To label or not to label: do young drinkers understand the alcohol content of supersized alcopops?

Alcohol consumption is the 7th leading risk factor for burden of disease worldwide (1). Poor understanding or underestimation of the alcohol content of different alcoholic drinks is considered an i...

Alcohol consumption is the 7th leading risk factor for burden of disease worldwide [1]. Poor understanding or underestimation of the alcohol content of different alcoholic drinks is considered an important factor contributing to the harm arising from alcohol consumption [2]. Underestimation of the alcohol content of drinks has clinical and public health implications, since underestimation is likely to result in overconsumption of alcoholic drinks [3; 4], which may have direct and/or indirect harmful effects for the individual and society at large. Studies find that consumers display poor knowledge of the alcohol units or standard drinks contained within alcoholic drinks, even when consumers are explicitly shown labels purporting to display such information [2 -4]. Poor understanding may stem from the complex calculations that go into expressing alcohol units or standard drinks of different alcoholic beverages, but also from inconsistent and/or non-transparent labelling (both mandatory and non-mandatory). These causal factors are likely further compounded by crosscountry differences in regulating the sale and consumption of alcoholic drinks.
Poor understanding or underestimation of the alcohol content of alcoholic drinks is of particular concern amongst young drinkers, who often display harmful levels of consumption and engage in bingeing behaviours more often than other segments of the population. The first article by Rossheim and colleagues [5] in this issue of the American Journal of Drug and Alcohol Abuse examined correlates of consumption of Four Loko amongst underage drinkers, a sugar sweetened and ready-to-drink supersized alcopop with strong alcohol concentration (ranging from 8%ABV to 14%ABV in some US states). Within a sample of 1,019 college students, Rossheim and colleagues found that amongst those who were alcohol drinkers, almost half had consumed Four Loko, with 93% of those consuming Four Loko before the legal age of drinking (below the age of 21). Worryingly, during their first drinking episode 57% reported consumption of at least one 23.5 ounce can of Four Lokothus, exceeding recommended standard drink recommendations per drinking occasion. Amongst those who exceeded the drinking recommendations and drank at least one can of Four Loko, 36% blacked out and 21% vomited (with such episodes being reported with higher frequency in states that allow the sale of Four Loko with higher alcohol strength).
The second article by Rossheim and colleagues [6]  These findings underscore the poor understanding of alcohol content within a large US college sample, and highlight that young drinkers are especially poor at understanding and estimating the content of higher %ABV drinks. Thus, the higher levels of underestimation found in this study may help explain the levels of more excessive and harmful consumption found in the first target article. Rossheim and colleagues' findings are in line with a recent study amongst a nationally representative UK sample of weekly wine and beer drinkers, which found better understanding of alcohol content of wines and beers displaying labels of lower %ABV [7]. Taken together, these findings suggest that regulations and policies mandating the production and sale of alcoholic drinks of lower %ABV may be beneficial in altering harmful alcohol consumption at the population level. This recommendation seems even more pertinent for alcopops, such as Four Loko, which are the alcoholic drink of choice of young drinkers, including underage drinkers. But, even more so, these recommendations seem pertinent for supersized alcopops containing particularly high %ABV per container.
Nevertheless, whilst these recent studies suggest that the development and sale of reduced %ABV drinks should be encouraged, we still lack an understanding of the mechanisms that drive this better understanding of alcohol content when alcoholic drinks are of lower or reduced strength. Future research should aim to examine underlying mechanisms, as well as gauge any potential moderators of the effects found thus far. For example, would the better understanding and estimations of alcohol content of drinks with lower %ABV appear in all contexts (e.g., lone vs. group drinking; out-of-home vs. in-home drinking) and for all groups (e.g., regular vs. heavy vs. occasional drinkers; younger vs. older drinkers)?
Gauging the impact of different labelling regulations on consumer knowledge across countries would also provide valuable evidence as to what type of label is most easily understood and heeded by different drinkers.
Furthermore, whilst the findings gauging consumers' explicit knowledge of the alcohol content of drinks with reduced alcohol strength seem promising, a recent behavioural study which examined actual consumption in a bar laboratory setting advises caution regarding widespread regulation encouraging the production and promotion of lower strength alcoholic drinks. Vasiljevic and colleagues [8] found that regular drinkers consumed approximately 20% more wine and beer when it was labelled as lower in alcohol strength, suggesting that lower strength alcoholic drinks may engender paradoxical effects. Thus, better reported understanding of alcohol content when drinks are labelled as lower in %ABV may not translate into less harmful levels of consumption. This dissociation between better reported knowledge and actual behaviour has previously been found in relation to foods labelled as lower in fat and calories and tobacco cigarettes labelled as 'lighter'. So even though the evidence pertaining to alcohol consumption of alcoholic drinks labelled as lower in strength is limited, these studies in related domains do cautiously suggest that simply mandating the production and sale of lower/reduced strength alcoholic drinks may not be the solution to harmful levels of consumption amongst the population.
As such, particular caution may be required for supersized sweet-flavoured alcopops such as Four Loko, which appeal to young (including underage) drinkers. Prior research has found that young drinkers report using alcohol unit or standard drink labels to purchase the cheapest alcohol, the label being used as a reference cue to purchase products with higher alcohol content [9; see also 10]. Thus, the development and availability of lower strength alcohol products may be advisable, but without prominent labelling of the reduced content of alcohol contained in such drinks [see also 11]. Future research programmes should aim to address these gaps in our knowledge.

Declaration of interests: None.
Funding: None.