Impact of alcohol strength on attitudes and decisions concerning special occasion drinking during pregnancy

Impact of alcohol strength on attitudes and decisions concerning special occasion drinking during pregnancy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of alcohol strength on attitudes and decisions concerning special occasion drinking during pregnancy Sam Burton, Rebecca Monk, Emma Davies, Megan Goodier, Abigail Rose This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6921157/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 Background Special occasions are a risk factor for drinking during pregnancy. This study determined the impact of alcohol strength on attitudes around, and perceived harm of, drinking in pregnancy. If perceived harm decreases with lower strength alcohol, this may promote drinking when abstinence is recommended. Methods Two online ‘special occasion’ vignette studies randomised female participants to one of three drink strength conditions (11%, 7.5%, 0% alcohol beverage volume [ABV]). In the study (N = 1030), participants were asked to imagine themselves or someone else choosing to consume the beverage when pregnant. Outcome measures assessed how harmful participants thought drink choice was, and the extent to which they agreed with the drink choice. Results The standard and lower strength alcohol beverages were viewed as more harmful than the alcohol-free drink ( p < .001), and participants agreed with the alcohol-free drink choice more than the standard and lower strength beverages ( p < .001). Perceived harm was greater in when rating own hypothetical alcohol use in comparison to rating observed hypothetical alcohol use ( p < .01). Participants who reported drinking in their own pregnancy rated the alcohol choices as less harmful and more agreeable than participants who had not consumed alcohol in their own pregnancies ( ps < .001). Conclusions Perceived harm, and the ability to apply the potential harms of drinking during pregnancy to one’s own circumstances, may be crucial in reducing the risk special occasions pose to alcohol exposed pregnancies. Public health campaigns should focus on facilitating this, compassionately explaining the risk of harms across a range of drinking behaviours, while explicitly tackling the stigma and shame women may experience around this public health issue. Psychology Alcohol exposed pregnancy Alcohol by volume Risk perception Alcohol harm Figures Figure 1 Figure 2 INTRODUCTION Alcohol is the most widely used drug of women of typical child-bearing age, and prenatal alcohol use is the dominant preventable cause of birth defects and intellectual disabilities ( 1 ). In 2016, the UK’s Chief Medical Officer guidelines were revised, adopting a ‘precautionary principle’ approach which recommended abstinence while trying to conceive and throughout pregnancy. However, the UK continues to have one of the highest estimated rates of alcohol exposed pregnancies (AEP): 41.3%, compared to a pooled global estimate of 9.8% ( 2 , 3 ). Subsequently, the UK also has a high modelled prevalence rate of FASD (3.2%) ( 4 ), and it is estimated that 1 in every 13 pregnancies with some level of alcohol exposure results in fetal alcohol spectrum disorder (FASD), with risk increasing with heavier drinking ( 5 ). FASD is an umbrella term covering a range of neurodevelopmental issues and is associated with poorer life outcomes ( 1 ) and an estimated UK cost of £2 b p/a ( 6 ). Low to moderate prenatal alcohol exposure is also associated with increased health risks to the child (e.g., mental health problems, low birth weight, preterm birth) ( 7 – 11 ). FASD can also impair the wellbeing of birth mothers, who are often blamed and stigmatised for drinking during pregnancy ( 12 ). There are common, inaccurate assumptions that birth mothers of children with FASD have alcohol use disorder, ‘wilfully’ drink during pregnancy despite known risks, and are unfit mothers ( 13 ). This can result in poorer maternal mental health with increased experiences of depression, guilt, and stress ( 14 , 15 ). Given that 28.5% of UK women report drinking alcohol following pregnancy recognition ( 16 ) and the significant potential harms of AEP to the mother and child, it is important to identify factors that may increase likelihood of drinking following pregnancy recognition. Evidence from several countries identifies special occasions as one such risk factor ( 17 – 20 ). Indeed, when Tsang and colleagues ( 21 ) surveyed pregnant women, they found that most women (61.3%) who drank after pregnancy recognition reported doing so during special occasions, and this included women who were non- and low-risk drinkers prior to pregnancy. Importantly, asking about special occasion drinking identified an additional 33.3% of respondents reporting alcohol use during pregnancy, who would not otherwise have been captured. This suggests that special occasions represent a risk to pregnant women that is likely under-reported and thus poorly understood. Perception of harm is another important factor, with many health behaviour change interventions incorporating risk perception components ( 22 ). Women often recognise that drinking in pregnancy can be harmful ( 19 , 23 , 24 ), whether or not they have been pregnant themselves ( 25 ). Yet contradictory attitudes are common, and the strength or ‘potency’ of the drink appears to influence harm perception ( 19 , 26 ). This raises the possibility that increasing the availability of lower strength alcohol products, while intended as a harm reduction strategy ( 27 ), may have some unintended, negative consequences. There are several categories of ‘NoLo’ drink products, e.g., alcohol-free (≤ 0.05% ABV), de-alcoholised (0.05–0.5% ABV), and low alcohol (≤ 1.2% ABV). There are also a growing range of alcohol products with an ABV lower than ‘standard’ (e.g., beers under 4%, wines under 11% [if wine is under 8% it may be called a wine-based drink]) ( 28 ). Importantly, there is a lack of awareness by the public in terms of what constitutes these categories ( 29 ), so it is possible that people may class lower than standard ABV beverages similarly to NoLo drinks and choose to drink them when they would normally abstain ( 30 ). In the context of recommendations to avoid all alcohol consumption during pregnancy, the perceived risk of such beverages may be a factor in women’s decision making, raising concern as the market share of these products increases. Supporting women to abstain from alcohol during pregnancy is a public health priority. Identifying factors that increase drinking during pregnancy or promote more accepting attitudes towards it can inform effective, evidence-based policies and public health interventions to reduce AEP. Social support can reduce and increase risky drinking in the general population ( 31 , 32 ), and pregnant women often report drinking with friends or family ( 33 ). Therefore, research should explore harm perception in both women who have been pregnant and those who have not, as both groups may influence pro/anti-attitudes of AEP and the latter could become pregnant in the future. However, there is an important distinction between these two populations, with those having experience of pregnancy likely to use their own alcohol use during this time to evaluate other pregnant people’s drinking behaviour. This is termed the ‘self-image bias’ ( 34 ), and has been demonstrated when assessing other’s drug use ( 35 ), therefore the impact of personal drinking habits needs to be considered. Additionally, when examining harm perceptions, it is important to consider the impact of ‘framing’. Evidence shows that individuals tend to underestimate the risks of their own alcohol use due to the ‘unrealistic optimism