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BackgroundIncreasing the availability of non-alcoholic options is a promising population-level intervention to reduce alcohol consumption, currently unassessed in naturalistic settings. This study in an online retail context aimed to estimate the impact of increasing the proportion of non-alcoholic (relative to alcoholic) drinks, on selection and purchasing of alcohol.Methods and ResultsAdults (n=737) residing in England and Wales who regularly purchased alcohol online were recruited between March-July 2021. Participants were randomly assigned to one of three groups: ‘25% non-alcoholic/75% alcoholic’; ‘50% non-alcoholic/50% alcoholic’; ‘75% non-alcoholic/25% alcoholic’, then selected drinks in a simulated online supermarket, before purchasing them in an actual online supermarket. The primary outcome was the number of alcohol units selected (with intention to purchase); secondary outcomes included actual purchasing. 607 participants (60% female, mean age = 38 years [range: 18-76]) completed the study and were included in the primary analysis. In the first part of a hurdle model, a greater proportion of participants in the ‘75% non-alcoholic’ group did not select any alcohol (13.1%) compared to the ‘25% non-alcoholic’ group (3.4%; 95% confidence interval [CI] - 2.09, -0.63; p < 0.001). There was no evidence of a difference between the ‘75% non-alcoholic’ and the ‘50% non-alcoholic’ (7.2%) groups (95% CI 0.10, 1.34; p = 0.022) or between the ‘50% non-alcoholic’ and the ‘25% non-alcoholic’ groups (95% CI -1.44, 0.17; p = 0.121). In the second part of a hurdle model in participants (559/607) selecting any drinks containing alcohol, the ‘75% non-alcoholic’ group selected fewer alcohol units compared to the ‘50% non-alcoholic’ (95% CI -0.44, -0.14; p < 0.001) and ‘25% non-alcoholic’ (95% CI - 0.54, -0.24; p < 0.001) groups, with no evidence of a difference between the ‘50% non-alcoholic’ and ‘25% non-alcoholic’ groups (95% CI -0.24, 0.05; p = 0.178). Overall, across all participants, 17.46 units (95% CI 15.24, 19.68) were selected in the ‘75% non-alcoholic’ group; 25.51 units (95% CI 22.60, 28.43) in the ‘50% non-alcoholic’ group; and 29.40 units (95% CI 26.39, 32.42) in the ‘25% non-alcoholic’ group. This corresponds to 8.1 fewer units (a 32% reduction) in the ‘75% non-alcoholic’ compared to the ‘50% non-alcoholic’ group, and 11.9 fewer alcohol units (41% reduction) compared to the ‘25% non-alcoholic’ group; 3.9 fewer units (13% reduction) were selected in the ‘50% non-alcoholic’ group than in the ‘25% non-alcoholic’ group.For all other outcomes, alcohol selection and purchasing were consistently lowest in the ‘75% non-alcoholic’ group.Study limitations include the setting not being entirely naturalistic due to using a simulated online supermarket as well as an actual online supermarket, and that there was substantial dropout between selection and purchasing.ConclusionsThis study provides evidence that substantially increasing the proportion of non-alcoholic drinks – from 25% to 50% or 75% - meaningfully reduces alcohol selection and purchasing. Further studies are warranted to assess whether these effects are realised in a range of real-world settings.Trial registrationISRCTN:11004483; OSF:https://osf.io/qfupwAuthor summaryWhy was this study done?Excessive alcohol consumption contributes to the global burden of non-communicable diseases, including cancer, heart disease and stroke. Interventions that change physical and economic environments have the potential to reduce alcohol consumption.Interventions targeting physical environments include availability interventions that involve changing the proportion of healthier options that are available, relative to less healthy options.A previous online study found that increasing the availability of non-alcoholic compared to alcoholic drinks reduced the hypothetical selection of alcoholic drinks, but there is an absence of evidence from naturalistic settings.What did the researchers do and find?This study evaluated the impact of increasing the proportion of non-alcoholic (relative to alcoholic) drinks, on selection and actual purchasing of alcohol.In a randomised controlled trial, 737 participants were randomly assigned to one of three groups with varying proportions of alcoholic versus non-alcoholic drinks ‘25% non-alcoholic/75% alcoholic’; ‘50% non-alcoholic/50% alcoholic’; ‘75% non-alcoholic/25% alcoholic’).Participants selected drinks from 64 options in a simulated online supermarket which was designed to look and function similarly to an online supermarket. Participants were then required to immediately purchase the same drinks in an actual online supermarket.It was found that increasing the proportion of non-alcoholic drinks – from 25% to 50% or 75% – reduced the amount of alcohol selected and bought, in this online supermarket setting.What do these findings mean?This study provides evidence that increasing the proportion of non-alcoholic drinks could reduce alcohol selection and purchasing, highlighting the potential for availability interventions to reduce alcohol sales at population level.Further studies are warranted to assess whether these effects are realised in a range of real-world settings

