pregnant Planning Father Adult child Adult child Adult child Other/ Total categories Female Female Male Male is is planning has child None of pregnant pregnant under 18 the above months Text only label Occasion 5 (0.1%) 2 (0.0%) 7 (0.2%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 3 (0.1%) 2 (0.0%) 1 (0.0%) 2 (0.0%) 22 (0.5%) understanding al drink ok Text only label Confusin 5 (0.1%) 2 (0.0%) 7 (0.2%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 4 (0.1%) 1 (0.0%) 2 (0.0%) 1 (0.0%) 22 (0.5%) understanding g message Text only label Pregnanc 0(0.0%) 0(0.0%) 0(0.0%) 0(0.0%) 0(0.0%) 1(0.0%) 1(0.0%) 0(0.0%) 0(0.0%) 3(0.1%) understanding 1(0.0) y and alcohol don’t mix
Total 588 495 1175 49 84 99 257 252 548 687 4234 (13.9%) (11.7%) (27.8%) (1.2%) (2.0%) (2.3%) (6.1%) (6.0%) (12.9%) (16.2%) (100.0%)
Alcohol and Pregnancy Labelling Evaluation - Appendices 53
Appendix 5: Key informant interviews Key informant interviews were conducted with experts and representatives of government, public health and industry to understand any differences between the views of public health and industry experts and to contextualise what is found through the field study of outlets. Each of the people interviewed was asked to provide their views based on having actually viewed the relevant labels. They were asked whether or not they were in a position to provide a response to a question – not based on opinion, but on experience. The initial list of key informants was provided by the Department and these key informants nominated colleagues to be invited to participate in an interview. Siggins Miller invited the key informants to participate in interviews with a Director or an Associate Director of Siggins Miller, and provided them with the agreed interview protocol to guide the discussion.13 In total 31 key informants were interviewed. Five were state and territory government representatives, 12 were public health representatives and 14 were representatives of industry. All but one key informant agreed to have their names included in the list people interviewed for this project. The state and territory government key informants considered themselves to be part of the public health group so their data is incorporated into the sections below which summarise the information provided by the public health key informants. The list of the key informants interviewed can be viewed at Appendix 1. 5.1 Summary Public health and industry key informants agreed that labelling is a useful thing to do; it has to be done properly with some research evidence behind it. It cannot be done by itself and expect to have any impact other than perhaps promoting further information seeking or some interpersonal communication if people see it and are prompted to wonder what it means. Neither public health nor industry is convinced that things are being done in the best way, not targeting the demographic, needing a joined up approach between government, industry, public health professionals and health care providers, more emphasis on health care providers as a key source of credible information to individuals in the target group and messages to the community to support pregnant women rather, than targeting them in a potentially punitive way. All informants agreed that: Australians have a right to know that alcohol should not be consumed by women who are pregnant in order to make better decisions about alcohol consumption and this right should be respected The complexity of the guidelines does not need to be reflected in a simple message on a label - saying “it’s best not to…” is ineffective, and it needs to be much more straightforward than that There is a need for a multi-faceted and integrated strategy Alcohol consumption during pregnancy is a very complex issue. For public health there are issues around the design of message, the research base for it and the independence of it in general. Some public health stakeholders believe that independence is crucial; it will lack credibility unless it is completely independent of industry. Some public health key informants were also concerned about the difficulty in having the conversation to get the best approach, the politicisation of something that is complex but essentially straightforward.
13 The protocol was provided as a data collection tool in the agreed Evaluation Framework
Alcohol and Pregnancy Labelling Evaluation - Appendices 54
Industry is willing to continue to work within a pragmatic timeframe. They genuinely link corporate social responsibility with sustainability. Industry is interested in consistency and managing the competitive environment. Industry believed that: The DWA message is good but for it to be effective it needs to be complemented by consistent information provided to consumers from a variety of sources – through a partnership approach There were no clear targets or criteria set by which government or stakeholders would be judged, including what was acceptable in terms of size text font pictogram and colour in the food packaging standards more broadly Flexibility within the two year voluntary period was very positive and welcomed by wine industry, so that it could manage implementation within vintage cycles Flexibility allowed industry groups to work to achieve 90 – 95% coverage of the product within their control, and continue to work with brands requiring more complex negotiations; import and niche brands have not been the focus in order to maximise take up for the maximum number of bottles in the market place Opportunities were missed for rolling out a comprehensive and integrated campaign Industry efforts to label alcohol products and support labelling and promotion developed through DWA is just the first step, that government and non-government organisations can build upon. 5.2 Detailed data analysis Table 13 below provides the de-identified detailed data analysis by key informant group and interview topic.
Alcohol and Pregnancy Labelling Evaluation - Appendices 55
Table 13: Key informant data analysis summary by group and interview topic
Key Informant interview summary PUBLIC HEALTH Implementation progress: Enablers: community expectation of, and right to, factual information about the risk of harm from a legal product for sale examples of integration between industry government and public health efforts in Europe the two year phased approach to replace labels minimised cost of implementation proactive industry labelling prior to the Review put it in a good negotiating position with government post the review industry desire to show government that it could do something without mandatory regulation Implementation progress: Challenges: problems with the limited evidence base for effectiveness, including: lack of evidence base about the effectiveness of labelling generally or a voluntary approach, particularly regarding pregnancy labels; and evidence pertaining to “low” levels of consumption on pregnancy lack of a collaborative culture (norm) or history between public health, government and industry to support the design and implementation of the initiative, including: perception of industry reluctance to highlight risks factors; perception that public health was aiming for something extreme; insufficient time at the commencement for discussion of mandatory vs self-regulatory approaches; disengagement by those who considered the voluntary approach to labelling to be flawed because it could not produce consistency in messaging, maximum reach through the widest coverage of product and/orlead to better and more effective labelling; and antipathy which reduced meaningful public health engagement in the early design of the initiative, including exclusion of industry from public health discussions. no clear expectations and objectives from government in the beginning Industry balancing commercial realities with initiatives designed to reduce consumption industry engaging in tactics to delay mandatory pregnancy labelling on alcohol products the supply and production chain (ie parallel imports could not be tracked or expected to comply with a voluntary approach.) Implementation progress: Lessons learned targeting of different demographics is better addressed through local level programs focussed on what they drink and where they drink it. government needed to clarify objectives to reduce fear and facilitate information sharing and clear discussion between stakeholders leadership is essential for relevant stakeholders to come together to achieve good outcomes implementation should follow the tobacco exemplar, seeking the involvement of expert independent researchers to develop the warning messages should not be looking for huge impacts, rather you are looking for small changes over time evidence of behaviour change has to underpin any attempt at creating mandatory laws Government should have required use of the FSANZ principles as the standard
Alcohol and Pregnancy Labelling Evaluation - Appendices 56
Key Informant interview summary take advantage of industry participation and then take it one step further (mandating it) FASD awareness has grown, but there is a whole population for whom services are yet to be properly developed: the diagnostic tool has been developed, but is not being used; consistent paediatric referral and management; and possible that when people think that drinking means getting drunk as opposed to drinking in general Economic Impacts (generally not aware of the specific cost to industry) should be some cost to industry, which is small compared to social harms from alcohol no cost to industry if they can incorporate the changes with other changes they are making to labels there is the cost of the labour of attaching the sticker to imports, the sticker itself would be low cost label is a valuable piece of real estate so the opportunity cost is higher than the cost of putting the label on the faster you want something implemented the more it will cost industry changes labels every year as a part of doing business, labelling costs are not new costs labelling campaigns are cost effective (compared with television campaigns) parallel imports should be considered in calculations (of coverage and market share) and economic analysis the economics were a disincentive for Industry to comply it is important that cost to Industry was not seen as a reason to not mandate costs will be higher for small operators so there may need to be special considerations given a voluntary system disadvantages those that comply when others then do not Visibility and readability (size, font, colour and placement) limited awareness of either the FSANZ guidelines, the FARE principles, or the DWA rules labels implemented had inconsistent messages, were small and discretely placed, overshadowed by surrounding information, and provide messages that target only a very small demographic needs to be differentiated from any other labelling and often is hidden next to the bar code consistency is paramount and will not be achieved in a voluntary regime should be on the front and rotating messages to maximise attention to the message. Content of labels: there is a need for decent research on the effectiveness of the pictogram; message should be based on scientific evidence and tested with consumers; the most effective labels are a combination of pictures and words; as any symbol red would be a good colour as it inherently means danger; important that the pictogram shows a pregnant woman with a drink in her hand; supporting material about why the symbol is on the label is critical; needs to say it is a warning; needs to say “do not drink” or “do not consume alcohol while pregnant.”; has to be clear and direct about where to go for further information; other more detailed pictograms include the pregnant woman holding her hand out to reject a drink, and the pregnant woman with the outline of the fetus included; and The FSANZ principles for perceptible
Alcohol and Pregnancy Labelling Evaluation - Appendices 57
Key Informant interview summary information on labels should be used as the standard Industry initiatives work by DWA had not been visible enough. DWA website is limited because it is supported by industry vested interests made it problematic that industry is leading the development of the messages labelling had not been leveraged by any external or contextual information, or promotion Supplementary information is critical to the effectiveness of the labels – mass media and aligned messaging, point of sale initiatives need to be backed up by social media and mass media the labels serve to provoke thought and start conversations industry could fund training to health professionals by government or public health professionals Government initiatives a lot of integrated elements are required for any social marketing campaign to be successful other efforts from government need to link to the label in order to maximise its effectiveness NDSHS was a mechanism for raising awareness, but there is no data that allow for assumptions to be made about drinking patterns of certain populations of pregnant women. an evaluation on how many obstetricians address the issue of drinking alcohol during pregnancy is needed. more access and support needed for brief interventions by health workers (research has shown support) the only way to get 100% coverage is to make it mandatory. if there is long term commitment to the label, other community programs can build on it government should fund a comprehensive research strategy so that the basis of any alcohol program for pregnant women is effective across the range of target groups the Government’s focus on Indigenous FASD is of concern because it consolidates the notion that Indigenous people have a greater drinking problem when the evidence does not suggest that. INDUSTRY Implementation progress: Enablers looked to improve industry corporate social responsibility – addressed contemporary and emerging sustainability issues (eg health and environment) industry led implementation of health warning labels on alcohol products commenced prior to the Labelling Logic Review Report
Alcohol and Pregnancy Labelling Evaluation - Appendices 58
Key Informant interview summary gave the initiative to DWA to develop and design it, and to engage other companies. complemented most companies’ corporate social responsibility programs, consistent with family owned medium sized wineries’ values. Reinforced existing large commitment to responsible consumption of alcohol in the organisational culture. the three largest companies were committed to implementing a consistent pregnancy message united approach, strategically managing competitive space; having a sensible approach to not confuse the consumer pre-investment into the existing DWA website and the ‘Get The Facts’ strategy. Contextual and comprehensive information that was not on label scale of the project, and simplicity of design helped the process. voluntary period created flexibility for the wine industry to manage their vintage cycles. Also allowed beer and spirits, and later wine companies, to work to achieve 90-95% coverage Implementation progress: Challenges Achieving alignments across the three major companies, getting commitment to a certain message and how many messages were to be used. Challenge on how to use DWA and how to allow companies to say this is part of the company’s corporate social responsibility commitment Government’s initial lack of understanding of the industry – the complexity, realistic timeframes and targets for coverage DWA messaging was not available to non-members, who created their own versions Clearer communication and understanding of Government expectations; implementation took places over one year, or 18 months at most, rather than the full two years Notion that labels themselves should provide health information; they could change behaviour rather than being given a prompt or a reminder Consistency in the design requirements of the label Differing timeframe and cost implications Difficulty labelling in different markets Retrospective labelling may be difficult due to shelf-life Cynicism towards initiative; misconception of DWA’s profile within the community Implementation progress: Lessons learned Clearer guidelines on prominence, rather than making size the focus need for Coordinated and integrated approach from partners, government, industry and health to make more impact Ensuring government and NGO's collaborate on clear and essential consumer messages.
Alcohol and Pregnancy Labelling Evaluation - Appendices 59
Key Informant interview summary Underestimation of the size of task for the initiative at a commercial level Balancing regulatory needs and requirements Label alone is not the solution to awareness and understanding - needs other elements to drive broader community awareness Economic Impacts Costs included personnel working on it to redesign the label to fit the warning in, making changes to plates and printing, running out or writing off old labels and running out of old stock cost of requirements is passed onto consumers. Important to balance the cost of having necessary and important consumer information against the competitive international market. Important to balance the cost of having necessary and important consumer information against the competitive international market. costs increase substantially if the labels were increased in size and the warning label rotated Visibility and readability (size, font, colour and placement) Already worked with DWA rules about size and style to achieve a minimal clean look and creating set parameters (form of the message, font, size and prominence) Difficulty in enforcing the standard recommended size for the labels problem with no standard, simple message/phrase that gives consumers all the information they need. Important that the label includes pictogram and DWA ‘Get the Facts’; label is too small to carry information on complex topic Industry Initiatives started using the label prior to DWA portal being established. Pushed acceptance at checkouts for point of sale material and helped DWA to start discussions with doctors. NHMRC guidelines fairly standard encourage DWA and WFA to be progressive and continually improve, recognise issues with the responsible alcohol consumption in society. Health warning alone, won’t change behaviour, only a reminder open to working in partnership supporting comprehensive and integrated program to raise awareness Government Initiatives Funded DWA to design, implement and evaluate a project to market pregnancy warning messages at point of sale. Good short term outcomes, but wider campaign required. Government involvement showed initiative was more than a label. Labels need to be part of an integrated public health campaign. Public health education and health care provider interventions make a difference. Industry shouldn't be seen as having the educational function
Alcohol and Pregnancy Labelling Evaluation - Appendices 60
Key Informant interview summary Best outcome would be complementing government and industry initiatives Legislation French regulation has become the European benchmark as far as industry was concerned, but the Australian back label is better than European/French. Useful to have the same EU pictogram, but also have the DWA ‘Get the Facts’ badge Pictogram attractive in global market as it transcends the language barrier and takes up minimum space Liquor suppliers in Australia clearly focused on being proactive – not to avoid penalty, but to do the right thing.
Alcohol and Pregnancy Labelling Evaluation - Appendices 61
Appendix 6: Literature and document review The literature and document review was conducted to understand the context within which industry was implementing the initiative, to inform the design of the consumer awareness survey, the field study of outlets and the industry study of costs, and to understand key factors impacting on implementation including: legislation, regulation and guidance on size and legibility of consumer information labelling on alcohol products nationally and internationally the activities of industry and government being conducted in parallel with the voluntary pregnancy health warning labelling of alcohol products reviews of evidence for the effectiveness of labelling social marketing best practice The results of the literature and document review presented below were used to inform the findings presented in the Report, particularly with respect to the following Terms of Reference: progress made by the alcohol industry in relation to implementing voluntary pregnancy health warnings regarding the risks of drinking while pregnant on alcohol product labels? visibility and readability (size, font, colour and placement) of pregnancy health warning messages on alcohol product labels meet broader labelling requirements? the role of government funded activities to support pregnancy health warnings, in particular the point of sale project and the project targeting consistent messaging by health professionals about the content of the 2009 NHMRC Australian guidelines on alcohol and pregnancy? Scope of the literature and document review Where possible this review appraises existing evaluations which synthesise the results of a number of studies. Information on alcohol labelling regulation was sourced from national and international government and community advocacy websites, and advice from stakeholders. Relevant reviews of the evidence and regulations were identified chiefly through Google Scholar, CINHAL, PubMed, and references and bibliographies in seminal articles and reports. Search terms included: alcohol in pregnancy, alcohol and health, alcohol harms, alcohol-related harm, harmful use, alcohol risk, labels on alcohol products, labelling alcoholic beverages, drinking by pregnant women alcohol regulation, food and beverage labelling regulation and policy, mandatory health warning labels, voluntary health warnings/consumer information labelling. The review then focused on recent publications in these categories: 1. The role of exposure to alcohol in pregnancy and the problem of Fetal Alcohol Spectrum Disorder (FASD) 2. Factors in effective reduction of risks to the unborn child arising from drinking alcohol during pregnancy 3. Government regulation of labels on alcohol products warning about drinking alcohol during pregnancy. 4. Reviews of evidence of the effectiveness of health warning labelling of alcohol products 5. Issues specific to the effectiveness of pregnancy health warning labels on alcohol products The results of our search and advice from stakeholders produced the bibliography for the Evaluation which is presented at section 2.7 below.
