Q and A: Point-of-Purchase Messaging About Alcohol and Pregnancy Act (SB 446 and HB 555)
Q. What are point-of-purchase health warning signs and why are they needed?
A. Point-of-Purchase warning signs provide information about alcohol and birth defects and are an important part of awareness efforts to reduce Fetal Alcohol Spectrum Disorders (FASD). These warning signs are a simple, cost-effective means of reaching consumers with prevention messages that help shift public attitudes to reject alcohol use during pregnancy. Warning signs amplify and complement other ongoing prevention strategies and reinforce federally required health notices on alcoholic beverage containers.[1] Clear support for health warning signs is conveyed through two objectives in Governor Crist’s 2009 Drug Control Strategy.[2]
Q. What are Fetal Alcohol Spectrum Disorders (FASD)?
A. Fetal Alcohol Spectrum Disorders (FASD) refers to a continuum of permanent birth defects caused by maternal consumption of alcohol during pregnancy and includes fetal alcohol syndrome. Children with FASD are at risk for failure in school, psychiatric problems, criminal behavior, substance abuse, and unemployment. The emotional and financial impact of these disorders is staggering. The estimated annual cost to Florida as a result of FASD, including the costs to the juvenile justice system and the costs related to special education, is over $432 million. Approximately 2,040 infants are born with FASD in Florida each year despite the fact that these disorders are 100% preventable if women abstain from alcohol while pregnant.[3]
Q. What message will go on the sign?
A. The required sign will read:
WARNING: DRINKING ANY BEVERAGES DURING PREGNANCY WHICH CONTAIN ALCOHOL CAN CAUSE SERIOUS LIFE-LONG BIRTH DEFECTS, INCLUDING FETAL ALCOHOL SYNDROME.
Q. Do warning signs really work?
A. Health warning signs increase knowledge and awareness of the harmful effects of alcohol on unborn children, particularly when included as part of a multicomponent effort.[4] Individuals exposed to two or three health warning messages are more than twice as likely to be aware of the risks of drinking during pregnancy than those who are not exposed to any messages.[5] Women of childbearing age who are exposed to multiple health warning messages (in the form of signs, labels, and ads) are more likely than others to reduce their alcohol consumption for health reasons.[6]
Evaluations of the warning signs in test cities in Florida concluded that “the sign has proved its effectiveness in generating awareness, attitude change, and behavior change; and it has proved its cost effciency, using the basic media coverage yardsticks of reach, frequency, and cost-per-thousand potential readers.”[7] For example, within 3 months of posting a warning sign at Leesburg High School, 49% of seniors had seen it; within 6 months awareness of the sign increased to 67%. Among those who had seen the sign, 71% said they would like additional information about health hazards. [8]
Among mothers in the Lake County Health Department’s Special Supplemental Food Program for Women, Infants, and Children (WIC), sign awareness reached 63% within 4 months of posting and 100% by the end of the evaluation period. Among WIC mothers who had seen the sign, 82% said they would like additional information about alcohol health hazards. At the time of this study, Lake County Health Department reports indicated that more than 50% of WIC mothers abstained from alcohol during pregnancy, compared to a national average of 30%.[9] When warning signs were included as a component of alcohol awareness and education programs, the health warning sign contributed to a 12% increase in voluntary self-referrals to the Lake/Sumter Mental Health Center and Hospital.[10]
Researchers have also examined the impact of health warning signs in New York City. Prior to the posters, 54% of respondents mentioned birth defects as a result of drinking while pregnant. Only a year after the posters were introduced, 68% mentioned birth defects as a consequence of drinking. This increase in awareness occurred among both men and women.[11]
Individuals who are exposed to health warning signs and messages, including women of childbearning age, are more likely than others to have a conversation about the dangers of drinking during pregnancy.[12] Women who are exposed to multiple messages, including media ads, beverage warning labels, and health warning signs, are over 3 times more likely than others to report having a conversation about these risks.[13] Encouraging pregnant women and healthcare providers to talk helps protect unborn children from harm because these conversations become an opportunity for screening, prevention, and treatment. Unfortunately, only 75% of pregnant women in Florida report talking about the risks of alcohol during a prenatal care visit. Florida’s Drug Control Strategy aims to increase this to at least 80% by December 2010. Health warnings signs are an integral component of these efforts.[14]
Q. Where will the warning signs be placed?
A. All vendors licensed to sell alcoholic beverages (for consumption on or off the premises) must prominently post the sign in a location that is clearly visible at the main entrance or cash register.