Background and aims:- \ud \ud Health warning labels (HWLs) on tobacco products reduce smoking. There is an absence of evidence concerning the impact of alcohol HWLs on selection or purchasing in naturalistic settings. Using a commercial-standard naturalistic shopping laboratory, this study aimed to estimate the impact on selection of alcoholic drinks of HWLs describing adverse health consequences of excessive alcohol consumption.\ud Design:- \ud \ud A between-subjects randomised experiment with three groups was conducted: group 1: image-and-text HWL; group 2: text-only HWL; group 3: no HWL.\ud Setting:- \ud \ud A commercial-standard naturalistic shopping laboratory in the United Kingdom.\ud Participants:- \ud \ud Adults (n = 399, 55% female) over the age of 18 years, who purchased beer or wine weekly to drink at home.\ud Interventions:- \ud \ud Participants were randomised to one of three groups varying in the HWL displayed on the packaging of the alcoholic drinks: (i) image-and-text HWL (n = 135); (ii) text-only HWL (n = 129); (iii) no HWL (n = 135). Participants completed a shopping task, selecting items from a range of alcoholic and non-alcoholic drinks, and snacks.\ud Measurement:- \ud \ud The primary outcome was the proportion of alcoholic drinks selected. Secondary outcomes included HWL ratings on negative emotional arousal and label acceptability.\ud Findings:- \ud \ud There was no clear evidence of a difference in the HWL groups for the percentage of drinks selected that were alcoholic compared to no HWL (44%): image-and-text HWL: 46% (odds ratio [OR] = 1.08, 95% confidence interval [CI] = 0.82, 1.42); text-only HWL: 41% (OR = 0.87, 95% CI = 0.67, 1.14). Concordant with there being no difference between groups, there was extreme evidence in favour of the null hypothesis (Bayes factor [BF] < 0.01). Negative emotional arousal was higher (P < 0.001) and acceptability lower (P < 0.001) in the image-and-text HWL group, compared to the text-only HWL group.\ud Conclusions:- \ud \ud In a naturalistic shopping laboratory, there was no evidence that health warning labels describing the adverse health consequences of excessive alcohol consumption changed selection behaviour.