Alcohol and Pregnancy Labelling Evaluation - Appendices 62
6.1 Context Drinking patterns of pregnant women in Australia Despite potential dangers to children’s health, drinking by pregnant women is fairly common in Anglo-Saxon countries such as Australia.14 15 Approximately half of pregnant women self-report drinking alcohol during their pregnancy (see Table 14 below). In Australia, the percentage of women who report drinking during their pregnancy appears to have decreased over time (60% in 2007 to 51% in 2010) but, as shown in Table 14, the proportion of women who report that they reduced the amount they drank while pregnant also appears to have decreased over time (57% in 2007 to 49% in 2010).16 17 18 Table 14: Pregnant Women who drank more, less or the same amount of alcohol compared with when they were neither pregnant nor breastfeeding, 2007 and 2010 (per cent) Drinking alcohol While While While While while pregnant pregnant pregnant breastfeeding breastfeeding 2007 2010 2007 2010 More **0.6 **0.4 **0.2 **0.1 Less 56.6 48.7 ↓ 70.2 62.2 ↓ Same *2.8 *2.0 4.5 3.5 Didn’t Drink 40.0 48.9 ↑ 25.1 34.4 ↑ Alcohol (a) Base is only pregnant women or women pregnant and breastfeeding (b) Base is women who were only breast feeding or pregnant and breastfeeding * Estimate has a relative standard error of 25% to 50% and should be used with caution ** Estimate has a relative standard greater than 50% and is considered to unreliable for general use Source: Australian Institute of Health and Welfare (2011). 2010 National Drug Strategy Household Survey report. Drug statistics series no. 25. Cat. No. PHE 145. Canberra: AIHW
The role of exposure to alcohol during pregnancy Alcohol exposure in pregnancy is a risk factor for poor pregnancy and child outcomes.19 It can cause low birth weight and a range of physical and neurodevelopmental problems.20 21 22 23 High-level or
14 World Health Organisation (2012). Addressing the harmful use of alcohol: a guide to developing effective alcohol legislation. Geneva: World Health Organisation (WHO) 15 World Health Organisation (2010). Global strategy to reduce the harmful use of alcohol. Geneva: World Health Organisation (WHO) 16 Callinan S, Room R (2012). Alcohol consumption during pregnancy: results from the 2010 National Drug Strategy Household Survey. Canberra: Foundation for Alcohol Education and Research (FARE), p21 17 National Indigenous Drug and Alcohol Committee (2012). Addressing fetal alcohol spectrum disorder in Australia. Canberra: Australian National Council on Drugs (ANCD) 18 These results should be treated with some caution as the data are based on self- reports for a highly sensitive issue. The time based differences may indicate that socially desirable responding has increased as we begin to understand that drinking during pregnancy is harmful. 19 Peadon E, Payne J, Henley N, D’Antoine H, Bartu A, O’leary C, Bower C, Elliot EJ (2010). Women's knowledge and attitudes regarding alcohol consumption in pregnancy: a national survey. BMC Public Health. 10: 510 20 National Health and Medical and Medical Research Council (2009). Australian guidelines to reduce health risks from drinking alcohol. Canberra: Commonwealth of Australia. 21 O’Leary CM, Nassar N, Kurinczuk JJ, Bower C (2009).The effect of maternal alcohol consumption on fetal growth and preterm birth. British Journal of Obstetrics and Gynaecology, 116(3): 390-400 22 Op cit 17 National Indigenous Drug and Alcohol Committee (2012) 23 Op cit 19 Peadon et al (2010)
Alcohol and Pregnancy Labelling Evaluation - Appendices 63
frequent intake of alcohol in pregnancy increases the risk of miscarriage, stillbirth and premature birth, and alcohol related birth defects and neurological problems described in the literature since 1968 under the umbrella of Fetal Alcohol Syndrome (FAS), and more recently24Fetal FASD.25 26 27 28 29 30 31 32 FASD describes a cluster of permanent birth defects caused by maternal consumption of alcohol during pregnancy”.33 34 Awareness and knowledge of the risks associated with drinking alcohol while pregnant A 2010 study of Australian women’s knowledge and attitudes regarding drinking alcohol while pregnant found that 97% of the 1,103 women surveyed agreed that alcohol can affect the unborn child. However, awareness of the specific risks to the unborn child arising from drinking alcohol during pregnancy was poor in the Australian female childbearing population.35 Since 2011, the FARE has conducted annual polling on awareness of the harms caused by drinking alcohol, including drinking while pregnant or breastfeeding. In 2014 a Galaxy Research questionnaire was designed in consultation with FARE and presented in an online survey to collect data from 1,545 respondents over the age of 18 years across Australia. It found that: 78% (65% in 2013) of Australians believed that pregnant women should not consume any alcohol in order to avoid harm to the fetus36 50% (47% in 2013) were aware of Fetal FAS and related disorders 15% (15% in 2013) believed that pregnant women can drink in moderation (safely drink small amounts of alcohol without harming their baby).37 Factors in effective reduction of risks A number of national and international guidelines about drinking during pregnancy have been developed because rates of drinking before and during pregnancy are high. The guidelines are based on evidence for alcohol-related harms summarised in existing systematic reviews of the literature, and single studies and data reports, including research on risks and harms arising from drinking
24 World Health Organisation (2004). Global Status Report on Alcohol and Health. Geneva: World Health Organisation (WHO) 25 Op cit 20 National Health and Medical and Medical Research Council (2009) 26 Peadon E, Payne J, Henley N, D’Antoine H, Bartu A, O’Leary C, Bower C, Elliot EJ (2011). Attitudes and behaviour predict women’s intention to drink alcohol during pregnancy: the challenge for health professionals BMC Public Health, 11: 584 27 Parliament of the Commonwealth of Australia (2012). Final report of the House of Representatives Standing Committee of Social Policy and Legal Affairs: FASD: the hidden harm. Inquiry into the prevention, diagnosis and management of Fetal Alcohol Spectrum Disorders. Canberra: Commonwealth of Australia 28 Op cit 17 National Indigenous Drug and Alcohol Committee (2012) 29 Foundation for Alcohol Education and Research (2012). The Australian Fetal Alcohol Spectrum Disorders Action Plan 2013-2016. Canberra: Foundation for Alcohol Education and Research (FARE) 30 Daube M, Kirby G, Mattick R (2009). Alcohol warning labels: Evidence of impact on alcohol consumption amongst women of childbearing age. Report 2 prepared for Food standards Australia New Zealand (FSANZ) 31 Food Labelling Law and Policy Review Panel (2011). Labelling Logic: review of food labelling law and policy. Canberra: Commonwealth of Australia 32 Op cit 21 O’Leary et al (2009) 33 Lee N, Jenner L (2013). Drug treatment: psychological and medical interventions. In A Ritter, T King & M Hamilton [Eds.] Drug Use in Australian Society. Melbourne: Oxford University Press 34 Op cit 20 National Health and Medical and Medical Research Council (2009) 35 Op cit 19 Peadon et al (2010) 36 This result is similar to that in FARE polls carried out in 2011 and 2012 37 Foundation for Alcohol Research and Education (2014). Annual Alcohol Poll: Attitudes and behaviours. Canberra: FARE
Alcohol and Pregnancy Labelling Evaluation - Appendices 64
during pregnancy. With the exception of the UK, the guidelines indicate consensus internationally that for women who are pregnant, the safest option is abstinence from alcohol.38 39 40 41 42 43 44 45 46 The relevant guideline (Guideline 4A) in the NHMRC Australian guidelines to reduce health risks from drinking alcohol, states that “For women who are pregnant or planning a pregnancy, not drinking is the safest option.” This guideline is based on systematic reviews of the literature including seminal studies and prospective cohort studies. The NHMRC Australian guidelines present a review of the evidence on risks associated with alcohol drinking patterns (amount and frequency) during pregnancy. The NHMRC Australian guidelines note the limitations of the studies and the difficulty in determining effects on pregnancy outcomes of low to moderate levels of alcohol consumption, but the available evidence does not warrant a “conclusion that drinking alcohol at low-moderate levels during pregnancy is safe.”47 In 2012, the Inquiry into the prevention, diagnosis and management of Fetal Alcohol Spectrum Disorders conducted by the Parliament of the Commonwealth of Australia, House of Representatives Standing Committee on Social Policy and Legal Affairs drew together the reviews of evidence and recommended that FASD should be addressed by: …ensuring that every woman knows the risk [of drinking alcohol during pregnancy] through providing accurate health information and advice, and fostering a changed attitude to alcohol consumption during pregnancy and across the wider community.48 Australian reports recommend that action to reduce risks and harm to the unborn child arising from drinking alcohol during pregnancy should seek to: increase awareness and knowledge of the advice not to drink alcohol during pregnancy. change attitudes to drinking alcohol among women who are pregnant or planning a pregnancy change alcohol drinking behaviour among women who are pregnant or planning a pregnancy change family and community attitudes to drinking alcohol during pregnancy.49 50 51
38 National Institute for Health and Clinical Experience (NICE) (2008). Antenatal Care: Routine Care for the Healthy Pregnant Woman. London: National Institute for Health and Clinical Experience (NICE) 39Op cit 20 National Health and Medical and Medical Research Council (2009) 40 The Danish National Board of Health (2010). Healthy Habits – before during and after pregnancy. 1st English edition (translated from the 2nd Danish edition). The Danish National Board of Health and The Danish Committee for Health Education 41 New Zealand Ministry of Health (2006). Food and Nutrition Guidelines for Healthy Pregnant and Breastfeeding Women: A background paper. Wellington: New Zealand Ministry of Health 42 International Centre for Alcohol Policies (ICAP) (2011). International Drinking Guidelines. Online text at http://www.icap.org/Table/InternationalGuidelinesOnDrinkingAndPregnancy 43 Public Health Agency of Canada (2011). The Sensible Guide to a Healthy Pregnancy. Ottawa: Public Health Agency of Canada 44 Op cit 15 World Health Organisation (2010) 45 U.S. Surgeon General (2005). U.S. Surgeon General Releases Advisory on Alcohol Use in Pregnancy [press release]. United States Department of Health and Human Services. Online text at: US Surgeon General Advisory on alcohol use in pregnancy. 46 Australian Health Ministers’ Advisory Council 2012, Clinical Practice Guidelines: Antenatal Care – Module 1. Canberra: Australian Government Department of Health and Ageing 47 Op cit 20 National Health and Medical and Medical Research Council (2009) p72 48 Op cit 27 Parliament of the Commonwealth of Australia (2012) 49 Op cit 27 Parliament of the Commonwealth of Australia (2012)
Alcohol and Pregnancy Labelling Evaluation - Appendices 65
To achieve these goals the range of prevention measures should include: whole of population awareness and education campaigns including options such as publication of data on the rates of alcohol consumption during pregnancy and data on the rates of alcohol-related pregnancy and birth outcomes in the Australian population social marketing initiatives which include the warnings within broader alcohol advertising (including health warnings on alcohol product, at the point of sale, on billboards and websites), and broadcast and social media campaigns increased healthcare professional screening and advice to women about alcohol during pregnancy other mechanisms to raise awareness of the harmful nature of alcohol consumption during pregnancy.52 53 54 Increasing consumer knowledge through social marketing initiatives Health warning labels on alcohol products are just one mechanism for raising awareness and increasing consumer knowledge of the risks associated with alcohol consumption. Of themselves they do not change drinking behaviours. Evidence from the literature suggests that consideration of a variety of strategies will enhance the likelihood that social marketing campaigns will be effective in increasing awareness and knowledge of health risk behaviours and changing health behaviours. Evidence based social marketing uses multiple strategies including advertising, public relations, printed materials, promotional items, signage, special events and displays, face-to-face selling and entertainment media to communicate with the target audience. 55 The effectiveness of a message can be determined by a number of factors associated with the person presenting the message, including the credibility (expertise, trustworthiness), attractiveness (familiarity/similarity, likeability) and power (perceived control over reinforcements, concerns about compliance) of the source. According to the research, the use of an influential individual (ie an ‘opinion leader’) early in the dissemination process can be useful in helping the target audience to successfully move through the change process, from awareness and understanding though to attitude change and ultimately behaviour change.56 Evidence suggests that an integrated marketing mix is essential in social marketing campaigns. A well-considered promotional strategy that encompasses and addresses the four P’s (product, price, place and promotion). A number of communication variables are fundamental in developing effective persuasive messages in social marketing campaigns. The effectiveness of a persuasive message is determined by a number of communication variables such as, source variables, message variables, channel variables, receiver variables and target variables. The content of the message being delivered to the target audience should be carefully considered to determine: what is included or not included in the message the organisation of the content in the message the extremity of the message
50 Op cit 16 Foundation for Alcohol Research and Education (2012) 51 Op cit 17 National Indigenous Drug and Alcohol Committee (2012) 52 Op cit 27 Parliament of the Commonwealth of Australia (2012) 53 Op cit 17 National Indigenous Drug and Alcohol Committee (2012) 54 Op cit 15 Foundation for Alcohol Research and Education (2012) 55 Grier S, Bryant C (2005). Social marketing in public health. Annual Review of Public Health. 26(1). 319. 56 Lefebvre & Flora (1988). Social Marketing and Public Health Intervention. Health Education and Behaviour. 15. 299
Alcohol and Pregnancy Labelling Evaluation - Appendices 66
the motivational strategies utilised to persuade the target audience.57 58 59 Motivation among the target audience to change their behaviour can be increased by emphasising high benefits and low costs of the behaviour change.60 61 Research also suggests that formative research to gain a deep understanding of the target audience, specifically what motivates and deters individuals from changing their behaviour is important.62 According to Miller and Ware (1989) and McGuire (1974), it is important to understand what and how personal characteristics affect how a message is received; these include gender, age, experience feelings of vulnerability and whether they have previously been predisposed to the message. Finally, continuous monitoring and revision of a social marketing campaign is necessary, to maintain the interest and motivation of the target audience. 6.2 Implementation of the pregnancy labelling voluntary initiative The FoFR Communique published online on 9 December 2011, announced Ministers’ agreements about initiatives in response to the recommendations of Labelling Logic. Of relevance to alcohol product pregnancy labelling was the following recommendation: Warnings about the risks of consuming alcohol while pregnant should be pursued. Industry is to be given the opportunity to introduce appropriate labelling on a voluntary basis for a period of two years before regulating for this change.63 On 1 March 2012, Health met with representatives of industry (brewers, distillers, and winemakers) to provide an update on the FoFR decision and related activities, and discuss the process for working in a complementary way to promote awareness of the risks of drinking alcohol during pregnancy. A workshop was held on 3 April 2012 involving the Health, industry representatives of brewers, distillers, winemakers and the National Alcohol Beverage Industries Council (NABIC) and FSANZ, to inform a paper to present to FoFR and further “unpack a way forward.” On 12 April 2012, Health met with counterparts in New Zealand and industry to discuss current state of play and a way forward on the FoFR decision. On 18 September 2012, in response to a letter from industry, FoFR wrote to industry outlining its expectations.64 Health provided funding to two projects to leverage and support the impact of the labelling initiative: DrinkWise Australia (an independent, not-for-profit organisation established in 2005 by the alcohol industry) conducted a point of sale project, funded from 29 June 2012 to 30 June 2013. It aimed to provide information on the risks of consuming alcohol during pregnancy to support the voluntary labelling initiative.
57 McGuire WJ (1974). Communication-persuasion models for drug education. In M Goodstadt (ed), Research on Methods and Programs for Drug Education, Addiction Research Foundation: Toronto. 58 McGuire WJ (1985). Attitudes and attitude change. In G Lindsay G & E Aronson (eds), Handbook of Social Psychology, 2. p 283. 59 McGuire WJ (1969). The Nature of Attitudes and Attitude Change . In G Lindsay G & E Aronson (eds), Handbook of Social Psychology, Addison-Wesley: Boston 60 Anderson AR (2002). Marketing social marketing in the social change marketplace. Journal of Public Policy and Marketing, 12(1) 61 Miller ME, Ware J (1989). Mass-media alcohol and drug campaigns: A consideration of relevant issues. National Campaign Against Drug Abuse. MS-9. Canberra. Australian Government 62 Op cit 25 Grier & Bryant (2005) 63 http://www.foodstandards.gov.au/media/pages/mediareleases/mediareleases2011/communiqulegislative5383.aspx 64 Email communication to Siggins Miller from the Department of Health on 24 April 2014
Alcohol and Pregnancy Labelling Evaluation - Appendices 67
the Foundation for Alcohol Research and Education (FARE) (a charitable organisation originally funded by Australian Government funds) is being funded from 29 June 2012to 30 June 2014 to support health professionals to provide consistent information on the risks of consuming alcohol during pregnancy. DWA was also funded by industry to provide resources to support industry to implement pregnancy labels in alcohol products (see Table 15 for an overview of the activities of four large companies and DWA from July 2011 to September 2012). Table 15: Activities of four large companies and DWA Date Activity 11 July 2011 DWA makes first version of Guidelines available – multiple messages
9 December 2011 Government agreements to pursue warnings about the risks of consuming alcohol while pregnant and give industry an opportunity to introduce appropriate labelling voluntarily over 2 years (FoFR Communique)
1 March 2012 Meeting with Health and industry reps to discuss process of implementation
3 April 2012 Working with the Health, FSANZ, industry representatives to jointly decide on implementation and document proposal in a paper to FoFR
12 April 2012 Health met with government counterparts in New Zealand and industry to further discuss current work and next steps
29 June 2012 Government funded DWA and FARE to conduct two complementary initiatives
18 September 2012 FoFR wrote to industry outlining expectations
25 September 2012 DWA created first portal to facilitate winery access to labelling resources
Activities implemented in parallel with the pregnancy labelling voluntary initiative Activities to leverage and support the uptake and impact of pregnancy labelling of alcohol These projects included the following complementary activities conducted nationally from 30 September 2012 to 30 June 2014: The Point of Sale Project: The Australian Government Department of Health provided funding to DWA specifically to support and leverage the impact of the voluntary pregnancy labelling initiative. DWA worked with industry to develop ‘point of sale’ information (a brochure and two A4 size convenience advertising posters) for consumers at major liquor retailers, clubs, pubs and hotels. The brochure was adapted to credit card size and supplied to licensed venues and shopping centres frequented by target audiences to be provided with convenience advertising posters. The project was designed to engage retailers and producers in providing responsible messages to consumers about reducing harmful drinking, particularly during pregnancy and to promote and explain the new pregnancy health warning labels. The target audience for the campaign was women of child bearing age (18 to 40 years) and their partners as influencers and providers of support. During development, the materials and their messages were focus tested with the target audiences. In total 1,134,000 brochures were produced and distributed nationally to 3,537 stores (Aldi, Coles, Metcash, Woolworths), and Winemakers Federation of Australia’s (WFA) members’ cellar doors. Distribution commenced on 29 October 2012. Gender specific advertising posters were placed in bathrooms in licensed venues and shopping centres in 2,623 display points and 1,070 takeaway card holders across 467 venues
Alcohol and Pregnancy Labelling Evaluation - Appendices 68
and 54 shopping centres in metropolitan and regional locations between 1 December 2012 and 28 February 2013. The project was supported by a Vox Pops video hosted on the DrinkWise website and media publicity about not drinking alcohol while pregnant in the form of media releases, audio news releases, five public information messages from experts and celebrities and 29 radio interviews with DWA representatives which were broadcast on radio 116 times over two days in regional and metropolitan Australia in late 2012. In addition, DWA resources developed for the initiative were uploaded to the WFA microsite housed on the DWA website to provide WFA members with free access to the site, brochures and posters. A pregnancy specific URL for the DrinkWise website was included on all collateral material to help drive traffic to the website where more detailed information was provided in the form of videos of medical experts, sports and media personalities and everyday Australians. 65 Industry activities implemented in parallel with the pregnancy labelling voluntary initiative In addition to this specific project, the alcohol industry peak bodies WFA and Wine Australia promoted the voluntary labelling initiative to members via their websites.66 67 68 Although the evidence base for these activities, and their impact in reducing rates of drinking while pregnant, is unclear, some specific examples are: In 2012, WFA entered into a partnership with DWA to ensure that all wineries had access to the pregnancy warning logos, whether or not they were members of DWA. WFA also sent a letter to members with a joint message from DWA highlighting the need for the wine industry to “not only meet government and community expectations, but also to demonstrate its genuine commitment to support initiatives that promote appropriate alcohol consumption.” The letter announced the core DWA campaign message “Get the Facts” and the DWA logo and website for use on labels in tandem with either the pregnant lady pictogram or the text message, “It’s safest not to drink while pregnant” and the focus on pregnancy warnings. WFA conducted a survey of the locally produced domestic sales market in late 2013 and disseminated the results to its members.69 In July 2011, Lion joined DrinkWise in the launch of consumer information messages including “It’s safest not to drink while pregnant”, explaining the initiative and Lion’s commitment to implement it and directing the reader to the DrinkWise website.70 In addition to using the DWA pregnancy pictogram and the DWA “Get the Facts” badge on their primary packaging, some distributors also presented the link to the DWA pregnancy web page on their websites, incorporated the DWA label into their secondary packaging,
65 DrinkWise Australia (2013). It’s safest not to drink while pregnant: Information to support the voluntary labelling initiatives on the risks of consuming alcohol during pregnancy. Final Report. Provided to the evaluators by DrinkWise Australia with permission to use it solely for the purpose of the Evaluation 66 http://www.wfa.org.au/resources/pregnancy-logo/ 67 http://www.brewers.org.au/our-views/alcohol-promotion/ 68 Wine Australia 2013 Compliance Guide for Australian Wine Producers Accessed 17 April 2014 at: http://www.wineaustralia.com/en/Production%20and%20Exporting/Labelling.aspx 69 Personal communication WFA email to Siggins Miller 17 April 2014. Used for the purpose of the Evaluation with permission. 70 http://lionco.com/2011/07/12/lion-joins-drinkwise-in-launch-of-consumer-information-messages/
Alcohol and Pregnancy Labelling Evaluation - Appendices 69
point of sale product brochures and catalogue materials, and promoted it at their cellar doors and with their retailers. More recently some distributers have incorporated it into their websites and marketing materials. Some in the alcohol industry were also promoting the pregnancy message and uptake of labels as part of their existing responsible drinking activities and programs. For example: - Diageo had a history of partnering with the public health sector to promote responsible drinking for example through the DRINKIQ.com initiative in the United Kingdom71 - Lion also had a history of investing in health education programs for young people in New Zealand, and funding a program developed by the Fetal Alcohol Support Trust (FAST) to educate young people about drinking while pregnant72 - The Pernod Ricard Australia website also provides links to the DWA and WFA websites, among others as part of its page on responsible consumption, and as part of its sustainability commitment. Since late 2012, global producers of beer, wine and spirits have been working on ten targeted actions which will continue to 2017 to build on efforts to discourage harmful drinking through international initiatives and partnerships on the industry actions in support of the World Health Organization (WHO) Global Strategy to Reduce the Harmful Use of Alcohol.73 The action areas include: - continuing to strengthen and expand marketing codes of practice [reflective of]…[the] resolve not to engage in marketing that could encourage excessive and irresponsible consumption, with a particular focus on digital marketing - making responsible product innovations and developing easily understood symbols or equivalent words to discourage drinking and driving and consumption by pregnant women and underage youth - reducing drinking and driving by collaborating with governments and non- governmental organizations to educate and enforce existing laws - enlisting the support of retailers to reduce harmful drinking and create “guiding principles of responsible beverage alcohol retailing.”74 Concurrent prevention initiatives to promote the 2009 NHMRC Australian guidelines A number of prevention initiatives designed to reduce risks and harm to the unborn child arising from drinking alcohol during pregnancy were implemented in parallel with the two-year implementation of the voluntary labelling initiative to place pregnancy health warning labels on alcohol products. They were implemented in Australia in the public health, advocacy, academic, not- for-profit community and the industry sectors to inform and educate the community and health care providers and to raise awareness and increase knowledge in the Australian population of the 2009 NHMRC guideline that “For women who are pregnant or planning a pregnancy, not drinking is the