Q. Who will see the signs?
A. Signs posted at the point-of-purchase can reach an estimated estimated 95% of all people in a community, including moderate, heavy, and potential drinkers, as well as those who purchase beverages for others. Once posted, these signs are able to continuously deliver this important warning at a cost of about one penny per thousand readers.[15]
Q. Who pays for the signs?
A. The signs will be downloaded for free from the Department of Business and Professional Regulation’s website. Many city and county governments in Florida have already assumed the minor costs of printing the signs.[16] These expenses are trivial when considering that if warning signs prevent just a single case of FASD, Florida will avert lifetime treatment costs ranging up to $4 million per affected individual and untold human costs to affected individuals, families, and communities.[17]
Other states have found different ways of delivering this warning message at minimal cost. For example, the Kentucky Department of Corrections produces their signs, for which the Office of Alcoholic Beverage Control pays $0.18 each. The total cost to Kentucky ranges from $270 to $360. Arizona’s Alcoholic Beverage Control provides the signs to licensees free of charge, at a cost of about 3 cents per sign ($65 to $100 per year total cost). In some states, licensees pay a fee for the signs ($12 in Delaware), while in others states (like Georgia) licensees simply download the signs from the Internet at no cost to the state.[18]
Q. How many states require warning signs? Do any Florida counties or cities require signs?
A. Posting alcohol warning signs at locations where alcohol is sold has been required in some states since 1983. As of January, 2008, twenty-three states and numerous localities had enacted laws mandating point-of-purchase warning signs.[19]
At least 12 Florida counties already require health warning signs, including Lake, Citrus, and Dade (which requires warnings in English, Spanish, and Creole).[20] Numerous cities and towns in Florida also passed ordinances requiring the signs, including Leesburg, Eustis, Umatilla, Lady Lake, Inverness, Clearwater, and Key West.[21]
Q. Will the signs hurt people who make a living selling alcohol?
A. Nobody should make a living selling alcohol to pregnant women. Counties that have implemented ordinances requiring the signs have not been challenged by retailers and there have been no code enforcement problems.[22]
Q. What organizations support the warnings signs?
A. The following organizations have endorsed legislation to require these health and safety messages:
· American Medical Association
· American Academy of Family Physicians
· American Academy of Pediatrics…
· Florida Medical Assocation
· Florida Public Health Association
· Florida Dietetic Association
· Center for Science in the Public Interest
· The Association of Retarded Citizens
· March of Dimes
· National Council on Alcoholism and Drug Dependence
· National Organization on Fetal Alcohol Syndrome
· National PTA
· American Public Health Association
· National Association of State Alcohol and Drug Abuse Directors
· U.S. Department of Health and Human Services [23]
In a 2007-2008 policy statement, the Health Committee of the National Conference of State Legislatures (NCSL) recommended that “special efforts should be made to warn pregnant women of the dangers of smoking, drug and alcohol use during pregnancy.”[24]
Q. Where can I go to find more information?
A. For questions regarding Florida’s Drug Control Strategy, please contact Jeff Cece with the Governor’s Office of Drug Control at or at (850)-413-8157. For additional information, please see the following resources:
The Substance Abuse and Mental Health Services Administration’s Fetal Alcohol Spectrum Disorders Center for Excellence: www.fascenter.samhsa.gov
Center for Science in the Public Interest’s “State Action Guide: Mandatory Point-of-Purchase Messaging on Alcohol and Pregnancy”: http://cspinet.org/new/pdf/state_action_guide.pdf.
“Fetal Alcohol Spectrum Disorders: Florida Resource Guide”: http://www.doh.state.fl.us/family/socialwork/pdf/fasd.pdf.
1
[1] Center for Science in the Public Interest. (October 2008). State Action Guide: Mandatory Point-of-Purchase Messaging on Alcohol and Pregnancy. Available at: http://cspinet.org/new/pdf/state_action_guide.pdf.
[2] Florida Office of Drug Control. (2009). Florida’s Drug Control Strategy. Available at: http://www.flgov.com/drugcontrol/odc_strategies.html.
[3] Fetal Alcohol Spectrum Disorders, Florida Resource Guide. Available at: http://www.fasdcenter.samhsa.gov/documents/FASDGuide12_021.pdf.
[4] Center for Science in the Public Interest. (October 2008). State Action Guide: Mandatory Point-of-Purchase Messaging on Alcohol and Pregnancy; Prugh, T. (1986). Point-of-Purchase Health Warning Notices. Alcohol Health & Research World, 10(4); Fenaughty, A. M. & MacKinnon, D. P. (1993). Immediate Effects of the Arizona Alcohol Warning Poster. Journal of Public Policy & Marketing, 12(1), 69-77; Kalsher, M. J., Clarke, S. W., & Wogalter, M. S. (1993). Communication of Alcohol Facts and Hazards by a Warning Poster. Journal of Public Policy & Marketing, 12(1), 78-90.
[5] Kaskuta, L. A. & Graves, K. (1994). Relationship Between Cumulative Exposure to Health Messages and Awareness and Behavior-Related Drinking During Pregnancy. American Journal of Health Promotion, 9(2), 115-124.
[6] Ibid.
[7] Cleary, D. (1989). Sign Ordinance Aimed at Alcohol Use by Young Adults in Two Florida Counties. Public Health Reports, 104(6), 525-526.
[8] Ibid.
