Mandatory Alcohol Health Warning Labels: Limited Visibility Despite High Regulatory Compliance in Mexico.

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Norberto Francisco Hernández-Llanes, Rafael Antonio Serna-Arreguin, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8469061/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction This study evaluated the physical characteristics and visibility of mandatory alcohol health warning labels on commercial beverage containers to assess their communicative effectiveness. Methods A descriptive observational study analyzed a sample of alcoholic beverage containers. Physical attributes—including warning location, font size, pictogram dimensions, and color contrast—were measured using standardized geometric approximations. Results While 97.4% of containers included warnings, only 11.5% placed them on the front label. Visibility was low: pictograms occupied less than 1% of the total label area, and font sizes averaged just 3.6 mm. Furthermore, only 19.2% adhered to officially approved color schemes, with most relying on low-contrast backgrounds. Discussion Although producers technically comply with mandatory regulations, their design choices structurally minimize warning salience. To restore public health impact, regulations must be urgently updated to mandate front-of-package placement, proportional sizing, and standardized high-contrast formats. Other Public Policy Alcohol Drinking Warning Labeling Risk Communication Health Education Public Policy Figures Figure 1 Figure 2 Figure 3 Introduction Alcohol consumption remains a leading global risk factor for mortality and morbidity, generating substantial social and economic burdens (Babor et al., 2022). Among the interventions for reduce alcohol harm to people, alcohol health warning labels (AHWL) have emerged as a relevant policy strategy aimed at informing consumers about health risks, including cancer, liver disease, and harms from intoxication (WHO, 2025). The term AHWL refers to the prominent information displayed on an alcoholic beverage product, packaging, or promotional material, that highlights the health risks associated with the product’s use (Purmehdi et al., 2017). Evidence suggests that well-designed AHWL—large, prominently located, visually contrasting, and using rotating messages—are more effective at increasing risk awareness and prompting cognitive engagement (Dimova & Mitchell, 2022; Jones, 2016; Purmehdi et al., 2017; Zuckermann et al., 2024). The effectiveness of AHWLs depends critically on their visual salience, defined as the ability of an element to capture the observer's attention based on its physical and contextual characteristics (Itti & Koch, 2001). Eye-tracking studies have shown that people pay little attention to warning elements because these elements compete directly with product branding elements; however, people pay more attention to the message when the size and salience of the message increase (Thomsen & Fulton, 2007). Despite their growing relevance, the impact of AHWL remains mixed across settings. Meta-analyses indicate robust effects on knowledge and risk perception (Correia et al., 2024; Edmunds et al., 2023; Hobin et al., 2025), but behavioral effects vary depending on design characteristics and regulatory enforcement (Clarke et al., 2021; E. L. Davies et al., 2022; Zhao et al., 2020). Prominent labels, with high contrast color combinations (like red or black text and a red border), use of images and prominent fonts for the health messages are characteristics associated with effective AHWL (Kemper et al., 2024; Kokole et al., 2021). International experience shows that when AHWL systems rely on voluntary industry compliance, warnings are frequently minimized—appearing in small sizes, in low-visibility locations, or using non-contrasting colors (Jané Llopis et al., 2020; Tinawi et al., 2018). Scientific literature has documented specific tactics used by the alcohol industry to systematically reduce the salience of health warnings, (Babor, 2020; Barlow et al., 2022; Cott et al., 2025). These practices have also been documented in debates surrounding the introduction of pregnancy warnings (Mathews et al., 2013; Millot et al., 2022) despite strong evidence available on fetal alcohol spectrum disorders (Chikritzhs et al., 2021). International experience reveals substantial differences between mandatory labeling systems with technical specifications and voluntary or mandatory systems without design standards. In countries with AHWS voluntary systems, warnings typically occupy insufficient size, are predominantly placed on the back of the package, and lack up-to-date health messages.(Alcohol Health Alliance UK, 2020; Dossou et al., 2017; Tinawi et al., 2018). In contrast, mandatory, specific design regulations such as frontal placement, minimum size proportional to the main surface area, and high-contrast schemes demonstrate an increase in attitudes, consumption, and buying behavior (Hobin et al., 2020; Zhao et al., 2020). In this context, Mexico is a unique and understudied case. Although AHWL are mandatory under the regulatory norm NOM-142-SSA1/SCFI-2014 (Diario Oficial de la Federación, 2016), there are no empirical evaluations of the characteristics, visibility, or effective salience of the warnings implemented on beverage containers. Furthermore, the norm does not specify requirements for the size, location, or contrast of AHWL. Assessing how alcohol industry operationalize mandatory requirements is essential to understanding whether the regulatory framework achieves its communication purpose. This study aims to characterize the design and placement of AHWL in a sample of alcoholic beverage