71 Wilkinson C, Allsop S, Cail D, Chikritzhs T, Daube M, Kirby G, Mattick R (2009). Report 1 Alcohol Warning Labels: Evidence of effectiveness on risky alcohol consumption and short term outcomes. Prepared for Food Standards Australia New Zealand. 72 Op cit 71 Wilkinson et al (2009) 73 Op cit 15 World Health Organisation (2010) 74 http://www.diageo.com/en-row/ourbrands/infocus/Pages/gapg.aspx
Alcohol and Pregnancy Labelling Evaluation - Appendices 70
safest option.”75 76 Some were designed to help health care professionals and communities to engage with best practice approaches to healthy pregnancy and translate the NHMRC guidelines into practice. Three projects entailed the production and dissemination of alcohol and pregnancy resource development for health professionals: 1. The Health Professionals Project: Health funded the Foundation for Alcohol Research and Education (FARE) to work with health professionals to further promote the messages in the Alcohol Guidelines on safe consumption. This project is designed to assist health professionals to raise awareness with their patients of the risks of harmful drinking and in particular the risk of drinking alcohol if pregnant or planning a pregnancy. This project is due to be completed by mid 2014. 2. The National Indigenous Fetal Alcohol Spectrum Disorders (FASD) Resource project aimed to develop culturally appropriate resources to assist health professionals in Aboriginal and Torres Strait health care settings to address the issues of alcohol and pregnancy and FASD. The National Drug Research Institute (NDRI) developed the FASD PosterMaker application (app), a tool which enables Indigenous communities across Australia to produce their own locally relevant and culturally appropriate resources that reflect the shared issues but local differences in addressing alcohol, pregnancy and FASD around the country. The iPad/Web FASD PosterMaker app is aimed primarily at helping health professionals; however it can also be used by others working with Aboriginal and Torres Strait Islander communities – for example, youth workers, teachers, alcohol and other drug workers – as an educational tool with the young people with whom they are working. Community members can collaborate with local health professionals to create their own posters to suit their needs around alcohol, pregnancy and FASD in their local communities. The FASD PosterMaker app has a range of pre-loaded culturally relevant images as well as evidence-based messages, which include messaging from the 2009 NHMRC guidelines that “For women who are pregnant or planning a pregnancy, not drinking is the safest option.” The FASD PosterMaker is available for download in the Apple Store, or at www.fasdpostermaker.com.au. 3. The National Antenatal Guidelines (Module 1) reflect the 2009 NHMRC guideline evidence and recommendations about alcohol and pregnancy for health care practitioners.77 Currently the Department of Health is managing the development of antenatal guidelines on behalf of all Australian governments. The National Antenatal Guidelines publicly released in March 2013. They include guidance on a wide range of care including routine physical examinations, screening tests and social and lifestyle advice for women with an uncomplicated pregnancy. The Antenatal Guidelines are designed to complement the Australian Dietary Guidelines, the Australian Guidelines to Reduce Health Risks from Drinking Alcohol, the National Perinatal Depression Initiative and the Australian National Breastfeeding Strategy 2010-2015.78 A further two activities target individuals:
75 Op cit 27 Parliament of the Commonwealth of Australia (2012) 76 Op cit 16 Foundation for Alcohol Research and Education (2012) 77 Module 1 addresses the first trimester of pregnancy; Module 2 is currently under development- it addresses the second and third trimesters of pregnancy. Module 1 was approved by the NHMRC in December 2011 and endorsed by health ministers in August 2012 and released in December 2012. 78 Op cit 46 Australian Health Ministers Advisory Council (2012)
Alcohol and Pregnancy Labelling Evaluation - Appendices 71
1. The Australian Government Pregnancy Birth and Baby website (last updated in July 2013) provides advice about alcohol during pregnancy and its effects on unborn children through links to resources on alcohol and the Pregnancy, Birth and Baby Helpline and Healthdirect Australia. 2. Two part-time specialist FASD clinics In addition to these projects, state and territory governments have developed FASD prevention strategies, including population and community approaches to reducing harms caused by alcohol use during pregnancy. For example: Department of Health, Western Australia Fetal Alcohol Spectrum Disorders Model of Care (2010), followed by the No alcohol while pregnant (Western Australian Government) campaign launched in September 2011 to promote the message that the safest option is to not drink alcohol during pregnancy, and when planning pregnancy and breastfeeding. Review of the results of the first 12 months of the Ord Valley Aboriginal Health Service’s fetal alcohol spectrum disorders program, 201179. Western Australia’s Drug and Alcohol Office has also received funding to develop a suite of indigenous focused FASD prevention initiatives. The Lililwan Project is a FASD prevalence study of children born in born in 2002 and 2003 in the Fitzroy Crossing Valley in the Kimberley region of Western Australia. It is the first population based study on the use of alcohol during pregnancy and FASD in Australia, and more specifically in Aboriginal communities. The study brings together allied health professionals, social workers, paediatricians and Aboriginal community navigators to review the medical and developmental history of Indigenous children in the Fitzroy Valley and provides treatment and referrals for children diagnosed with FASD. It was implemented through a partnership with Nindilingarri Cultural Health Services, Marninwarntikura Women’s Resource Centre, The Gorge Institute for Global health and the Discipline of Paediatrics and Child Health at the University of Sydney Medical School.80 Nationally accredited FASD training certificate developed through a collaboration between the Russell Family Fetal Alcohol Disorders Association (based in Victoria) and the registered training organisation Training Connections.81 Research and advocacy activities have been conducted in the two year implementation period of the alcohol industry voluntary pregnancy labelling initiative. Surveys, forums, inquiries, social and news media activities, research and the development and dissemination of results of research and position papers on alcohol product labelling. Examples include: NHMRC funding of $2m to two projects: - A Study of Pregnancy in the Aboriginal and Torres Strait Islander Community of Cherbourg in Queensland - Screening of Juvenile Justice Clients for FASD in Western Australia Submissions from government, community public health and healthcare professionals, industry and researchers in 2011 to The House of Representatives Standing Committee on Social Policy and Legal Affairs, Inquiry into Fetal Alcohol Spectrum Disorders concerning
79 Bridge P (2011). Ord valley Aboriginal Health Service’s fetal alcohol spectrum disorders program: Big steps, solid outcome. Australian Indigenous HealthBulletin 11(4) 80 www.georgeinstitute.org 81 http://rffada.org/
Alcohol and Pregnancy Labelling Evaluation - Appendices 72
prevention strategies to inform the community about the risk to the fetus of drinking alcohol during pregnancy and the dissemination of the 2009 NHMRC Australian guideline that “For women who are pregnant or planning a pregnancy, not drinking is the safest option.” ongoing work by FARE, NOFASD and NAAA to conduct or support research; and provide submissions to inquiries to inform FASD and alcohol labelling policy, including surveys and studies of alcohol labelling uptake and economic analyses82 83 84 85 86 publication by the Australian National Council on Drugs (ANCD) of the National Indigenous Drug and Alcohol Committee (NIDAC) paper: Addressing fetal alcohol spectrum disorder in Australia87 survey on food and alcohol during pregnancy88 publication of data on the rates of alcohol consumption during pregnancy in the Australian population89 90 91 publication of analyses of data on alcohol use and alcohol related pregnancy and birth outcomes.92 93 94 95
82 IPSOS Social Research Institute (2012). Alcohol Education and Research Foundation policy position paper. Alcohol product labelling: Health warning labels and consumer information. Accessed 7 March 2014 at: http://www.fare.org.au/wp-content/uploads/2011/07/AER-Policy-Paper_FINAL.pdf 83 IPSOS Social Research Institute (2012). Alcohol label audit. Report prepared for the Foundation for Alcohol Research and Education (FARE) Accessed 4 March 2014 at: http://www.fare.org.au/wp-content/uploads/2011/07/Alcohol-Label-Audit- September-2013.pdf 84 Op cit 27 Parliament of the Commonwealth of Australia (2012) 85 FARE Annual Alcohol Polls 2011, 2012, 2013 on attitudes and behaviours (including awareness of the risks of drinking alcohol) and dissemination of the results http://www.fare.org.au 86 Breen C, Burns L (2012) Improving services to families affected by FASD. Canberra: FARE 87 Op cit 17 National Indigenous Drug and Alcohol Council (2012) 88 Flinders University survey into the eating and drinking habits of pregnant women. Accessed 20 March 2013 at http://www.pregnancybirthbaby.org.au/survey-food-and-alcohol-during-pregnancy 89 Op cit 16 Callinan & Room (2012) 90 Australian Institute of Health and Welfare (2008). 2007 National drug strategy household survey report. Canberra: Australian Institute of health and Welfare (AIHW) 91 Australian Institute of Health and Welfare (2011). 2010 National drug strategy household survey report. Canberra: Australian Institute of health and Welfare (AIHW) 92 Op cit 17 National Indigenous Drug and Alcohol Committee (2012) 93 Op cit 36 FARE (2012) 94 Op cit 27 Parliament of the Commonwealth of Australia (2012) 95 Wilson M, Stearne, Gray D, Saggers S (2010). The Harmful Use of Alcohol amongst indigenous Australians. Online publication at: http://www.healthinfonet.ecu.edu.au/alcoholuse_review
Alcohol and Pregnancy Labelling Evaluation - Appendices 73
6.3 National and international pregnancy labelling context Health warning labels on alcohol products Health oriented warnings on alcoholic beverages can include content about: number of standard drinks advice about certain ingredients (eg non-alcoholic ingredients, caffeine, sulphites) advice about how to use the beverage advice about potential adverse consequences of drinking.96 97 98 99 100 101 The governments of 18 countries require producer/manufacturers to provide a specific health warning on the labels on alcoholic beverages. The rationale behind locating health warning messages on alcohol containers is that in so doing, the message will reach the majority of drinkers and more frequently expose more frequent drinkers to it. 102 Other locations are: at the point of sale in schoolrooms in alcohol advertising media (billboards, websites, television, newspapers, magazines, and electronic media) in editorial promoting the sale of alcoholic beverages. Alcohol labelling regulation nationally and internationally is expressed though one or a combination of: food standards laws and codes industry initiatives to promote healthy use of alcohol through labelling or point-of-sale advertising voluntary agreements reached between industry and government in relation to alcohol and labelling.103 Types of consumer information Consumer information about beverage alcohol products (primary packaging containers, such as bottles cans and casks and/or secondary packaging such as boxes, cartons and shrink wrap, or both). The products may contain factual information about the beverage or the container (such as alcohol
96 Op cit 31 Food Labelling Law and Policy Review Panel (2011) 97 Op cit 71 Wilkinson et al (2009) 98 Wilkinson & Room (2009). Warnings on alcohol containers and advertisements: international experience and evidence on effects. Drug and Alcohol Review, 28(4): 426-435 99 International Centre for Alcohol Policies (ICAP) (2011). Health warning labels (ICAP Policy Tables) Accessed 4 March 2014 at http://www.icap.org/Table/HealthWarningLabels. 100 Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented at the European Alcohol and Health Forum. Brussels EAHF 101 Food Standards Australia New Zealand (FSANZ) (2013).Australia and New Zealand Food Standards Code (Standard 2.7.1 – Labelling of Alcoholic Beverages and Food Containing alcohol; Standard 1.2.9 Legibility Requirements 102 Op cit 98 Wilkinson & Room (2009) 103 Stockwell T (2006). A review of research into the impacts of alcohol warning labels on attitudes and behaviour. British Columbia, Canada: University of Victoria, Centre for Addictions Research of BC
Alcohol and Pregnancy Labelling Evaluation - Appendices 74
volume, standard drinks, method of production, country of production, ingredients) or directional information, such as health warnings or recycling prompts/reminders.104 105 Factual information requirements are regulated through international trade agreements, industry commitments to codes of good practice as well as food standards laws and codes of practice.106 107 Since 1995, the FSANZ108 Code has required labels on beverage alcohol containers to legibly display: The alcohol content standard drinks in line with the NHMRC Australian guidelines (which define 1 standard drink as equivalent to 10g of alcohol) certain ingredients (eg caffeine, sulphates). The Code does not require that alcohol product labels display information about safe consumption or warnings about health risks associated with drinking alcohol. After a period from 2009 to 2010 during which industry in Australia initiated the introduction of safe or responsible consumption of alcohol messages on alcohol products, the Commonwealth of Australia responded to the recommendation of the Labelling Logic Review report by allowing industry to voluntarily implement pregnancy health warnings on alcohol product labels in the period from December 2011 – 2013.109 In the European Union, all producers are legally obliged to provide “safety” warnings on product labels if the product has potentially negative side effects. Chapter III Article 5 of Directive 2001/195/EC of the European Parliament states that “producers shall provide consumers with relevant information to enable them to assess risks inherent in a product.” Other trade and industry agreements require producers to display information such as country of origin.110 6.4 Rationales for health warning labelling of alcohol products The rationale for requiring health warnings on alcohol products is to raise awareness of the potential adverse consequences of harmful levels and patterns of use. In a number of countries health warning labels are used to offer directional information about drinking behavior. They tend to take the form of reminders about: general and specific health risks associated with alcohol consumption (eg in El Salvador the government requires alcohol product labels to display the message:“The excessive consumption of this product is harmful to health and creates addiction. Its sale is banned to those under 18 years of age.”) the dangers of drinking while driving or operating machinery (eg the South African Government requires producers to display one of a number of health warning messages on
104 Op cit 98 Wilkinson & Room (2009) 105 International Centre for Alcohol Policies (2013).Health Warning Labels. ICAP Policy Tools Series – Issues Briefings. Washington DC: ICAP 106 World Wine Trade Group (2007). Agreement on Requirements for Wine Labelling. Canberra: World Wine Trade Group 107 Global Alcohol Producers Group (GAPG) (2012). Reducing Harmful Use of Alcohol: Beer Wine and Spirits Producers Commitments. Accessed 17 April 2014 at: www.global-actions.org 108 FSANZ is the a statutory authority under the Food Standards Australia New Zealand Act 1991 to work with governments in Australia and New Zealand to develop and maintain the Australia New Zealand Food Standards Code which regulates the labelling and composition of food including beverage alcohol. 109 Op cit 31 Food Labelling Law and Policy Review Panel (2011) 110 World Wine Trade Group (2007). Agreement on Requirements for Wine Labelling. Canberra: World Wine Trade Group
Alcohol and Pregnancy Labelling Evaluation - Appendices 75
alcohol product labels including the following drink driving warning: “Alcohol reduces driving ability, don’t drink and drive” (Table 16) the dangers of drinking during pregnancy (eg the French government requires producers to incorporate the red pregnant lady symbol on all alcoholic beverages (Table 17)). Labels may also include additional information, such as reference to guidelines for safe levels of consumption of alcohol and references to websites which provide detailed information about health risks associated with alcohol consumption. In a 2009 report on alcohol warning labels prepared for FSANZ by Wilkinson and colleagues, 18 countries had either mandatory or voluntary health warning labels.111 By 2011, 17 countries had mandated health warnings (including France’s mandatory pregnancy label), with other countries including Slovenia and the Netherlands in the process of introducing mandatory requirements for health warning labels.112 In 2013, Israel passed laws requiring health warning labels referring to the negative effects of excessive alcohol consumption on all alcoholic beverages.113 The number of countries with alcohol labelling regulation, and the nature of that regulation is shown in Figure 1 below. Mandatory health warnings have been implemented in 20 countries, whereas only four countries have specific mandatory pregnancy warnings (ie based on guidelines about alcohol se during pregnancy). The reverse is true for the voluntary programs, where almost twice as many countries are engaged in voluntary pregnancy health labelling initiatives (29) compared with those engaged in voluntary general health warning initiatives (14).
111 Op cit 71 Wilkinson et al (2009) 112 Op cit 105 ICAP (2013) 113 State of Israel, Ministry of health. Regulations to Limit the Advertisement and Marketing of Alcoholic Beverages (Warning Label), 2013
Alcohol and Pregnancy Labelling Evaluation - Appendices 76
Figure 1: Number of countries with mandatory or voluntary general health and pregnancy specific health warning labelling policies (2014)
35 29
30 Mandatory Voluntary
25 20 20 14 15
10 Number of countries of Number 4 5
0 General health warning Pregnancy warning Warning type
Pregnancy health warning labelling of alcohol products In Australia and the European Union, public health professionals are seeking a standard, mandatory approach to pregnancy health warning labelling (much like the approach France has adopted).114 Currently there is no legislation requiring producers in Australia or the European Union Member States to provide pregnancy health warning labels on alcohol beverage containers. Since 2009, industry peak bodies have been assisting industry with labels and working with government to provide media campaign resources and websites material covering the issue (eg Eurocare, the International Centre for Alcohol Policies [ICAP] and DWA).115 116 117 118 119 In 2009, Wilkinson and Room examined the international experience and evidence on the effects of warnings on alcohol containers and advertisements, and noted that “there seems to be an international trend towards warnings [on alcohol products] specifically concerning pregnancy.”120 Our review indicates that in the period from 2009 to 2014 the number of countries with pregnancy warning labelling in train, increased from six to 33.121 122
114 Op cit 27 Parliament of the Commonwealth of Australia (2012) 115 Op cit 100 Farke (2011) 116 DrinkWise Australia (2013). It is safest not to drink alcohol while pregnant: Information to support the voluntary labelling initiative on the risks of consuming alcohol during pregnancy: Final report. Canberra: DrinkWise Australia 117 Eurocare – European Alcohol Policy Alliance (2011). Position Paper on: Health Warning Messages on Alcoholic Beverages. Brussells: Eurocare 118 Op cit 98 Wilkinson & Room (2009) 119 International Centre for Alcohol Policies (ICAP) (2013).Health Warning Labels. ICAP Policy Tools Series – Issues Briefings. Washington DC: ICAP 120 Op cit 98 Wilkinson & Room (2009) 121 Op cit 71 Wilkinson et al (2009) 122 Op cit 100 Farke (2011)
Alcohol and Pregnancy Labelling Evaluation - Appendices 77
6.5 Voluntary vs mandatory pregnancy health warning labelling arrangements Of the 33 countries with pregnancy health warning labels, 29 are implementing voluntary pregnancy warning labelling initiatives. South Africa, the Russian Federation and the United States are the only countries with both mandatory health warning labels and prescribed pregnancy health warning labels. The only other country to have mandatory pregnancy health warning labels is France, where it is the only mandatory health warning label. Twenty five of the 29 countries with voluntary pregnancy labelling initiatives currently use the red pregnant lady pictogram mandated in France (see Table 17 below). Publicly available information reviewed for this section does not specify the type of voluntary arrangement in progress – that is, whether or not the arrangement is industry led or based on an agreement between government and industry. There are some indications that voluntary implementation of pregnancy health warning labelling has been largely industry led and includes adoption of the French pictogram. Sweden provides an interesting example because government regulation requires a health warning on alcohol advertising (such as billboards or television commercials) but not on alcohol product labels or packages. Nevertheless, Swedish manufacturers are voluntarily producing labels with the French pregnant lady pictogram.123 Content Governments typically require that factual statements are accurate but might not otherwise regulate them. In the case of pregnancy warning labels, the health information presented varies. Some countries provide directive information and then refer to guidelines or (as is the case in Australia) to a website where explanatory information can be found. In some countries messages have been developed and updated based on contemporary evidence for what works to make the label directive and prominent.124 Some countries advise that it is best to rotate health warning messages. Evidence for effectiveness of poster, billboard and television advertising, and tobacco packaging suggests that, rotation of multiple warnings is a more effective way to maintain the interest and attention of the viewer.125 126 Interestingly, these studies looked at the label in isolation, and did not take into account the possible impact of rotating alcohol product labels on the effectiveness of parallel initiatives and integrated public health campaigns. Legibility Legibility requirements and guidance specify various formats and locations for pregnancy health warning messages on alcoholic beverage containers.127 128 129 In Australia a number of sources of guidance have been developed in recent years, the Victorian Health Promotion Foundation provided guidance on alcohol warning labels in 2009 following its research into labelling of alcohol products. Prior to the commencement of the voluntary labelling initiative in December 2011, DWA provided industry with guidance and resources on label content design format size etc. FARE produced principles and recommended label formats in 2011/12. Reviewers of the evidence for effectiveness of labelling approaches, and public health advocates have consistently critiqued the inconsistent
123 Op cit 100 Farke (2011) 124 Op cit 98 Wilkinson & Room (2009) 125 Wogalter & Brelsford (1994). Incidental Exposure to Rotating Warnings on Alcoholic Beverage Labels. Proceedings of the Human Factors and Ergonomics society 38th Annual Meeting. 126 Wogalter MS, Laughery KR (1996). Warning! Sign and label effectiveness. Current Directions in Psychological Science. 127 Op cit 117 Eurocare (2011) 128 Op cit 98 Wilkinson & Room (2009) 129 Op cit 101 Food Standards Australia New Zealand (FSANZ) (2013)
Alcohol and Pregnancy Labelling Evaluation - Appendices 78
placement, poor legibility and small dimensions of messages.130 Different countries’ labelling legibility requirements and guidance are outlined in Table 16 and Table 17 below. The tables present two matrices which summarise, by country, publicly available information describing the extent and nature of regulation of health warnings on alcohol products. Table 16 lists both government- mandated and voluntary general health warning (excluding pregnancy warnings) label requirements for different countries, with examples of text and graphics used and links to supplementary guidelines and advice. Table 17 outlines similar information specific to pregnancy warning labels on alcohol products. In summary legibility requirements and guidance address: font type and size (Germany, Japan, Thailand, United States) clarity and contrast (Costa Rica, France, Japan, South Africa, United States) colours (Costa Rica, Ecuador, South Africa, Thailand) placement (France, Germany, Japan, Thailand, United States) size and proportions (Costa Rica, Ecuador, South Africa, Thailand, Uzbekistan). In addition, pictorials, colour, and signal icons can increase the noticeability of warning information on alcohol containers.131 Notably, Thailand is the only country that mandates the use of both pictures and text. In Australia, the voluntary initiative is led by DWA. In the scheme, producers who subscribe to the program may choose between several combinations of the DWA logo, ‘Get the Facts’ and a pregnant woman pictogram similar to the one used in France, but coloured green instead of red and holding a glass with a stem instead of a beaker. The DWA guidelines also include recommendations on minimum size and exclusion area, colour and placement. FSANZ have mandatory warning and advisory statements and declarations guidelines which advise on legibility, prominence and contrast.
