labelling system had been effective almost a year. Certain knowledge, attitude and behavioural variables were measured by identical questions both years, and, the second year, a number of specific questions were added concerning explicit reactions to the labelling system. EXPLICIT REACTIONS By means of mass media publicity and similar things the warning labels as such are generally known by most Swedish people. But there is a striking difference between smokers and non-smokers, so that smokers have a much better detailed knowledge of the shape of the system. This should most probably be interpreted as an indication that smokers in general have really studied the labels, noticing them rather than neglecting them. Around half the population believes that warning notices do have a favourable effect. The two major ways by which favourable effects are believed to occur are: (1) making people better aware of the health hazards related to smoking, and (2) encouraging people to stop smoking or encouraging young people to remain non-smokers. The belief that warning notices might encourage smokers to stop is held equally by smokers and non-smokers, which strengthens the credibility of these answers. The majority of respondents also think that a rotation system is better than having a single warning statement. The main reason for that is stated as the rotation system evoking curiosity so that the notice is really read, not neglected. Again, this is an opinion held equally by smokers and non-smokers, i.e., it is not just non-smokers' belief but smokers' actual, self-reported reaction. When asking about the declaration of content we got an equally favourable reaction by around half the respondents stating that they think it really does good. Even more smokers than non-smokers say so. They generally indicate that the way the declaration of content is useful is that it facilitates choosing a brand yielding smaller amounts of harmful substances. Here again there is a striking difference so that smokers know much better in detail how the declaration system is shaped, and this gives further evidence that the smokers have both noticed and understood the system. CHANGES THAT SEEM RELATED TO THE LABELLING SYSTEM Knowledge Both 1976 and 1977 the respondents were asked to what degree they approved or disapproved to statements like "Smokers are more susceptible than nonsmokers to general air pollution". The content of this statement coincides with the content of one of the 16 warning notices. Among those who have been exposed to the warning notice, that is the smokers, there is a definite change towards increased knowledge of this, while there is less significant change in non-smokers, which serve as a non-exposed "control group". This pattern could be interpreted as evidence for the attributability of the knowledge change to the exposure to the warning labels. This means that the warning labels have not only been noticed and understood but have also made an impact on people's knowledge. Behavior The study has also registered the choice of brand of everyone of the cigarette smokers. Both among men and women in the different age groups there is a consistent pattern of shift towards "weaker" brands. This might of course be, at least partly, due to other influences as well, but, as stated above, the smokers had explicitly stated that they felt the declaration being useful just as a tool for that sort of change and that makes it rather probable that the actual change of that kind that has occurred has been very much an effect of the introduction of the declaration system. In Sweden smoking rates among males have been decreasing since 1969 and rather constant among women since 1970. When looking at figures for 1977 compared to 1976 (that is a comparison between the last year before and the first year after the introduction of the labelling system), we find an accelerated decrease among men and a beginning decrease among women. No definite conclusions about trends can be drawn from figures relating to just two consecutive years. However, since a lot of smokers have indicated that the warning notices might induce smoking cessation (see above) it seems probable that the actual increase in smoking cessation at the very time of the introduction of the warning notices could be at least partly attributable to these labels. In summary, this study supports the idea that the Swedish labelling system has beneficially influenced the smoking behaviour of the Swedish population both by contributing to an increased number of people stopping smoking and by encouraging remaining smokers to change to brands yielding lower amounts per cigarette of harmful substances. One significant difference between the health dangers of cigarette smoking and those of alcohol consumption is that the only way to avoid the risks from cigarettes is to stop smoking them entirely. The purpose of a health warning label on alcoholic beverages, on the other hand, is to promote responsible decisionmaking about whether and how much to drink, and to urge extreme caution about any drinking during pregnancy. As Secretary Califano said in his June 29, 1979, letter to Senator Riegle: Our experience to date suggests that warnings are more effective where people have a means of partially moderating their behavior, rather than a stark choice of either doing or not doing the potentially hazardous activity. For this reason, alcohol labelling might well be effective since it is excessive or irresponsible use, not use per se, which is of concern. APPENDIX TEXT OF RESPONSES The following letters responded to the six questions on consumer health warnings for alcoholic beverages and related issues posed by Senator Riegle: 1. Would warning labels be effective in raising public awareness of the health hazards involved in the use of alcohol? 2. Should such warning labels, if any, be of a general nature, or should they address specific dangers such as the fetal alcohol syndrome, driving impairment, etc.? 3. Should Congress consider requiring a rotating system of labeling? For example, Congress could require that 10 percent of the labels contain a warning about the fetal alcohol syndrome, 10 percent on driving impairment, etc. Should such warning labels be required on beer and wine as well as distilled spirits? 4. 5. Should beer and wine containers be required to indicate the percentage of alcohol per volume? 6. Should warning labels also be required on advertisements of alcoholic beverages? Some names and addresses haye been deleted to preserve rights of privacy. Thank you for your letter concerning warning labels on As you know, alcohol abuse and alcoholism are major national Alcohol abuse and alcoholism arise from complex interactions of social stresses, economic problems, behavioral reactions, prevailing attitudes and individuals' choices about how to cope. Because these causes are so varied, if we are to reduce the levels of alcohol abuse and alcoholism in our society, we must use all the means at our disposal. For this reason, HEW has recently undertaken a major initiative against alcohol abuse and alcoholism, involving educational efforts directed at the young, expanded research, occupation based alcoholism programs, training programs for health care professionals, exploring increased coverage by Medicare/ Medicaid and private insurance of alcoholism treatment--as well as efforts to warn people about alcohol abuse. In such an overall effort to encourage sensible attitudes and |