Impact on alcohol selection and online purchasing of changing the proportion of available non-alcoholic versus alcoholic drinks: A randomised controlled trial

The Roles of Alcohol Availability, Overserving, and Enforcement in Recreational and Social Settings on Alcohol Misuse and Harms: A Comparison of Australia and the United States

OBJECTIVE

The purpose of this study was to examine how alcohol availability, overserving, and enforcement in recreational and social settings are related to alcohol misuse and alcohol-impaired driving among young adults in Victoria, Australia, and Washington State, United States.

METHOD

Longitudinal data came from 1,430 participants in Victoria (n = 757; 52% female) and Washington (n = 673; 53% female), surveyed in 2014 (age 25 years) and 2018 (age 29 years) from the International Youth Development Study, a population-based, cross-national study to examine factors influencing substance use. Path modeling tested associations between age 25 perceptions of the alcohol environment, age 25 social alcohol consumption, and age 29 alcohol-related harms. Multiple-group modeling examined differences in parameter estimates across both states.

RESULTS

Age 25 perceptions of the alcohol environment (alcohol availability, overservice in evening social venues, legal enforcement) and alcohol consumption in evening social settings were similar between the two states. Higher alcohol availability and perceived tendency of evening social venues to overserve were associated with higher alcohol consumption in these contexts. In turn, higher alcohol consumption in these settings was associated with more problematic alcohol use and an increased likelihood of alcohol-impaired driving 4 years later. The perceived likelihood of legal enforcement in evening social settings was not related to alcohol consumption in these contexts.

CONCLUSIONS

The recreational and social settings commonly frequented by young adults can influence drinking behaviors and alcohol-related harms. Reducing alcohol availability and overservicing in settings where young adults often congregate and socialize could reduce problematic alcohol use and alcohol-impaired driving.

Calorie (energy) labelling for changing selection and consumption of food or alcohol

BACKGROUND

Overconsumption of food and consumption of any amount of alcohol increases the risk of non-communicable diseases. Calorie (energy) labelling is advocated as a means to reduce energy intake from food and alcoholic drinks. However, there is continued uncertainty about these potential impacts, with a 2018 Cochrane review identifying only a small body of low-certainty evidence. This review updates and extends the 2018 Cochrane review to provide a timely reassessment of evidence for the effects of calorie labelling on people's selection and consumption of food or alcoholic drinks.

OBJECTIVES

- To estimate the effect of calorie labelling for food (including non-alcoholic drinks) and alcoholic drinks on selection (with or without purchasing) and consumption. - To assess possible modifiers - label type, setting, and socioeconomic status - of the effect of calorie labelling on selection (with or without purchasing) and consumption of food and alcohol.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, five other published or grey literature databases, trial registries, and key websites, followed by backwards and forwards citation searches. Using a semi-automated workflow, we searched for and selected records and corresponding reports of eligible studies, with these searches current to 2 August 2021. Updated searches were conducted in September 2023 but their results are not fully integrated into this version of the review.

SELECTION CRITERIA

Eligible studies were randomised controlled trials (RCTs) or quasi-RCTs with between-subjects (parallel group) or within-subjects (cross-over) designs, interrupted time series studies, or controlled before-after studies comparing calorie labelling with no calorie labelling, applied to food (including non-alcoholic drinks) or alcoholic drinks. Eligible studies also needed to objectively measure participants' selection (with or without purchasing) or consumption, in real-world, naturalistic laboratory, or laboratory settings.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion and extracted study data. We applied the Cochrane RoB 2 tool and ROBINS-I to assess risk of bias in included studies. Where possible, we used (random-effects) meta-analyses to estimate summary effect sizes as standardised mean differences (SMDs) with 95% confidence intervals (CIs), and subgroup analyses to investigate potential effect modifiers, including study, intervention, and participant characteristics. We synthesised data from other studies in a narrative summary. We rated the certainty of evidence using GRADE.