130 Op cit 98 Wilkinson & Room (2009) 131 Laughery KR, Young SL., Vaubel KP, Brelsford JW, Rowe AL (1993). Explicitness of consequence information in warnings. Safety Science 16: 5-6
Alcohol and Pregnancy Labelling Evaluation - Appendices 79
Table 16: Countries with alcohol product information and health warning labelling policy other than pregnancy, grouped as mandatory or voluntary Mandated/ Country Health and Safety Warning Label Text/Guidance Other Warning Label Requirements and Sources voluntary Mandatory Argentina “Drink in moderation” See Law no. 24.788 of 5 March 1997: National Law on the Prevention of Alcoholism
“Sale prohibited to persons under 18 years of age” Mandatory Australia Net content – must appear on the front label and Council of Australian Governments Legislative and Governance Forum on Food Regulation 2011 be a minimum of 3.3mm high
Number of standard drinks (1995)
Mandatory Brazil “Avoid the excessive consumption of alcohol” Applied to beverage alcohol (13.GL or higher).
See Law N.9.294, 15 July 1996 Mandatory Colombia “An excess of alcohol is harmful to your health” See Decree No. 1298 DE 1994 Mandatory Costa Rica “Drinking alcohol is harmful to your health” Health warnings must appear clearly visible. Proportions need to be such that the warning is distinguishable from any other writing, and it shall be printed in a color contrasting that used for other writing. “Alcohol abuse is harmful to your health”
See Decree no. 15549-S: Alcoholic Beverages - Health Warning Labels Mandatory Ecuador “Warning: The excessive consumption of alcohol Warnings must be legible, using distinguishable colors and occupy 10% of the total surface area. limits your capacity to operate machinery and can cause harm to your health and family” See Reglamento General a la Ley Organica de Defense del Consumidor Publicada en el Suplemento del Registro Official, No. 116 del 10 de Julio del 2000 “The sale of this product is prohibited for those younger than 18 years old” Mandatory El Salvador “The excessive consumption of this product is See Ley Reguladora de la Produccion y Comercializacion del Alcohol y las bebidas alcoholicas, Decree harmful to health and creates addiction. Its sale is no. 587 banned to those under 18 years of age” Mandatory Germany “Sale prohibited to persons under 18 years of age.” The HWL must be displayed on the packaging in the same typeface, size, and color as the brand or trade name or, where there is neither, as the product designation; on bottles, the warning must be displayed on the front of the packaging. The German Brewers label their products with logos to remind about age limits or to promote their drink and drive prevention campaign. Some of the See Federal Ministry of Justice Youth Protection Law spirits producers also use the logo of the “DON‟T DRINK AND DRIVE” campaign. In Germany, spirits-based ready-to-drink mixtures – "alcopops" – are defined by law as spirits-drinks which means that the minimum age applied is 18 years (rather than 16 years as for beer and wine). A clause in the Protection of Minors Act., introduced in 2004, requires "alcopops" to carry the message: “Not for supply to persons less than 18 years old” (clause 9, Protection of Minors Act).
Alcohol and Pregnancy Labelling Evaluation - Appendices 80
Mandated/ Country Health and Safety Warning Label Text/Guidance Other Warning Label Requirements and Sources voluntary Source: Campaign “Don‟t Drink and Drive” http://www.ddad.de/ Deutscher Brauer-Bund http://www.bier-erst-ab-16.de/ Mandatory Guatemala “The excess consumption of this product is harmful Guatemalan Congress decree 90-97, issued 1997, Articulo 49: La Publicidad y el Consumo Perjudicial to the consumer’s health” Mandatory Honduras Not Specified Not Specified Mandatory Israel Alcohol content >15.5% “Warning: Excessive See consumption of alcohol is life threatening and is http://www.health.gov.il/English/News_and_Events/Spokespersons_Messages/Pages/30072013_1.aspx detrimental to health!”
Alcohol content <15.5%: “Warning: Contains alcohol- it is recommended to refrain from excessive consumption” Mandatory Mexico “Abuse of this product is hazardous to your health” See Article 218 of the General Health Law Mandatory Russian “Alcohol is not for children and teenagers up to age Must label wine and vodka and other spirits. Federation 18, pregnant & nursing women, or for persons with diseases of the central nervous system, kidneys, See Ministry of Health in a decree dated January 19, 2007 No. 49 liver, and other digestive organs” Mandatory Slovenia The warning “not suitable for children” is displayed Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper (only for on containers as well as packages of all foodstuffs, presented at the European Alcohol and Health Forum. Brussels EAHF foodstuffs) which contain alcohol. Mandatory South “Alcohol reduces driving ability, don’t drink and (1) Container labels for alcohol beverages must contain at least one of the [seven] health messages. Africa drive” (2) A health message referred to in subregulation shall – (i) be visible, legible, and indelible and the “Don’t drink and walk on the road, you may be legibility thereof shall not be affected by any other matter, printed or otherwise; (ii) be on a space killed” specifically devoted for it, which must be at least one eighth of the total size of the container label; and (iii) be in black on a white background. “Alcohol increases your risk to personal injuries” See Foodstuffs, Cosmetics and Disinfectants Act, 1972 - Regulations Relating to Health Messages on Container Labels of Alcoholic Beverages, 24 August 2007 “Alcohol is a major cause of violence and crime”
“Alcohol abuse is dangerous to your health”
“Alcohol is addictive” Mandatory South One of the below messages must be placed on On all spirits containers: Korea alcohol beverage containers: “Excessive drinking may cause cirrhosis of the liver or liver cancer and increase the probability of a) Warning: Excessive consumption of accidents while driving or working.” alcohol may cause liver cirrhosis or liver cancer and is especially detrimental to See http://www.kfda.go.kr the mental and physical health of minors. OR
Alcohol and Pregnancy Labelling Evaluation - Appendices 81
Mandated/ Country Health and Safety Warning Label Text/Guidance Other Warning Label Requirements and Sources voluntary b) Warning: Excessive consumption of alcohol may cause liver cirrhosis or liver cancer, and especially, women who drink while they are pregnant increase the risk of congenital abnormalities. OR c) Excessive consumption of alcohol may cause liver cirrhosis or liver cancer, and consumption of alcoholic beverages impairs your ability to drive a car or operate machinery and may increase the likelihood of car accidents or accidents during work. Mandatory Taiwan “Excessive drinking endangers health” See The Tobacco and Alcohol Administration Act (2009-06-25) Mandatory Thailand “Liquor drinking may cause cirrhosis and sexual Warning pictures and messages for disadvantages or dangers of alcoholic beverages shall be made in impotency” pictures with 4 colours …, provided that each form shall be used for 1,000 containers: (a) if the containers are square shape, the warning pictures shall have the size of not less than 50% (b) if the containers are in cylindrical shape, the warning pictures shall have the size of not less than 40% of the total space of the “Drunk driving may cause disability or death” containers.
“Liquor drinking may cause less consciousness See Alcohol Beverage Control Act B.E. 2551 (2008) and death”
“Liquor drinking is dangerous to health and causes less consciousness”
“Liquor drinking is harmful to you and destroys your family” Mandatory United “GOVERNMENT WARNING: (1) (2) Consumption The health warning statement must appear on the brand label or separate front label, or on a back or side States of alcoholic beverages impairs your ability to drive label, separate and apart from all other information. a car or operate machinery, and may cause health problems” It must be readily legible under ordinary conditions, and must appear on a contrasting background. Furthermore, labels bearing the warning must be firmly affixed to the container The words ‘‘GOVERNMENT WARNING’’ must appear in capital letters and in bold type. Minimum type size is specified for containers of various sizes.
See Title 27: Alcohol, Tobacco and Firearms. Part 16 – Alcoholic Beverage Health Warning Statement, § 16.21 Mandatory Label Information Mandatory Uzbekistan Not available Beverage alcohol containers must include a medical warning occupying not less than 40% of the basic area of the label in the form of text and/or images.
Alcohol and Pregnancy Labelling Evaluation - Appendices 82
Mandated/ Country Health and Safety Warning Label Text/Guidance Other Warning Label Requirements and Sources voluntary See Law 302 On restriction of Distribution and Taking of Alcohol and Tobacco Products Voluntary Australia “Kids and Alcohol don’t mix” DrinkWise Australia labels text and “Get the Facts” badge recommended
“Do not drink and drive” National Health and Medical Research Council (2009). Australian guidelines https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/ds10-alcohol.pdf “Is your drinking harming yourself or others?”
“It’s safest not to drink alcohol if pregnant” "Drink responsibly” Voluntary Bulgaria The government provides notes about risks for the See Executive Agency on Vine and Wine http://www.eavw.com/en/ health on the labels of alcoholic beverages See http://ec.europa.eu/health/archive/ph_determinants/life_style/alcohol/documents/bulgaria_en.pdf Voluntary Belgium Voluntary use of labels by a number of brands Voluntary Brazil On packages and labels, it is reiterated that sale Applied to beverages below 13.GL. and consumption of the product are only for persons older than 18 years See Conselho Nacional de Autorregulamentação Publicitária, CONAR Voluntary Canada Voluntary use of labels by a number of brands Health advisory or warning labels are not required in Canada and there are no proposals for such a requirement at this time. However, since February 2005, licensed establishments in Ontario have been required to display specific warning signs about the risk of alcohol use in pregnancy (Dell and Roberts, 2005). Voluntary Chile “CCU asks you to drink responsibly” HWL are placed on Compañia Cevecerias Unidas S.A. (CCU) products.
“Product for those 18 and older” Voluntary China Recommended: See GB10344-2005: General Standard for the Labeling of Prepackaged Alcoholic Beverages
“Overdrinking is harmful to heath Voluntary Denmark Alcohol contents units directive 2000/13/Ec Of The European Parliament And Of The CounciL - Revised in 2009.
Enjoy responsibly Voluntary Germany Beer? Sorry, at 16 years / Enjoy beer consciously See Federal Ministry of Justice Youth Protection Law Voluntary Japan “Be careful not to drink in excess” Displayed in an easy-to-read location on the container, using uniform Japanese font, at least 6 pts in size.
“Drink in moderation” See Self-Regulatory Code of Advertisement Practices and Container Labeling for Alcoholic Beverages Voluntary Lithuania The voluntary campaign “18+” started on 23rd One of the video clips is available under the following web link: November 2010. The campaign is conducted by the alcohol producers in Lithuania, mainly by the http://www.videopasaulis.lt/video/30357/riciardas-berankis-lietuvos-aludariu-gildijos-socialine- brewers. Within the scope of the campaign
Alcohol and Pregnancy Labelling Evaluation - Appendices 83
Mandated/ Country Health and Safety Warning Label Text/Guidance Other Warning Label Requirements and Sources voluntary commercials are shown in TV, radio, internet, etc. kampanija.html In the spots, famous national sports idols and other idols, which are very popular among young people, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper are shown. Additionally, 2 million beer bottles will presented at the European Alcohol and Health Forum. Brussels EAHF be labelled with the “18+” logo. The intention is to raise the awareness that alcohol is not allowed for minors.
Voluntary The Voluntary use of labels by a number of brands Responsible drinking website (2004) http://www.drinkwijzer.info/ Netherland s http://www.enjoyheinekenresponsibly.com Voluntary Spain Voluntary use of labels Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented at the European Alcohol and Health Forum. Brussels EAHF Voluntary United “The Chief Medical Officer recommend men do not Labels also include the website address of the Drinkaware Trust (www.drinkaware.co.uk), a national Kingdom regularly exceed 3-4 units daily and women, 2-3 charity providing consumer information about alcohol, and one of the three following messages as a units daily” heading: “Know Your Limits,” “Enjoy Responsibly,” or “Drink Responsibly.”
See http://www.dh.gov.uk/
United Kingdom 2007 (agreement):
Alcohol content in units Lower-risk guidelines Alcohol and pregnancy message
Note: it is not against regulations to display the following message which is common: “PREGNANCY Most studies show that 1-2 units of alcohol once or twice a week do not cause harm in pregnancy”
Alcohol and Pregnancy Labelling Evaluation - Appendices 84
Table 17: Countries with a specific pregnancy warning labelling policy, grouped as mandatory or voluntary Mandated Country Health and Safety Warning Label Text/Guidance Other Warning Label Requirements andSources / Voluntary Mandated France “Drinking alcoholic beverages during pregnancy Packaging of all beverage alcohol products sold or distributed (including for free as promotion) in France must even in small quantities can have grave/serious have at least one of the two health messages recommending that pregnant women do not drink alcohol. consequences for the health of the baby” The health message must appear in the same visual field as the obligatory labelling on the alcohol content. OR use the government-issued symbol showing a diagonal line being superimposed on an image The warning message must be written on a contrasting background in a manner that is visible, reliable, clear, of a pregnant woman holding a glass understandable, and indelible.
See http://www.vins-bourgogne.fr/connaitre/la-terre-de-bourgogne/l-etiquetage/gallery_files/site/321/360.pdf
Mandated Russian “Alcohol is not for children and teenagers up to Must label wine and vodka and other spirits. Federation age 18, pregnant & nursing women, or for persons with diseases of the central nervous See Ministry of Health in a decree dated January 19, 2007 No. 49 system, kidneys, liver, and other digestive organs” Mandated South Africa “Drinking during pregnancy can be harmful to (1) Container labels for alcohol beverages must contain at least one of the [seven] health messages, with the your unborn baby” pregnancy label only one of the seven choices.
(2) A health message referred to in sub regulation shall – (i) be visible, legible, and indelible and the legibility thereof shall not be affected by any other matter, printed or otherwise; (ii) be on a space specifically devoted for it, which must be at least one eight of the total size of the container label; and (iii) be in black on a white background.
See Foodstuffs, Cosmetics and Disinfectants Act, 1972 - Regulations Relating to Health Messages on Container Labels of Alcoholic Beverages, 24 August 2007 Mandated United “GOVERNMENT WARNING: (1) According to The health warning statement must appear on the brand label or separate front label, or on a back or side States the Surgeon General, women should not drink label, separate and apart from all other information. alcoholic beverages during pregnancy because of the risk of birth defects” It must be readily legible under ordinary conditions, and must appear on a contrasting background. Furthermore, labels bearing the warning must be firmly affixed to the container.
The words ‘‘GOVERNMENT WARNING’’ must appear in capital letters and in bold type. Minimum type size is specified for containers of various sizes.