bias’, while judging other people’s drinking as more harmful ( 36 , 37 , 38 ). As such, it is useful to compare harm perception when judging personal versus other people’s alcohol use, to explore how best to frame public health messaging for maximal impact. The current research used a vignette (scenario) method to determine, for the first time, attitudes and decision making around special occasion alcohol use during pregnancy, and the impact of alcohol strength on these outcomes. Based on the perceived reduced risk of harm from lower alcohol strength products, we hypothesised that individuals exposed to scenarios depicting lower strength alcohol consumption would judge drinking during pregnancy as less harmful and more acceptable than standard alcohol strength vignettes. By incorporating vignettes depicting the participant’s personal (hypothetical) alcohol use vs that of another pregnant woman, we assessed the (unrealistic) optimism bias, and hypothesised that people would judge other pregnant woman’s alcohol use as most harmful. Finally, given the self-image bias, we hypothesised that within participants who had experience of pregnancy, their own alcohol use during pregnancy would reflect their harm and acceptability judgements of AEP in the vignettes. METHODS Participants All participants were aged 18 or over, were fluent in English, and self-identified as being assigned female at birth, in total 1030 participants were recruited. Measures Demographics Age, ethnicity, sexuality, gender identity, relationship status, highest level of education, current occupation, average household income (before tax), history of pregnancy, number and age of children, UK area of residence. In study 3 participants were asked how many weeks pregnant they were. Current alcohol consumption The Timeline Followback (TLFB, ( 39 )) assessed weekly alcohol use. Using a diary format, participants were asked to record how many and what type of drink (e.g., large/small glass of wine, pint of beer) they had consumed over the past 14 days. Drinks were converted to units (1 UK unit = 8 g alcohol) and an average was calculated for weekly alcohol unit consumption. Alcohol harm : The alcohol use disorders identification test (AUDIT ( 40 )) assessed alcohol use and potentially harmful drinking behaviour (10 items). Scores indicate 0–7: low risk drinking, 8–15: increasing risk, 16–19: higher risk, 20 + possible dependence. For women it is recommended that low risk drinking is scored 0–6. Alcohol use and pregnancy Participants who indicated they were currently or historically pregnant were asked whether they changed their drinking habits (increased, no change, decreased, abstained) during different stages (3 months before pregnancy, 0–2 weeks, 3–6 weeks, 7–12 weeks, 12–26 week [second trimester], from week 27 [third trimester]). Participants were also asked in what contexts they had consumed alcohol during pregnancy. Several fixed options were given (e.g., special occasions [wedding, party], special periods [Christmas, Easter], with friends when out, with partner at home, when alone etc) as well as free text options. Vignette/Scenario : A short scenario described a woman called Sarah attending her friend’s wedding reception or as if the participant was attending as themselves, in both they are pregnant. Participants were randomly assigned to a vignette. As the vignette progressed, accompanying images were included to help the participant imagine the scenario (e.g., wedding marquee, people celebrating). The atmosphere was described as exciting and fun, with the individual enjoying spending time with friends. The scenario explains that the group decides to go to the bar to get drinks and everyone chooses to get a glass of sparkling wine to celebrate. The vignette states that the individual wants to join her friends and then introduces the information that the individual is pregnant. The vignette states that the individual asks the bar person if there is an alcohol-free sparkling wine available. At this point, participants are randomised to one of three drink availability conditions: standard 11% ABV, lower strength 7.5% ABV, and alcohol free 0.0% ABV. In each condition, Sarah decides to accept the drink that is available. Attitudes around choice (primary outcome) Following the end of the vignette, participants were asked two questions, ‘Do you agree with Sarah’s/your drink choice?’ and ‘To what extent do you think Sarah’s/your choice may harm her/your baby?’. Participants responded on a sliding scale from 0 (not at all) to 100 (very much). Procedure The study recruited participants through social media sites (e.g., Twitter, Facebook) and Prolific (an online research recruitment platform). Interested individuals clicked on a link, which took them to the Participant Information Sheet. After providing online consent, participants provided demographic information, before reading the vignette and completing all questions in the order provided above (i.e. personal drinking habits were recorded after the vignette task to avoid these scales influencing responses). Sections on personal drinking habits included a statement that we made no judgement on participant’s alcohol choices. Two attention checks were distributed throughout the study. A debrief at the end provided guidelines on alcohol use during pregnancy and signposting to further information. Analysis : Participants were removed who did not pass attention checks (n = 21) leaving a final combined sample of 1130. Analysis was performed in R studio using the dplyr packages. Between subjects ANOVA’s were applied using the aov function in R. Independent variables were scenario (2 levels: self and other person), alcohol (three levels: no alcohol, low alcohol, standard alcohol) and drank in pregnancy (two levels: consumed alcohol, consumed no alcohol). Dependent variables were perceived harm of consuming alcohol (scored 0-100), and extent of which the participant agrees with the drink choice (scored 0-100). Sub-group analysis was conducted on those who were currently pregnant, as a sensitivity analysis. Ethics statement : Participants provided online informed consent: a tick box stating they had read/understood the participant information sheet, met inclusion criteria, and agreed to take part in the study. Only after this consent was provided did the study launch (via Qualtrics). The studies received ethical approval from the Psychology Research Ethics Committee at Liverpool John Moores University. Data collection occurred between 23/01/2022-21/12/2024. RESULTS Participant characteristics There were no significant differences between observed and self-rated vignette demographics (see Table 1). There were also no differences in demographics ( p >.05); mean age (standard deviation) was 39.40 (±12.91) years, and most participants were white (76.21%), married/cohabiting (58.13%), heterosexual (81.19%), and employed (64.68%) (see supplemental Table 1 for full demographic breakdown). Of the respondents who reported having been pregnant, 19.42% reported alcohol use at some point in pregnancy. Table 1 : Descriptive characteristics of the sample, split by study and total, displaying means (standard deviations), median (interquartile range) and n (%) Self-Vignette (n=606) Sarah Vignette (n=522) Total (n=1030) Age Mean (SD) Median (IQR) 37.62 (12.80) 34.00 (17.00) 36.98 (10.89) 34.00 (11.00) 37.31 (11.94) 34.00 (14.00) Weekly alcohol units Mean (SD) Median (IQR) 8.01 (15.48) 2.07 (9.71) 5.83 (11.21) .71 (9.71) 6.99 (13.70) 1.34 (8.52) AUDIT Mean (SD) Median (IQR) n harmful drinkers (%) n hazardous drinkers (%) 4.99 (5.63) 3.00 (6.00) 83 (13.72) 15 (2.48) 4.55 (4.53) 3.50 (6.00) 121 (23.18) 4 (.77) 4.78 (5.15) 3.00 (6.00) 204 (18.05) 19 (1.68) Ethnicity Any Other 4 (.67%) 4 (.77%) 8 (.71%) Asian - British 25 (4.12%) 19 (3.64%) 44 (3.89%) Asian - Other 11 (1.82%) 5 (.96%) 16 (1.42%) Black - British 29 (4.79%) 8 (1.53%) 37 (3.27%) Black - Other 39 (6.44%) 4 (.77%) 43 (3.80%) Mixed - Any 14 (2.31%) 15 (2.87%) 29 (2.57%) White - Other 50 (8.25%) 46 (8.81%) 96 (8.50%) White British 401 (66.17%) 404 (77.40%) 806 (71.33%) Missing 29 (4.79%) 13 (2.48%) 43 (3.80%) I prefer not to answer this question 4 (.67%) 4 (.77%) 8 (.71%) Relationship Status Divorced or separated 28 (4.62%) 17 (3.26%) 45 (3.98%) I prefer not to answer this question 2 (.33%) 2 (.38%) 4 (.35%) In a relationship (not co-habitating) 74 (12.21%) 46 (8.81%) 121 (10.71%) Married or co-habitating 367 (60.56%) 360 (68.97%) 727 (64.34%) Single 97 (16.01%) 75 (14.37%) 172 (15.22%) Widowed 4 (.66%) 1 (.19%) 5 (.44%) Missing 34 (5.61%) 21 (4.02%) 56 (4.96%) Education Doctorate degree 40 (6.60%) 19 (3.64%) 59 (5.22%) Master's degree 128 (21.12%) 99 (18.97%) 228 (20.17%) Bachelor's degree 210 (34.65%) 200 (38.31%) 410 (36.28%) Professional degree 16 (2.64%) 10 (1.92%) 26 (2.30%) Trade/technical/vocational training 40 (6.60%) 63 (12.07%) 103 (9.12%) Secondary School / College (e.g. A'Level) 97 (16.01%) 77 (14.75%) 174 (15.40%) Secondary school (e.g. GCSE) 42 (6.93%) 39 (7.47%) 81 (7.17%) Primary school 2 (.33%) 0 2 (.18%) Other, please specify 4 (.66%) 4 (.76%) 8 (.71%) Prefer not to answer 1 (.17%) 1 2 (.18%) Missing 26 (4.29%) 11 (2.11%) 37 (3.27) Employment Employed 395 (65.16%) 353 (67.62%) 749 (66.30%) Self-employed 44 (7.26%) 36 (6.90%) 80 (7.08%) Maternity leave 30 (4.95%) 24 (4.60%) 54 (4.78%) Stay at home mum/homemaker 39 (6.44%) 50 (9.58%) 89 (7.88%) Retired 27 (4.46%) 18 (3.45%) 45 (3.98%) Unable to work 13 (2.15%) 9 (1.72%) 22 (1.95%) Unemployed 21 (3.47%) 20 (3.83%) 41 (3.63%) Prefer not to answer 11 (1.82%) 5 (.96%) 16 (1.42%) Missing 26 (4.29%) 7 (1.34%) 34 (3.01%) Country of Residence United Kingdom 576 (95.05%) 513 (98.28%) 1090 (96.46%) Other 8 (1.32%) 3 (.57%) 12 (1.06%) Missing 22 (3.63%) 6 (1.15%) 28 (2.48%) Sexuality Heterosexual 497 (82.01%) 437 (83.72%) 935 (82.74%) Bisexual 33 (5.45%) 46 (8.81%) 79 (6.99%) Lesbian/Gay 18 (2.97%) 13 (2.49%) 31 (2.74%) Other 9 (1.49%) 6 (1.15%) 15 (1.33%) Prefer not to say 14 (2.31%) 11 (2.11%) 25 (2.21%) Missing 35 (5.77%) 9 (1.72%) 45 (3.99%) Gender Woman 574 (94.72%) 509 (97.51%) 1084 (95.93%) Transman 4 (.66%) 0 4 (.35%) Gender fluid 0 1 (.19%) 1 (.09%) Non-binary 0 3 (.58%) 3 (.27%) Other 1 (.17%) 2 (.38%) 3 (.27%) Prefer not to say 1 (.17%) 0 1 (.09%) Missing 26 (4.28%) 7 (1.34%) 34 (3.00%) Descriptive characteristics of the sample, split by study and total, displaying means (standard deviations), median (interquartile range) and n (%) Perceived harm analysis Between subjects ANOVA was applied with independent variables of scenario (two levels: own and observed drinking scenarios), alcohol alcohol (three levels: no alcohol, lower alcohol, and standard alcohol) and drank in pregnancy (two levels: consumed alcohol, consumed no alcohol), and the dependent variable of perceived harm of the vignette’s drink choice on the unborn baby. There was a significant main effect of scenario on perceived harm, F(1,693)=22.35, p <.001, h 2 p =.03. Contrary to our hypothesis based on the unrealistic optimism bias, those in the ‘own drinking’ scenario (M= 36.74, SD=35.01) reported higher levels of perceived harm than those in the ‘observed drinking’ scenario (M=29.04, SD=31.85, p< .001). Additionally, alcohol was a significant main effect, F(2, 693)=46.07, p< .001, h 2 p =.12. Against our hypothesis, both standard (M=45.17, SD=33.16) and lower strength alcohol (M=41.91, SD=33.05) were viewed as significantly more harmful to the unborn baby than non-alcohol drinks (M=11.78, SD=23.48, p< .001), but there was no significant difference between lower or standard strength alcohol ( p =.373). [Insert Figure 1 here] Of participants who had experienced pregnancy but not currently pregnant (n=409), there was a main effect of drinking in pregnancy, F(1,693)=16.92, p <.001, h 2 p =.02. In line with our hypothesis based on the self-image bias, those who consumed alcohol during pregnancy (M=20.12, SD=27.18) viewed the consumption of alcohol as significantly less harmful to the unborn baby than those who had not consumed alcohol during pregnancy (M=32.96, SD=34.78, p <.001). Sub-group analysis was carried out on those who were currently pregnant (n=296). Between subjects ANOVA was applied with independent variables of scenario (two levels: own and observed drinking scenarios) and alcohol (three levels: no alcohol, lower alcohol, and standard alcohol), and the dependent variable of perceived harm of the vignette’s drink choice on the unborn baby. There was a significant main effect of alcohol, F(2,294)=23.31, p <.001, h 2 p =.14, on harm perception. Standard (M=46.70, SD=33.51) and lower strength alcohol (M=43.35, SD=32.36) were viewed as significantly more harmful to the unborn baby than non-alcohol drinks (M=19.37, SD=31.98, p< .001), but there was no significant difference between lower or standard strength alcohol ( p =.774). There was a significant interaction between scenario and alcohol, F(2,294)=4.07, p <.05, h 2 p =.03. Post hoc analysis showed a significant difference between perception of harm for no alcohol wine (0% ABV) based upon observing (M=7.92, SD=21.32) and own (M=29.33, SD=36.31), p .996). Agreement with choice analysis Between subjects ANOVA was applied with independent variables of scenario (two levels: own and observed drinking scenarios), alcohol (three levels: no alcohol, lower alcohol, and standard alcohol) and drinking in pregnancy (two levels: consumed alcohol, consumed no alcohol), on the dependent variable of extent of which participants agreed with the drink choice. There was a main effect of scenario, F(1,694)=11.65, p <.001, h 2 p =.02, those who observed Sarah drinking (M=42.49, SD=40.99) agreed with alcohol use significantly more than those who rated their own drinking (M=39.93, SD=39.59, p <.001). There was a significant main effect of alcohol, F(2,694)=293.84, p <.001, h 2 p =.46. No alcohol drinks (M=84.02, SD=25.82) were significantly more agreeable than lower alcohol (M=22.85, SD=28.95, p <.001) and standard alcohol drinks (M=17.23, SD=24.87, p <.001), but there was no significant difference between lower and standard strength alcohol ( p =.181). [Insert Figure 2 here] There was a main effect of drinking in pregnancy, F(1,694)=65.79, p <.001, h 2 p =.09, those who consumed alcohol during pregnancy (M=55.53, SD=36.09) reported higher levels of agreement with the drink choice than those who had not consumed alcohol during pregnancy (M=36.65, SD=41.16, p <.001). Sub-group analysis was carried out on those who were currently pregnant (n=296). Between subjects ANOVA was applied with independent variables of scenario (two levels: own and observed drinking scenarios) and alcohol (three levels: no alcohol, lower alcohol, and standard alcohol), and the dependent variable of perceived harm of the vignette’s drink choice on the unborn baby. There was a significant main effect of alcohol, F(2,294)=147.06, p <.001, h 2 p =.50, on agreement perception. Standard (M=16.56, SD=22.74) and lower strength alcohol (M=21.29, SD=29.73) were viewed as significantly less agreeable to consume than non-alcohol drinks (M=77.25, SD=31.89, p< .001), but there was no significant difference between lower or standard strength alcohol ( p =.454). There was a significant interaction between scenario and alcohol, F(2,294)=3.47, p <.05, h 2 p =.02. Post hoc analysis showed a significant difference between perception of agreeableness for no alcohol wine (0% ABV) based upon observing (M=86.00, SD=26.36) and own (M=69.63, SD=34.48), p .996). DISCUSSION Supporting women to