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Background: Alcohol health-warning labels are a policy option that can contribute to the reduction of alcohol-related harms, but their effects and public perception depend on their content and format. Our study aimed to investigate the effect of health warnings on knowledge that alcohol causes cancer, the perceptions of three different message topics (responsible drinking, general health harm of alcohol, and alcohol causing cancer), and the role of images included with the cancer message., Methods: In this online survey experiment, distributed in 14 European countries and targeting adults of the legal alcohol-purchase age who consumed alcohol, participants were randomly allocated to one of six label conditions using a pseudorandom number generator stratified by survey language before completing a questionnaire with items measuring knowledge and label perceptions. Effect on knowledge was assessed as a primary outcome by comparing participants who had increased knowledge after exposure to labels with the rest of the sample, for the six label conditions. Label perceptions were compared between label conditions as secondary outcomes., Findings: 19 110 participants completed the survey and were eligible for analysis. Our results showed that a third of the participants exposed to the cancer message increased their knowledge of alcohol causing cancer (increase for 1131 [32·5%, 95% CI 29·8 to 35·2] of 3409 participants [weighted percentage] for text-only message; increase for 1096 [33·3%, 30·4 to 36·2] of 3198 [weighted percentage] for message inlcuding pictogram; and increase for 1030 [32·5%, 29·6 to 35·4] of 3242 [weighted percentage] for message including graphic image), compared with an increase for 76 (2·4%, -1·2 to 6·0) of 3018 participants who viewed the control message. Logistic regression showed that cancer messages increased knowledge compared with the control label (odds ratio [OR] text only 20·20, 95% CI 15·88 to 26·12; OR pictogram 21·16, 16·62 to 27·38; OR graphic-image 20·61, 16·19 to 26·68). Cancer messages had the highest perceived impact and relevance, followed by general health harm and responsibility messages. Text-only and pictogram cancer messages were seen as clear, comprehensive, and acceptable, whereas those including an image of a patient with cancer had lower acceptability and the highest avoidance rating of all the labels. The only identified interaction between perceptions and experimental conditions (with gender) indicated higher comprehensibility and acceptability ratings of cancer labels than responsibility messages and control labels by women, with the results reversed in men., Interpretation: Health warnings are an effective policy option to increase knowledge of alcohol causing cancer, with a generalisable effect across several countries. Europeans consider alcohol health-warning labels to be comprehensible and acceptable, with cancer-specific health warnings having the highest perceived impact and relevance., Funding: EU4Health., Competing Interests: Declaration of interests AO, CF-B, GG, MN, and TL are staff members of WHO. AT, DC, DK, and JR are WHO consultants. We alone are responsible for the views expressed here and these do not necessarily represent the decisions or the stated policy of WHO. AO, CF-B, DC, DK, and MN have been funded for their work on EVID-ACTION project by the European Commission grant., (Copyright © 2024 World Health Organization. Published by Elsevier Ltd. This is an Open Access article published under the CC BY-NC-ND 3.0 IGO license which permits users to download and share the article for non-commercial purposes, so long as the article is reproduced in the whole without changes, and provided the original source is properly cited. This article shall not be used or reproduced in association with the promotion of commercial products, services, or any entity. There should be no suggestion that WHO endorses any specific organisation, products, or services. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.)

Objectives: This paper describes the design and implementation of an online survey experiment to investigate the effects of alcohol warning labels on alcohol-related knowledge, risk perceptions and intentions., Method: The survey collected self-reported data from 14 European countries through two waves of data collection with different recruitment strategies: dissemination via social media and public health agencies was followed by paid-for Facebook ads. The latter strategy was adopted to achieve broader population representation. Post-stratification weighting was used to match the sample to population demographics., Results: The survey received over 34,000 visits and resulted in a sample size of 19,601 participants with complete data on key sociodemographic characteristics. The responses in the first wave were over-representing females and higher educated people, thus the dissemination was complemented by the paid-for Facebook ads targeting more diverse populations but had higher attrition rate., Conclusion: Experiments can be integrated into general population surveys. Pan-European results can be achieved with limited resources and a combination of sampling methods to compensate for different biases, and statistical adjustments., (© 2024 World Health Organization; licensed by John Wiley & Sons Ltd. International Journal of Methods in Psychiatric Research published by John Wiley & Sons Ltd.)

Objective: In the EU, which has the highest drinking levels worldwide, cancer is the primary cause of alcohol-attributable deaths. Existing studies show gaps in public knowledge, but there is lack of systematic appraisal. The report presents original data from a cross-sectional survey conducted within the framework of an online experimental study in 14 European countries, which among other things assessed baseline knowledge of the alcohol-NCD link, particularly cancer., Methods: Online questionnaire among adults who consume alcohol conducted in 14 countries in 2022-2023 using different recruitment strategies and applying population weights for the final sample. Baseline assessments measured participants' knowledge of alcohol-attributable health issues (with a specific focus on cancer)., Results: Baseline knowledge assessment showed that 90% indicated a causal role of alcohol for liver disease, 68% for heart diseases, and only 53% for cancer. Knowledge of specific alcohol-attributable cancer types was lower, with 39% aware of the link between alcohol use and colon cancer, 28% regarding oral cancer, and only 15% regarding female breast cancer. Knowledge levels varied across different countries and population groups., Conclusion: Most Europeans do not know which cancers can be caused by alcohol use and knowledge is low specifically for female breast cancer. More awareness raising and prevention efforts are needed, such as the placement of cancer-specific health warnings on alcohol container labels., (© 2024. The Author(s).)

Background: Alcohol increases cancer risk, but less is known about public awareness of this link. This scoping review summarizes recent findings on the public awareness of alcohol as a cancer risk factor in European Union and UK., Methods: Four databases (Web of Science, MEDLINE, PsycInfo, CINAHL) were searched for papers containing data on awareness of alcohol as cancer risk factor in EU or UK published between January 2017 and December 2022, and complemented with grey literature searches., Results: In total, 45 studies were included covering 18 EU countries (Austria, Belgium, Cyprus, Czechia, Denmark, Finland, France, Germany, Hungary, Ireland, Italy, Netherlands, Poland, Romania, Slovakia, Slovenia, Spain, Sweden) and UK, presenting data collected between 2009 and 2022. Studies covered general population (17 studied a nationally representative sample), women, health professionals, patients and young people. Awareness of alcohol causing cancer in general was higher and studied more often than awareness of alcohol's impact on specific cancers. Among the EU general population, awareness of the link between alcohol and breast cancer ranged between 10% and 20%, head and neck cancer 15-25%, colorectal and oesophagus cancer 15-45% and liver cancer 40%. Awareness was higher among young people and specialized health professions and lower among women (the latter specifically for the breast cancer)., Conclusions: While awareness rates varied depending on the exact question wording, many studies showed low awareness of the alcohol-cancer link, especially for specific types such as breast and colon cancer. Public should be better informed about alcohol consumption-related cancer risk., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Public Health Association.)