See Title 27: Alcohol, Tobacco and Firearms. Part 16 – Alcoholic Beverage Health Warning Statement, § 16.21 Mandatory Label Information
Alcohol and Pregnancy Labelling Evaluation - Appendices 85
Mandated Country Health and Safety Warning Label Text/Guidance Other Warning Label Requirements andSources / Voluntary Voluntary Australia “For women who are pregnant or planning a Council of Australian Governments Legislative and Governance Forum on Food Regulation 2011 pregnancy, not drinking is the safest option” (Commonwealth of Australia 2009 )“It is safest National Health and Medical Research Council (2009). Australian guidelines not to drink while pregnant” https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/ds10-alcohol.pdf
Review recommended after 2 years of voluntary implementation by industry Voluntary Austria Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented mainly with the French pictogram at the European Alcohol and Health Forum. Brussels EAHF
Voluntary Belgium Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented mainly with the French pictogram at the European Alcohol and Health Forum. Brussels EAHF
Voluntary Bulgaria Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented mainly with the French pictogram at the European Alcohol and Health Forum. Brussels EAHF
Voluntary Cyprus Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented mainly with the French pictogram at the European Alcohol and Health Forum. Brussels EAHF
Voluntary China Recommended: See GB10344-2005: General Standard for the Labeling of Prepackaged Alcoholic Beverages
“Pregnant women and children shall not drink” Voluntary Czech Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented Republic mainly with the French pictogram at the European Alcohol and Health Forum. Brussels EAHF
Alcohol and Pregnancy Labelling Evaluation - Appendices 86
Mandated Country Health and Safety Warning Label Text/Guidance Other Warning Label Requirements andSources / Voluntary
Voluntary Denmark Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented mainly with the French pictogram at the European Alcohol and Health Forum. Brussels EAHF
Voluntary Estonia Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented mainly with the French pictogram at the European Alcohol and Health Forum. Brussels EAHF
Voluntary Finland “WARNING: Alcohol is hazardous to the Was introduced as legislation to the parliament in 2007, but abandoned as a mandatory measure in 2008. See development of the foetus and to your health”. http://www.dss3a.com/btg/pdf/Parallels/Sat/montonen_sat_strand2bis_casefinland.pdf
Voluntary use of labels by a number of brands, mainly with the French pictogram
Voluntary Germany Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented mainly with the French pictogram at the European Alcohol and Health Forum. Brussels EAHF
Voluntary Hungary Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented mainly with the French pictogram at the European Alcohol and Health Forum. Brussels EAHF
Voluntary Ireland Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented mainly with the French pictogram at the European Alcohol and Health Forum. Brussels EAHF
Alcohol and Pregnancy Labelling Evaluation - Appendices 87
Mandated Country Health and Safety Warning Label Text/Guidance Other Warning Label Requirements andSources / Voluntary Voluntary Italy Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented mainly with the French pictogram at the European Alcohol and Health Forum. Brussels EAHF
Voluntary Japan “Drinking alcohol during pregnancy or nursing Displayed in an easy-to-read location on the container, using uniform Japanese font, at least 6 pts in size. may adversely affect the development of your fetus or child” See Self-Regulatory Code of Advertisement Practices and Container Labeling for Alcoholic Beverages Voluntary Latvia Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented mainly with the French pictogram at the European Alcohol and Health Forum. Brussels EAHF
Voluntary Lithuania Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented mainly with the French pictogram at the European Alcohol and Health Forum. Brussels EAHF
Voluntary Luxembourg Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented mainly with the French pictogram at the European Alcohol and Health Forum. Brussels EAHF
Voluntary Malta Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented mainly with the French pictogram at the European Alcohol and Health Forum. Brussels EAHF
Voluntary The Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented Netherlands mainly with the French pictogram at the European Alcohol and Health Forum. Brussels EAHF
Voluntary Poland Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented at the European Alcohol and Health Forum. Brussels EAHF
Alcohol and Pregnancy Labelling Evaluation - Appendices 88
Mandated Country Health and Safety Warning Label Text/Guidance Other Warning Label Requirements andSources / Voluntary mainly with the French pictogram
Voluntary Portugal Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented mainly with the French pictogram at the European Alcohol and Health Forum. Brussels EAHF
Voluntary Romania Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented mainly with the French pictogram at the European Alcohol and Health Forum. Brussels EAHF
Voluntary Slovak Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented Republic mainly with the French pictogram at the European Alcohol and Health Forum. Brussels EAHF
Voluntary Slovenia Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented mainly with the French pictogram at the European Alcohol and Health Forum. Brussels EAHF
Voluntary South Korea The below messages is a part of one of three See http://www.kfda.go.kr messages that can be chosen: “Women who drink while they are pregnant increase the risk of congenital abnormalities.” Voluntary Spain Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented mainly with the French pictogram at the European Alcohol and Health Forum. Brussels EAHF
Voluntary Sweden Voluntary use of labels by a number of brands, Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented at the European Alcohol and Health Forum. Brussels EAHF
Alcohol and Pregnancy Labelling Evaluation - Appendices 89
Mandated Country Health and Safety Warning Label Text/Guidance Other Warning Label Requirements andSources / Voluntary mainly with the French pictogram
Voluntary United “Avoid alcohol if pregnant or trying to conceive” Note: it is not against regulations to display the following message which is common: “PREGNANCY Kingdom Most studies show that 1-2 units of alcohol once or twice a week do not cause harm in pregnancy”
Alcohol and Pregnancy Labelling Evaluation - Appendices 90
6.6 Evidence for the effectiveness of health warnings on alcohol products Reviews of evidence of the effectiveness of health warning labelling of alcohol products Studies of the effectiveness of health warning labels on alcohol products have been reviewed by Stockwell (2006)132, Wilkinson and Room (2009)133, WHO (2010)134, Anderson (2012)135, and Jones and Gordon (2013)136. Each of these reviewers focussed on international experience and evaluations of warning labels on alcohol products, and noted some or all of the following limitations of the published research: Difficulty in comparing studies from different countries because of differences in contexts and in what is measured and how it is measured Lack of baseline measures Lack of control groups Small sample sizes Difficulty in determining the contribution of labelling interventions to increase awareness and understanding of health risks and behaviour change in the context of other interventions with the same aims.137 Reviewers concluded that studies concerning the effectiveness of product labelling and advertising campaigns designed to warn the population about the risks of drink driving and smoking could usefully inform efforts to implement other health warning labelling initiatives. The lessons learned from these public health campaigns include: Community support exists for health warnings and information on alcohol and tobacco product labels138 139 Labelling has been one part of a wide ranging strategy on drink driving and smoking, and part of integrated public health campaigns including multi media campaigns140 141 In Australia, the alcohol labelling code does not prescribe how to display mandated alcohol contents and number of standard drinks, but it does provide guidelines142 143 Mandatory tobacco labelling prescribes how to display health warning information to ensure that it is more graphic, coloured and larger (design factors)144
132 Op cit 103 Stockwell (2006) 133 Op cit 98 Wilkinson & Room (2009) 134 Op cit 15 World Health Organisation (2010) 135 Anderson, P (2012). The impact of alcohol on health. In P Anderson, L Møller & G Galea (eds) Alcohol in the European Union. Copenhagen, Denmark: World Health Organization (WHO) 136 Jones S, Gordon R (2013). Alcohol warning labels: are they effective? Deeble Institute Evidence Brief, Australian Healthcare and Hospitals Association, no: 6 137 Op cit 98 Wilkinson & Room (2009) 138 Op cit 98 Wilkinson & Room (2009) 139 Thompson LM, Vandenberg B, Fitzgerald JM (2012). An exploratory study of drinkers views of health information and warning labels on alcohol containers. Drug and Alcohol Review, 31: 240-247 140 Op cit 139 Thompson et al (2012) 141 Op cit 98 Wilkinson & Room (2009) 142 Op cit 139 Thompson et al (2012) 143 Op cit 98 Wilkinson & Room (2009) 144 Op cit 98 Wilkinson & Room (2009)
Alcohol and Pregnancy Labelling Evaluation - Appendices 91
Tobacco labels are rotated over time to maximise impact.145 146 It must be noted however that drink driving and tobacco are different from drinking alcohol during pregnancy. Drink driving is illegal and that the impact of the campaign may be different in the case of drink driving vs drinking while pregnant because drinking and driving is illegal and there are legal consequences. The reviews noted that, in general, information and education on the risks of alcohol and how to reduce harm can increase awareness and knowledge. Health warning labels on alcohol products were one vehicle for raising awareness and increasing knowledge of risks associated with alcohol consumption, including alcohol consumption during pregnancy. Most of the evaluation studies have focussed on how the use of health warning labels on alcohol products is accepted and supported by the public. We note use of standard drink labels on alcohol containers was supported by 69% of respondents in the National Drug Strategy Household Survey (2004) and remained strong but decreased in the 2007 and 2010 surveys to 65.8% and 61.9% respectively.147 Warning labels are important in helping to establish a social understanding that alcohol is a special and hazardous commodity.148 In spite of the methodological difficulties, some evidence indicates that although health warnings on alcoholic beverage containers “…do not lead to changes in drinking behaviour, they do impact on intentions to change drinking patterns and remind consumers about the risks associated with alcohol consumption.”149 Other sources indicate that there is no evidence that health warning labels on alcohol products impact on drinking behaviour (including heavy drinkers, pregnant women and young people), but high risk drinkers were more likely than others to recall the health warning message. A 2013 review of the literature by the International Centre for Alcohol Policy found that “…while consumers are generally aware of the existence of health warning labels on alcohol products, comprehension and recall of the messages is low.”150 There remains limited evidence on the effectiveness of alcohol warning labels and pregnancy warning labels specifically. Reviewers conclude that there is scope for further research about: Drinkers’ interactions with different label displays presented in differing contexts (eg effects of seeing the labels in the context of other visual material on alcohol containers) The impact of format and wording If labels should be rotated and updated periodically. Issues specific to the effectiveness of pregnancy health warning labels on alcohol products Stockwell’s 2006 review of mandatory pregnancy health warning labelling of alcoholic beverages in the US found that labelling had minimal or no effects on drinking behaviour.151 However, in relation to recall of messages Stockwell (2006)152 found evidence that the “…highest risk groups of drinkers
145 Op cit 98 Wilkinson & Room (2009) 146 Op cit 135 Anderson (2012) 147 Op cit 91 Australian Institute of Health and Welfare (2011) 148 Op cit 98 Wilkinson & Room (2009) 149 Op cit 15 World Health Organisation (2010) 150 International Centre for Alcohol Policy (2013). Health warning labelling of alcohol products. ICAP Policy Tools Issues Briefing Series. Washington DC: ICAP 151 Op cit 71 Stockwell (2006) 152 Op cit 71 Stockwell (2006)
Alcohol and Pregnancy Labelling Evaluation - Appendices 92
(including young people, pregnant women and heavy drinkers) are particularly likely to recall the messages.”153 A recent study identified that some women report experiencing peer pressure to drink alcohol during pregnancy from partners, parents and friends.154 Reviewers note that there is no evidence that would support an expectation that pregnancy health warning labels in and of themselves would cause attitudinal or behaviour change. Research shows that awareness of the pregnancy messages on the labels in the whole population can lead to conversations about not drinking alcohol during pregnancy; and may contribute to change in attitudes and behaviours which may in turn lead to reductions in alcohol consumption and risk of poor pregnancy and childhood outcomes.155 156 Pregnancy health warnings on alcoholic beverages were mandated in France in 2007 to promote abstinence during pregnancy. The labels were introduced with a 1 year transition period. Implementation was accompanied by an extensive media campaign. Anderson reviewed the study conducted by Guillemont and Leon (2008) who conducted two surveys each with 1000 respondents over the age of 15 by telephone - one in 2004 and one in 2007. They found evidence for increasing awareness and recall of the messages especially among teenagers and pregnant women. The survey results showed that: …the recommendation that pregnant women should not drink alcohol was better known after the introduction of the health warning (87% of the respondents) than before (82%). After the introduction of the label, 30% thought that the risk for the foetus [sic] started after the first glass compared with 25% in 2004. Anderson 2012, p6 In summary the available evidence suggests that: There is some evidence to suggest that health warning labels are important in helping to establish a social understanding that alcohol is a special and hazardous commodity. Reviews of the available evidence on the effectiveness of health warning labels on alcohol products have found that health warning labels can raise awareness of harmful use of alcohol. Currently no evidence exists to support that either health warnings more broadly nor pregnancy health warnings on labels can by themselves cause behaviour change. When pregnancy warnings on alcohol products are supported by broader health promotion strategies (eg integrated mass and social media campaigns as well as and advertising to promote interpersonal communication) awareness and recall of messages about the potential for alcohol related harm can increase over time.
153 Op cit 103 Stockwell (2006) 154 Deshpande S, Rundle-Thiele SR (2012). Segmenting and Targeting American University Students to Promote Responsible Alcohol Use: A Case for Applying Social Marketing Principles. Health Marketing Quarterly, 28(4): 287-303 155 Op cit 98 Wilkinson & Room (2009) 156 Op cit 135 Anderson (2012)
Alcohol and Pregnancy Labelling Evaluation - Appendices 93
6.7 Bibliography Context Anderson AR (2002). Marketing social marketing in the social change marketplace. Journal of Public Policy and Marketing, 12(1). Pg. 3-13. Online at http://www.jstor.org/stable/30000704 Anderson AE, Hure AJ, Forder PM, Powers J, Kay-Lambkin F, Loxton DJ (2014). Risky drinking patterns are being continued into pregnancy: A prospective cohort study. DOI: 10.1371/journal.pone.0086171 Australian Government (2013). Responding to the Impact of Fetal Alcohol Spectrum Disorders in Australia: A Commonwealth Action Plan. Commonwealth response to Standing Committee report online at: https://www.health.gov.au/internet/main/publishing.nsf/Content/0FD6C7C289CD31C9CA2 57BF0001F96BD/$File/Commonwealth-Action-Plan.pdf Australian Health Ministers’ Advisory Council (2012). Clinical Practice Guidelines: Antenatal Care – Module 1. Canberra: Australian Government Department of Health and Ageing Australian Institute of Health and Welfare (2011). 2010 National Drug Strategy Household Survey report. Drug statistics series no. 25. Cat. No. PHE 145. Canberra: AIHW Babor T, Caetano R, Casswell S, Edwards G, Giesbracht N, Graham K, Grube J, Hill L, Holder H, Homel R, Livingston M, Osterberg E, Rehm J, Room R, Rossow I (2010). Alcohol: no ordinary commodity – research and public policy. Pan American Health Organization. Oxford: Oxford University Press Callinan S, Room R (2012). Alcohol consumption during pregnancy: results from the 2010 National Drug Strategy Household Survey. Canberra: Foundation for Alcohol Education and Research (FARE) Breen C, Burns L (2012). Improving services to families affected by FASD. Canberra: FARE British Medical Association Board of Science (2007). Fetal Alcohol Spectrum Disorders. A guide for healthcare professionals. British Medical Association Bridge P (2011). Ord valley Aboriginal Health Service’s fetal alcohol spectrum disorders program: Big steps, solid outcome. Australian Indigenous HealthBulletin, 11(4). Retrieved from http://healthbulletin.org.au/wp- content/uploads/2011/10/bulletin_review_bridge_2011.pdf Carson G, Cox LV, Crane J, Croteau P, Graves L, Kluka S, Koren G, Martel MJ, Midmer D, Nulman I, Poole N, Senikas V, Wood R (2010). Society of obstetricians and gynaecologists of Canada. Alcohol use and pregnancy consensus clinical guidelines. Journal of Obstetrics and Gynaecology of Canada, 32, S1-S31 Daube M, Kirby G, Mattick R (2009). Report 2 Alcohol warning labels: Evidence of impact on alcohol consumption amongst women of childbearing age. Report prepared for Food Standards Australia New Zealand (FSANZ) online at: http://www.foodstandards.gov.au/code/applications/Pages/applicationa576label3785.aspx DrinkWise Australia (2013). It is safest not to drink alcohol while pregnant: Information to support the voluntary labelling initiative on the risks of consuming alcohol during pregnancy: Final report. Canberra: DrinkWise Australia Euromonitor International (2011) Wine-Australia in Country Sector Briefing April 2011. Euromonitor International: Australia. http://www.euromonitor.com/australia Foundation for Alcohol and Education (2013).The Australian Fetal Alcohol Spectrum Disorders Action Plan 2013-2016. Canberra: Foundation for Alcohol Education and Research (FARE)
Alcohol and Pregnancy Labelling Evaluation - Appendices 94
Context Foundation for Alcohol Research and Education (2014). Annual Alcohol Poll: Attitudes and behaviours. Canberra FARE Accessed 14 April 2014 at: http://www.fare.org.au/research- development/community-polling/2014-poll/ Grier S, Bryant C (2005). Social marketing in public health. Annual Review of Public Health. 26(1). p319-339. doi: 10.1146/annurev.publhealth.26021304.144610 Health Technology Analysts (2010). Exploratory economic analysis of different prevention strategies in Australia and New Zealand. Report prepared for Food Standards Australia New Zealand (FSANZ) International Centre for Alcohol Policies (ICAP) (2011). International Drinking Guidelines. Online text at: http://www.icap.org/Table/InternationalGuidelinesOnDrinkingAndPregnancy International Centre for Alcohol Policy (ICAP) (2013). Health Warning labelling of alcohol products. ICAP Policy Tools Issues Briefing Series. Retrieved from: http://www.icap.org/LinkClick.aspx?fileticket=wFqDsZVkk1E%3D&tabid=243 IPSOS Social Research Institute (2012). AER foundation policy position paper. Alcohol product labelling: Health warning labels and consumer information. Accessed 7 March 2014 at: http://www.fare.org.au/wp-content/uploads/2011/07/AER-Policy-Paper_FINAL.pdf IPSOS Social Research Institute (2012). Alcohol label audit. Report prepared for the Foundation for Alcohol Research and Education (FARE) Accessed 4 March 2014 at: http://www.fare.org.au/wp-content/uploads/2011/07/Alcohol-Label-Audit-September- 2013.pdf Lee N, Jenner L (2013). Drug treatment: psychological and medical interventions. In A Ritter, T King & M Hamilton [Eds.] Drug Use in Australian Society. Melbourne: Oxford University Press Lefebvre & Flora (1988). Social Marketing and Public Health Intervention. Health Education and Behaviour. 15. 299. doi: 10.1177/109019818801500305. Online version found at http://heb.sagepub.com/content/15/3/299 McDonald D (2013). Drug Laws and regulations. In A Ritter, T King & M Hamilton (eds), Drug Use in Australian Society. Melbourne: Oxford University Press McGuire WJ (1974). Communication-persuasion models for drug education. In M Goodstadt (ed), Research on Methods and Programs for Drug Education, Toronto: Addiction Research Foundation McGuire WJ (1985). Attitudes and attitude change. In G Lindsay & E Aronson (eds), Handbook of Social Psychology, 2. p. 283. New York. Random House. McGuire WJ (1969). The Nature of Attitudes and Attitude Change. In G Lindsay & E Aronson (eds), Handbook of Social Psychology. Boston. Addison-Wesley. Mengel MB, Searight HR & Cook K (2006). Preventing alcohol-exposed pregnancies. The Journal of the American Board of Family Medicine, 19(5): 494-505 Miller ME, Ware J (1989). Mass-media alcohol and drug campaigns: A consideration of relevant issues. National Campaign Against Drug Abuse. MS-9. Canberra. Australian Government National Indigenous Drug and Alcohol Committee (2012). Addressing fetal alcohol spectrum disorder in Australia. Canberra: Australian National Council on Drugs (ANCD). Retrieved from: http://www.nidac.org.au/images/PDFs/NIDACpublications/FASD.pdf. National Preventative Health Taskforce Alcohol Working Group (2009). Preventing alcohol-related harm in Australia: a window of opportunity, including addendum for October 2008 to June 2009, Technical Report no. 3. Canberra: Department of Health and Ageing. Retrieved from: http://www.health.gov.au/internet/preventativehealth/publishing.nsf/Content/tech- alcohol-toc
Alcohol and Pregnancy Labelling Evaluation - Appendices 95