MAIN RESULTS

We included 25 studies (23 food, 2 alcohol and food), comprising 18 RCTs, one quasi-RCT, two interrupted time series studies, and four controlled before-after studies. Most studies were conducted in real-world field settings (16/25, with 13 of these in restaurants or cafeterias and three in supermarkets); six studies were conducted in naturalistic laboratories that attempted to mimic a real-world setting; and three studies were conducted in laboratory settings. Most studies assessed the impact of calorie labelling on menus or menu boards (18/25); six studies assessed the impact of calorie labelling directly on, or placed adjacent to, products or their packaging; and one study assessed labels on both menus and on product packaging. The most frequently assessed labelling type was simple calorie labelling (20/25), with other studies assessing calorie labelling with information about at least one other nutrient, or calories with physical activity calorie equivalent (PACE) labelling (or both). Twenty-four studies were conducted in high-income countries, with 15 in the USA, six in the UK, one in Ireland, one in France, and one in Canada. Most studies (18/25) were conducted in high socioeconomic status populations, while six studies included both low and high socioeconomic groups, and one study included only participants from low socioeconomic groups. Twenty-four studies included a measure of selection of food (with or without purchasing), most of which measured selection with purchasing (17/24), and eight studies included a measure of consumption of food. Calorie labelling of food led to a small reduction in energy selected (SMD -0.06, 95% CI -0.08 to -0.03; 16 randomised studies, 19 comparisons, 9850 participants; high-certainty evidence), with near-identical effects when including only studies at low risk of bias, and when including only studies of selection with purchasing. There may be a larger reduction in consumption (SMD -0.19, 95% CI -0.33 to -0.05; 8 randomised studies, 10 comparisons, 2134 participants; low-certainty evidence). These effect sizes suggest that, for an average meal of 600 kcal, adults exposed to calorie labelling would select 11 kcal less (equivalent to a 1.8% reduction), and consume 35 kcal less (equivalent to a 5.9% reduction). The direction of effect observed in the six non-randomised studies was broadly consistent with that observed in the 16 randomised studies. Only two studies focused on alcoholic drinks, and these studies also included a measure of selection of food (including non-alcoholic drinks). Their results were inconclusive, with inconsistent effects and wide 95% CIs encompassing both harm and benefit, and the evidence was of very low certainty.

AUTHORS' CONCLUSIONS

Current evidence suggests that calorie labelling of food (including non-alcoholic drinks) on menus, products, and packaging leads to small reductions in energy selected and purchased, with potentially meaningful impacts on population health when applied at scale. The evidence assessing the impact of calorie labelling of food on consumption suggests a similar effect to that observed for selection and purchasing, although there is less evidence and it is of lower certainty. There is insufficient evidence to estimate the effect of calorie labelling of alcoholic drinks, and more high-quality studies are needed. Further research is needed to assess potential moderators of the intervention effect observed for food, particularly socioeconomic status. Wider potential effects of implementation that are not assessed by this review also merit further examination, including systemic impacts of calorie labelling on industry actions, and potential individual harms and benefits.

Impact on beer sales of removing the pint serving size: An A-B-A reversal trial in pubs, bars, and restaurants in England

BACKGROUND

Smaller serving sizes could contribute towards reducing alcohol consumption across populations and thereby decrease the risk of 7 cancers and other diseases. To our knowledge, the current study is the first to assess the impact on beer, lager, and cider sales (hereafter, for ease, referred to just as "beer sales") of removing the largest draught serving size (1 imperial pint) from the options available in licensed premises under real-word conditions.

METHODS AND FINDINGS

The study was conducted between February and May 2023, in 13 licensed premises in England. It used an A-B-A reversal design, set over 3 consecutive 4-weekly periods with "A" representing the nonintervention periods during which standard serving sizes were served, and "B" representing the intervention period when the largest serving size of draught beer (1 imperial pint (568 ml)) was removed from existing ranges so that the largest size available was two-thirds of a pint. Where two-third pints were not served, the intervention included introducing this serving size in conjunction with removing the pint serving size. The primary outcome was the mean daily volume of all beer sold, including draught, bottles, and cans (in ml), extracted from electronic sales data. Secondary outcomes were mean daily volume of wine sold (ml) and daily revenue (£). Thirteen premises completed the study, 12 of which did so per protocol and were included in the primary analysis. After adjusting for prespecified covariates, the intervention resulted in a mean daily change of -2,769 ml (95% CI [-4,188, -1,578] p < 0.001) or -9.7% (95% CI [-13.5%, -6.1%] in beer sold. The daily volume of wine sold increased during the intervention period by 232 ml (95% CI [13, 487], p = 0.035) or 7.2% (95% CI [0.4%, 14.5%]). Daily revenues decreased by 5.0% (95% CI [9.6%, -0.3%], p = 0.038).

CONCLUSIONS

Removing the largest serving size (the imperial pint) for draught beer reduced the volume of beer sold. Given the potential of this intervention to reduce alcohol consumption, it merits consideration in alcohol control policies.

TRIAL REGISTRATION

ISRCTN.com ISRCTN18365249.