Background There is ongoing clinical and research interest in determining whether providing personalised risk information could motivate risk-reducing health behaviours. We aimed to assess the impact on behaviours and risk factors of feeding back to individuals’ images of their bodies generated via medical imaging technologies in assessing their current disease status or risk. Methods and findings A systematic review with meta-analysis was conducted using Cochrane methods. MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched up to July 28, 2021, with backward and forward citation searches up to July 29, 2021. Eligible studies were randomised controlled trials including adults who underwent medical imaging procedures assessing current health status or risk of disease, for which personal risk may be reduced by modifying behaviour. Trials included an intervention group that received the imaging procedure plus feedback of visualised results and assessed subsequent risk-reducing health behaviour. We examined 12,620 abstracts and included 21 studies, involving 9,248 randomised participants. Studies reported on 10 risk-reducing behaviours, with most data for smoking (8 studies; n = 4,308), medication use (6 studies; n = 4,539), and physical activity (4 studies; n = 1,877). Meta-analysis revealed beneficial effects of feedback of visualised medical imaging results on reduced smoking (risk ratio 1.11, 95% confidence interval [CI] 1.01 to 1.23, p = 0.04), healthier diet (standardised mean difference [SMD] 0.30, 95% CI 0.11 to 0.50, p = 0.003), increased physical activity (SMD 0.11, 95% CI 0.003 to 0.21, p = 0.04), and increased oral hygiene behaviours (SMD 0.35, 95% CI 0.13 to 0.57, p = 0.002). In addition, single studies reported increased skin self-examination and increased foot care. For other behavioural outcomes (medication use, sun protection, tanning booth use, and blood glucose testing) estimates favoured the intervention but were not statistically significant. Regarding secondary risk factor outcomes, there was clear evidence for reduced systolic blood pressure, waist circumference, and improved oral health, and some indication of reduced Framingham risk score. There was no evidence of any adverse effects, including anxiety, depression, or stress, although these were rarely assessed. A key limitation is that there were some concerns about risk of bias for all studies, with evidence for most outcomes being of low certainty. In particular, valid and precise measures of behaviour were rarely used, and there were few instances of preregistered protocols and analysis plans, increasing the likelihood of selective outcome reporting. Conclusions In this study, we observed that feedback of medical images to individuals has the potential to motivate risk-reducing behaviours and reduce risk factors. Should this promise be corroborated through further adequately powered trials that better mitigate against risk of bias, such interventions could usefully capitalise upon the widespread and growing use of medical imaging technologies in healthcare.

© 2020 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction Aim: To estimate the effects of wine glass size on volume of wine sold in bars and restaurants. Design: A mega-analysis combining raw (as opposed to aggregate-level) data from eight studies conducted in five establishments. A multiple treatment reversal design was used for each data set, with wine glass size changed fortnightly while serving sizes were unaffected, in studies lasting between 14 and 26 weeks. Setting and participants: Five bars and restaurants in England participated in studies between 2015 and 2018, using wine glasses of five sizes: 250, 300, 370, 450 and 510 ml, with the largest size only used in bars. Measurements: Daily volume of wine sold by the glass, bottle or carafe for non-sparkling wine were recorded at bars (594 days) and restaurants (427 days), averaging 4 months per study. Findings: Mega-analysis combining data from bars did not find a significant effect of glass size on volume of wine sold compared with 300-ml glasses: the volume of wine sold using 370-ml glasses was 0.5% lower [95% confidence interval (CI) = –8.1% to 6.1%], using 450-ml glasses was 1.0% higher (95% CI = –9.1 to 12.2) and using 510-ml glasses was 0.4% lower (95% CI = –9.4 to 9.4). For restaurants, compared with 300-ml glasses, the volume of wine sold using 250-ml glasses did not show a significant difference: 9.6% lower (95% CI = –19.0 to 0.7). Using 370-ml glasses the volume of wine sold was 7.3% higher (95% CI = 1.5% to 13.5%); no significant effect was found using 450-ml glasses: 0.9% higher (95% CI = –5.5 to 7.7). Conclusions: The volume of wine sold in restaurants in England may be greater when 370-ml glasses are used compared with 300-ml wine glasses, but may not be in bars. This might be related to restaurants compared with bars selling more wine in bottles and carafes, which require free-pouring.

Background The physical properties of tableware could influence selection and consumption of food and alcohol. There is considerable uncertainty, however, around the potential effects of different sizes and shapes of tableware on how much food and alcohol people self-serve. These studies aimed to estimate the impact of: 1. Plate size and shape on amount of food self-served; 2.Wine glass and bottle size on amount of wine self-poured. Methods 140 adults participated in two laboratory studies—each using randomised within-subjects factorial designs—where they self-served food (Study 1) and wine (Study 2): Study 1: 3 plate sizes (small; medium; large) × 2 plate shapes (circular; square). Study 2: 3 wine glass sizes (small; medium; large) × 2 wine bottle sizes (75 cl; 50 cl). Results Study 1: There was a main effect of plate size: less was self-served on small (76 g less, p p p = 0.46) or a size and shape interaction (p = 0.47). Study 2: There was a main effect of glass size: less was self-served in small (34 ml less, p p p = 0.20) or a glass and bottle size interaction (p = 0.18). Conclusions Smaller tableware (i.e. plates and wine glasses) decreases the amount of food and wine self-served in an initial serving. Future studies are required to generate estimates on selection and consumption in real world settings when numerous servings are possible. Protocol registration information: OSF (https://osf.io/dj3c6/) and ISRCTN (10.1186/ISRCTN66774780).