Context National Health and Medical and Medical Research Council (2009). Australian guidelines to reduce health risks from drinking alcohol. Canberra: Commonwealth of Australia, NHMRC https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/ds10-alcohol.pdf National Health and Medical Research Council (2012). Clinical Practice Guidelines Antenatal Care – Module 1. Canberra: Commonwealth of Australia NHMRC. Accessed 20 March at: http://www.health.gov.au/antenatal National Institute for Health and Clinical Experience (NICE) (2008). Antenatal Care: Routine Care for the Healthy Pregnant Woman. London: National Institute for Health and Clinical Experience (NICE). Retrieved from: http://www.nice.org.uk/nicemedia/live/11947/40111/40111.pdf New Zealand Law Commission (2010). Alcohol in Our Lives, curbing the harm. Wellington: Law Commission Report No 14. Retrieved from: www.austlii.edu.au/nz/other/lawreform/NZLCR/2010/114.pdf New Zealand Ministry of Health (2006). Food and Nutrition Guidelines for Healthy Pregnant and Breastfeeding Women: A background paper. Wellington: New Zealand Ministry of Health. Retrieved from: http://www.health.govt.nz/publication/food-and-nutrition-guidelines- healthy-pregnant-and-breastfeeding-women-background-paper O’Leary CM, Nassar N, Kurinczuk JJ, Bower C (2009).The effect of maternal alcohol consumption on fetal growth and preterm birth. British Journal of Obstetrics and Gynaecology 116(3): 390- 400. DOI: 10.1111/j.1471-0528.2008.02058.x Peadon E, Payne J, Henley N, D’Antoine H, Bartu A, O’leary C, Bower C, Elliot EJ (2010). Women's knowledge and attitudes regarding alcohol consumption in pregnancy: a national survey. BMC Public Health. 10: 510. DOI: 10.1186/1471-2458-10-510 Peadon E, Rhys-Jones B, Bower C & Elliott EJ (2009). Systematic review of interventions for children with Fetal Alcohol Spectrum Disorders. BMC pediatrics, 9(1): 35. Accessed 4 March 2014 at: http://www.biomedcentral.com/1471-2431/9/35. Parliament of the Commonwealth of Australia (2012).Final report of the House of Representatives Standing Committee of Social Policy and Legal Affairs: FASD: the hidden harm. Inquiry into the prevention, diagnosis and management of Fetal Alcohol Spectrum Disorders. Canberra: Commonwealth of Australia. Accessed 27 February 2014 at: http://www.aph.gov.au/parliamentary_business/committees/house_of_representatives_co mmittees?url=spla/fasd/report.htm Public Health Agency of Canada (2011). The Sensible Guide to a Healthy Pregnancy. Ottawa: Public Health Agency of Canada (PHAC). Online text at http://www.phac-aspc.gc.ca/hp-gs/guide- eng.php Pricewaterhouse Coopers (PWC) (2008). Cost of Labelling Schedule. Report, prepared by PricewaterhouseCoopers for Food Standards Australia New Zealand (FSANZ). Accessed 27 February at: http://www.foodstandards.gov.au/publications/Pages/costscheduleforfoodl5765.aspx Roarty L, Frances K, Allsop S, O'Leary CM, McBride N, Wilkes ET (2014). Alcohol, pregnancy and Fetal Alcohol Spectrum Disorders. Resources for health professionals working in Aboriginal and Torres Strait Islander health care settings. [T228] Skagerstróm J, Chang G & Nilsen P (2011). Predictors of drinking during pregnancy: a systematic review. Journal of women's health, 20(6): 901-913. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3159119/
Alcohol and Pregnancy Labelling Evaluation - Appendices 96
Context The Danish National Board of Health (2010). Healthy Habits – before during and after pregnancy. 1st English edition (translated from the 2nd Danish edition). The Danish National Board of Health and The Danish Committee for Health Education. Retrieved from: http://sundhedsstyrelsen.dk/publ/publ2010/cff/english/sundevaner_en.pdf Thomson LM, Vandenberg B, Fitzgerald JL (2012). An exploratory study of drinkers views of health information and warning labels on alcohol containers. Drug and Alcohol Review 31: 240-247 U.S. Surgeon General (2005). U.S. Surgeon General Releases Advisory on Alcohol Use in Pregnancy [press release]. United States Department of Health and Human Services. Accessed 4 March 2014 at: http://www.come-over.to/FAS/SurGenAdvisory.htm. Wilson M, Stearne, Gray D, Saggers S (2010). The Harmful Use of Alcohol amongst Indigenous Australians. Online publication. Accessed 2 March 2014 at: http://www.healthinfonet.ecu.edu.au/alcoholuse_review Wilkinson C, Allsop S, Cail D, Chikritzhs T, Daube M, Kirby G, Mattick R (2009). Report 1 Alcohol Warning Labels: Evidence of effectiveness on risky alcohol consumption and short term outcomes. Prepared for the Food Standards Australia New Zealand. Accessed 4 March 2014 at: http://www.foodstandards.gov.au/code/applications/documents/Curtin%20University%20o f%20Technology_Alcohol%20Warning%20Labels.pdf Wine Australia 2013 Compliance Guide for Australian Wine Producers. Accessed 17 April 2014 at: http://www.wineaustralia.com/en/Production%20and%20Exporting/Labelling.aspx World Health Organisation (2010) Global Strategy to Reduce the Harmful Use of Alcohol. Geneva World Health Organisation (WHO). Accessed 4 March 2014 at: http://www.who.int/substance_abuse/alcstratenglishfinal.pdf World Health Organisation (2011). Global Status Report on Alcohol and Health Online text. Accessed 2 March 2014 at: http://www.who.int/substance_abuse/publications/global_alcohol_report/en/ World Health Organisation (2004). Global Status Report on Alcohol and Health. Geneva: World Health Organisation (WHO). Accessed 2 March 2014 at: http://www.who.int/substance_abuse/publications/global_status_report_2004_overview.p df
Regulation Campden & Chorleywood Food Research Association Group (CCFRA) (2008). Monitoring implementation of alcohol labelling regime (including advice to women on alcohol and pregnancy). Online resource. Accessed 5 March 2014 at: http://www.dh.gov.uk/en/Publichealth/Healthimprovement/Alcoholmisuse/DH_085390 Eurocare – European Alcohol Policy Alliance (2009). Labelling initatives: a brief summary of health warnings on alcoholic beverages. Brussells: Eurocare, Accessed 2 March 2014 at: http://www.eurocare.org/resources/policy_issues/labelling Eurocare – European Alcohol Policy Alliance(2011). Position Paper on: Health Warning Messages on Alcoholic Beverages. Brussells: Eurocare, Accessed 2 March 2014 at: http://www.eurocare.org/resources/policy_issues/labelling Eurocare – European Alcohol Policy Alliance(2012). Eurocare library of alcohol health warning labels. Brussells: Eurocare, Accessed 2 March 2014 at: http://www.eurocare.org/resources/policy_issues/labelling
Alcohol and Pregnancy Labelling Evaluation - Appendices 97
Regulation European Commission (2006). Communication from the Commission of 24th October 2006, An EU strategy to support Member States in reducing alcohol related harm, COM 625 final. Accessed 5 March 2014 at: http://eur- lex.europa.eu/LexUriServ/site/en/com/2006/com2006_0625en01.pdf Food Standards Australia New Zealand (FSANZ) (2007). Initial assessment report. Application A576: labelling alcoholic beverages with a pregnancy health advisory label. Canberra:FSANZ. Retrieved from: http://www.foodstandards.gov.au/code/applications/pages/applicationa576label3785.aspx Food Standards Australia New Zealand (FSANZ). (2013). Australia and New Zealand Food Standards Code (Standard 2.7.1 – Labelling of Alcoholic Beverages and Food Containing alcohol; Standard 1.2.9 Legibility Requirements. Canberra:FSANZ. Retrieved from: http://www.foodstandards.gov.au/code/code-revision/FSANZ%20Code%20revision/43%20- %20Standard%202%207%201%2021%20Feb%2014.docx Food Labelling Law and Policy Review Panel (2011). Labelling Logic: review of food labelling law and policy. Canberra: Commonwealth of Australia International Centre for Alcohol Policies (ICAP) (2011). Health warning labels (ICAP Policy Tables) Accessed 4 March 2014 at http://www.icap.org/Table/HealthWarningLabels. International Centre for alcohol Policies (ICAP) (2009) International guidelines on drinking and pregnancy. Accessed 4 March 2014 at: http://www.icap.org/Table/InternationalGuidelinesOnDrinkingAndPregnancy International Centre for Alcohol Policies (2013).Health Warning Labels. ICAP Policy Tools Series – Issues Briefings. Washington DC: ICAP. Retrieved from http://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&ved=0C CoQFjAA&url=http%3A%2F%2Fwww.icap.org%2FLinkClick.aspx%3Ffileticket%3D9o8t7WI8Z %252F4%253D%26tabid%3D243&ei=7VJgU_n2JoqkigeOooGYBw&usg=AFQjCNET- Jn3jqZuQV2g0qsu8y8oN574wQ Office of National Drug Control Policy (2011). National Drug Control Strategy 2011. Washington DC: Office of National Drug Policy. Retrieved from: www.whitehouse.gov/ondcp/2011-national- drug-control-strategy Room R, Schmidt L, Rhem J, Mäkelä P (2008). International regulationof alcohol. British Medical Journal 337:a2364. DOI: http://dx.doi.org/10.1136/bmj.a2364 World Health Organisation (2012). Addressing the harmful use of alcohol: a guide to developing effective alcohol legislation. Geneva: WHO. Retrieved from: http://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&cad=rja &uact=8&ved=0CCgQFjAA&url=http%3A%2F%2Fwww.who.int%2Fsubstance_abuse%2Fmsb alcstragegy.pdf&ei=emZgU-XXN42QlQXQ3oCIAw&usg=AFQjCNFuR- sLZfldoswfvIROC9YRdMUsJA World Health Organisation Global Health Observatory data Repository. Warning and consumer information labels: Health Warning labels on alcohol containers by country. Accessed 5 March 2014 at: http://apps.who.int/gho/data/node.main.A1193?lang=en World Wine Trade Group (2007). Agreement on Requirements for Wine Labelling. Canberra: World Wine Trade Group. Retrieved from http://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&ved=0C CgQFjAA&url=http%3A%2F%2Fwww.ita.doc.gov%2Ftd%2Focg%2Fwwtglabel.pdf&ei=MVJgU 8CINOn9iAf_mYDgAw&usg=AFQjCNGlQ0YzMxkivfB7zCF- Mk9R1oDCtw&bvm=bv.65636070,d.aGc
Alcohol and Pregnancy Labelling Evaluation - Appendices 98
Evidence for effectiveness of pregnancy health warnings on alcohol products Anderson P (2012). The impact of alcohol on health. In P Anderson, L Møller and G Galea (2012). Alcohol in the European Union. Copenhagen, Denmark: World Health Organization (WHO) Andrews JC, Netemeyer RG, Durvasula S (1991). Effects of consumption frequency on believability and attitudes toward alcohol warning labels. Journal of Consumer Affairs, 25(2): 323-338 Agostinelli G, Grube J (2002). Alcohol counter-advertising and the media. Alcohol Research & Health, 26(1): 15-21 DeCarlo TE (1997). Alcohol warnings and warning labels: an examination of alternative alcohol warning messages and perceived effectiveness. Journal of Consumer Marketing, 14(6): 448- 462 Deshpande S, Rundle-Thiele SR (2012). Segmenting and targeting American university students to promote responsible alcohol use: A case for applying social marketing principles. Health Marketing Quarterly, 28(4): 287-303 Doran CM, Hall, WD, Shakeshaft AP, Vos T, Cobiac LJ (2010). Alcohol policy reform in Australia: What we can learn form the evidence. Medical Journal of Australia, 193(8) 468-470 DrinkWise Australia (2013). It is safest not to drink alcohol while pregnant: Information to support the voluntary labelling initiative on the risks of consuming alcohol during pregnancy: Final report. Canberra: DrinkWise Australia Farke W (2011). Consumer labelling of alcohol beverages – a review of practices in Europe. Paper presented at the European Alcohol and Health Forum. Brussels: EAHF Foundation for Alcohol Research and Education (2011) Alcohol warning labels: attitudes and perceptions. Canberra: Foundation for Alcohol Research and Education (FARE) Greenfield TK, Graves KL & Kaskutas LA (1999). Long‐term effects of alcohol warning labels: Findings from a comparison of the United States and Ontario, Canada. Psychology & marketing, 16(3): 261-282 Greenfield TK, Kaskutas LA (1998). Five years' exposure to alcohol warning label messages and their impacts: evidence from diffusion analysis. Applied Behavioral Science Review, 6(1): 39-68 Guillemont J, Léon C (2008). Alcool et grossesse: connaissances du grand public en 2007 et evolutions en trios ans. Évolutions, 15. http://www.inpes.sante.fr/CFESBases/catalogue/pdf/1117.pdf Hammond D, Fong G, McNeill A, Borland R, Cummings K (2006). Effectiveness of cigarette warning labels in informing smokers about the risks of smoking: findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco control, 15(suppl 3): iii19-iii25 Hankin JR, Firestone IJ, Sloan JJ, Ager JW, Sokol RJ, Martier SS (1996a). Heeding the alcoholic beverage warning label during pregnancy: Multiparae versus nulliparae. Journal of Studies on Alcohol and Drugs, 57(2): 171 Hankin JR, Sloan JJ, Firestone IJ, Ager JW, Sokol RJ, Martier SS (1996b). Has awareness of the alcohol warning label reached its upper limit? Alcoholism: Clinical and Experimental Research, 20(3): 440-444 Australian Institute of Health and Welfare (2011). 2010 National drug strategy household survey report. Canberra: Australian Institute of Health and Welfare (AIHW) Hilton ME (1993). An overview of recent findings on alcoholic beverage warning labels. Journal of Public Policy & Marketing: 1-9 Jones S, Gordon R (2013). Alcohol warning labels: are they effective? Deeble Institute Evidence Brief, Australian Healthcare and Hospitals Association no: 6
Alcohol and Pregnancy Labelling Evaluation - Appendices 99
Evidence for effectiveness of pregnancy health warnings on alcohol products Jones SC, Gregory P (2010). Health warning labels on alcohol products-the views of Australian university students. Contemp. Drug Probs., 37: 109 Jones SC, Gregory P (2009). The impact of more visible standard drink labelling on youth alcohol consumption: Helping young people drink (ir)responsibly? Drug abd Alcohol Review 28: 230- 234. Retrieved from: http://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&cad=rja &uact=8&ved=0CCgQFjAA&url=http%3A%2F%2Fro.uow.edu.au%2Fcgi%2Fviewcontent.cgi% 3Farticle%3D1152%26context%3Dhbspapers&ei=kmdgU- 79MMXXkAWI7oHgBQ&usg=AFQjCNFK1Cz1GEthrnnEYL-gUu9bhBwsgg Laughery KR, Young SL., Vaubel KP, Brelsford JW, Rowe AL (1993). Explicitness of consequence information in warnings. Safety Science, 16(5-6). p 597-613. Online at http://dx.doi.org/10.1016/0925-7535(93)90025-9 MacKinnon DP, Nohre L, Pentz MA, Stacy AW (2000). The alcohol warning and adolescents: 5-year effects. American journal of public health, 90(10): 1589 MacKinnon DP, Nohre L, Cheong J, Stacy AW, Pentz MA (2001). Longitudinal relationship between the alcohol warning label alcohol consumption. J Stud Alcohol 62(2): 221-227nd Parackal SM, Parackal MK, Harraway JA (2010). Warning labels on alcohol containers as a source of information on alcohol consumption in pregnancy among New Zealand women. International Journal of Drug Policy, 21(4): 302-305 Patterson LT, Hunnicutt GG, Stutts MA (1992). Young adults' perceptions of warnings and risks associated with alcohol consumption. Journal of Public Policy & Marketing: 96-103 Peters E, Romer D, Slovic P, Jamieson KH, Wharfield L, Mertz C, Carpenter SM (2007). The impact and acceptability of Canadian-style cigarette warning labels among US smokers and nonsmokers. Nicotine & Tobacco Research, 9(4): 473-481 Room R (2012). Individualised control of drinkers: back to the future? Contemporary Drug Problems, 39(2): 311-343. Retrieved from: http://www.robinroom.net/Individualised.doc Scholes‐Balog KE, Heerde JA, Hemphill SA (2012). Alcohol warning labels: Unlikely to affect alcohol‐ related beliefs and behaviours in adolescents. Australian and New Zealand journal of public health, 36(6): 524-529 Stockley CS (2001). The effectiveness of strategies such as health warning labels to reduce alcohol- related harms—an Australian perspective. International Journal of Drug Policy, 12(2): 153- 166 Stockwell T (2006). A review of research into the impacts of alcohol warning labels on attitudes and behaviour. British Columbia, Canada: University of Victoria, Centre for Addictions Research of BC Thompson LM, Vandenberg B, Fitzgerald J M (2012). An exploratory study of drinkers views of health information and warning labels on alcohol containers. Drug and Alcohol Review, 31: 240-247 Tobin C, Moodie AR, Livingstone C (2011). A review of public opinion towards alcohol controls in Australia. BMC Public Health, 11(1): 58 Wilkinson C, Room R (2009). Warnings on alcohol containers and advertisements: international experience and evidence on effects. Drug and Alcohol Review, 28(4): 426-435 Wogalter MS, Conzola VC, Smith-Jackson TL (2002). Research based guidelines for warning design and evaluation. Applied Ergonomics 33(3): 219-230. Accessed at: http://dx.doi.org/10.1016/S0003-6870(02)00009-1
Alcohol and Pregnancy Labelling Evaluation - Appendices 100
Evidence for effectiveness of pregnancy health warnings on alcohol products Wogalter SW, Brelsford, JW (1994). Incidental Exposure to Rotating Warnings on Alcoholic Beverage Labels. Proceedings of the Human Factors and Ergonomics society 38th Annual Meeting. Accessed at: http://pro.sagepub.com/content/38/5/374.short Wogalter MS, Laughery KR (1996). Warning! Sign and label effectiveness. Current Directions in Psychological Science, 5(2): 33-37 World Health Organisation (2010). Global Strategy to Reduce the harmful use of alcohol. Geneva: World Health Organisation (WHO). Retrieved from: http://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&cad=rja &uact=8&ved=0CCgQFjAA&url=http%3A%2F%2Fwww.who.int%2Fsubstance_abuse%2Fmsb alcstragegy.pdf&ei=4WlgU6H6E4WekwXayoHYCw&usg=AFQjCNFuR- sLZfldoswfvIROC9YRdMUsJA&bvm=bv.65636070,d.aGc
Alcohol and Pregnancy Labelling Evaluation - Appendices 101
Department of the Prime Minister and Cabinet
Indigenous Advancement Strategy Guidelines
July 2014
Preface
These guidelines set out the terms and conditions on which an applicant may access Australian Government grant funding through the Indigenous Advancement Strategy. These Guidelines may be amended from time to time.
Contents PART I: INTRODUCTION ...... 3 1 Programme Overview ...... 3 1.1 The Programmes ...... 4 PART II: APPYLING FOR GRANT FUNDING ...... 5 2 Making an application for grant funding ...... 5 2.1 Types of selection processes ...... 5 2.2 How to apply ...... 6 2.3 Application kit ...... 6 2.4 Partnership approach ...... 6 2.5 General Selection Criteria ...... 7 2.6 Eligibility for organisations ...... 7 2.7 Eligibility for individuals...... 8 2.8 Other Requirements ...... 8 2.8.1 Commonwealth Procurement Rules ...... 8 2.8.2 Incorporation Requirement ...... 8 3 Roles and Responsibilities ...... 9 3.1 Role of the Minister ...... 9 3.2 Role of the Department of the Prime Minister and Cabinet ...... 9 3.3 Contact Details ...... 9 4 Other Information ...... 9 ANNEXURE 1: APPLICATION FORM ...... 10 ANNEXURE 2: PROGRAMME OUTCOMES ...... 11 ANNEXURE 3: DEPARTMENTAL CONTACTS ...... 18 ANNEXURE 4: FURTHER INFORMATION...... 20
PART I: INTRODUCTION
1 Programme Overview
The Australian Government is committed to improving the lives of Indigenous Australians through increased participation in education and work, and making communities safer where the ordinary rule of law applies.
The Government has committed $4.8 billion over four years to the Indigenous Advancement Strategy (the Strategy). In addition, a further $3.7 billion has been allocated through National Partnership Agreements, Special Accounts and Special Appropriations. When taken into account, the total Indigenous-specific funding through the Prime Minister and Cabinet portfolio is $8.5 billion. A significant level of grant funding is also available through Indigenous-specific and mainstream programmes delivered by other agencies.
These guidelines apply to the $4.8 billion of programme funding over four years that is available under the five programmes contained within the Strategy, as outlined in Section 1.1 and Annexure 2. The Strategy will direct grant funding towards national priorities as well as the needs of Indigenous communities and regions.
The Strategy will be implemented from 1 July 2014 with a transition period of 12 months to allow continuity of frontline services and time for communities and service providers to adjust to the new arrangements. The Strategy will replace more than 150 individual programmes and activities with five broad programmes. The objective of the Strategy is to improve outcomes for Indigenous Australians, with a particular focus on: • Getting Indigenous Australians into work, fostering Indigenous business and ensuring Indigenous people receive economic and social benefits from the effective management of their land and native title rights; • Getting children to school, improving literacy and numeracy and supporting families to give children a good start in life; • Increasing Year 12 attainment and pathways to further training and education; • Making communities safer so that Indigenous people enjoy similar levels of physical, emotional and social wellbeing as that enjoyed by other Australians; • Increasing participation and acceptance of Indigenous Australians in the economic and social life of the nation; and • Addressing the disproportionate disadvantage in remote Australia and the need for strategic grant funding for local solutions.
The new flexible programme structure will support a new way of engaging with Indigenous people, communities, industries, business and service providers, allowing for joint development and implementation of solutions that will sustainably improve outcomes, including through regional and/ or place-based solutions. The Department of the Prime Minister and Cabinet (the Department) will work in with grant funding recipients to ensure that the Government’s funding results in improved outcomes for Indigenous people. Where appropriate, Grant Funding recipients will be expected to work closely with Indigenous communities in the design and delivery of projects. The Department may consider redirecting Grant Funding where outcomes are not improving.
Grant Funding may be drawn from across one or more programmes to address national priorities and community issues.
The Strategy is broad in scope, and flexible enough to support a wide range of activities, with a focus on action to achieve clear and measurable results, and with payment linked to the achievement of results and intended outcomes. The Strategy has been designed to reduce red tape and duplication for grant funding recipients, increase flexibility, and more efficiently provide evidence based grant funding to make sure that resources hit the ground and deliver results for Indigenous people.
The Strategy will be supported by the establishment of a new regional PM&C Network. Staff in the PM&C Network will engage with communities to negotiate and implement tailored local solutions designed to achieve results against government priorities. Implementation of the PM&C Network will commence from 1 July 2014 with a 12-18 month transition period.