containers sold in Mexico and to assess the extent to which current practices align with international recommendations and effective risk communication principles. Methods Study design and sample We conducted a descriptive observational study using a convenience sample of 78 empty alcoholic beverage containers collected through a public institutional call. Eligible containers included any commercially available alcoholic beverages with intact labels. Containers with illegible, damaged, or incomplete labels were excluded. Data collection and measurements The methodology was adapted from Tinawi et al. (2018). First, each container received a unique identifier. We recorded brand, beverage type, origin, container material, capacity in mL, and alcohol-by-volume percentage. Warning message characteristics For analyze the warning message characteristics, we measured, the presence/absence of the warning message, the location over the container (front, back, side, marbete), and the font size (mm). Pictogram characteristics The pictograms (Figure 1) were classified according to NOM-142-SSA1/SCFI-2014 in four types: prohibition for under 18 years (A), prohibition for vehicle drivers (B), prohibition during pregnancy (C), recommended for over 18 years (D). Measurements included pictogram diameter (mm) and calculated area (mm²). ***** Insert Figure 1 here ***** Note: A) Prohibition for use by persons aged under 18 (“prohibition for under 18 years”), B) Prohibition of consumption by drivers of motor vehicles (“prohibition for vehicle conductors”), C) Prohibition of use by pregnant women (“prohibition on pregnancy”) and D) Recommended for consumption by people over 18 years (“recommended for over 18 years”). Surface area estimation Surface areas for containers and labels were estimated using standardized geometric approximations: Cylindrical containers: Area = 2π × (diameter/2) × height Rectangular prism containers: Area = 2 × (height + width) × height Label surface was approximate as a rectangle and the area was calculated as height × width; marbete area was approximate using also the cylindrical area mentioned earlier. The value of π was fixed at 3.1416. Pictogram area followed π × (diameter/2)². All measurements were performed in duplicate; discrepancies were resolved through a third independent measurement. Color contrast assessment Background, figure, and line colors of pictograms were categorized into light, dark, intermediate, or transparent, and color was coded for use analysis. Compliance with the official Mexican color scheme was also recorded. Statistical analysis We computed frequencies, percentages, and means with standard deviations. Differences across beverage types were evaluated using chi-square tests with bootstrap simulation (2,000 iterations) to account for small cell counts, following recommendations for categorical data with sparse distributions (Agresti, 2013). Analyses were conducted in R version 4.2.2 (R Core Team, 2025) and graphics were made using the ggplot2 library (Wickhan, 2016). Results Sample characteristics are shown in Table 1. Seventy-eight containers were analyzed, spanning beer (n=15), wine (n=11), spirits (n=37), and liqueurs/cocktails (n=15). Most containers were made of glass (84.7%). Domestic products represented 65.4% of the sample. Front labels were present on nearly all containers (98.7%), while marbetes appeared on nearby half (55.1%). ***** Insert Table 1 here ***** Positioning and size of health warning messages The analysis of positioning and size of health warning messages is showed in Supplementary Table 1. A total of 97.4% of containers displayed a health warning message. However, only 11.5% placed it on the front label. The back label was the predominant location (66.7%). Wine was the only category with no front-label warnings. The average font size was 3.6 mm. Pictogram presence, location, and size Pictogram size and location is showed in Table 2. The three mandatory pictograms were widely used — prohibition for under 18 years, prohibition for vehicle drivers, and prohibition during pregnancy — (present in ~80% of containers). Only 19.2% of containers displayed the “recommended for over 18 years” pictogram. Two containers (2.5%) in the analyzed sample lacked any pictogram. Mean pictogram areas were: • Mandatory pictograms: 45 mm² (approx. 7.6 mm diameter) • “Over 18 years” pictogram: 108 mm² (approx. 11.8 mm diameter) Pictogram size did not significantly differ between beverage types. In contrast to pictogram mean size, labels occupied an average of 43.7% of container surface (Supplementary Table 2). However, pictograms represented less than 1% of total label area (Figure 2). The front label averaged 10,123 mm², while pictograms averaged 136 mm², further illustrating the extremely limited visual footprint. ***** Insert Figure 2 here ***** Note: Red dots represent the surface area of the pictograms. Color use in pictograms Light backgrounds were most common (56.8%), followed by transparent backgrounds (18.4%). Only 19.2% adhered to the official high-contrast scheme. Intermediate colors—mainly red—were frequent in pictogram lines (35.5%). Considerable heterogeneity and non-standard color combinations were observed (Figure 3). ***** Insert Figure 3 here ***** Note: bg = Pictogram background, px = Pictogram symbol, ln = Pictogram line. Discussion This study provides the first empirical assessment of AHWL characteristics under a mandatory system, revealing a fundamental misalignment between regulatory compliance and effective risk communication. Although nearly all containers included a health warning, several structural design features minimized visibility: Our findings of an average pictogram size of 