The need for further alcohol control research: A response to a functional magnetic resonance imaging study on alcohol warnings by Gallopel-Morvan et al.

Gallopel-Morvan et al. (2024) should be commended for their recent multi-disciplinary functional magnetic resonance imaging (fMRI)-based study exploring the impact of alcohol warning labels. This research is the first neuroimaging-based study to examine the impacts of small text-only alcohol warnings compared with larger text-and-picture alcohol warnings. The results are important, as they clearly demonstrate that enhanced warnings elicit less activity in key regions of the brain's reward system and may diminish the desire to consume alcohol.

This type of robust research related to alcohol control is vital given the significant negative impact of alcohol on mortality and morbidity (GBD 2019 Risk Factors Collaborators, 2020; Mayshak et al., 2022; Younossi et al., 2023). Alcohol is an important Commercial Determinant of Health (CDoH) that inflicts a deadly toll (WHO, 2024). The World Health Organization estimates that alcohol is responsible for three million deaths per annum, as well as reaping a huge toll in terms of morbidity and negative social impacts (WHO, 2018, 2022).

It must be acknowledged there is a well-established and large range of robust empirical and experimental research on the topic of alcohol warning labels, now subject to multiple systematic reviews and meta-analyses (Clarke et al., 2020; Correia et al., 2024; Giesbrecht et al., 2022; Joyce et al., 2024; Kokole et al., 2021; Zuckermann et al., 2014), including some real-world evaluation (Vallance, et al., 2020). Recent research has also explored the use of eye-tracking software to explore this topic (Kersbergen & Field, 2017; Lacoste-Badie et al., 2022). However, in its use of fMRI to explore alcohol warning labels, Gallopel-Morvan et al. (2024) have pioneered cutting-edge research in this field.

Concerns over robust research should not be taken lightly as the global alcohol industry, “Big Alcohol,” similar to the tobacco and sugar industries, has an established track record of malfeasance in the research arena (Ennis, 2023; Houghton, 2024; Mitchell & McCambridge, 2022, 2023). The strong influence of the Wine and Beer lobbies, both within the EU and elsewhere, should not be under-estimated (Millot, Maani, et al., 2022; Millot, Serra, & Gallopel-Morvan, 2022; Severi & Hawkins, 2024. Gallopel-Morvan et al.'s (2024) fMRI-based research will be harder for the industry to debunk or misrepresent.

Figure 1 details the combined text and pictograph alcohol warning label that will be required on containers of alcohol in Ireland by 2026, as required under the Public Health (Alcohol) Act, 2018. Obvious limitations with this warning include the lack of more impactful imagery, as the general public is now familiar with via tobacco packaging, and the limited number of negative outcomes associated with alcohol addressed. Ireland is currently at the forefront of legislated alcohol control initiatives within the European Union based on this initiative, despite legal hurdles (Lancet, 2023) and industry opposition (Lesch & McCambridge, 2022; Vallance et al., 2020). Recent research suggests that public support for alcohol warning labels in Ireland is at odds with industry opposition, with over 80% of the population supporting such warning labels (Calnan et al., 2023).

The type of fMRI research conducted by Gallopel-Morvan et al. (2024), alongside more standard survey and qualitative approaches, should now be used to help develop a suite of impactful alcohol warning labels. The staleness of warning imagery is an accepted issue in media and advertising, hence why EU regulations require tobacco packaging to include a rotating suite of 14 different text warnings, and three different images for each warning. Therefore, any packet of cigarettes purchased in the EU features 1 of 42 potential warnings.

However, the Irish legislation should be seen as just a first step at the EU level on the road to more comprehensive alcohol warning labels and alcohol control. Table 1 details a potential list of topics that future alcohol warnings could include, each with associated and impactful imagery. Similar to EU tobacco control measures, such warnings could be varied on alcohol packaging, with accompanying warning imagery also being rotated. In developing such alcohol warnings, fMRI could help produce robust evidence of effectiveness. The high volume of alcohol consumed within blocs such as the EU would ensure that most people who drink alcohol would be exposed to the full range of adverts within a relatively short time period (Jané-Llopis et al., 2020).

Approaches such as fMRI and more routine research methods should also be combined to explore how to fine-tune alcohol warning labels for maximum impact. Potential elements to be examined are outlined in Table 2. Further investigations might also usefully explore issues such as bland packaging and container shape to minimize the appeal of this toxic, carcinogenic, mutagenic, addictive, and psychotropic product.

For such a technologically complex study, Gallopel-Morvan et al.'s study impressively includes an impressive achieved sample of 74 people. However, all 74 are male. Future research using fMRI and allied approaches to alcohol control must be sure to include women in their studies. The history of medical research, especially before the 1990s, exhibits an alarming gender imbalance, with women routinely and systematically excluded from many studies (Plevkova et al., 2020). Similarly, future photographic alcohol warning labels must also be balanced for gender and race, something lacking in current EU tobacco warning labels (O'Doherty, Houghton, McInerney, Duncan, & Houghton, 2019; O'Doherty, Houghton, McInerney, Houghton, & Duncan, 2019).

Gallopel-Morvan et al.'s study represents an important step forward in alcohol control. More studies incorporating this approach are required to develop and fine-tune effective alcohol warning labels, as well as much-needed warnings in cognate areas, including gambling control. However, even coordinated action on alcohol warning labels at the EU level, which we are currently far from achieving, would only help protect less than 450 million people. Effective and comprehensive global action on alcohol control will require a WHO Framework Convention on Alcohol Control, similar to that which already exists for tobacco (Room & Cisneros Örnberg, 2021).

Dr. Frank Houghton is in receipt of a grant from the Higher Education Authority (HEA) in Ireland to develop alcohol warning labels for the island of Ireland.