1.1 The Programmes
Indigenous Advancement - Jobs, Land and Economy Programme This programme aims to get adults into work, foster viable Indigenous business and assist Indigenous people to generate economic and social benefits from land and sea use and native title rights, particularly in remote areas.
Indigenous Advancement - Children and Schooling Programme This programme focuses on getting children to school, improving education outcomes including Year 12 attainment, improving youth transition to vocational and higher education and work, as well as, supporting families to give children a good start in life through improved early childhood development, care, education and school readiness.
Indigenous Advancement - Safety and Wellbeing Programme This programme is about ensuring the ordinary law of the land applies in Indigenous communities, and that Indigenous people enjoy similar levels of physical, emotional and social wellbeing enjoyed by other Australians.
Indigenous Advancement - Culture and Capability Programme This programme will support Indigenous Australians to maintain their culture, participate equally in the economic and social life of the nation and ensure that Indigenous organisations are capable of delivering quality services to their clients.
Indigenous Advancement - Remote Australia Strategies Programme This programme will address social and economic disadvantage in remote Australia and support flexible solutions based on community and government priorities.
The outcomes, objectives, scope and performance information for each programme are outlined in Annexure 2. Where there is additional information relevant to individual grant funding rounds, this will be outlined in the relevant Application Kit.
PART II: APPYLING FOR GRANT FUNDING
2 Making an application for grant funding
2.1 Types of selection processes The programmes under the Strategy can invest in a diverse range of activity. Access to grant funding through the programmes will be available through a variety of means and at various times throughout the year. The Department proposes to undertake a mix of the following processes to achieve the priorities and outcomes for the Strategy:
The bulk of grant funding will be available through:
• open competitive grants rounds will be conducted to enable entities to receive grant funding and deliver outcomes through the Strategy. The open and competitive rounds will open and close to applications at nominated dates, with eligible applications assessed against the assessment criteria set out for the relevant outcome in the application kit, and then prioritised against competing, eligible application for the available grant funding.
Other opportunities for grant funding will be available through:
• targeted or restricted grant rounds where the Department approaches a particular, potential applicant or applicants and invites them to submit a proposal to deliver an outcome. Targeted grant rounds may be open to existing grant funding recipients as well as other entities. The targeted entities will be selected based on the specialised requirements of the outcome/s required. Targeted rounds will be open to a small number of potential providers based on specialised requirements.
• direct grant allocation processes where the Department directly approaches an existing Grant Funding Recipient to expand their current service delivery or undertake new service delivery. In these cases, the Department may assess the grant funding recipient’s current performance and capacity to deliver an expanded service, or capability to deliver a new service.
• a demand-driven process where applications may be submitted at any time and will be assessed on a value for money basis against clear selection criteria.
The Department may also make one-off or ad hoc grants that do not involve a planned selection process, but are designed to meet a specific need, often due to urgency or other circumstances.
The type of selection process used will be determined according to one or more of the following: • the objective of the grant funding; • the likely number and type of applications; • the nature of the grant funding; • the value of the grant funding; • the geographic location of the activity; • the need for particular expertise or understanding of Indigenous culture, people and local community needs; and • the need for timeliness and cost-effectiveness in the decision-making process while maintaining rigour, equity and accountability.
2.2 How to apply
When the Department proposes to undertake grant funding in one or more programmes, the nature of grant funding and details of requirements for the grant funding will be specified in an Application Kit, which will be posted on the Department’s website at www.dpmc.gov.au.
Potential applicants will be provided with reasonable prior notice of any open grant round by all or some of the means listed below.
The Department may advertise any grant processes: • in major national newspapers and other selected newspapers; • on the Department’s website at www.dpmc.gov.au; • on the Government Grants website at www.grantslink.gov.au.
Any advertisement will inform potential applicants of where to obtain the Application Kit for the relevant process.
2.3 Application kit
The Application Kit for any grant funding process may include: • these Guidelines; • a Grant Round Summary; • an Application Form; and • a Grant Agreement template.
The provision of any grant funding by the Department will be subject to sufficient funds being available under Parliamentary appropriations. The Department may provide grant funding over the short or long-term.
The Department may seek applications for grant funding at the times and in the manner determined by the Department. The Department may specify limits on the number of applications which a person or organisation may submit for grant funding strategies. The limits, if any, will be specified in the Application Kit for the grant funding.
2.4 Partnership approach
The bulk of grant funding under this Strategy will be provided through open grant processes. However, in addition to any public calls for applications outlined above and detailed in the Application Kit, the Department may also approach a provider, community, region, business or jurisdiction to enter into ad hoc, place based or regional grant funding discussions at any time.
A provider, community, region or jurisdiction may approach the Department to discuss proposals for placed based strategies or demand driven activities at any time. Unless otherwise specified in an Application Kit: • Applications should be in the formation of the Application Form at Annexure 1 • For place based initiatives, contact should be made through the Department’s relevant State or Regional Office outlined at Annexure 3. • Applications must address one or more of the outcomes outlined in Annexure 2. • The Department will assess applications against the General Selection Criteria outlined at Section 2.5 and notify the applicant at the completion of the assessment process.
The Department will work with grant funding recipients to ensure that the Government’s grant funding results in improved outcomes for Indigenous people. The delivery of services will be flexible to respond to local needs and provide capacity for Government and providers to work together to alter course where desired outcomes are not being achieved.
The Department may consider redirecting grant funding where outcomes have not improved. This may include reducing or redirecting the scope of grant funding in a funding agreement or ceasing the grant funding. Funding agreements will provide specific detail about these requirements.
2.5 General Selection Criteria
Unless otherwise stated in the Application Kit, applicants will be assessed based on their ability to:
• Demonstrate a good understanding of the need for the outcome in the chosen community and/or target group; • Describe how the implementation of their proposal will achieve the outcomes required as well as demonstrate value for money; • Demonstrate their experience and/or capacity in effectively developing, delivering, managing and monitoring grant funding to achieve outcomes in the chosen community and/or across the target group; • Demonstrate their capability (experience and qualifications) to deliver outcomes in the chosen community and/or target group including the ability to manage financial affairs and strong governance arrangements; and • Demonstrate a commitment to Indigenous participation in the design and delivery of the activity, in particular: o By ensuring that relevant Indigenous communities are consulted in the development of the project and support the delivery of the project; and o through a commitment to employing Indigenous Australians.
Additional criteria specific to a particular type of grant funding, or requirements for industry specific capability may also apply for some grant funding. These requirements, together with any weightings and word limits will be set out in the applicable Application Kit.
Statutory requirements apply to funding to perform representative body functions under the Native Title Act 1993.
2.6 Eligibility for organisations
Unless otherwise set out in the Application Kit, applicants must:
• Have a legal personality and full legal capacity to enter into an Agreement with the Commonwealth. An unincorporated association is not a legal person and will not be contracted by the Department; • Not be bankrupt or subject to insolvency proceedings (as relevant to the entity type); • Have an ABN and be registered for GST purposes, where relevant; • Be financially viable, as assessed by the Department; and • Not have been named as non-compliant under the Workplace Gender Equality Act 2012.
The Department may also take into account any previous or current non-compliance with any Commonwealth agreements.
States or territories may apply for grant funding unless the applicable Application Kit specifically excludes them.
Applicants that do not, as determined by the Department at its sole discretion, meet these requirements may be deemed ineligible for Grant Funding.
2.7 Eligibility for individuals
While it is expected that Grant Funding will primarily be delivered through organisations, individuals will not be precluded from receiving grant funding, unless otherwise specified in the Application Kit.
2.8 Other Requirements 2.8.1 Commonwealth Procurement Rules
Funds appropriated for the purpose of the Strategy may also be used for the procurement of work directly related to the purpose of the programmes, for example research projects. Such procurements will be undertaken in accordance with the requirements of the Commonwealth Procurement Rules and for purposes that are consistent with the priorities and required outcomes of the Strategy. This includes through the use of Indigenous businesses where appropriate and in line with the Indigenous Opportunities Policy. Procurement processes will be conducted independently of any grant rounds.
2.8.2 Incorporation Requirement
All organisations receiving grant funding of $500,000 (GST exclusive) or more in any single financial year through the Strategy will be required to: • for an Indigenous Organisation, be incorporated under the Corporations (Aboriginal and Torres Strait Islander) Act 2006; or • for other organisations, be incorporated under the Corporations Act 2001; and • once applied, all organisations must continue to meet this requirement whilst receiving any amount of grant funding from the Strategy.
This requirement applies to all grant funding under agreements or contract variations executed on or after 1 July 2014. The requirement applies once cumulative grant funding of $500,000 (GST exclusive) or more in any financial year is provided under the Strategy after 1 July 2014.
This requirement does not apply to statutory bodies, state, territory or local governments or grant funding for capital works.
Organisations will have six months from the date of execution of the Agreement or contract variation to comply with the requirement. The Department may consider longer transition periods for organisations that can demonstrate that more time is required to comply with the requirement. Costs associated with the administration and registration of organisations transferring from one regulatory regime to another are to be met by the organisation.
Organisations will need to comply with the requirement as part of their grant funding agreement. Non-compliance will constitute a breach and may result in the termination of the grant funding agreement.
The Minister for Indigenous Affairs, or an approved delegate, may provide an exemption from the requirement. Further information on exemptions can be sourced through [email protected]. Applications will be considered on a case-by-case basis, and will take into account information demonstrating that the organisation is well-governed, high-performing and low risk.
Requests for an exemption from the requirement, or consideration to extend the transition period can be forwarded to [email protected]
3 Roles and Responsibilities 3.1 Role of the Minister The Minister for Indigenous Affairs has overall responsibility for the Strategy. The final decision about grant funding will be made by: • the Minister on advice provided by the Department; or • the Department where the Minister delegates authority to the Department; or • where funding is to perform representative body functions under the Native Title Act 1993, by the Secretary of the Department. The Minister for the Environment has grant funding responsibility for the Indigenous Protected Areas programme. The Minister for the Environment may delegate authority to the Minister for Indigenous Affairs. 3.2 Role of the Department of the Prime Minister and Cabinet The Department will be responsible for the development and dissemination of all application documentation under the Strategy and for ensuring that such documentation is in accordance with the Strategy’s aims and objectives.
The Department will be responsible for notifying applicants of the outcomes of any Grant Funding arrangement process and will be responsible for responding to queries in relation to the application process, and for resolving any uncertainties that may arise in relation to application requirements. The Department will also manage the Grant Funding arrangements under the Strategy and undertake all assessment processes. The Department will also be responsible for all management and monitoring requirements of successful applicants in any process under the Strategy, including managing Grant Funding agreements.
3.3 Contact Details Contact details are listed at Annexure 3.
4 Other Information
Further information about administrative arrangements is included at Annexure 4. This includes further information about: • Grant Funding agreements • The process for notifying applicants of the outcome of their application • Reporting and monitoring framework • Evaluation • Value for Money • Conflicts of Interest • Complaints Processes • Freedom of Information • Privacy Act 1988 • Glossary of Terms
ANNEXURE 1: APPLICATION FORM
ANNEXURE 2: PROGRAMME OUTCOMES
The Department of the Prime Minister and Cabinet may fund activities consistent with the following programmes and outcomes.
Indigenous Advancement - Jobs, Land and Economy
Description This Programme provides support to connect working age Indigenous Australians with real and sustainable jobs, foster Indigenous business and assist Indigenous people to generate economic and social benefits from economic assets, including Indigenous-owned land. This includes assisting Indigenous people to leverage their land assets to create economic and social benefits for themselves and their communities. It also supports Indigenous people to have their native title rights recognised. The Jobs, Land and the Economy programme supplements a range of State, Territory and Australian Government programmes which aim to improve the vocational, workplace and entrepreneurial skills of Indigenous Australians to improve employment outcomes and support the development of Indigenous businesses. The programme addresses current gaps between these services and targets additional investment where it can maximise employment opportunities for Indigenous Australians. Outcome Increased Indigenous employment, business and economic development. Objectives To get Indigenous Australians into work, foster Indigenous business and assist Indigenous people to generate economic and social benefits from the use of their land and native title rights. Through this programme the Government is aiming to contribute to: • Halving the gap in employment outcomes between Indigenous and other Australians by 2018.
What this programme will fund This programme will support activity that will achieve outcomes such as, but not limited to the following: • Activities that support employment outcomes for Indigenous jobseekers, including retention at 26 weeks. • Activities that provide employment, training and participation services and build skills and work-readiness of job seekers in remote Australia. • Development of Indigenous businesses and community enterprises. • Support for school students/graduates to connect to real employment. • Activities that support jobs in sea and land management. • Negotiation and agreement of township leases. • Support for Indigenous land owners who wish to leverage their land assets to create economic development opportunities, including support for those wishing to pursue localised decision- making on land use. • Activities that support long-term, tradable tenure, including land reform and land administration; • Facilitation, assistance and settlement of land rights claims.
• Effective agreement-making under the Native Title Act 1993, to generate sustainable economic and social benefits from native title rights and interests. • Building capacity of native title corporations to assist in managing native title rights and interests to promote sustainable economic and social benefits, and meet their statutory obligations.
The following types of services are not in scope under this outcome: • Youth engagement and transition activities for compulsory school-aged children that do not have links to a guaranteed job. • Adult vocational education and training (VET) activities that are already supported through mainstream Commonwealth or State/Territory Government programmes. • Cultural heritage and land management activities that are typically State/Territory government responsibility and subject to State legislation are administered by state(s).
Outcome indicators for this programme • Increase in the number of Indigenous employment and participation rates. • Number of employment places filled with assistance from the Indigenous Advancement - Jobs, Land and the Economy Programme and proportion retained to 26 weeks. • Proportion of job seekers in employment, education or training three months following participating in the Indigenous Advancement – Jobs, Land and the Economy Programme. • Number of Indigenous land and sea management jobs contracted. • Number of land claims being progressed or finalised under Commonwealth land rights legislation and number of township leases being negotiated, agreed or in place. • Number of Native title claims finalised * *Progress of Native Title claims is influenced by the activities of various parties in the Native Title system, including the Federal Court of Australia and State and Territory governments. Some parts of the system are funded by the Attorney General’s Department.
Indigenous Advancement - Children and Schooling Description This programme supports activities which nurture and educate Aboriginal and Torres Strait Islander children, youth and adults to improve pathways to prosperity and wellbeing. This includes improving family and parenting support; early childhood development, care and education; school education; youth engagement and transition; and higher education. The programme has a critical focus on increased school attendance and improved educational outcomes which lead to employment. The Children and Schooling programme complements a range of State, Territory and Australian Government programmes which aim to improve the education outcomes and positive development of Indigenous Australians. The programme provides opportunities to fill gaps between existing services, enables innovation and leverages further grant funding. Outcome Increased Indigenous school attendance, improved educational outcomes and improved youth transitions to further education and work.
Objectives
To support families to give children a good start in life through improved early childhood development, care, education and school readiness; get children to school, improve literacy and numeracy, and support successful youth transitions to further education and work. Through this programme the Government is aiming to contribute to: • Halving the gap for Indigenous students in reading, writing and numeracy by 2018. • Attaining 90 per cent school attendance by 2018. • Halving the gap for Indigenous people aged 20-24 years old in Year 12 attainment or equivalent attainment rates by 2020.
What this programme will fund This programme will support activity that will achieve Indigenous outcomes such as, but not limited to the following: • Increasing participation and positive learning outcomes in early childhood development, care and education leading to improved school readiness. • Increasing school attendance and improving educational outcomes. • Increasing Year 12 attainment and pathways to further training and education. • Increasing course completions in university-level study. • Increasing the capacity of Indigenous families and communities to engage with schools and other education providers.
The Australian Government grant funding will be used to: • Primarily focus on ‘outside the school gate’ activities (actions which support the capacity building of parents, care-givers and communities) to complement mainstream grant funding. • Engage parents and community to help drive the demand for quality educations and training, including early childhood education and care. • Support youth engagement and school retention and/or transition activities for compulsory school-aged childhood education and care. • Prioritise support for Aboriginal and Torres Strait Islander children/families and young people who may not currently engage with learning opportunities or mainstream education. • Target grant funding to those most disadvantaged, specifically in rural and remote localities; • Leverage greater grant funding in the provision of education for Indigenous Australians; and • Demonstrate national leadership in Aboriginal and Torres Strait Islander education.
While innovative measures drawing on multiple grant funding sources or building on the following list are welcome, this programme will not pay for elements of measures: • Funded through recurrent school grant funding or grant funding to early learning services or higher education such as teachers and curriculum resources; • Funded through ABSTUDY or Family Tax Benefit including travel and living allowances at boarding schools or universities; and • Already being delivered in the community by the State/ Territory or Local government.
The following activities also managed by the Department are not covered by the Children and Schooling programme, as they have separate guidelines or administrative arrangements. • Away from base for mixed mode delivery (supporting university and VET students who study at home but are required to also spend periods of time at institutions) – Section 13 of the Indigenous Education (Targeted Assistance) Act 2000.
• Commonwealth Scholarships Programme (supporting University students) – under parts 2.4 of the Higher Education Support Act 2003. • Indigenous Staff Scholarships (supporting the upskilling of Indigenous staff in universities) - under parts 2.4 of the Higher Education Support Act 2003. • Indigenous Support Programme (supporting engagement of Indigenous students in university) - under parts 2.3 of the Higher Education Support Act 2003. • Aboriginal Tutorial Assistance Scheme (ATAS) Superannuation (a reserve fulfilling superannuation obligations for some former ATAS employees).
Outcome indicators for this programme • Percentage increase in the access and participation of children in early childhood care and education. • Indigenous school attendance rates. • Year 12 or equivalent attainment – number and proportion of Indigenous young people (aged 20-24) with year 12 or equivalent Australian Qualifications Framework (AQF) Certificate II level (or above). • Higher Education – number and proportion of Indigenous 20-64 year olds with or working towards post school qualification in AQF Certificate III level (or above). • Percentage of Indigenous students meeting National Minimum Standards in National Assessment Programme – Literacy and Numeracy (NAPLAN). • Increase in the number or proportion of Aboriginal and Torres Strait Islander people involved.
Indigenous Advancement - Safety and Wellbeing Description This programme supports the enhancement of Indigenous wellbeing and community safety. This includes grant funding for strategies known to enhance community safety, including the prevention of family violence, combatting alcohol and other substance misuse, reduce offending and supporting victims of crime. Activities that support wellbeing, that have broader implications for health policy and complement (not duplicate) those health services delivered by the Department of Health will also be considered under this programme. Outcome Increased levels of community safety and wellbeing, and less alcohol and substance misuse and associated harm. Objectives To ensure the ordinary rule of law applies in Indigenous communities, and to ensure Indigenous people enjoy similar levels of physical, emotional and social wellbeing enjoyed by other Australians by fostering the ability of Indigenous Australians to engage in education, employment and other opportunities.
Through this programme the Government is aiming to contribute to:
• Closing the gap in life expectancy within a generation (by 2031). • Halving the gap in mortality rates for Indigenous children under five by 2018. • Making communities safer.
What this programme will fund This programme will support activity that will achieve outcomes such as, but not limited to the following: • Improved health, social and emotional wellbeing. • Improved drug, alcohol and substance misuse prevention and treatment. • A reduction of offending, violence and victimisation in communities.
This programme will not pay for: • Services or activities that are the responsibility of the Commonwealth Departments of Health, or Attorney General’s or State or Territory Governments.
Outcome indicators for this programme • Reduced violence in Indigenous communities. • Number of Indigenous specific alcohol and other drug treatment services and activities. • Number of sites providing low aromatic fuel.
Indigenous Advancement - Culture and Capability
Description This programme supports acknowledgement of the unique place Indigenous peoples have in Australian society and giving them a strong and representative voice. Grant funding will be provided for strategies known to positively impact Indigenous participation and acceptance, such as positive and respectful forms of engagement, supporting Indigenous capacity at the individual, family, community and organisational levels, and enhancing governance and leadership skills to maximise the chances of achieving real and sustainable change for the better.
Outcome Progress towards a referendum on constitutional recognition, participation in society and organisational capacity.