45 mm² (less than 1% of the label area) are consistent with studies conducted in systems lacking rigorous technical specifications, as is observed in other countries like New Zealand (Tinawi et al., 2018 ), where it is reported that average pictograms were 38 to 42 mm², occupying 0.8% of the front label area. Small font size used in AHLW (mean = 3.6 mm) is far below thresholds associated with increased noticeability. Studies on tobacco labels show that increasing the size of the warning from 50% to 80% enhances its salience and impact on cognitive processes related to the abstinence process (Gravely et al., 2016 ). The font size is below the recommended threshold of 5 mm or greater for optimal legibility of warning texts (Madhavan, 2007 ) The prevalence of the frontal location of AHWL (11.5%) was higher than that observed in Australia (T. Davies et al., 2025 ), but this is contrary to international recommendations that emphasize front-of-package salience (Dimova & Mitchell, 2022 ; WHO, 2025 ). We found that only 19.2% adhered to the official color scheme (white background, black figure, and red line), which is a critical problem. There is a high prevalence of low-contrast or transparent backgrounds, which reduces perceptual salience. This is consistent with design strategies identified as "dark patterns," which are used by the alcohol industry to obscure health information (Petticrew et al., 2020 ). Research on visual perception shows that warnings with light contrast > 70% (e.g., black on yellow) increase detection by 350% compared to contrasts < 30% (Wogalter et al., 2012 ). Our finding of 56.8% of clear backgrounds without color specification of the figure suggests nominal compliance without adherence to the communicative purpose. The prevalence of transparent backgrounds (18.4%) is problematic because it allows the color of the alcoholic liquid to serve as the background. This varies the contrast depending on the product and reduces perceptual consistency. While this practice is not prohibited by the Mexican regulatory framework, it contradicts the basic principles of risk communication (Wogalter et al., 2012 ). Our results therefore suggest strategic or technical compliance, whereby producers meet minimum regulatory parameters while reducing visual prominence. Comparisons with experimental evidence reinforce this concern. Studies in Canada demonstrate that large, high-contrast labels can significantly increase awareness of risks such as cancer (Hobin et al., 2020 , 2025 ; Vallance et al., 2020 ). These findings underscore that design—not merely the presence—of warnings determines their effectiveness. The discrepancy between our observational findings and experimental evidence in Mexico is revealing. Experimental evidence had demonstrated that pictograms covering 33% of the package surface significantly increased cognitive processing of risks without reducing purchase intention (López-Olmedo et al., 2023 ), however, our results show that actual implementation averages less than 1% coverage—a difference of more than 30 times. Additionally, the limited adherence to official color standards aligns with documented industry tactics aimed at weakening the impact of public health messaging (Barlow et al., 2022 ; Cott et al., 2025 ). Although our study did not quantify corporate responsibility messages, previous evidence indicates that removing “drink responsibly” statements enhances the salience of risk warnings (Davies et al., 2023), suggesting an area for future investigation in the Mexican context. One strength of our study is our systematic characterization of multiple design parameters, such as location, size, contrast, and relative surface area, which are not usually evaluated together. Limitations of the study Our findings should be interpreted considering several limitations. First, the convenience sample limits representativeness, although the consistency of observed patterns across beverage types suggests a systemic issue. Second, geometric approximations may introduce estimation error, particularly for irregular containers, though our approach aligns with previously validated methods (Tinawi et al., 2018 ). Finally, the study does not assess consumer awareness or behavioral outcomes; however, its objective was solely to characterize compliance with design features. The limitations noted, such as the convenience sample and geometric approximations, are shared with similar international studies (Tinawi et al., 2018 ; Vallance et al., 2018 ) and they do not invalidate the conclusions about systematic trends. The consistency of our findings with the international literature indicates that our results are valid beyond our specific sample. Conclusions This study provides the first empirical evidence that Mexico's current mandatory framework has resulted in nominal compliance but functional ineffectiveness, by practices in Mexico that systematically minimize the visibility of health warnings on alcoholic beverages. Our findings suggest that allowing producers to have discretion over design specifications (size, contrast, and location) results in the systematic minimization of the risk message. Mexico has maintained regulations without specifications regarding proportional size, mandatory placement, or contrast standards since 2014. This explains why our findings replicate patterns seen in voluntary systems despite the regulations being technically "mandatory". Therefore, Mexico urgently needs a policy reform that goes beyond simple compliance monitoring and focuses on redefining technical standards. Evidence shows that AHWL, used in conjunction with other public health strategies, are a cost-effective measure to warn the population