abstain during pregnancy is a public health priority which can substantially benefit both mother and child wellbeing and health (41, 42). Population-wide strategies have identified lower strength alcohol products as one way to reduce alcohol harms (27). However, it is possible that if lower strength alcohol is perceived as less harmful, then some individuals may be more likely to drink alcohol when, typically, they would choose to abstain (e.g., in pregnancy). It is also known that special occasions can be a time when drinking in pregnancy is more likely (21). This study used a novel vignette paradigm to explore perceived harm of drinking alcohol at varying strengths during pregnancy, and the extent to which women agreed with drinking choices during a special occasion. Indicating that people draw distinctions between products when considering what to consume during pregnancy, we found (as expected) that both standard (11% ABV) and lower (7.5% ABV) alcohol products were perceived as more harmful than the alcohol-free beverage, and people agreed less with the drink choice when it contained any alcohol. Unexpectedly, there was no difference in perceived harm or agreement between the standard and lower ABV drinks. The precautionary principle of abstinence was introduced in the UK in 2016 and, as part of standard care, midwives should be providing this information at antenatal appointments. As such, our findings may be viewed as promising evidence that the recommendations to abstain entirely throughout pregnancy maybe influencing women, and that lower alcohol products are being placed in the same category of harm as products of standard ABV, even in the context of a special occasion (which is a known risk factor for drinking in pregnancy (21)). On the other hand, certain groups of women, e.g. those with alcohol use disorder, can find abstinence very difficult to achieve (33). Although controversial and beyond this study, future research may look at the potential for harm reduction strategies in complex needs group, which incorporate low alcohol products, perhaps as part of a stepped treatment approach towards the recommended abstinence goals. Also affording a somewhat optimistic view, while there were no differences in agreement with drink choice, participants who were asked to imagine their own consumption in the scenario reported higher levels of perceived harm than the participants asked to assess another person’s (Sarah’s) drinking. In a manifestation of the (unrealistic) optimism bias (36, 37), it has been shown that people tend to underestimate risk of harms from their own alcohol use, while judging other people’s drinking as more harmful (37, 38, 43), yet our current finding suggests this is not the case when judging pregnancy-related alcohol harm. This fits with a study that found a lack of unrealistic optimism bias in South African pregnant women regarding risks of drinking in pregnancy (44). Indeed, in the context of pregnancy, self-perceptions of harm may be magnified in contrast to perceived harm to others, perhaps because fetus protection is a primary motive for not drinking during pregnancy (23, 45-47). Our findings therefore suggest that asking women to evaluate potential alcohol risks in a more personal way (i.e., harm to your own pregnancy) may be an effective strategy to magnify perceived potential harms and thus reduce AEP. Of more concern, although expected, is our finding that respondents who had consumed alcohol during their own pregnancies tended to perceive the consumption of alcohol in the vignettes as less harmful and more agreeable than respondents who did not drink during their own pregnancy. According to the self-image bias, we judge others by our own yardstick (34) and this has been found to apply to assessment of other people’s drug use (35). Evidence suggests that some pregnant women and mothers are not convinced that low level alcohol use during pregnancy is harmful, they find the evidence and information given confusing, inconsistent and/or incorrect, and some believe that abstinence messaging is patriarchal (23, 24, 45). Women, who had previously been pregnant but weren’t currently, judged drinking in pregnancy to be less harmful, they may be more likely to drink when pregnant but may also project that belief onto others in a similar situation. This is in contrast to women who were currently pregnant who viewed all alcohol consumption as harmful in comparison to no alcohol alternatives. This could have implications for pregnant women who may be subjected to social pressures during special occasions where normative affordances for consumption are particularly high (48, 49). There are limitations to this study. First, we specified ABV % based on products that are currently on the market to make the results more applicable, however, it is not known whether there is a ‘tipping point’ at which ABV % is perceived as significantly more or less harmful. If such a tipping point exists, this may differ across beverage type. For instance, we used wine in the current study, but some women perceive risk from wine consumption as lower than other types of alcohol when pregnant (19, 48, 50, 51), and use type of alcohol rather than strength to evaluate risk (19). Second, we focused on a single drinking occasion during a celebratory event, because special occasion drinking is a known risk for drinking in pregnancy. However, evidence shows that many women feel that low level, occasional alcohol use is acceptable during pregnancy (19, 23). Given the evidence that risk of fetal alcohol harms is greater as levels of consumption increase and is particularly associated with binge drinking (52, 53), these attitudes are understandable. It is therefore possible that perceived harm and agreement would differ if we had included more ‘every day’ drinking scenarios. Third, we recruited women with and without experience of pregnancy. Although non-pregnant women are not the immediate target audience of this research, their inclusion is important. Better understanding of the factors that influence women’s attitudes and decisions around alcohol use behaviour during pregnancy can inform prevention strategies, either for women who become pregnant in the future and/or which incorporate components of social support/transmission of health information and advice. Last, we recruited a convenience sample which reported low levels of alcohol use, and we cannot assume heavier drinkers would respond in a similar way. Future research can overcome these limitations by assessing perceptions towards a wider variety of alcohol strengths and products (e.g., wine/beer/spirits), across different situations, and by comparing different subpopulations of drinkers to develop a more nuanced understanding of this issue. This is important given the finding that people who consume higher levels of alcohol use may underestimate how harmful alcohol can be (54). Future research could also use ecological momentary assessment tools to assess how drinking attitudes and harm perception may differ across pregnancy. We would highlight, that despite our participant group’s low level of current drinking, 19.42% reported some level of drinking in pregnancy. This finding confirms that alcohol exposed pregnancy in the UK is a significant public health issue and not something restricted to pregnant people with pre-existing hazardous or harmful drinking behaviours. We would also argue that any strategies to increase prevalence rates of abstinence during pregnancy carefully consider women’s perceptions of harm across drinking levels, and work with women to develop ways to justify the precautionary principle which focuses on supporting the health and wellbeing of the woman, as well as the child. This novel study suggests that