Objectives To support Indigenous Australians to maintain their culture and participate equally in the economic and social life of the Nation and ensure that Indigenous organisations are capable of delivering quality services to their clients, particularly in remote areas.
This programme enables the Government to contribute to the Closing the Gap targets and key priorities of increased participation in education and work, and making communities safer where the ordinary rule of law applies.
What this programme will fund This programme will support activity that will achieve outcomes such as, but not limited to the following: • Improved leadership and governance capacity of Indigenous people, families, organisations and communities.
• Maintaining culture, supporting healing, protecting Indigenous heritage. • Providing access to, and supporting or enhancing, Indigenous broadcasting and communications services. • Improved participation in society, and acceptance of Indigenous Australians. • Strengthening the capacity of Indigenous organisations so that they are able to effectively deliver Government services to Indigenous people and communities. • Engaging Indigenous peoples on decisions over matters which affect them. • Improved participation in society, and acceptance of Indigenous Australians, including through access to Indigenous interpreters. • Support for the recognition of Indigenous people in the Commonwealth of Australia Constitution.
Outcome indicators for this programme • Release of a draft proposal for a constitutional amendment to recognise Indigenous peoples and completion of a review under the Aboriginal and Torres Strait Islander Peoples Recognition Act 2013. • Number of cultural projects and activities supported. • Increased proportion of Indigenous organisations receiving significant grant funding from the Australian Government under this outcome which are registered under the Corporations (Aboriginal and Torres Strait Islander Act) 2006. • Number of hours of Indigenous interpreting undertaken by qualified or accredited interpreters.
Indigenous Advancement - Remote Australia Strategies
Description This programme supports the provision of infrastructure, housing, telecommunications and home ownership in remote Indigenous communities, as well as the development of local and regional place-based approaches. Outcome Improved infrastructure, housing and local engagement in remote Australia and advance progress in employment, education and community safety. Objectives To address the disproportionate disadvantage in remote Australia and the need for strategic grant funding in infrastructure, housing and local solutions. This programme enables the Government to contribute to the Closing the Gap targets and key priorities of increased participation in education and work, and ensuring safe communities where the ordinary rule of law applies.
What this programme will fund This programme will fund activity leading to one or more of the following outcomes: • Increased home ownership, particularly on Indigenous owned land. • Improved Indigenous telecommunications activities to remote areas. • Discrete support for remote infrastructure, including renewable energy systems.
• Flexible, place-based agreements with Indigenous communities and regions to improve Indigenous school attendance and attainment, employment, community safety and other enabling services.
Support is not available under this programme for: • Construction or management of public or community housing as this component is funded through the National Partnership Agreement on Remote Indigenous Housing.
Outcome indicators for this programme • Increased number of new home owners on Indigenous land. • Number of operating community phones in remote Indigenous communities. • Tailored support for remote infrastructure provided • Strong engagement with local communities and regions resulting in agreements to improve Indigenous school attendance and attainment, employment and safer communities.
Assessing performance
The performance of a funded activity will be assessed on the basis of whether it is achieving its stated outcomes. Applicants seeking grant funding may be requested to nominate one or more key outcome indicators, against which they will be assessed over the course of the project. In addition, the Department will source a range of data and information on outcomes to inform its judgment. Where strategies are not delivering outcomes, the Department may consider reducing or redirecting grant funding, or ceasing the grant funding.
ANNEXURE 3: DEPARTMENTAL CONTACTS
If you have questions about funding under the new Indigenous Advancement Strategy, and what it means for you, please contact your local PM&C office in the first instance. You may also send funding related questions to [email protected].
Queensland Office Physical Address Postal Address Toll Free Brisbane – Level 6, 215 Adelaide Street GPO Box 9932 QLD State Office Brisbane QLD 4000 Brisbane QLD 4001 Brisbane/Roma Level 6, 215 Adelaide Street GPO Box 9932 Brisbane QLD 4000 Brisbane QLD 4001 Cairns Level 8, 46-48 Sheridan St PO Box 1599 Cairns QLD 4870 Cairns QLD 4870 Mount Isa Ground Floor, 42-44 PO Box 2416 Simpson St Mt Isa QLD 4825 Mt Isa QLD 4825 1800 079 098 Rockhampton Level 1, 36 East St PO Box 550 Rockhampton QLD 4700 Rockhampton QLD 4700 Thursday Island Cnr Victoria & Hastings St PO Box 393 Thursday Island Thursday Island QLD 4875 Toowoomba Level 1, 516 Ruthven Street PO Box 888 Toowoomba QLD 4350 Toowoomba QLD 4350 Townsville Level 4, 235-259 Stanley St PO Box 1293 Townsville QLD 4810 Townsville QLD 4810
Office Physical Address Postal Address Toll Free Sydney – Level 8, 255 Elizabeth St GPO Box 9932 NSW State Office Sydney NSW 2000 Sydney NSW 2001 Batemans Bay BayLink Building, 3 Flora PO Box 510 Cres, Batemans Bay NSW Batemans Bay NSW 2536 2536 Coffs Harbour 17 Duke St PO Box 1335 Coffs Harbour NSW 2450 Coffs Harbour NSW 2450 Dubbo Level 1, 65 Church St PO Box 1083 Dubbo NSW 2830 Dubbo NSW 2830 Griffith 136 Yambil Street PO Box 1551 Griffith NSW 2680 Griffith NSW 2680 Lismore 29 Molesworth Street PO Box 778 Lismore NSW 2480 Lismore NSW 2480 Newcastle 3 Hopetoun St PO Box 627 Charlestown NSW 2990 Charlestown NSW 2990 1800 079 098 Nowra 55-57 Berry Street PO Box 329 Nowra NSW 2541 Nowra NSW 2541 Orange 21 William St PO Box 2308 Orange NSW 2800 Orange NSW 2800 Queanbeyan 1 Monaro St PO Box 172 Queanbeyan NSW 2620 Queanbeyan NSW 2620 Tamworth Unit 2, 180-182 Peel St PO Box 684 Tamworth NSW 2340 Tamworth NSW 2340 Wagga Wagga 1st Floor, 2 O'Reily St PO Box 144 Wagga Wagga NSW 2650 Wagga Wagga NSW 2650 Walgett 44 Fox St Walgett NSW 2832 Wilcannia 34-36 Reid St Wilcannia NSW 2836
Office Physical Address Postal Address Toll Free Darwin - State Level 4-6 Jacana House, GPO Box 9932 Office 39-41 Woods St Darwin NT 0800 Darwin NT 0800 Katherine Level 1, Randazzo Building, PO Box 84 14 Katherine Terrace Katherine NT 0851 1800 079 098 Katherine NT 0850 Nhulunbuy 74 Chesterfield St, PO Box 246 1800 089 148 Nhulunbuy NT 0880 Nhulunbuy NT 0881 Alice Springs Jock Nelson Building, PO Box 2255 Level 2, 16 Hartley St Alice Springs NT 0871 1800 079 098 Alice Springs NT 0870 Tennant Creek 1-9 Paterson St PO Box 321 1800 079 098 Tennant Creek NT 0861 Tennant Creek NT 0861
Toll Free Office Physical Address Postal Address
Adelaide – Level 18, 11/29 Waymouth GPO Box 9932 SA State Office St, Adelaide SA 5001 Adelaide SA 5001 Ceduna Cnr Merghiny & East PO Box 396 1800 079 098 Terrace, Ceduna SA 5690 Ceduna SA 5690 Port Augusta 34 Stirling Road PO Box 2214 Port Augusta SA 5700 Port Augusta SA 5700
Western Australia Toll Free Office Physical Address Postal Address
Perth – Level 12, 152-158 George's PO Box 9932 WA State Office Terrace Perth WA 6848 1800 079 098 Perth WA 6000 QV1 Building, 250 St George PO Box 9932
Terrace Perth WA 6848 1800 079 098 Perth WA 6000 Broome 1 Short St PO Box 613 Broome WA 6725 Broome WA 6725 1800 079 098
Derby 37 Rowan Strret PO Box 1009 Derby WA 6728 Derby WA 6728 1800 079 098
Geraldton First Floor, 5 Chapman Rd PO Box 146 Geraldton WA 6530 Geraldton WA 6531 1800 079 098
Kalgoorlie 43 Boulder Road PO Box 490 Kalgoorlie WA 6430 Kalgoorlie WA 6430 1800 193 357
Kununurra U4/16 Riverfig Avenue PO Box 260 Kununurra WA 6743 Kununurra WA 6743 1800 193 348
South Headland Commonwealth Building PO Box 2628 First Floor, 3 Brand St South Hedland WA 6722 1800 079 098 South Hedland WA 6722
Victoria and Tasmania Toll Free Office Physical Address Postal Address
Melbourne Level 3, Casseldon Pl, GPO Box 9932 2 Lonsdale St Melbourne VIC 3001 Melbourne VIC 3000 1800 079 098 Mildura 112-124 Deakin Ave PO Box 10241 Mildura VIC 3502 Mildura Vic 3502 Hobart Level 1, 199 Collins St GPO Box 9820
Hobart TAS 7000 Hobart TAS 7001
ANNEXURE 4: FURTHER INFORMATION
Agreements
Successful organisations (Provider/s) will be required to enter into an Agreement with the Commonwealth.
The Agreement will form the legal agreement between the Department and the Provider over the Grant Funding period. Once executed, the Agreement will constitute the entire agreement between the parties. There is no binding contract until the Agreement is agreed to and signed by the relevant Departmental delegate and duly executed by the person or persons authorised to bind the Provider. Grant Funding will only be provided in accordance with the terms of an executed Agreement and the Provider must comply with all requirements of the Agreement.
The Agreement will also cover: • reporting and financial management requirements • insurance (to cover Provider’s obligations in relation to the Grant Funding to be delivered) • compliance with the Australian Privacy Principles as set out in Section 14 of the Privacy Act 1988 • requirements to maintain the confidentiality of any information deemed by the Commonwealth to be confidential
The Agreement offered may differ from the draft Agreement provided as an example at the time of applying for the grant funding. Advice to successful applicants may contain details of any negotiation process for the contractual arrangements.
Types of Agreement
The terms and conditions of the Agreement may vary depending on the size and nature of the Grant Funding and level of risk. A draft Agreement will be included with the Application Kit for Grant Funding. This draft is subject to change following negotiation with the successful applicant.
If an applicant is deemed successful, the Department will offer an Agreement for review, negotiation and execution. The Agreement will set out the terms and conditions on which the Grant funding will be provided.
Goods and services tax (GST)
Unless otherwise indicated by the Department, Grant Funding provided under the Indigenous Advancement Strategy is subject to GST.
Providers required under tax law to be registered for GST must ensure they are registered in order to receive Grant Funding under this Programme.
Legal and Financial Advice
The Department does not provide financial or legal advice to organisations. Providers should seek their own independent professional advice on all financial and legal matters, including compliance with any statutory obligations.
Indigenous Interpreters
Applicants should take into account the cultural and linguistic needs of Indigenous peoples whose first language is not English. In developing their proposals applicants should be mindful of the Commonwealth Ombudsman’s Best Practice Principles for interpreting.
Monitoring, Performance Reporting and Improvement
The Department will monitor the performance of Government grant funding to ensure that it is meeting objectives and outcomes. All Agreements made between Providers or organisations and the Department must include systematic, timely monitoring that demonstrates if results are being achieved and supports ongoing adaptation and innovation where necessary.
Successful applicants may be required to submit to the Department reports concerning the Grant Funding, in the format and by the due dates detailed in the Agreement. Providers may be required to collect data to measure how the project contributes to the identified outcomes and Strategy objectives. Providers will be asked to collect data and maintain records to assist with performance monitoring.
The Department is committed to reducing red tape for successful applicants and will work with organisations to minimise the volume of reporting requirements to maintain transparency and accountability requirements.
The Department is committed to a comprehensive and systematic approach to the effective management of potential opportunities and risk. Any Grant Funding will be managed according to its level of risk to the Commonwealth. As such, applicants and Providers may be subject to a risk management assessment, and depending on level of grant funding and risk, a Financial Viability check, before entering into any contractual arrangement and periodically thereafter during the grant funding term.
Financial reporting
The Indigenous Advancement Programme is managed to ensure the efficient and effective, ethical and economical use of public monies. Grant Funding must only be used for the purposes for which it was provided. The Department may require Providers and organisations to provide financial statements/reports in accordance with the Agreement. Providers may be required to submit: • a final report on the Grant Funding outcomes, and • independently audited financial statements and other financial information.
Full details of what Providers must submit to acquit the grant funding will be in the Agreement and attached schedules.
Other reporting requirements
Providers may be required to provide other reports, such as progress reports, on the grant funding and the Provider.
Evaluation
Quality evaluation will help Indigenous people, communities and government to clearly see whether they are getting the results they expect and assist Government to invest in what works. To support a consistent and quality evaluation approach, a number of principles will guide evaluation activity. These include: • independence, impartiality and transparency • cultural respect, competence and ethical behaviour • designing evaluation to support utilisation and build on what is already know • avoiding duplication and minimising respondent burden
• learning and adaptation through a cycle of critical review and improvement • strengthening capacity, using participative approaches and joint ownership
Conflicts of Interest
Applicants must indicate any potential perceived or actual conflict of interest arising in relation to proposed projects or spending activities. The Department may decide not to consider an application or select a provider if there is the possibility of a perceived conflict of interest. Applicants should include a statement addressing this and demonstrate why a conflict of interest will not result from the granting of grant funding for the project, or how the conflict will be managed.
All parties involved in or associated with the Strategy’s spending have an obligation to disclose all potential perceived or actual conflicts of interest related to the spending or the project.
A conflict of interest arises where a person makes a decision or exercises a power in a way that may be, or may be perceived to be, influenced by either material personal interests (financial or non-financial) or material personal associations. Examples of when a conflict of interest arises include where: • decision makers or agency staff involved in spending activities have a direct or indirect interest in the applicant, which may influence the selection of a particular project or activity; • members of expert or advisory panels or committees have a direct or indirect interest in informing a decision about expenditure or providing advice on grants; and • a provider has a direct or indirect interest, which may influence the selection of their particular project or activity during the application process. Conflicts may also arise when undertaking the grant project.
The Department has appropriate mechanisms in place for identifying and managing potential or actual conflicts of interest such as requiring assessment staff to sign conflict of interest declarations prior to undertaking the assessment of applications.
Record keeping
Providers must comply with the Record Keeping requirements as set out in the Agreement.
Notification of Outcome
The Department will advise all applicants in writing of the outcome of the grant funding process, including whether or not their application was successful, unsuccessful or ineligible.
Successful applicants
Successful applicants funded under the Strategy will be required to enter into an Agreement with the Department.
Opportunity for feedback
Applicants that were unsuccessful or ineligible may be provided with reasons for the application not being successful or eligible in the grant funding process.
The Department reserves the right to not offer individualised feedback for each application in a grant funding process and may offer general feedback on any grant funding process. Any opportunity for individualised feedback will be set out in the advice to the applicant on the outcome of the grant funding process.
Complaints Processes
Complaints about the conduct of grant funding processes may be sent in writing to the address contained in Application Kit, or to [email protected]
Value for Money
The Department will consider whether each grant application represents value for money and will look at expected results, funding requested and the contribution the applicant organisation will make.
Providers must contribute to achieving value with public money by: • considering how best to deliver the grant funding strategy to target groups or individuals. This may involve using existing processes and technologies or professional standards, or it may involve innovation and performance improvement by the provider or agency staff; • having in place an effective risk management approach that will minimise risk and ensure that the grant funding is achieving the outcomes, objectives and performance indicators; • ongoing monitoring and management of the grant as appropriate. This may involve the effective use of organisational processes, procedures and systems to produce the required reporting information, or it may involve adjusting activities to ensure they are meeting the objectives and performance indicators; • contributing to Government priorities through collaborative delivery of grant funding strategies; and • participating in evaluations of Grant Funding.
Other processes available
Any applicant may complain to the Commonwealth Ombudsman about any administrative action taken by the Department in relation to the Strategy. Contact details are as follows:
Commonwealth Ombudsman GPO Box 442 CANBERRA ACT 2601
Further details are available via the Commonwealth Ombudsman website at www.ombudsman.gov.au or by telephone on 1300 362 072.
The Ombudsman is an independent statutory officer who has extensive powers to investigate and report on official actions. No charge is made for the Ombudsman’s investigations. The Ombudsman will generally not investigate a matter that is being dealt with by a court or tribunal and may decline to investigate if he/she considers that a matter should be taken up with a court or tribunal, or for a variety of other reasons.
Freedom of Information
A person who wants to gain access to documents held by the Department may make an FOI request. Requests to access documents must be in writing. FOI requests should be sent to: The FOI Contact Officer Department of the Prime Minister and Cabinet PO Box 6500 CANBERRA ACT 2600 Requests may also be lodged via email to [email protected].
There is no fee for making a request but the Freedom of Information Act 1982 provides that charges may be imposed for processing requests. Requests must provide enough information about the documents sought to enable the Department to identify them. The FOI Coordinator can be contacted on (02) 6271 5849 to discuss any prospective request. Detailed information about FOI can be found at the website for the Office of the Australian Information Commissioner.
Glossary
Agreement means the contractual arrangements between the Commonwealth and the Provider for the Grant Funding.
Assessment Criteria are the specified principles or standards, against which applications will be judged. These criteria are also used to assess the merits of proposals and, in the case of a competitive granting activity, to determine applicant rankings.
Commonwealth Grant Rules and Guidelines (CGRGs) establish the overarching Commonwealth grants policy framework and articulate the expectations for all non-corporate Commonwealth entities in relation to grants administration. Under this overarching framework, non-corporate Commonwealth entities develop their own specific grants administration practices based on the mandatory requirements and principles of grants administration in the CGRGs. The CGRGs are issued by the Finance Minister under section 101 of the Public Governance, Performance and Accountability Act 2013 (PGPA Act).
Corporations Act 2001 means an act of the Commonwealth of Australia that sets out the laws dealing with business entities in Australia at federal and interstate level. It focuses primarily on companies, although it also covers some laws relating to other entities such as partnerships and managed grant funding schemes. Incorporation can be applied for through the Australian Securities and Grant funding Commission (ASIC) at www.asic.gov.au
Corporations (Aboriginal and Torres Strait Islander) Act 2006 means the set of laws that establishes the Registrar of Aboriginal and Torres Strait Islander Corporations, now called the Registrar of Indigenous Corporations, and allows Aboriginal and Torres Strait Islander groups to form corporations. The Corporations (Aboriginal and Torres Strait Islander) Act 2006 (CATSI Act) replaced the Aboriginal Councils and Associations Act 1976 (ACA Act). Under the CATSI Act, laws governing Indigenous corporations have been modernised while retaining special measures to meet the specific needs of Indigenous people. Incorporation can be applied for through the Office of the Registrar of Indigenous Corporations (ORIC) at www.oric.gov.au.
Department means the Department of the Prime Minister and Cabinet.
Eligibility criteria refer to the mandatory criteria which must be met for a grant application to qualify for a grant. Eligibility criteria may apply in addition to assessment criteria.
Financial Year means a 12 month period beginning 1 July of one year and ending 30 June the following year (and any part of such a period occurring at the beginning or end of the term of an Agreement).
Indigenous Organisation is an organisation that satisfies the Indigeneity requirement under Section 29-5 of the Corporations (Aboriginal and Torres Strait Islander) Act 2006 being: • corporations with five (5) or more members – at least 51 per cent of their members must be Aboriginal or Torres Strait Islander people • corporations with two (2) to four (4) members – all but one of their members must be Aboriginal and/ or Torres Strait Islander people • corporations with one (1) member – that member must be an Aboriginal and/ or Torres Strait Islander person.
Grant Funding refers to a combination of activities, projects or services undertaken by Providers; Organisations or Individuals agreed by the Department through the Strategy.
Priority grant funding Area/s refers to grant funding streams within the Indigenous Advancement Strategy.
Selection criteria comprise eligibility criteria and assessment criteria.
Selection process is the method used to select potential Grant Funding Recipients. This process may involve comparative assessment of applications or the assessment of applications against the eligibility criteria and/or the assessment criteria.