Reducing harmful consumption of food (including non-alcoholic drinks) and alcoholic drinks would prevent much disease. Evidence from tobacco control shows that placing health warning labels (HWLs) on these products reduces their selection and consumption. A systematic review with meta-analysis was conducted using Cochrane methods to assess the impact on selection (including hypothetical selection) or consumption of food or alcoholic drinks with image-and-text (sometimes termed 'pictorial') and text-only HWLs placed on these products. Studies were required to be randomised or quasi-randomised controlled trials. Fourteen studies were included, three on alcohol, eleven on food. For our primary outcomes, eleven studies measured selection and one measured consumption (two measured only other secondary outcomes). Meta-analysis of twelve comparisons from nine studies (n=12,635) found HWLs reduced selection of the targeted product compared to a control group with no HWL (RR=0.74 (95% CI 0.68 to 0.80)), with participants 26% less likely to choose a product displaying a HWL. A planned subgroup analysis suggested a larger effect on selection of image-and-text HWLs (RR=0.65 (95% CI 0.54 to 0.80)) than text-only HWLs (RR=0.79 (95% CI 0.74 to 0.85)), but this difference was not statistically significant. These findings suggest significant potential for HWLs to reduce selection of food and alcohol, but all experimental studies to date were conducted in laboratory or online settings with outcomes assessed immediately after a single exposure. Studies in field and more naturalistic laboratory settings are urgently needed to estimate the potential effects of HWLs on food and alcohol. published

Background: Increasing the availability of lower energy foods increases their selection. The current studies examine the extent to which this effect could be mediated by social norms – assessed by perceived popularity of foods – which may be implied by their relative availability. Methods: Study 1 (Online): 2340 UK adults estimated the perceived popularity of lower energy products. For each of eight trials, participants were randomised to one of six groups (between-subjects 3x2) to see photos of cafeteria shelves varying in the availability of lower energy options (1/4 lower energy; 1/2 lower energy; 3/4 lower energy) and fullness of shelves (fuller; emptier).Study 2 (Laboratory): 139 English adults were asked to select a snack. Participants were randomised to select from trays varying in the availability of the lower energy option (1/3 lower energy; 2/3 lower energy) and fullness of tray (fuller; emptier). Results: Study 1: Evidence for an interaction was found, such that when shelves were full, a higher proportion of lower energy options led to greater perceived popularity of lower energy products (1/4 lower energy: 40.9% (95%CIs: 40.1,41.8); 3/4 lower energy: 47.2% (46.3,48.0)), whereas when shelves were emptier, a higher proportion of lower energy options led to lower perceived popularity (1/4 lower energy: 48.4% (47.5,49.2); 3/4 lower energy: 39.2% (38.3,40.0)).Study 2: When the tray was fuller, participants were more likely – albeit non-significantly (main effects: p=0.05; interactions: p=0.07) – to select a lower energy snack when 2/3 of the available snacks were lower energy (35.7% (18.5,52.9)) than when 1/3 were lower energy (15.4% (4.2,26.5)). For emptier trays, lower energy selections decreased as the relative availability of lower energy snacks increased (1/3 lower energy snacks: 36.0% (17.9,54.1); 2/3 lower energy snacks: 27.8% (13.9,41.7)). Conclusions:These studies provide novel evidence that social norms may mediate the impact of availability on food selection. In addition, they suggest that the effect of availability may vary in different contexts, moderated by display layout through its impact on perceived product popularity. Trial registration. ISRCTN: ISRCTN10512908; 31/01/2020