lower strength alcohol products are still perceived as harmful when considering special occasion drinking during pregnancy. This means that lower strength alcohol products may not be a risk for alcohol use in pregnancy, although we have outlined recommendations for future research to confirm this. This work also reinforces the importance that public health campaigns to reduce AEP should be framed so that women can understand that potential harms are directly applicable to their own drinking behaviours and pregnancy, and aligns with efforts to ensure women do not feel judged or stigmatised for their behaviour, and that compassionate framing supports women’s wellbeing. Declarations Ethical approval and consent to participate: Ethical approval was obtained from School of Psychology Research Ethics Committee, Liverpool John Moores University (reference number 22-PSY-020). Participants were informed, and their involvement was voluntary. Consent was obtained from all subjects. The study was conducted in accordance with the Declaration of Helsinki. Consent for publication: Consent is given as the individuals in the study are entirely unidentifiable and there are no details on individuals reported. Availability of data and materials: Data can be accessed on the following link on the OSF repository https://osf.io/kpq63/?view_only=681f9a50c4f4429ea3219b9dc521e875. Competing interest: None to declare. Funding: This work received no funding. Author Contributions: Conceptualisation SB, RM, ED, AKR: Data Curation SB, AKR: Formal analysis SB, Investigation: SB, RM, ED, MG, AKR: Methodology SB, RM, ED, AKR: Project administration SB: Resources SB, RM, ED, AKR: Software SB, AKR: Validation SB, RM, ED, AKR: Visualisation SB: Writing- Original Draft Preparation, SB, RM, ED, MG, AKR: Writing-Reviewing & Editing, SB, RM, ED, MG, AKR Acknowledgements: None References Baer JS, Sampson PD, Barr HM, Connor PD, Streissguth AP (2003) A 21-year longitudinal analysis of the effects of prenatal alcohol exposure on young adult drinking. Arch Gen Psychiatry 60(4):377–385 Popova S, Lange S, Probst C, Gmel G, Rehm J (2018) Global prevalence of alcohol use and binge drinking during pregnancy, and fetal alcohol spectrum disorder. Biochem Cell Biol 96(2):237–240 Popova S, Lange S, Probst C, Gmel G, Rehm J (2017) Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis. Lancet Glob Health 5(3):e290–e9 Lange S, Probst C, Gmel G, Rehm J, Burd L, Popova S (2017) Global Prevalence of Fetal Alcohol Spectrum Disorder Among Children and Youth: A Systematic Review and Meta-analysis. JAMA Pediatr 171(10):948–956 Lange S, Probst C, Rehm J, Popova S (2017) Prevalence of binge drinking during pregnancy by country and World Health Organization region: Systematic review and meta-analysis. Reprod Toxicol 73:214–221 Schölin L, Mukherjee RA, Aiton N, Blackburn C, Brown S, Flemming KM et al (2021) Fetal alcohol spectrum disorders: an overview of current evidence and activities in the UK. Arch Dis Child 106(7):636–640 Easey KE, Dyer ML, Timpson NJ, Munafò MR (2019) Prenatal alcohol exposure and offspring mental health: A systematic review. Drug Alcohol Depend 197:344–353 Addila AE, Azale T, Gete YK, Yitayal M (2021) The effects of maternal alcohol consumption during pregnancy on adverse fetal outcomes among pregnant women attending antenatal care at public health facilities in Gondar town, Northwest Ethiopia: a prospective cohort study. Substance Abuse Treatment, Prevention, and Policy. ;16(1):64 Chambers CD, Coles C, Kable J, Akshoomoff N, Xu R, Zellner JA et al (2019) Fetal Alcohol Spectrum Disorders in a Pacific Southwest City: Maternal and Child Characteristics. Alcohol Clin Exp Res 43(12):2578–2590 Mamluk L, Edwards HB, Savović J, Leach V, Jones T, Moore THM et al (2017) Low alcohol consumption and pregnancy and childhood outcomes: time to change guidelines indicating apparently ‘safe’ levels of alcohol during pregnancy? A systematic review and meta-analyses. Bmj Open 7(7):e015410 Chang G (2023) Reducing Prenatal Alcohol Exposure and the Incidence of FASD: Is the Past Prologue? Alcohol Res 43(1):02 Morton Ninomiya ME, Almomani Y, Dunbar Winsor K, Burns N, Harding KD, Ropson M et al (2023) Supporting pregnant and parenting women who use alcohol during pregnancy: A scoping review of trauma-informed approaches. Womens Health (Lond) 19:17455057221148304 Abadir AM, Ickowicz A (2016) Fetal alcohol spectrum disorder: reconsidering blame. CMAJ 188(3):171–172 Paley B, O'Connor MJ, Frankel F, Marquardt R (2006) Predictors of stress in parents of children with fetal alcohol spectrum disorders. J Dev Behav Pediatr 27(5):396–404 Sanders J, Buck G (2018) A long journey: biological and non-biological parents’ experiences raising children with FASD. J Popul Ther Clin Pharmacol. ;17(2) Mårdby A-C, Lupattelli A, Hensing G, Nordeng H (2017) Consumption of alcohol during pregnancy—A multinational European study. Women Birth 30(4):e207–e13 Muggli E, O’Leary C, Donath S, Orsini F, Forster D, Anderson PJ et al (2016) Did you ever drink more? A detailed description of pregnant women’s drinking patterns. BMC Public Health 16(1):683 Bakhireva LN, Leeman L, Roberts M, Rodriguez DE, Jacobson SW (2021) You Didn't Drink During Pregnancy. Did You? Alcohol Clin Exp Res 45(3):543–547 Meurk CS, Broom A, Adams J, Hall W, Lucke J (2014) Factors influencing women’s decisions to drink alcohol during pregnancy: findings of a qualitative study with implications for health communication. BMC Pregnancy Childbirth 14(1):246 Schölin L, Hughes K, Bellis MA, Eriksson C, Porcellato L (2018) Exploring practices and perceptions of alcohol use during pregnancy in England and Sweden through a cross-cultural lens. Eur J Public Health 28(3):533–537 Tsang TW, Kingsland M, Doherty E, Anderson AE, Tully B, Crooks K et al (2022) Predictors of alcohol use during pregnancy in Australian women. Drug Alcohol Rev 41(1):171–181 Ferrer R, Klein WM (2015) Risk perceptions and health behavior. Curr Opin Psychol 5:85–89 Ujhelyi Gomez K, Goodwin L, Chisholm A, Rose AK (2022) Alcohol use during pregnancy and motherhood: Attitudes and experiences of pregnant women, mothers, and healthcare professionals. PLoS ONE 17(12):e0275609 Hammer R, Rapp E (2022) Women's views and experiences of occasional alcohol consumption during pregnancy: A systematic review of qualitative studies and their recommendations. Midwifery 111:103357 Elek E, Harris SL, Squire CM, Margolis M, Weber MK, Dang EP et al (2013) Women's Knowledge, Views, and Experiences Regarding Alcohol Use and Pregnancy: Opportunities to Improve Health Messages. Am J Health Educ 44(4):177–190 Erng MN, Reid N, Moritz KM, van Driel M (2023) Prenatal alcohol exposure risk perception dimensions and influencing factors: A systematic review and conceptual model. Aust N Z J Public Health 47(3):100047 Government H (2019) Advancing our health: prevention in the 2020s. UK Care DoHS (2018) Low Alcohol Descriptors Guidance. UK Corfe S, Hyde R, Shepherd J (2020) Alcohol-free and low-strength drinks. Understanding their role in reducing alcohol-related harms. UK Holmes J, Angus C, Meier PS (2015) UK alcohol industry’s billion units pledge: interim evaluation flawed. BMJ: Br Med J 350:h1301 Wang M, Liu S, Zhan Y, Shi J (2010) Daily work-family conflict and alcohol use: testing the cross-level moderation effects of peer drinking norms and social support. J Appl Psychol 95(2):377–386 Rosenquist JN, Murabito J, Fowler JH, Christakis NA (2010) The Spread of Alcohol Consumption Behavior in a Large Social Network. Ann Intern Med 152(7):426–433 Popova S, Dozet D, Akhand Laboni S, Brower K, Temple V (2022) Why do women consume alcohol during pregnancy or while breastfeeding? Drug Alcohol Rev 41(4):759–777 Hill T, Smith ND, Hoffman H (1988) Self-image bias and the