Research Update

Alcohol Use and Pregnancy: An Important Canadian Public Health and Social Issue

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6.3 Public Awareness Activities

Public awareness activities are the most common universal prevention measure. However, many have weak designs and have not been evaluated. Mandated warning labels are the most studied universal prevention measure on this issue, with almost all of the research originating in the US, which enacted this policy in 1989.

In a 2002 review of studies on warning labels in the US, Hankin concluded that after several years of heightened awareness of the labels and their messages, general population awareness levels tended to slip in subsequent years. Stockwell suggested that rotating and changing the messages would have the effect of keeping them fresh and would reduce this “slippage” in awareness.¹³² Hankin further found that “low-risk” pregnant women reduced their alcohol consumption following the implementation of the warning label, but women who drank heavily during pregnancy did not.¹³³ In another of the few studies on warning labels and pregnant women, Kaskutas et al. surveyed a nationally representative sample of pregnant women in the US over a five-year span on their awareness of warning labels, signs, advertisements and posters. They found that there was no relationship between awareness of the various messages and drinking levels during pregnancy.¹³⁴ In a 1999 study, Greenfield et al. found a positive relationship between the amount of exposure to warning labels and conversations about drinking and pregnancy.¹³⁵

On February 1, 2005, Bill-43, referred to as "Sandy's Law," came into effect in Ontario. This Bill requires establishments that are licensed to serve or sell alcohol to post specific warning signs about the risks of alcohol use in pregnancy. The regulations specify the types of licensed establishments affected by this new law, the size, language, wording and images for the signs, and where the signs must be posted. The message on the signs reads: "WARNING: Drinking alcohol during pregnancy can cause birth defects and brain damage to your baby. 1-877-FAS-INFO www.alcoholfreepregnancy.ca."

Fenaughty and MacKinnon studied the effectiveness of a legislated warning poster in Arizona.¹³⁶ The poster was required in all establishments selling alcohol, and included the statement, “Warning: Drinking Distilled Spirits, Beer, Coolers, Wine and Other Alcoholic Beverages during Pregnancy Can Cause Birth Defects.” They found that most of those studied had become aware of the poster and its message, but that it had minimal impact on their beliefs regarding the effect of alcohol on the fetus. Women and older subjects were more likely to be aware of the poster than men and younger subjects, respectively.

Responsible beverage service (RBS) programs work with managers and servers in licensed establishments to help ensure that beverages are served responsibly (i.e. not served to minors, intoxicated or disruptive patrons). There is good evidence to support these programs generally.¹³⁷ Some may see RBS programs having preventative potential on this issue by placing servers in a role of refusing to sell alcohol to pregnant women; however, this would be generally viewed as discriminatory and contentious. RBS programs may have a role to play in raising awareness of this issue among bar managers and servers, but there is no documentation of the impact of this type of measure.

In 1999-2000, the Alberta Alcohol and Drug Abuse Commission (AADAC) conducted an awareness-raising campaign for the Alberta Partnership on FAS. Among other aims, the campaign intended to increase the awareness and profile of FAS in the province and used television, radio and newspaper advertisements in addition to local initiatives that included private sector involvement. A sample of 800 Albertans was surveyed prior to the campaign, with another sample surveyed immediately following the television portion of the campaign (a period of three months). According to a number of measures, a generally high level of awareness and support for action remained unchanged as a result of the campaign. However, recall of information related to alcohol and pregnancy rose significantly, with 61% of Albertans reporting having seen, heard or read something about this issue prior to the mass media element of the campaign compared with 73% immediately following.¹³⁸

Health care providers are in an excellent position to offer brief, universal messages to increase general public knowledge of the risks of alcohol use to the fetus and the prevalence of unintended pregnancies. A general message that has been recommended is "being sexually active, a frequent alcohol user, and not using effective contraception places a woman at risk for having an alcohol-exposed pregnancy."¹³⁹ Important leadership on this issue was provided by the US's top physician, the US Surgeon General, during an update of a 1981 statement in February of 2005, advising women who are pregnant or considering becoming pregnant to abstain from alcohol.¹⁴⁰

Insight: Evaluation – Poor at Best

Overall, public awareness-raising campaigns, while common, tend not to be evaluated. The goals of such programs are also often not clearly articulated, making it difficult to evaluate them using scientific methods. When the campaigns are evaluated, as with warning labels, they tend to show modest benefits in terms of knowledge gains among the general public and behaviour change seems confined to low-risk women.

Some conclude that the small positive effect of beverage container warning labels and other awareness-raising activities justifies a measure that costs government virtually nothing and the alcohol industry very little.¹⁴¹ Others caution that harm may be caused by public awareness messages that recommend abstinence as the only safe option for pregnant women. They argue that, given the high percentage of women of childbearing age who drink, the high number of unplanned pregnancies discovered later in their term, and that FASD is diagnosed primarily in the children of heavy-drinking women, these public messages are unduly “alarmist.” The contention is that these messages may lead to unnecessary anxiety and possible termination of pregnancy among low-risk women, while failing to reach the women at greatest risk.^142,143

In the face of some indication that exposure to lower amounts of alcohol may increase risk of stillbirth and have an effect on the growth and cognitive skills of a child,^xxiv the broad message of abstinence during pregnancy is the most prudent universal message.¹⁴⁴ This general message needs to be complemented by clear, targeted messages from physicians and other practitioners in contact with pregnant women to clarify the degree of risk associated with different patterns of drinking (e.g. low, occasional levels of drinking vs. frequent and binge drinking), and particular sub-populations (e.g. women who drink during pregnancy who are considered high risk). Clear definitions of low, moderate, occasional and frequent drinking need to be agreed upon to support these messages. It is important that women, who for whatever reason, have consumed alcohol during pregnancy, be made aware that stopping or reducing their consumption at any point, while attending to their overall health, will increase the likelihood of positive outcomes for their unborn child.¹⁴⁵ (See also section 7 – Selective Prevention Strategies).

Public awareness campaigns alone seem unable to shift behaviour among higher risk women; however, it is arguable whether they should be held to that standard. By raising awareness, these campaigns can help to establish overall norms on an issue – norms that may help some pregnant women garner the support they need from partners, family and friends to avoid use of alcohol.¹⁴⁶

Insight: "Tilling the Soil"

The role for public awareness campaigns best supported by the literature is to contribute to larger, multi-component strategies.¹⁴⁷ These strategies must be well defined, evaluated and draw upon available advice. Beyond that, it has been suggested that these universal prevention measures can play an important role in "tilling the soil," in that an informed public may be more inclined to support public expenditures for more intensive strategies to address this issue.¹⁴⁸

It is critical that these efforts be well designed and evaluated, and take advantage of available advice, such as the 2003 guide Keys to a Successful Alcohol and Pregnancy Communication Campaign, by the Ontario government's Best Start program.¹⁴⁹

xxiv. There are, however, concerns with these studies due to a lack of consensus on what constitutes low and moderate drinking. In several cases, they are based on weekly averages that could hide high consumption during one or two occasions during the week.

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