Nice to get a win for public health

Dr Ingrid Johnston and Professor Simone Pettigrew


We often say in public health that it’s a long, hard game. Sometimes it feels as though the wins are incremental at best, and all too rare. All the more reason then, to celebrate them when they do happen.

On Friday 17th July 2020, an opportunity to celebrate presented itself in the form of the adoption across Australia and New Zealand of clear, visible mandatory pregnancy warning labels on alcoholic products. This important reform will directly impact on Australia’s leading cause of preventable, non-genetic disability – Fetal Alcohol Spectrum Disorder.

This welcome decision was nearly blocked by political lobbying from the alcohol industry.

The path leading up to this decision was a long, hard road, summarised here:

  • 17 February 2006 – an application was made to Food Standards Australia New Zealand (FSANZ) to require a health advisory label on alcoholic beverage containers advising of the risks of consuming alcohol when planning to become pregnant and during pregnancy.
  • 12 December 2007 – The FSANZ initial assessment report responded to that application noting “it is known that drinking alcohol during pregnancy can be associated with varying degrees of harm to the unborn child”.
  • 12 February 2009 – An evidence report presented to FSANZ – Alcohol warning labels: Evidence of effectiveness on risky alcohol consumption and short term outcomes noted that over 20 countries already had mandatory alcohol warning labels, and included information on the elements of effective labels.
  • 12 May 2009 – An evidence report presented to FSANZ – Alcohol warning labels: Evidence of impact on alcohol consumption amongst women of childbearing age noted that at least 5 countries already had labels warning about the risk of alcohol use during pregnancy, but noted a lack of evidence of their effectiveness.
  • May 2010 – An analysis report was presented to FSANZ – Fetal Alcohol Spectrum Disorder (FASD) exploratory economic analysis of different prevention strategies in Australia and New Zealand. This report provided cost-effectiveness analyses of warning labels, public media campaigns, education sessions for all pregnant women, and residential care for pregnant women at high-risk. The report found that both education sessions and labels were the most cost-effective over the longer term and noted that the most effective prevention program incorporates multiple reinforcing strategies.
  • January 2011 – The Labelling Logic review report from the independent Panel for the Review of Food Labelling Law and Policy, commissioned by the Australia and New Zealand Food Regulation Ministerial Council, included Recommendation 25: That a suitably worded warning message about the risks of consuming alcohol while pregnant be mandated on individual containers of alcoholic beverages and at the point of sale for unpackaged alcoholic beverages, as support for ongoing broader community education.
  • In response, the Forum provided the alcohol industry with a two-year period, commencing December 2011, to adopt the voluntary initiative to place pregnancy health warning labels on alcohol products, before regulating such a change.
  • 23 May 2014 – an evaluation report to FSANZ of the voluntary scheme found that just 38% of all available alcoholic beverage products contained the label, and only 4% of women were aware of them. In response, the Forum agreed to extend the existing trial on voluntary uptake of pregnancy health warnings on alcohol product labels and undertake another review in a further two years.
  • 31 May 2017 – a second evaluation report to FSANZ found that 48% of all available alcoholic beverage products contained the label, and that consumers felt that the use of green colour in the voluntary label can confuse readers by suggesting that alcohol should be consumed, and red colour should be used to indicate danger. In response, Forum Ministers asked the Food Regulation Standing Committee to expedite for earliest possible consideration the development of a policy options consultations paper including: mandatory versus voluntary application; most appropriate pictogram; and most appropriate and most easy to understand message to discourage drinking during pregnancy.
  • October 2018 – a Decision Regulation Impact Statement (DRIS) with four options for progressing pregnancy warning labels on packaged alcoholic beverages was presented to Forum Ministers. The Forum agreed that, based on the evidence, a mandatory labelling standard for pregnancy warning labels on packaged alcoholic beverages should be developed and should include a pictogram and relevant warning statement. The Forum requested Food Standards Australia New Zealand (FSANZ) develop this mandatory labelling standard as a priority and that the work be completed expeditiously.
  • October 2019 – FSANZ released an updated literature review on pregnancy warning labels on packaged alcohol and the results of a consumer survey on the effectiveness of particular label elements, along with a cost-benefit analysis. The literature review identified 5 elements for warning label effectiveness – attention, reading and comprehension, recall, judgement and behavioural compliance. It was found that few of the existing mandated warnings incorporated these design factors. The survey report found that the words “any amount of alcohol can cause lifelong harm to your baby” best conveyed the message to not drink any alcohol while pregnant. The cost-benefit analysis found that even under the worst case scenario in terms of expense to industry, only 3.2% of Fetal Alcohol Spectrum Disorder cases needed to be avoided or mitigated each year to break even with costs over 20 years.
  • 31 January 2020 – FSANZ approved a draft variation to the Australia New Zealand Food Standards Code to require a pregnancy warning label on packaged alcoholic beverages sold in Australia and New Zealand based on the evidence of the most effective label.
  • 9 April 2020 – Australian and New Zealand Ministerial Forum on Food Regulation requested a review of the decision under the criterion in the Food Regulation Agreement regarding an unreasonable cost burden on industry. The Forum requested the review consider the colour requirements and signal wording of the pregnancy warning label.
  • 24 June 2020 – FSANZ notified the Forum of its decision to reaffirm the proposed amendment with two changes:
    • The signal words HEALTH WARNING changed to PREGNANCY WARNING
    • The transition period for implementation of the pregnancy warning label is extended from 2 to 3 years
  • 17 July 2020 – Forum Ministers accepted the proposed draft standards, with an implementation period of 3 years from the date of gazettal.