perception of other persons' skills. Eur J Social Psychol 18(3):293–298 Monk RL, Heim D (2011) Self-image bias in drug use attributions. Psychol Addict Behav 25(4):645–651 Weinstein ND (1980) Unrealistic optimism about future life events. J Personal Soc Psychol 39(5):806–820 Shepperd JA, Klein WMP, Waters EA, Weinstein ND (2013) Taking Stock of Unrealistic Optimism. Perspect Psychol Sci 8(4):395–411 Gual A, Ángel Arbesú J, Zarco J, Balcells-Oliveró MdlM, López-Pelayo H, Miquel L et al (2017) Risky Drinkers Underestimate their Own Alcohol Consumption. Alcohol Alcohol 52(4):516–517 Sobell LC (1993) Timeline followback: A technique for assessing self-reported alcohol consumption. In: Litten RZ, J. A, (ed) Measuring alcohol consumption: psychosocial and biological methods. Humana, New Jersey Babor T, Higgins-Biddle JC, Saunders J, Monteiro M (2001) AUDIT. The Alcohol Use Disorders Identification Test. Guidelines for Use in Primary Care. Second Edition England PH (2020) Maternity high impact area 4: Reducing the incidence of harms caused by alcohol in pregnancy. London UK England PH (2020) Early years high impact area 2: Maternal mental health. London UK Morris J, Tattan-Birch H, Albery IP, Heather N, Moss AC (2024) Look away now! Defensive processing and unrealistic optimism by level of alcohol consumption. Psychol Health. :1–19 Louw JG, Tomlinson M, Olivier L (2018) Unrealistic optimism with regard to drinking during pregnancy among women of childbearing age in a South African community. South Afr J Psychol 48(2):219–229 Fleming KM, Gomez KU, Goodwin L, Rose AK (2023) Identifying the motives for and against drinking during pregnancy and motherhood, and factors associated with increased maternal alcohol use. J Public Health Martinelli JL, Germano CMR, de Avó LRS, Fontanella BJB, Melo DG (2019) Motivation for alcohol consumption or abstinence during pregnancy: A clinical-qualitative study in Brazil. PLoS ONE 14(10):e0223351 Jones SC, Telenta J (2012) What influences Australian women to not drink alcohol during pregnancy? Aust J Prim Health 18(1):68–73 Crawford-Williams F, Steen M, Esterman A, Fielder A, Mikocka-Walus A (2015) My midwife said that having a glass of red wine was actually better for the baby: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy. BMC Pregnancy Childbirth 15(1):79 Fletcher T, Mullan B, Finlay-Jones A (2022) Perceptions of two different alcohol use behaviours in pregnancy: an application of the prototype/willingness model. Health Psychol Behav Med 10(1):1071–1085 Dumas A, Toutain S, Hill C, Simmat-Durand L (2018) Warning about drinking during pregnancy: lessons from the French experience. Reproductive Health 15(1):20 Corrales-Gutierrez I, Mendoza R, Gomez-Baya D, Leon-Larios F (2019) Pregnant Women’s Risk Perception of the Teratogenic Effects of Alcohol Consumption in Pregnancy. J Clin Med 8(6):907 Popova S, Charness ME, Burd L, Crawford A, Hoyme HE, Mukherjee RAS et al (2023) Fetal alcohol spectrum disorders. Nat Reviews Disease Primers 9(1):11 Mukherjee R, Cook PA, Fleming KM, Norgate SH (2017) What can be done to lessen morbidity associated with fetal alcohol spectrum disorders? Arch Dis Child 102(5):463–467 Sanchez-Ramirez DC, Franklin RC, Voaklander D (2018) Perceptions About Alcohol Harm and Alcohol-control Strategies Among People With High Risk of Alcohol Consumption in Alberta, Canada and Queensland, Australia. J Prev Med Public Health 51(1):41–50 Additional Declarations The authors declare no competing interests. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6921157","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":472984979,"identity":"244f229f-9ac2-4891-a933-497577d40587","order_by":0,"name":"Sam Burton","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYJACZih18IAEVISxgQgtQMVsCSRr4TE4ABPBq0W+gfcAc2HbvTp+6Z4PByxzDjPwtx9gk5yBR4vBAb4E5pltxRKSc85uOCC57TCDxJkENskN+LQA3cPM25YgYXAjF6KF4QYDm+QDvA6Da8l5ANYiT0gLwwGEFgawFgOQFrwOO8yXcHjGuQTJmTPSDIBa0nkMzyQ2W+Lzvnx778HHBWUJ/PwSyQ8fS26zlpM7fvjgzR58DmPmYTgAZ4Nih4iI5EEwGT8QUDsKRsEoGAUjEwAA6U5JKJWmwjwAAAAASUVORK5CYII=","orcid":"","institution":"Liverpool John Moores University","correspondingAuthor":true,"prefix":"","firstName":"Sam","middleName":"","lastName":"Burton","suffix":""},{"id":472984980,"identity":"164bdf55-3712-4a7b-9630-66598ff7a9d8","order_by":1,"name":"Rebecca Monk","email":"","orcid":"","institution":"Edge Hill University","correspondingAuthor":false,"prefix":"","firstName":"Rebecca","middleName":"","lastName":"Monk","suffix":""},{"id":472984981,"identity":"bb6b34d6-6df7-4aba-a558-15d5981e151d","order_by":2,"name":"Emma Davies","email":"","orcid":"","institution":"Oxford Brookes University","correspondingAuthor":false,"prefix":"","firstName":"Emma","middleName":"","lastName":"Davies","suffix":""},{"id":472984982,"identity":"e094dfc4-1fbc-49c4-be4b-df6ceb22d117","order_by":3,"name":"Megan Goodier","email":"","orcid":"","institution":"Liverpool John Moores University","correspondingAuthor":false,"prefix":"","firstName":"Megan","middleName":"","lastName":"Goodier","suffix":""},{"id":472984983,"identity":"5355ff69-c9d2-4327-9243-3b7f2420b6c5","order_by":4,"name":"Abigail Rose","email":"","orcid":"","institution":"Liverpool John Moores University","correspondingAuthor":false,"prefix":"","firstName":"Abigail","middleName":"","lastName":"Rose","suffix":""}],"badges":[],"createdAt":"2025-06-18 09:03:04","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6921157/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6921157/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85071439,"identity":"da85f0d4-0b98-42e3-a376-18fca8af44fa","added_by":"auto","created_at":"2025-06-20 15:40:06","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":46290,"visible":true,"origin":"","legend":"\u003cp\u003eAlcoholic (7.5 and 11 %) drinks were perceived as more harmful than alcohol-free drinks. Perceived harm scores were higher in the ‘own’ drinking scenario compared with the ‘observed’ drinking scenario.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6921157/v1/4a12abd9b7effe8fb6818bb4.jpeg"},{"id":85072044,"identity":"4ae59721-8bab-4c12-a0a0-64e43ba4e75c","added_by":"auto","created_at":"2025-06-20 15:48:06","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":44698,"visible":true,"origin":"","legend":"\u003cp\u003eParticipants agreed more with the alcohol-free choice compared with either the lower (7.5% ABV) or standard (115 ABV) alcoholic drink choices.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6921157/v1/19fea6232b38b6d5d7104f52.jpeg"},{"id":85072848,"identity":"5bca8408-158d-4b3f-a050-9fd72fe0e21c","added_by":"auto","created_at":"2025-06-20 15:56:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":967900,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6921157/v1/5fdad276-c877-4133-9eea-588fb0b2ff09.