of the risks associated with the consumption of alcoholic beverages. Current Mexican regulations allow label designs that minimize the visual impact of warnings, which allows industry influence to maintain weak regulations, so it is imperative to modernize its regulations by aligning them with international best practices that require: 1) mandatory front-of-package placement, 2) a minimum size defined as a percentage of the package rather than in absolute millimeters, 3) standardized, high-contrast color schemes, and, 4) avoid alcohol-industry messages. Declarations Conflict of Interest None Funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Data Availability Statement The data and code underlying this article will be shared on reasonable request to the corresponding author. Author contributions: CRediT Statement Norberto Francisco Hernández-Llanes: Conceptualization, Methodology, Formal Analysis, Software , Writing - Original Draft. 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Supplementary Files ST1AHWLinMexico.docx Supplementary Table 1: Comparative analysis of characteristics and position of the health warning message by beverage type. ST2AHWLinMexico.docx Supplementary Table 2: Comparative analysis of localization and size of the containers, labels, and pictograms by beverage type. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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07:03:56","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":97246,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8469061/v1/73a42064a7f5963a51ed61fb.html"},{"id":100357655,"identity":"68250f57-1544-434e-b07d-f8127513a25a","added_by":"auto","created_at":"2026-01-16 07:20:09","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":53656,"visible":true,"origin":"","legend":"\u003cp\u003ePictograms legally permitted for use in Mexico\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8469061/v1/00d7cbc6a0c3be8830da5e9b.jpg"},{"id":100357605,"identity":"aea7bb47-a0a0-4fce-940f-215256ec729d","added_by":"auto","created_at":"2026-01-16 07:20:06","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":45150,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of the surface area proportion occupied by containers, labels and pictograms of alcoholic containers.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8469061/v1/205f2ed11cd50e8505835f83.png"},{"id":100357250,"identity":"3933af0a-84b3-4eb5-839a-488cbabc54a9","added_by":"auto","created_at":"2026-01-16 07:19:31","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":98281,"visible":true,"origin":"","legend":"\u003cp\u003eColor combinations in pictogram health warning of alcoholic labels\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-8469061/v1/9857bbb737d5b0c8684bab05.png"},{"id":100377173,"identity":"64802736-b213-4554-b693-ab53ab20485b","added_by":"auto","created_at":"2026-01-16 08:47:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":871684,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8469061/v1/e0651f8d-8a89-4d93-883d-7297c208a18f.pdf"},{"id":99860944,"identity":"89ca7104-8d1f-41cd-8a7a-01cbd924140a","added_by":"auto","created_at":"2026-01-09 07:03:56","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":13771,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary Table 1: Comparative analysis of characteristics and position of the health warning message by beverage type.\u003c/p\u003e","description":"","filename":"ST1AHWLinMexico.docx","url":"https://assets-eu.researchsquare.com/files/rs-8469061/v1/066d7d5bddb40d437ddf0908.docx"},{"id":99860949,"identity":"b7255bd5-6b4c-45bc-adaa-12f63916e39f","added_by":"auto","created_at":"2026-01-09 07:03:56","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":15097,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary Table 2: Comparative analysis of localization and size of the containers, labels, and pictograms by beverage type.\u003c/p\u003e","description":"","filename":"ST2AHWLinMexico.docx","url":"https://assets-eu.researchsquare.com/files/rs-8469061/v1/cb95d7563ce9172971594c4f.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eMandatory Alcohol Health Warning Labels: Limited Visibility Despite High Regulatory Compliance in Mexico.\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAlcohol consumption remains a leading global risk factor for mortality and morbidity, generating substantial social and economic burdens (Babor et\u0026nbsp;al., 2022). Among the interventions for reduce alcohol harm to people, alcohol health warning labels (AHWL) have emerged as a relevant policy strategy aimed at informing consumers about health risks, including cancer, liver disease, and harms from intoxication (WHO, 2025).\u003c/p\u003e\n\u003cp\u003eThe term AHWL refers to the prominent information displayed on an alcoholic beverage product, packaging, or promotional material, that highlights the health risks associated with the product’s use (Purmehdi et\u0026nbsp;al., 2017).\u003c/p\u003e\n\u003cp\u003eEvidence suggests that well-designed AHWL—large, prominently located, visually contrasting, and using rotating messages—are more effective at increasing risk awareness and prompting cognitive engagement (Dimova \u0026amp; Mitchell, 2022; Jones, 2016; Purmehdi et\u0026nbsp;al., 2017; Zuckermann et\u0026nbsp;al., 2024). The effectiveness of AHWLs depends critically on their visual salience, defined as the ability of an element to capture the observer's attention based on its physical and contextual characteristics (Itti \u0026amp; Koch, 2001). Eye-tracking studies have shown that people pay little attention to warning elements because these elements compete directly with product branding elements; however, people pay more attention to the message when the size and salience of the message increase (Thomsen \u0026amp; Fulton, 2007).