It isn’t every day you get to write about a policy win to prevent and reduce alcohol harm. The pace of progress on alcohol policies continues to be inversely related to alcohol’s level of harm (to alcohol users themselves as well as others) and magnitude of alcohol harm inequities. In an effort to inform the practice of building healthy public policy, Dr. Nicki Jackson in this inspiring guest expert opinion describes nine lessons learned in the journey towards implementation of a best practice pregnancy health warning label on alcohol products.
And Nicki outlines the next steps highlighting three crucial aspects for the way forward.

This guest expert opinion is written by Dr. Nicki Jackson, Executive Director, Alcohol Healthwatch.

Many readers of this blog will be aware that alcohol is a known teratogen, shown to cause fetal alcohol spectrum disorder (FASD) as well as alcohol-related premature birth, miscarriage and stillbirth. It is a serious public health matter with no known safe level of alcohol use during pregnancy. The official health advice in New Zealand is for women who could be pregnant, are pregnant or trying to get pregnant, to stop consuming alcohol.

Despite the obvious need for accurate consumer information on this harmful product, the battle to mandate an effective warning label has spanned more than two decades.

Dr. Nicki Jackson

Increasing health literacy, via a visible health warning label on a product that can cause significant preventable and permanent damage, should be straightforward. Whilst it is unlikely to be the silver bullet to preventing harm, in much the same way as speed limits don’t prevent all accidents due to speeding, it does provide a foundation on which to wrap around other supportive strategies that would be weakened by the absence of the product warning. Despite the obvious need for accurate consumer information on this harmful product, the battle to mandate an effective warning label has spanned more than two decades. Nothing comes easy when it concerns alcohol.

In New Zealand and Australia, labelling of alcohol is regulated by specified food standard codes. A bi-lateral trade treaty requires that food products sold in both countries abide by the same rules. This is overseen by a regulatory body, called Food Standards Australia New Zealand (FSANZ). The major decision-making process nevertheless remains political.

Successive New Zealand governments over the past two decades have been relatively positive towards mandating a pregnancy health warning for alcohol, for which we in New Zealand are grateful. However, under the bi-national food treaty, the Ministerial Forum for Food Regulation (FoFR) is where the ‘yea or nay’ of food labelling decision-making sits. For the smaller of the two nations, the ‘bi-lateral’ is in name only and inherently biased with New Zealand only having one vote out of ten on the FoFR, the other nine being shared amongst Australian states, territories and the federal Government. This voting ratio is inequitable and unjust, particularly in light of the differences in population size (i.e. 25 million in Australia vs. 5 million in New Zealand) as well as our own obligations in New Zealand to effectively uphold the Treaty of Waitangi by promoting and protecting the health of Māori (the Indigenous people of Aotearoa New Zealand). This unequal arrangement has always meant that New Zealand had a mountain to climb and, a bit like Sir Edmond Hillary, required a co-ordinated team approach to reach the summit. 

Without going into the agony and ecstasy of all that ensued over two decades, suffice to say we overcame enormous odds and in July 2020, celebrations took place throughout Australia and New Zealand as a majority of Ministers voted in favour of a best practice pregnancy health warning label.

Lessons Learned

Forming a population health alliance between Australian and New Zealand colleagues was vital, not just politically, but to effectively counter the relentless industry lobbying and media publicity intended to dissuade Ministers against voting for a best practice label. 

Like many roads to effective regulation of alcohol, the label’s history showcases how profit-focused corporations interfere politically in public health decision-making and should never be relied upon to safeguard the nation’s public health.

Big Alcohol Lobbying

The liquor lobby, while publically proclaiming their approval of a pregnancy warning, was actively determined to ensure the label would be limited to being the least effective, least noticeable and least persuasive. In particular, the industry was heard crying foul about the cost to alcohol producers from the inclusion of red ink. Their campaign, ‘Not this label’, generated a cast of thousands signing a letter to the Ministers concerned. When it came to voting time on the best practice label proposed by the regulatory body, FSANZ, another label without the red colour was introduced into the voting process. Thankfully, this new amendment was voted down with Ministers voting 6:4 in favour of the best practice label that included the red colour.

The industry did achieve a small concession in being given three years to implement the change, which is two years longer than the public health sector advocated, or that which generally applies to other food producer groups.

As such, by July 31 2023, all alcohol products (>200ml) available for sale in New Zealand and Australia must display the visible and consistent warning shown below (only the pictogram is required on smaller products).

Public Health Advocacy Lessons

Caterina Giorgi of the Foundation for Alcohol Research and Education (FARE) has already explained many of the lessons from the advocacy success story in this great podcast.

We are extremely grateful to the families living with FASD who shared their stories.”

Dr. Nicki Jackson

We believe the lessons from the lengthy saga to attain one small measure towards improved health outcomes have been:

  1. Expect to be in it for the long haul – because the alcohol industry is,
  2. Actively build and constantly share your evidence base,
  3. Never underestimate the power of stories, especially by those with lived experience of FASD,
  4. Build a coalition of the willing, able to reach multiple sectors of society and achieve solidarity including with the media,
  5. Use multiple strategies and tools,
  6. Be nimble – expect the unexpected and respond swiftly,
  7. Be consistent in your goal – demand best practice, and
  8. This is, and can be far more, than just a label on a bottle.

There is immense pride in knowing that New Zealand and Australia now have the world’s strongest, most visible pregnancy health warning label.

We acknowledge the work of FSANZ and the strong leadership shown by FARE in Australia. We are extremely grateful to the families living with FASD who shared their stories and advocated relentlessly, and the Ministers who voted in favour of protecting the future of our children.

Next Steps

A consistent, universal message now provides stakeholders with an opportunity to build prevention awareness across our communities, in multiple ways. The label provides a constant reminder in our alcohol consumption environments and is a conversation starter for those who perhaps felt uncomfortable about raising the subject. Thus, it assists to create the supportive environments that are essential to enable alcohol-free pregnancies. The label can also underpin health professionals’ ability to engage with clients meaningfully, beyond the ubiquitous yes/no alcohol use tick box.  

The pregnancy health warning label on alcohol products assists to create the supportive environments that are essential to enable alcohol-free pregnancies.”

Dr. Nicki Jackson

The label also presents a platform from which to launch other evidence-based harm reduction strategies. In particular, we can build on the strong trans-Tasman community action and partnerships that were created during the mobilisation for the best practice label.

Last, but certainly not least, we must ensure we understand the impact of our efforts on equity. In the 20+ yearlong battle to get the effective label over the line, longstanding inequities in preventable health outcomes continued or widened. Equity must remain at the forefront going forward.

About Our Guest Expert

Dr. Nicki Jackson, Executive Director, Alcohol Healthwatch

Dr. Nicki Jackson

Dr. Nicki Jacksom is the Executive Director of Alcohol Healthwatch in New Zealand.

Her background includes managing the alcohol and tobacco regulatory and health promotion activities of the Auckland Regional Public Health Service.

Nicki’s work in public health evidence has been recognised by the World Health Organisation.

In 2016, she completed her PhD investigating adolescent alcohol use in New Zealand and won the University of Auckland Vice Chancellor’s Excellence Award for best Doctoral thesis at the University in 2016. She is also an Honorary Academic at the University of Auckland.

You can follow Nicki on Twitter: @DrNickiJackson