[9] Cleary, D. (1989). Sign Ordinance Aimed at Alcohol Use by Young Adults in Two Florida Counties. Public Health Reports, 104(6), 525-526; Cleary, D. (1996). Florida Goes Statewide with Alcohol Health Warning Signs. American Journal of Public Health, 86(6), 882-883.
[10] Cleary, D. (1989). Sign Ordinance Aimed at Alcohol Use by Young Adults in Two Florida Counties. Public Health Reports, 104(6), 525-526.
[11] Prugh, T. (1986). Point-of-Purchase Health Warning Notices. Alcohol Health & Research World, 10(4); Hankin, J. R. (2002). Fetal Alcohol Syndrome Prevention Research. A National Institute on Alcohol Abuse and Alcoholism publication available at http://pubs.niaaa.nih.gov/publications/arh26-1/58-65.htm.
[12] Kaskutas, L. & Graves, K. (1992). Effects of Warning Labels after Eighteen Months: An Examination of Intervening Processes and Attendant Changes Associated with the Labels. Berkeley Alcohol Research Group; Graves, K. (1993). An Evaluation fo the Alcohol Warning Label: A Comparison of the United States and Ontario, Canada between 1990 and 1991. Journal of Public Policy & Marketing, 12(1), 1-11; Kaskuta, L. A. & Graves, K. (1994). Relationship Between Cumulative Exposure to Health Messages and Awareness and Behavior-Related Drinking During Pregnancy. American Journal of Health Promotion, 9(2), 115-124.
[13] Kaskuta, L. A. & Graves, K. (1994). Relationship Between Cumulative Exposure to Health Messages and Awareness and Behavior-Related Drinking During Pregnancy. American Journal of Health Promotion, 9(2), 115-124.
[14] Florida Office of Drug Control. (2009). Florida’s Drug Control Strategy. Available at: http://www.flgov.com/drugcontrol/odc_strategies.html.
[15] Cleary, D. (1989). Sign Ordinance Aimed at Alcohol Use by Young Adults in Two Florida Counties. Public Health Reports, 104(6), 525-526; Cleary, D. (1996). Florida Goes Statewide with Alcohol Health Warning Signs. American Journal of Public Health, 86(6), 882-883; Center for Science in the Public Interest. (October 2008). State Action Guide: Mandatory Point-of-Purchase Messaging on Alcohol and Pregnancy; Barrett, M. E., Wong, F. Y., McKay, D. R. R. (1993). Self-Reported Alcohol Use Among Women of Childbearing Age and Their Knowledge of Alcohol Warning Labels and Signs. Archives of Family Medicine, 2, 1260-1264; Marin, G. (1994). Self-Reported Awareness of the Presence of Product Warning Messages and Signs by Hispanics in San Francisco. Public Health Reports, 109(2), 275-283.
[16] Cleary, D. (1989). Sign Ordinance Aimed at Alcohol Use by Young Adults in Two Florida Counties. Public Health Reports, 104(6), 525-526; Cleary, D. (1996). Florida Goes Statewide with Alcohol Health Warning Signs. American Journal of Public Health, 86(6), 882-883.
[17] Harwood, H. The Economic Costs of Fetal Alcohol Syndrome. Available at: http://www.fascenter.samhsa.gov/documents/RickHarwoodPresentation.pdf.
[18] Center for Science in the Public Interest. (October 2008). State Action Guide: Mandatory Point-of-Purchase Messaging on Alcohol and Pregnancy.
[19] Ibid.
[20] Center for Science in the Public Interest. (October 2008). State Action Guide: Mandatory Point-of-Purchase Messaging on Alcohol and Pregnancy; Cleary, D. (1989). Sign Ordinance Aimed at Alcohol Use by Young Adults in Two Florida Counties. Public Health Reports, 104(6), 525-526; Cleary, D. (1996). Florida Goes Statewide with Alcohol Health Warning Signs. American Journal of Public Health, 86(6), 882-883.
[21] Cleary, D. (1989). Sign Ordinance Aimed at Alcohol Use by Young Adults in Two Florida Counties. Public Health Reports, 104(6), 525-526; Lake County Board of County Commissioners Meeting (April 4, 1989). Available at http://www.lakecountyclerk.org/boardmin/1989/04/1989-04-04_Regular_Meeting.htm;
Prugh, T. (1986). Point-of-Purchase Health Warning Notices. Alcohol Health & Research World, 10(4); Ordinance fo the City of Key West (No. 07-10).
[22] Cleary, D. (1989). Sign Ordinance Aimed at Alcohol Use by Young Adults in Two Florida Counties. Public Health Reports, 104(6), 525-526.
[23] Center for Science in the Public Interest. (October 2008). State Action Guide: Mandatory Point-of-Purchase Messaging on Alcohol and Pregnancy; Cleary, D. (1989). Sign Ordinance Aimed at Alcohol Use by Young Adults in Two Florida Counties. Public Health Reports, 104(6), 525-526.
[24] Center for Science in the Public Interest. (October 2008). State Action Guide: Mandatory Point-of-Purchase Messaging on Alcohol and Pregnancy.