\u003c/p\u003e\n\u003cp\u003eDespite their growing relevance, the impact of AHWL remains mixed across settings. Meta-analyses indicate robust effects on knowledge and risk perception (Correia et\u0026nbsp;al., 2024; Edmunds et\u0026nbsp;al., 2023; Hobin et\u0026nbsp;al., 2025), but behavioral effects vary depending on design characteristics and regulatory enforcement (Clarke et\u0026nbsp;al., 2021; E. L. Davies et\u0026nbsp;al., 2022; Zhao et\u0026nbsp;al., 2020). Prominent labels, with high contrast color combinations (like red or black text and a red border), use of images and prominent fonts for the health messages are characteristics associated with effective AHWL (Kemper et\u0026nbsp;al., 2024; Kokole et\u0026nbsp;al., 2021).\u003c/p\u003e\n\u003cp\u003eInternational experience shows that when AHWL systems rely on voluntary industry compliance, warnings are frequently minimized—appearing in small sizes, in low-visibility locations, or using non-contrasting colors (Jané Llopis et al., 2020; Tinawi et al., 2018).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eScientific literature has documented specific tactics used by the alcohol industry to systematically reduce the salience of health warnings, (Babor, 2020; Barlow et\u0026nbsp;al., 2022; Cott et\u0026nbsp;al., 2025). These practices have also been documented in debates surrounding the introduction of pregnancy warnings (Mathews et\u0026nbsp;al., 2013; Millot et\u0026nbsp;al., 2022) despite strong evidence available on fetal alcohol spectrum disorders (Chikritzhs et\u0026nbsp;al., 2021).\u003c/p\u003e\n\u003cp\u003eInternational experience reveals substantial differences between mandatory labeling systems with technical specifications and voluntary or mandatory systems without design standards.\u003c/p\u003e\n\u003cp\u003eIn countries with AHWS voluntary systems, warnings typically occupy insufficient size, are predominantly placed on the back of the package, and lack up-to-date health messages.(Alcohol Health Alliance UK, 2020; Dossou et al., 2017; Tinawi et al., 2018). In contrast, mandatory, specific design regulations such as frontal placement, minimum size proportional to the main surface area, and high-contrast schemes demonstrate an increase in attitudes, consumption, and buying behavior (Hobin et al., 2020; Zhao et al., 2020).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this context, Mexico is a unique and understudied case. Although AHWL are mandatory under the regulatory norm NOM-142-SSA1/SCFI-2014 (Diario Oficial de la Federación, 2016), there are no empirical evaluations of the characteristics, visibility, or effective salience of the warnings implemented on beverage containers. Furthermore, the norm does not specify requirements for the size, location, or contrast of AHWL.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAssessing how alcohol industry operationalize mandatory requirements is essential to understanding whether the regulatory framework achieves its communication purpose.\u003c/p\u003e\n\u003cp\u003eThis study aims to characterize the design and placement of AHWL in a sample of alcoholic beverage containers sold in Mexico and to assess the extent to which current practices align with international recommendations and effective risk communication principles.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design and sample\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a descriptive observational study using a convenience sample of 78 empty alcoholic beverage containers collected through a public institutional call. Eligible containers included any commercially available alcoholic beverages with intact labels. Containers with illegible, damaged, or incomplete labels were excluded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection and measurements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe methodology was adapted from Tinawi et al. (2018). First, each container received a unique identifier. We recorded brand, beverage type, origin, container material, capacity in mL, and alcohol-by-volume percentage.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eWarning message characteristics\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor analyze the warning message characteristics, we measured, the presence/absence of the warning message, the location over the container (front, back, side, marbete), and the font size (mm).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePictogram characteristics\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe pictograms (Figure 1) were classified according to NOM-142-SSA1/SCFI-2014 in four types:\u0026nbsp;\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eprohibition for under 18 years (A),\u003c/li\u003e\n \u003cli\u003eprohibition for vehicle drivers (B),\u003c/li\u003e\n \u003cli\u003eprohibition during pregnancy (C),\u003c/li\u003e\n \u003cli\u003erecommended for over 18 years (D).\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eMeasurements included pictogram diameter (mm) and calculated area (mm²).\u003c/p\u003e\n\u003cp\u003e***** Insert Figure 1 here *****\u003c/p\u003e\n\u003cp\u003eNote: A) Prohibition for use by persons aged under 18 (“prohibition for under 18 years”), B) Prohibition of consumption by drivers of motor vehicles (“prohibition for vehicle conductors”), C) Prohibition of use by pregnant women (“prohibition on pregnancy”) and D) Recommended for consumption by people over 18 years (“recommended for over 18 years”).