Changing the availability and positioning of more vs. less environmentally sustainable products: A randomised controlled trial in an online experimental supermarket

Food purchasing behaviours are shaped by the choices available to shoppers and the way they are offered for sale. This study tested whether prominent positioning of more sustainable food items online and increasing their relative availability might reduce the environmental impact of foods selected in a 2x2 (availability x position) factorial randomised controlled trial. Participants (n = 1179) selected items in a shopping task in an experimental online supermarket. The availability intervention added lower-impact products to the regular range. The positioning intervention biased product order to give prominence to lower-impact products. The primary outcome was the environmental impact score (ranging from 1 "least impact" to 5 "most impact", of each item in shopping baskets) analysed using Welch's ANOVA. Secondary outcomes included interactions (analysed via linear regression) by gender, age group, education, income and meat consumption and we assessed intervention acceptability (using different frames) in a post-experiment questionnaire. Compared to control (mean = 21.6), mean eco quintile score was significantly reduced when availability & order was altered (-2.30; 95%CI: 3.04; -1.56) and when order only was changed (-1.67; 95%CI: 2.42; -0.92). No significant difference between availability only (-0.02; 95%CI: 0.73; 0.69) and control was found. There were no significant interactions between interventions or by demographic characteristics. Both interventions were acceptable under certain frames (positioning emphasising lower-impact products: 70.3% support; increasing lower-impact items: 74.3% support). Prominent positioning of more sustainable products may be an effective strategy to encourage more sustainable food purchasing. Increasing availability of more sustainable products alone did not significantly alter the environment impact of products selected.

The impact of introducing alcohol-free beer options in bars and public houses on alcohol sales and revenue: A randomised crossover field trial

AIMS

The study aimed to estimate the impact of introducing a draught alcohol-free beer, thereby increasing the relative availability of these products, on alcohol sales and monetary takings in bars and pubs in England.

DESIGN

Randomised crossover field trial.

SETTING

England.

PARTICIPANTS

Fourteen venues that did not previously sell draught alcohol-free beer.

INTERVENTION AND COMPARATOR

Venues completed two intervention periods and two control periods in a randomised order over 8 weeks. Intervention periods involved replacing one draught alcoholic beer with an alcohol-free beer. Control periods operated business as usual.

MEASUREMENTS

The primary outcome was mean weekly volume (in litres) of draught alcoholic beer sold. The secondary outcome was mean weekly revenue [in GBP (£)] from all drinks. Analyses adjusted for randomised order, special events, season and busyness.

FINDINGS

The adjusted mean difference in weekly sales of draught alcoholic beer was -20 L [95% confidence interval (CI) = -41 to +0.4], equivalent to a 4% reduction (95% CI = 8% reduction to 0.1% increase) in the volume of alcoholic draught beer sold when draught alcohol-free beer was available. Excluding venues that failed at least one fidelity check resulted in an adjusted mean difference of -29 L per week (95% CI = -53 to -5), equivalent to a 5% reduction (95% CI = 8% reduction to 0.8% reduction). The adjusted mean difference in weekly revenue was +61 GBP per week (95% CI = -328 to +450), equivalent to a 1% increase (95% CI = 5% decrease to 7% increase) when draught alcohol-free beer was available.

CONCLUSIONS

Introducing a draught alcohol-free beer in bars and pubs in England reduced the volume of draught alcoholic beer sold by 4% to 5%, with no evidence of the intervention impacting net revenue.

Impact on wine sales of removing the largest serving size by the glass: An A-B-A reversal trial in 21 pubs, bars, and restaurants in England

BACKGROUND

Interventions that alter aspects of the physical environments in which unhealthy behaviours occur have the potential to change behaviour at scale, i.e., across populations, and thereby decrease the risk of several diseases. One set of such interventions involves reducing serving sizes, which could reduce alcohol consumption. The effect of modifying the available range of serving sizes of wine in a real-world setting is unknown. We aimed to assess the impact on the volume of wine sold of removing the largest serving size by the glass from the options available in licensed premises.

METHODS AND FINDINGS

The study was conducted between September 2021 and May 2022 in 21 licensed premises in England that sold wine by the glass in serving sizes greater than 125 ml (i.e., 175 ml or 250 ml) and used an electronic point of sale till system. It used an A-B-A reversal design, set over 3 four-weekly periods. "A" represented the nonintervention periods during which standard serving sizes were served and "B" the intervention period when the largest serving size for a glass of wine was removed from the existing range in each establishment: 250 ml (18 premises) or 175 ml (3 premises). The primary outcome was the daily volume of wine sold, extracted from sales data. Twenty-one premises completed the study, 20 of which did so per protocol and were included in the primary analysis. After adjusting for prespecified covariates, the intervention resulted in -420·8 millilitres (ml) (95% confidence intervals (CIs) -681·4 to -160·2 p = 0·002) or -7·6% (95% CI -12·3%, -2·9%) less wine being sold per day. There was no evidence that sales of beer and cider or total daily revenues changed but the study was not powered to detect differences in these outcomes. The main study limitation is that we were unable to assess the sales of other alcoholic drinks apart from wine, beer, and cider, estimated to comprise approximately 30% of alcoholic drinks sold in participating premises.