BackgroundExcessive consumption of energy-dense food increases the risk of obesity, which in turn increases the risk of non-communicable diseases, including heart disease, type 2 diabetes and most non-smoking-related cancers. Health warning labels (HWLs) that communicate the adverse health consequences of excess energy consumption could reduce intake of energy-dense foods. The aim of the current study was to estimate the impact on selection of energy-dense snacks of (a) image-and-text HWLs (b) text-only HWLs and (c) calorie information. Methods A between-subjects, 3 (HWL: image-and-text, text-only, no label) x 2 (calorie information: present, absent), factorial experimental design. Participants (N=4,134) were randomised to view a selection of energy-dense and non-energy-dense snacks with one of five label types or no label. The primary outcome was the proportion of participants selecting an energy-dense snack in a hypothetical vending machine task.ResultsThe proportion of participants selecting an energy-dense snack was reduced in all label groups, relative to the no label group (image-and-text HWL: 37%; image-and-text HWL with calories: 38%; text-only HWL: 48%; text-only HWL with calories: 44%; calories only: 54%; no label: 59%). Participants were least likely to select an energy-dense snack in the image-and-text HWL group and most likely in the no label group (OR = 0.46, 95%CI = 0.40, 0.54, p < 0.001).Conclusions Health warning labels – particularly those including an image and text - have the potential to reduce selection of energy-dense snacks in an online setting. Their impact on selection and consumption in real-world settings awaits testing.Trial registration: The study protocol (https://osf.io/6n7h9, registered: April 1st 2019) and data analysis plan (https://osf.io/zvrs5) were pre-registered on the Open Science Framework. KeywordsHealth warning labels, pictorial labels, graphic warnings, snacks, food, choice architecture, energy-dense

AIMS: Information provided on glass labels may be an effective method to reduce alcohol consumption. The aim of this study was to assess the impact of glass labels conveying unit information and a health warning in reducing ad libitum alcohol consumption. METHODS: A cluster-randomized experimental study was conducted to measure the efficacy of a labeled glass in reducing alcohol consumption in a semi naturalistic bar laboratory setting, in a sample of 81 pairs (n = 162) of UK young adult drinkers. Pairs were randomized to receive two 340-ml glasses of beer or wine: labeled or plain (control). Alcohol consumption was assessed in an ad libitum drinking period, and urge to drink was measured at baseline and postdrinking period. Focus groups (n = 2) were conducted, and thematic analysis was used to gain an insight into the acceptability and the perceived effectiveness of the glasses. RESULTS: Mean unit consumption was 1.62 (SD ± 0.83) units in the labeled glass condition and 1.69 (SD ± 0.82) units in the non labeled glass condition. There were no significant effects of the labeled glasses on ad libitum alcohol consumption (95% CI -0.25 to 0.37, p = 0.35), despite participants (85%) noticing the information. Qualitative analysis of focus groups indicated that although participants perceived the glasses as a useful tool for increasing awareness of units and guidelines, they were viewed as limited in their potential to change drinking behavior due to the unappealing design of the glass and a view that unit guidelines were not relevant to drinking patterns or contexts. CONCLUSIONS: Labeled glasses did not change alcohol consumption in the current study, potentially due to ineffectiveness of this type of message in a young adult population. The information on the glasses was attended to, highlighting that glasses could be a feasible tool for providing information.