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSurface area estimation\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSurface areas for containers and labels were estimated using standardized geometric approximations:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eCylindrical containers: Area = 2π × (diameter/2) × height\u003c/li\u003e\n \u003cli\u003eRectangular prism containers: Area = 2 × (height + width) × height\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eLabel surface was approximate as a rectangle and the area was calculated as height × width; marbete area was approximate using also the cylindrical area mentioned earlier. The value of π was fixed at 3.1416. Pictogram area followed π × (diameter/2)².\u003c/p\u003e\n\u003cp\u003eAll measurements were performed in duplicate; discrepancies were resolved through a third independent measurement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eColor contrast assessment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBackground, figure, and line colors of pictograms were categorized into light, dark, intermediate, or transparent, and color was coded for use analysis. Compliance with the official Mexican color scheme was also recorded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe computed frequencies, percentages, and means with standard deviations. Differences across beverage types were evaluated using chi-square tests with bootstrap simulation (2,000 iterations) to account for small cell counts, following recommendations for categorical data with sparse distributions (Agresti, 2013).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnalyses were conducted in R version 4.2.2 (R Core Team, 2025) and graphics were made using the ggplot2 library (Wickhan, 2016).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eSample characteristics are shown in Table 1. Seventy-eight containers were analyzed, spanning beer (n=15), wine (n=11), spirits (n=37), and liqueurs/cocktails (n=15). Most containers were made of glass (84.7%). Domestic products represented 65.4% of the sample. Front labels were present on nearly all containers (98.7%), while marbetes appeared on nearby half (55.1%).\u003c/p\u003e\n\u003cp\u003e***** Insert Table 1 here *****\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePositioning and size of health warning messages\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe analysis of positioning and size of health warning messages is showed in Supplementary Table 1. A total of 97.4% of containers displayed a health warning message. However, only 11.5% placed it on the front label. The back label was the predominant location (66.7%). Wine was the only category with no front-label warnings. The average font size was 3.6 mm.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePictogram presence, location, and size\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Pictogram size and location is showed in Table 2. The three mandatory pictograms were widely used — prohibition for under 18 years, prohibition for vehicle drivers, and prohibition during pregnancy — (present in ~80% of containers). Only 19.2% of containers displayed the “recommended for over 18 years” pictogram. Two containers (2.5%) in the analyzed sample lacked any pictogram.\u003c/p\u003e\n\u003cp\u003eMean pictogram areas were:\u003c/p\u003e\n\u003cp\u003e•\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Mandatory pictograms: 45 mm² (approx. 7.6 mm diameter)\u003c/p\u003e\n\u003cp\u003e•\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;“Over 18 years” pictogram: 108 mm² (approx. 11.8 mm diameter)\u003c/p\u003e\n\u003cp\u003ePictogram size did not significantly differ between beverage types.\u003c/p\u003e\n\u003cp\u003eIn contrast to pictogram mean size, labels occupied an average of 43.7% of container surface (Supplementary Table 2). However, pictograms represented less than 1% of total label area (Figure 2). The front label averaged 10,123 mm², while pictograms averaged 136 mm², further illustrating the extremely limited visual footprint.\u003c/p\u003e\n\u003cp\u003e***** Insert Figure 2 here *****\u003c/p\u003e\n\u003cp\u003eNote: Red dots represent the surface area of the pictograms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eColor use in pictograms\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLight backgrounds were most common (56.8%), followed by transparent backgrounds (18.4%). Only 19.2% adhered to the official high-contrast scheme. Intermediate colors—mainly red—were frequent in pictogram lines (35.5%). Considerable heterogeneity and non-standard color combinations were observed (Figure 3).\u003c/p\u003e\n\u003cp\u003e***** Insert Figure 3 here *****\u003c/p\u003e\n\u003cp\u003eNote: bg = Pictogram background, px = Pictogram symbol, ln = Pictogram line.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e This study provides the first empirical assessment of AHWL characteristics under a mandatory system, revealing a fundamental misalignment between regulatory compliance and effective risk communication.\u003c/p\u003e \u003cp\u003eAlthough nearly all containers included a health warning, several structural design features minimized visibility:\u003c/p\u003e \u003cp\u003eOur findings of an average pictogram size of 45 mm\u0026sup2; (less than 1% of the label area) are consistent with studies conducted in systems lacking rigorous technical specifications, as is observed in other countries like New Zealand (Tinawi et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), where it is reported that average pictograms were 38 to 42 mm\u0026sup2;, occupying 0.8% of the front label area.