CONCLUSIONS

Removing the largest serving size of wine by the glass from those available reduced the volume of wine sold. This promising intervention for decreasing alcohol consumption across populations merits consideration as part of alcohol licensing regulations.

TRIAL REGISTRATION

ISRCTN https://doi.org/10.1186/ISRCTN33169631; OSF https://osf.io/xkgdb.

Impact of health warning labels and calorie labels on selection and purchasing of alcoholic and non-alcoholic drinks: A randomized controlled trial

AIMS

To estimate the impact on selection and actual purchasing of (a) health warning labels (text-only and image-and-text) on alcoholic drinks and (b) calorie labels on alcoholic and non-alcoholic drinks.

DESIGN

Parallel-groups randomised controlled trial.

SETTING

Drinks were selected in a simulated online supermarket, before being purchased in an actual online supermarket.

PARTICIPANTS

Adults in England and Wales who regularly consumed and purchased beer or wine online (n = 651). Six hundred and eight participants completed the study and were included in the primary analysis.

INTERVENTIONS

Participants were randomized to one of six groups in a between-subjects three [health warning labels (HWLs) (i): image-and-text HWL; (ii) text-only HWL; (iii) no HWL] × 2 (calorie labels: present versus absent) factorial design (n per group 103-113).

MEASUREMENTS

The primary outcome measure was the number of alcohol units selected (with intention to purchase); secondary outcomes included alcohol units purchased and calories selected and purchased. There was no time limit for selection. For purchasing, participants were directed to purchase their drinks immediately (although they were allowed up to 2 weeks to do so).

FINDINGS

There was no evidence of main effects for either (a) HWLs or (b) calorie labels on the number of alcohol units selected (HWLs: F(2,599)  = 0.406, P = 0.666; calorie labels: F(1,599)  = 0.002, P = 0.961). There was also no evidence of an interaction between HWLs and calorie labels, and no evidence of an overall difference on any secondary outcomes. In pre-specified subgroup analyses comparing the 'calorie label only' group (n = 101) with the 'no label' group (n = 104) there was no evidence that calorie labels reduced the number of calories selected (unadjusted means: 1913 calories versus 2203, P = 0.643). Among the 75% of participants who went on to purchase drinks, those in the 'calorie label only' group (n = 74) purchased fewer calories than those in the 'no label' group (n = 79) (unadjusted means: 1532 versus 2090, P = 0.028).

CONCLUSIONS

There was no evidence that health warning labels reduced the number of alcohol units selected or purchased in an online retail context. There was some evidence suggesting that calorie labels on alcoholic and non-alcoholic drinks may reduce calories purchased from both types of drinks.

Impact on sales of adding a smaller serving size of beer and cider in licensed premises: an A-B-A reversal design

BACKGROUND

Smaller serving sizes of alcoholic drinks could reduce alcohol consumption across populations thereby lowering the risk of many diseases. The effect of modifying the available range of serving sizes of beer and cider in a real-world setting has yet to be studied. The current study assessed the impact on beer and cider sales of adding a serving size of draught beer and cider (2/3 pint) that was between the current smallest (1/2 pint) and largest (1 pint) standard serving sizes.

METHODS

Twenty-two licensed premises in England consented to taking part in the study. The study used an ABA reversal design, set over three 4-weekly periods, with A representing the non-intervention periods, during which standard serving sizes were served and B the intervention period when a 2/3 pint serving size of draught beer and cider was added to the existing range, along with smaller 1/2 pint and larger 1 pint serving sizes. The primary outcome was the daily volume of beer and cider sold, extracted from sales data.

RESULTS

Fourteen premises started the study, of which thirteen completed it. Twelve of those did so per protocol and were included in the primary analysis. After adjusting for pre-specified covariates, the intervention did not have a significant effect on the volume of beer and cider sold per day (3.14 ml; 95%CIs -2.29 to 8.58; p = 0.257).

CONCLUSIONS

In licensed premises, there was no evidence that adding a smaller serving size for draught beer and cider (2/3 pint) when the smallest (1/2 pint) and largest (1 pint) sizes were still available, affected the volume of beer and cider sold. Studies are warranted to assess the impact of removing the largest serving size.

TRIAL REGISTRATION

ISRCTN: https://doi.org/10.1186/ISRCTN33169631 (08/09/2021), OSF: https://osf.io/xkgdb/ (08/09/2021).