Aims Evidence from tobacco research suggests that health warning labels (HWLs) depicting the adverse consequences of consumption change smoking behaviours, with image‐and‐text (also known as ‘pictorial’ or ‘graphic’) HWLs most effective. There is an absence of evidence concerning the potential impact of HWLs placed on alcohol products on selection of those products. This study aimed to obtain a preliminary assessment of the possible impact of (i) image‐and‐text, (ii) text‐only, and (iii) image‐only HWLs on selection of alcoholic versus non‐alcoholic drinks. Design A between‐subjects randomised experiment with a 2 (image: present versus absent) × 2 (text: present versus absent) factorial design. Setting The study was conducted on the online survey platform Qualtrics. Participants Participants (n = 6024) were adults over the age of 18 who consumed beer or wine regularly (i.e. at least once a week), recruited through a market research agency. Interventions Participants were randomised to one of four groups varying in the HWL displayed on the packaging of alcoholic drinks: (i) image‐and‐text HWL; (ii) text‐only HWL; (iii) image‐only HWL; and (iv) no HWL. HWLs depicted bowel cancer, breast cancer and liver cancer, which were each displayed twice across six alcoholic drinks. Each group viewed six alcoholic and six non‐alcoholic drinks and selected one drink that they would like to consume. Measurements The primary outcome was the proportion of participants selecting an alcoholic versus a non‐alcoholic drink. Findings Alcoholic drink selection was lower for all HWL types compared with no HWL (image‐and‐text: 56%; image‐only: 49%; text‐only: 61%; no HWL: 77%), with selection lowest for HWLs that included an image. Image‐and‐text HWLs reduced the odds of selecting an alcoholic drink compared with text‐only HWLs (OR = 0.80, 95% CI = 0.69, 0.92), but increased the odds of selecting an alcoholic drink compared with image‐only HWLs (OR = 1.34, 95% CI = 1.16, 1.55). Conclusions Health warning labels communicating the increased risk of cancers associated with alcohol consumption reduced selection of alcoholic versus non‐alcoholic drinks in a hypothetical choice task in an online setting; labels displaying images had the largest effect. Their impact in laboratory and real‐world field settings using physical products awaits investigation.

HighlightsDrinkers underestimated the number of drinks that constituted 14 units.Unit understanding was greater for novel unit labels compared to industry labels.Motivation to drink less was higher for cancer and negatively-framed messages.

Background: Health warning labels (HWLs) using images and text to depict the negative health consequences of tobacco consumption are effective and acceptable for changing smoking-related outcomes. There is currently limited evidence concerning their potential use for reducing consumption of alcoholic drinks and energy-dense foods. The aim of this research was to describe the potential effectiveness and acceptability of image-and-text (also known as pictorial or graphic) HWLs applied to: i. alcoholic drinks and ii. energy-dense snack foods. Methods: Two online studies were conducted using between-subjects designs with general population samples. Participants rated one of 21 image-and-text HWLs on alcoholic drinks (n = 5528), or one of 18 image-and-text HWLs on energy-dense snacks (n = 4618). HWLs comprised a graphic image with explanatory text, depicting, respectively, seven diseases linked to excess alcohol consumption, and six diseases linked to excess energy intake. Diseases included heart disease and various cancers. Outcomes were negative emotional arousal, desire to consume the labelled product, and acceptability of the label. Free-text comments relating to HWLs were content analysed. Results: For both alcoholic drinks and energy-dense snacks, HWLs depicting bowel cancer generated the highest levels of negative emotional arousal and lowest desire to consume the product, but were the least acceptable. Acceptability was generally low for HWLs applied to alcohol, with 3 of 21 rated as acceptable, and was generally high for snacks, with 13 of 18 rated as acceptable. The majority of free-text comments expressed negative reactions to HWLs on alcohol or energy-dense snacks. Conclusions: Image-and-text health warning labels depicting bowel cancer showed greatest potential for reducing selection and consumption of alcoholic drinks and energy-dense snacks, although they were the least acceptable. Laboratory and field studies are needed to assess their impact on selection and consumption.

Health warning labels (HWLs) could reduce harmful consumption of food (including non-alcoholic drinks) and alcoholic drinks. A systematic review with meta-analysis using Cochrane methods was conducted to assess the impact on selection (including hypothetical selection) or consumption of food or alcoholic drink products displaying image-andtext (sometimes termed 'pictorial') and text-only HWLs. Fourteen randomised controlled trials were included, three for alcohol, eleven for food. For the primary outcomes, eleven studies measured selection and one measured consumption (two measured only other secondary outcomes). Meta-analysis of twelve comparisons from nine studies (n=12,635) found HWLs reduced selection of the targeted product compared with no HWL (RR=0.74 (95%CI 0.68-0.80)), with participants 26% less likely to choose a product displaying a HWL. A planned subgroup analysis suggested a larger (although not statistically significant) effect on selection of image-and-text HWLs (RR=0.65 (95%CI 0.54-0.80)) than text-only HWLs (RR=0.79 (95%CI 0.74-0.85)). These findings suggest significant potential for HWLs to reduce selection of food and alcoholic drinks, but all experimental studies to date were conducted in laboratory or online settings with outcomes assessed immediately after a single exposure. Studies in field and naturalistic laboratory settings are needed to estimate the potential effects of food and alcohol HWLs.Study registration: PROSPERO 2018 (registration number: CRD42018106522).