\u003c/p\u003e \u003cp\u003eSmall font size used in AHLW (mean\u0026thinsp;=\u0026thinsp;3.6 mm) is far below thresholds associated with increased noticeability. Studies on tobacco labels show that increasing the size of the warning from 50% to 80% enhances its salience and impact on cognitive processes related to the abstinence process (Gravely et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). The font size is below the recommended threshold of 5 mm or greater for optimal legibility of warning texts (Madhavan, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2007\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe prevalence of the frontal location of AHWL (11.5%) was higher than that observed in Australia (T. Davies et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), but this is contrary to international recommendations that emphasize front-of-package salience (Dimova \u0026amp; Mitchell, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; WHO, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe found that only 19.2% adhered to the official color scheme (white background, black figure, and red line), which is a critical problem. There is a high prevalence of low-contrast or transparent backgrounds, which reduces perceptual salience. This is consistent with design strategies identified as \"dark patterns,\" which are used by the alcohol industry to obscure health information (Petticrew et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Research on visual perception shows that warnings with light contrast\u0026thinsp;\u0026gt;\u0026thinsp;70% (e.g., black on yellow) increase detection by 350% compared to contrasts\u0026thinsp;\u0026lt;\u0026thinsp;30% (Wogalter et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Our finding of 56.8% of clear backgrounds without color specification of the figure suggests nominal compliance without adherence to the communicative purpose.\u003c/p\u003e \u003cp\u003eThe prevalence of transparent backgrounds (18.4%) is problematic because it allows the color of the alcoholic liquid to serve as the background. This varies the contrast depending on the product and reduces perceptual consistency. While this practice is not prohibited by the Mexican regulatory framework, it contradicts the basic principles of risk communication (Wogalter et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur results therefore suggest strategic or technical compliance, whereby producers meet minimum regulatory parameters while reducing visual prominence. Comparisons with experimental evidence reinforce this concern. Studies in Canada demonstrate that large, high-contrast labels can significantly increase awareness of risks such as cancer (Hobin et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2020\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Vallance et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). These findings underscore that design\u0026mdash;not merely the presence\u0026mdash;of warnings determines their effectiveness.\u003c/p\u003e \u003cp\u003eThe discrepancy between our observational findings and experimental evidence in Mexico is revealing. Experimental evidence had demonstrated that pictograms covering 33% of the package surface significantly increased cognitive processing of risks without reducing purchase intention (L\u0026oacute;pez-Olmedo et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), however, our results show that actual implementation averages less than 1% coverage\u0026mdash;a difference of more than 30 times.\u003c/p\u003e \u003cp\u003eAdditionally, the limited adherence to official color standards aligns with documented industry tactics aimed at weakening the impact of public health messaging (Barlow et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Cott et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Although our study did not quantify corporate responsibility messages, previous evidence indicates that removing \u0026ldquo;drink responsibly\u0026rdquo; statements enhances the salience of risk warnings (Davies et al., 2023), suggesting an area for future investigation in the Mexican context.\u003c/p\u003e \u003cp\u003eOne strength of our study is our systematic characterization of multiple design parameters, such as location, size, contrast, and relative surface area, which are not usually evaluated together.\u003c/p\u003e\n\u003ch3\u003eLimitations of the study\u003c/h3\u003e\n\u003cp\u003eOur findings should be interpreted considering several limitations. First, the convenience sample limits representativeness, although the consistency of observed patterns across beverage types suggests a systemic issue. Second, geometric approximations may introduce estimation error, particularly for irregular containers, though our approach aligns with previously validated methods (Tinawi et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Finally, the study does not assess consumer awareness or behavioral outcomes; however, its objective was solely to characterize compliance with design features.\u003c/p\u003e \u003cp\u003eThe limitations noted, such as the convenience sample and geometric approximations, are shared with similar international studies (Tinawi et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Vallance et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) and they do not invalidate the conclusions about systematic trends. The consistency of our findings with the international literature indicates that our results are valid beyond our specific sample.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study provides the first empirical evidence that Mexico's current mandatory framework has resulted in nominal compliance but functional ineffectiveness, by practices in Mexico that systematically minimize the visibility of health warnings on alcoholic beverages.