So by the time the 3 year transition period for mandatory labels ends in 2023, it will have been 17 years since the idea was first proposed. That’s a long, hard road indeed for something which will take up less than 20mm of an alcoholic beverage label and is a simple, inexpensive form of information provision to reduce alcohol-related harms.

Along every step of that road, public health, alcohol and FASD experts have worked tirelessly to ensure that we progressed along to the next step, responding to each incremental decision and argument. Not enough evidence that it’s necessary? We’ll get some more. Don’t think it needs to be mandatory? We’ll show you why voluntary isn’t working. Think it will be too expensive? We’ll show you it’s not. Think that contrast will be just as good as the colour red? We’ll show you why it’s not.

And all the way along, public health efforts were opposed by a strong and consistent campaign by the alcohol industry. In a somewhat curious move, the final communique from the Forum Ministers and the press release from Minister Colbeck’s office both specifically referenced attempts to push through the industry’s preferred label, despite clear evidence and recommendations from FSANZ and Government Departmental advice that it would be less effective and that arguments from industry about cost burdens were not justified:

The Australian Government proposed an amendment to remove the colour prescriptions for the label and instead to prescribe the pregnancy warning label to have contrasting colours in accordance with the general legibility requirements outlined in the Australia New Zealand Food Standards Code (1.2.1-24). This was not agreed but was supported by South Australia, New South Wales and Queensland.

Simultaneously, on the other hand, other Federal politicians chose to reference the triumph of evidence and public health over industry profits.

We join in saluting each and every one of the hundreds of organisations and thousands of individuals who have advocated for this simple but effective health measure, many of whom have been there since the beginning in 2006. We also acknowledge the persistence and hard work of many who work in government agencies such as FSANZ and Federal and state Departments of Health. Their names are rarely linked to these successes but their efforts are vital to achieving outcomes of this kind.

Public health is a long, hard road. The wins deserve to be celebrated.


Dr Ingrid Johnston is a senior policy officer at PHAA with a diverse background in public health both in Australia and overseas, including with government (State and Federal), academic, and community sector organisations. After many years working across forensic mental health, family violence, youth justice and prison health, Ingrid completed a PhD on adaptation of disaster response to climate change on remote Pacific islands and is on the Board of Australia’s Climate and Health Alliance.

Professor Simone Pettigrew is the Head of Food Policy at the George Institute for Global Health. Her broad areas of expertise include behavioural psychology, health promotion, health policy, communications, social marketing, and intervention research. Along with nutrition, her substantive areas of research include obesity, physical activity, alcohol consumption, smoking, active transport, and healthy ageing. Simone sits on numerous advisory committees and regularly performs research consultancies for NGO and government entities.



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