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eImpact of alcohol strength on attitudes and decisions concerning special occasion drinking during pregnancy\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eAlcohol is the most widely used drug of women of typical child-bearing age, and prenatal alcohol use is the dominant preventable cause of birth defects and intellectual disabilities (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In 2016, the UK\u0026rsquo;s Chief Medical Officer guidelines were revised, adopting a \u0026lsquo;precautionary principle\u0026rsquo; approach which recommended abstinence while trying to conceive and throughout pregnancy. However, the UK continues to have one of the highest estimated rates of alcohol exposed pregnancies (AEP): 41.3%, compared to a pooled global estimate of 9.8% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Subsequently, the UK also has a high modelled prevalence rate of FASD (3.2%) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), and it is estimated that 1 in every 13 pregnancies with some level of alcohol exposure results in fetal alcohol spectrum disorder (FASD), with risk increasing with heavier drinking (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). FASD is an umbrella term covering a range of neurodevelopmental issues and is associated with poorer life outcomes (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) and an estimated UK cost of \u0026pound;2 b p/a (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Low to moderate prenatal alcohol exposure is also associated with increased health risks to the child (e.g., mental health problems, low birth weight, preterm birth) (\u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). FASD can also impair the wellbeing of birth mothers, who are often blamed and stigmatised for drinking during pregnancy (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). There are common, inaccurate assumptions that birth mothers of children with FASD have alcohol use disorder, \u0026lsquo;wilfully\u0026rsquo; drink during pregnancy despite known risks, and are unfit mothers (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). This can result in poorer maternal mental health with increased experiences of depression, guilt, and stress (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven that 28.5% of UK women report drinking alcohol following pregnancy recognition (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) and the significant potential harms of AEP to the mother and child, it is important to identify factors that may increase likelihood of drinking following pregnancy recognition. Evidence from several countries identifies special occasions as one such risk factor (\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Indeed, when Tsang and colleagues (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) surveyed pregnant women, they found that most women (61.3%) who drank after pregnancy recognition reported doing so during special occasions, and this included women who were non- and low-risk drinkers prior to pregnancy. Importantly, asking about special occasion drinking identified an additional 33.3% of respondents reporting alcohol use during pregnancy, who would not otherwise have been captured. This suggests that special occasions represent a risk to pregnant women that is likely under-reported and thus poorly understood.\u003c/p\u003e \u003cp\u003ePerception of harm is another important factor, with many health behaviour change interventions incorporating risk perception components (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Women often recognise that drinking in pregnancy can be harmful (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), whether or not they have been pregnant themselves (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Yet contradictory attitudes are common, and the strength or \u0026lsquo;potency\u0026rsquo; of the drink appears to influence harm perception (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). This raises the possibility that increasing the availability of lower strength alcohol products, while intended as a harm reduction strategy (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), may have some unintended, negative consequences. There are several categories of \u0026lsquo;NoLo\u0026rsquo; drink products, e.g., alcohol-free (\u0026le;\u0026thinsp;0.05% ABV), de-alcoholised (0.05\u0026ndash;0.5% ABV), and low alcohol (\u0026le;\u0026thinsp;1.2% ABV). There are also a growing range of alcohol products with an ABV lower than \u0026lsquo;standard\u0026rsquo; (e.g., beers under 4%, wines under 11% [if wine is under 8% it may be called a wine-based drink]) (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Importantly, there is a lack of awareness by the public in terms of what constitutes these categories (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), so it is possible that people may class lower than standard ABV beverages similarly to NoLo drinks and choose to drink them when they would normally abstain (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). In the context of recommendations to avoid all alcohol consumption during pregnancy, the perceived risk of such beverages may be a factor in women\u0026rsquo;s decision making, raising concern as the market share of these products increases.\u003c/p\u003e \u003cp\u003eSupporting women to abstain from alcohol during pregnancy is a public health priority. Identifying factors that increase drinking during pregnancy or promote more accepting attitudes towards it can inform effective, evidence-based policies and public health interventions to reduce AEP. Social support can reduce and increase risky drinking in the general population (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), and pregnant women often report drinking with friends or family (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Therefore, research should explore harm perception in both women who have been pregnant and those who have not, as both groups may influence pro/anti-attitudes of AEP and the latter could become pregnant in the future. However, there is an important distinction between these two populations, with those having experience of pregnancy likely to use their own alcohol use during this time to evaluate other pregnant people\u0026rsquo;s drinking behaviour. This is termed the \u0026lsquo;self-image bias\u0026rsquo; (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), and has been demonstrated when assessing other\u0026rsquo;s drug use (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), therefore the impact of personal drinking habits needs to be considered. Additionally, when examining harm perceptions, it is important to consider the impact of \u0026lsquo;framing\u0026rsquo;. Evidence shows that individuals tend to underestimate the risks of their own alcohol use due to the \u0026lsquo;unrealistic optimism bias\u0026rsquo;, while judging other people\u0026rsquo;s drinking as more harmful (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). As such, it is useful to compare harm perception when judging personal versus other people\u0026rsquo;s alcohol use, to explore how best to frame public health messaging for maximal impact.\u003c/p\u003e \u003cp\u003eThe current research used a vignette (scenario) method to determine, for the first time, attitudes and decision making around special occasion alcohol use during pregnancy, and the impact of alcohol strength on these outcomes. Based on the perceived reduced risk of harm from lower alcohol strength products, we hypothesised that individuals exposed to scenarios depicting lower strength alcohol consumption would judge drinking during pregnancy as less harmful and more acceptable than standard alcohol strength vignettes. By incorporating vignettes depicting the participant\u0026rsquo;s personal (hypothetical) alcohol use \u003cem\u003evs\u003c/em\u003e that of another pregnant woman, we assessed the (unrealistic) optimism bias, and hypothesised that people would judge other pregnant woman\u0026rsquo;s alcohol use as most harmful. Finally, given the self-image bias, we hypothesised that within participants who had experience of pregnancy, their own alcohol use during pregnancy would reflect their harm and acceptability judgements of AEP in the vignettes.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eAll participants were aged 18 or over, were fluent in English, and self-identified as being assigned female at birth, in total 1030 participants were recruited.