Aims:- \ud \ud Evidence from tobacco research suggests that health warning labels (HWLs) depicting the adverse consequences of consumption change smoking behaviours, with image-and-text (also known as ‘pictorial’ or ‘graphic’) HWLs most effective. There is an absence of evidence concerning the potential impact of HWLs placed on alcohol products on selection of those products. This study aimed to obtain a preliminary assessment of the possible impact of (i) image-and-text, (ii) text-only, and (iii) image-only HWLs on selection of alcoholic versus non-alcoholic drinks.\ud Design:- \ud \ud A between-subjects randomised experiment with a 2 (image: present versus absent) × 2 (text: present versus absent) factorial design.\ud Setting:- \ud \ud The study was conducted on the online survey platform Qualtrics.\ud Participants:- \ud \ud Participants (n = 6024) were adults over the age of 18 who consumed beer or wine regularly (i.e. at least once a week), recruited through a market research agency.\ud Interventions:- \ud \ud Participants were randomised to one of four groups varying in the HWL displayed on the packaging of alcoholic drinks: (i) image-and-text HWL; (ii) text-only HWL; (iii) image-only HWL; and (iv) no HWL. HWLs depicted bowel cancer, breast cancer and liver cancer, which were each displayed twice across six alcoholic drinks. Each group viewed six alcoholic and six non-alcoholic drinks and selected one drink that they would like to consume.\ud Measurements:- \ud \ud The primary outcome was the proportion of participants selecting an alcoholic versus a non-alcoholic drink.\ud Findings:- \ud \ud Alcoholic drink selection was lower for all HWL types compared with no HWL (image-and-text: 56%; image-only: 49%; text-only: 61%; no HWL: 77%), with selection lowest for HWLs that included an image. Image-and-text HWLs reduced the odds of selecting an alcoholic drink compared with text-only HWLs (OR = 0.80, 95% CI = 0.69, 0.92), but increased the odds of selecting an alcoholic drink compared with image-only HWLs (OR = 1.34, 95% CI = 1.16, 1.55).\ud Conclusions:- \ud \ud Health warning labels communicating the increased risk of cancers associated with alcohol consumption reduced selection of alcoholic versus non-alcoholic drinks in a hypothetical choice task in an online setting; labels displaying images had the largest effect. Their impact in laboratory and real-world field settings using physical products awaits investigation.

Objective Previous research suggests that wine glass size affects sales of wine in bars, with more wine purchased when served in larger glasses. The current four studies, conducted in one restaurant (Studies 1 and 2) and two bars (Studies 3 and 4) in Cambridge, England, aim to establish the reproducibility of this effect of glass size on sales. A multiple treatment reversal design was used, involving wine being served in sequential fortnightly periods in different sized glasses of the same design (290 ml, 350 ml, and 450 ml). The primary outcome was daily wine volume (ml) sold. Results Restaurant: Daily wine volume sold was 13% (95% CI 2%, 24%) higher when served with 350 ml vs. 290 ml glasses in Study 1. A similar direction of effect was seen in Study 2 (6%; 95% CI − 1%, 15%). Bars: Daily wine volume sold was 21% (95% CI 9%, 35%) higher when served with 450 ml vs. 350 ml glasses in Study 3. This effect was not observed in Study 4 (− 7%, 95% CI − 16%, 3%). Meaningful differences were not demonstrated with any other glass comparison. These results partially replicate previous studies showing that larger glasses increase wine sales. Considerable uncertainty remains about the magnitude of any effect and the contexts in which it might occur. Trial registration Study 1: ISRCTN17958895 (21/07/2017), Study 2: ISRCTN17097810 (29/03/2018), Study 3 and 4: ISRCTN39401124 (10/05/2018)

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To estimate the effect of energy labelling for food (including non‐alcoholic drinks) and alcoholic drinks on healthier selection (with or without purchasing) and consumption. To assess possible modifiers – energy label type, setting and socioeconomic status ‐ of the effect of energy labelling on selection and consumption of food and alcohol.

In the current study we investigated the effect of a brief personalised feedback intervention (BPI), compared to an active control intervention, on outcome measures of (i) alcohol consumption (ii) frequency of binge drinking and (iii) readiness to change (RTC). A sample of 103 college students (mean age=23.85) who consumed alcohol regularly provided baseline measures of drinking behaviour and readiness to change before completing an alcohol-related quiz on the UK Department of Health's Change4Life website (active control). The study was a between subjects design and half the participants were randomly allocated to the BPI group (N=52), who received 10 minutes personalised feedback on their drinking in addition to the alcohol-related quiz. At a two-week follow-up, participants (N=103) repeated the questionnaire battery, and attempted to recall the answers to the alcohol quiz. Results indicated that both groups significantly reduced their alcohol consumption and frequency of binge drinking but there were no significant group differences in either of these measures. We conclude that the provision of generalised information can be as efficient as a BPI for the reduction of alcohol consumption in students.