\u003c/p\u003e \u003cp\u003eOur findings suggest that allowing producers to have discretion over design specifications (size, contrast, and location) results in the systematic minimization of the risk message. Mexico has maintained regulations without specifications regarding proportional size, mandatory placement, or contrast standards since 2014. This explains why our findings replicate patterns seen in voluntary systems despite the regulations being technically \"mandatory\".\u003c/p\u003e \u003cp\u003eTherefore, Mexico urgently needs a policy reform that goes beyond simple compliance monitoring and focuses on redefining technical standards.\u003c/p\u003e \u003cp\u003eEvidence shows that AHWL, used in conjunction with other public health strategies, are a cost-effective measure to warn the population of the risks associated with the consumption of alcoholic beverages.\u003c/p\u003e \u003cp\u003eCurrent Mexican regulations allow label designs that minimize the visual impact of warnings, which allows industry influence to maintain weak regulations, so it is imperative to modernize its regulations by aligning them with international best practices that require: 1) mandatory front-of-package placement, 2) a minimum size defined as a percentage of the package rather than in absolute millimeters, 3) standardized, high-contrast color schemes, and, 4) avoid alcohol-industry messages.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data and code underlying this article will be shared on reasonable request to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions: CRediT Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNorberto Francisco Hernández-Llanes:\u0026nbsp;\u003c/strong\u003eConceptualization, Methodology, Formal Analysis, Software\u003cstrong\u003e,\u003c/strong\u003e Writing - Original Draft.\u003cstrong\u003e\u0026nbsp;Rafael Antonio Serna-Arreguin:\u0026nbsp;\u003c/strong\u003eMethodology, Investigation, Resources, Data Curation, Writing - Original Draft.\u003cstrong\u003e\u0026nbsp;Juan Arturo Sabines-Torres:\u0026nbsp;\u003c/strong\u003eConceptualization, Methodology\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003eInvestigation, Writing - Review \u0026amp; Editing.\u003cstrong\u003e\u0026nbsp;Marycarmen Noemi Bustos-Gamiño:\u0026nbsp;\u003c/strong\u003eConceptualization, Writing - Review \u0026amp; Editing.\u003cstrong\u003e\u0026nbsp;Jorge Villatoro-Velázquez:\u003c/strong\u003e Conceptualization, Writing - Review \u0026amp; Editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAgresti, A. 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The Effects of Alcohol Warning Labels on Population Alcohol Consumption: An Interrupted Time Series Analysis of Alcohol Sales in Yukon, Canada. \u003cem\u003eJournal of Studies on Alcohol and Drugs\u003c/em\u003e, \u003cem\u003e81\u003c/em\u003e(2), 225\u0026ndash;237. https://doi.org/10.15288/jsad.2020.81.225\u003c/li\u003e\n\u003cli\u003eZuckermann, A. M. E., Morissette, K., Boland, L., Garcia, A. J., Domingo, F. R., Stockwell, T., \u0026amp; Hobin, E. (2024). The effects of alcohol container labels on consumption behaviour, knowledge, and support for labelling: A systematic review. \u003cem\u003eThe Lancet Public Health\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(7), e481\u0026ndash;e494. https://doi.org/10.1016/S2468-2667(24)00097-5\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are not available with this version.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Alcohol Drinking, Warning Labeling, Risk Communication, Health Education, Public Policy","lastPublishedDoi":"10.21203/rs.3.rs-8469061/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8469061/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e This study evaluated the physical characteristics and visibility of mandatory alcohol health warning labels on commercial beverage containers to assess their communicative effectiveness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e A descriptive observational study analyzed a sample of alcoholic beverage containers. Physical attributes—including warning location, font size, pictogram dimensions, and color contrast—were measured using standardized geometric approximations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e While 97.4% of containers included warnings, only 11.5% placed them on the front label. Visibility was low: pictograms occupied less than 1% of the total label area, and font sizes averaged just 3.6 mm. Furthermore, only 19.2% adhered to officially approved color schemes, with most relying on low-contrast backgrounds.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e Although producers technically comply with mandatory regulations, their design choices structurally minimize warning salience. To restore public health impact, regulations must be urgently updated to mandate front-of-package placement, proportional sizing, and standardized high-contrast formats.\u003c/p\u003e","manuscriptTitle":"Mandatory Alcohol Health Warning Labels: Limited Visibility Despite High Regulatory Compliance in Mexico.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-09 07:03:51","doi":"10.21203/rs.3.rs-8469061/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e263b270-eda7-43a0-b4dd-f295cc8cd376","owner":[],"postedDate":"January 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":60304168,"name":"Other Public Policy"}],"tags":[],"updatedAt":"2026-01-09T07:03:51+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-09 07:03:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8469061","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8469061","identity":"rs-8469061","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}