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eDemographics\u003c/strong\u003e \u003cp\u003eAge, ethnicity, sexuality, gender identity, relationship status, highest level of education, current occupation, average household income (before tax), history of pregnancy, number and age of children, UK area of residence. In study 3 participants were asked how many weeks pregnant they were.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCurrent alcohol consumption\u003c/strong\u003e \u003cp\u003eThe Timeline Followback (TLFB, (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e)) assessed weekly alcohol use. Using a diary format, participants were asked to record how many and what type of drink (e.g., large/small glass of wine, pint of beer) they had consumed over the past 14 days. Drinks were converted to units (1 UK unit\u0026thinsp;=\u0026thinsp;8 g alcohol) and an average was calculated for weekly alcohol unit consumption.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eAlcohol harm\u003c/em\u003e: The alcohol use disorders identification test (AUDIT (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e)) assessed alcohol use and potentially harmful drinking behaviour (10 items). Scores indicate 0\u0026ndash;7: low risk drinking, 8\u0026ndash;15: increasing risk, 16\u0026ndash;19: higher risk, 20\u0026thinsp;+\u0026thinsp;possible dependence. For women it is recommended that low risk drinking is scored 0\u0026ndash;6.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAlcohol use and pregnancy\u003c/strong\u003e \u003cp\u003eParticipants who indicated they were currently or historically pregnant were asked whether they changed their drinking habits (increased, no change, decreased, abstained) during different stages (3 months before pregnancy, 0\u0026ndash;2 weeks, 3\u0026ndash;6 weeks, 7\u0026ndash;12 weeks, 12\u0026ndash;26 week [second trimester], from week 27 [third trimester]). Participants were also asked in what contexts they had consumed alcohol during pregnancy. Several fixed options were given (e.g., special occasions [wedding, party], special periods [Christmas, Easter], with friends when out, with partner at home, when alone etc) as well as free text options.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eVignette/Scenario\u003c/em\u003e: A short scenario described a woman called Sarah attending her friend\u0026rsquo;s wedding reception or as if the participant was attending as themselves, in both they are pregnant. Participants were randomly assigned to a vignette. As the vignette progressed, accompanying images were included to help the participant imagine the scenario (e.g., wedding marquee, people celebrating). The atmosphere was described as exciting and fun, with the individual enjoying spending time with friends. The scenario explains that the group decides to go to the bar to get drinks and everyone chooses to get a glass of sparkling wine to celebrate. The vignette states that the individual wants to join her friends and then introduces the information that the individual is pregnant. The vignette states that the individual asks the bar person if there is an alcohol-free sparkling wine available. At this point, participants are randomised to one of three drink availability conditions: standard 11% ABV, lower strength 7.5% ABV, and alcohol free 0.0% ABV. In each condition, Sarah decides to accept the drink that is available.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAttitudes around choice (primary outcome)\u003c/strong\u003e \u003cp\u003eFollowing the end of the vignette, participants were asked two questions, \u0026lsquo;Do you agree with Sarah\u0026rsquo;s/your drink choice?\u0026rsquo; and \u0026lsquo;To what extent do you think Sarah\u0026rsquo;s/your choice may harm her/your baby?\u0026rsquo;. Participants responded on a sliding scale from 0 (not at all) to 100 (very much).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eProcedure\u003c/strong\u003e \u003cp\u003eThe study recruited participants through social media sites (e.g., Twitter, Facebook) and Prolific (an online research recruitment platform). Interested individuals clicked on a link, which took them to the Participant Information Sheet. After providing online consent, participants provided demographic information, before reading the vignette and completing all questions in the order provided above (i.e. personal drinking habits were recorded after the vignette task to avoid these scales influencing responses). Sections on personal drinking habits included a statement that we made no judgement on participant\u0026rsquo;s alcohol choices. Two attention checks were distributed throughout the study. A debrief at the end provided guidelines on alcohol use during pregnancy and signposting to further information.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eAnalysis\u003c/b\u003e: Participants were removed who did not pass attention checks (n\u0026thinsp;=\u0026thinsp;21) leaving a final combined sample of 1130. Analysis was performed in R studio using the dplyr packages. Between subjects ANOVA\u0026rsquo;s were applied using the aov function in R. Independent variables were scenario (2 levels: self and other person), alcohol (three levels: no alcohol, low alcohol, standard alcohol) and drank in pregnancy (two levels: consumed alcohol, consumed no alcohol). Dependent variables were perceived harm of consuming alcohol (scored 0-100), and extent of which the participant agrees with the drink choice (scored 0-100). Sub-group analysis was conducted on those who were currently pregnant, as a sensitivity analysis.\u003c/p\u003e \u003cp\u003e\u003cb\u003eEthics statement\u003c/b\u003e: Participants provided online informed consent: a tick box stating they had read/understood the participant information sheet, met inclusion criteria, and agreed to take part in the study. Only after this consent was provided did the study launch (via Qualtrics). The studies received ethical approval from the Psychology Research Ethics Committee at Liverpool John Moores University. Data collection occurred between 23/01/2022-21/12/2024.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cem\u003eParticipant characteristics\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThere were no significant differences between observed and self-rated vignette demographics (see Table 1). There were also no differences in demographics (\u003cem\u003ep\u003c/em\u003e\u0026gt;.05); mean age (standard deviation) was 39.40 (\u0026plusmn;12.91) years, and most participants were white (76.21%), married/cohabiting (58.13%), heterosexual (81.19%), and employed (64.68%) (see supplemental Table 1 for full demographic breakdown). Of the respondents who reported having been pregnant, 19.42% reported alcohol use at some point in pregnancy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Descriptive characteristics of the sample, split by study and total, displaying means (standard deviations), median (interquartile range) and n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"641\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-Vignette\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=606)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSarah Vignette (n=522)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Total\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=1030)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e37.62 (12.80)\u003c/p\u003e\n \u003cp\u003e34.00 (17.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e36.98 (10.89)\u003c/p\u003e\n \u003cp\u003e34.00 (11.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e37.31 (11.94)\u003c/p\u003e\n \u003cp\u003e34.00 (14.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeekly alcohol units\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8.01 (15.48)\u003c/p\u003e\n \u003cp\u003e2.07 (9.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5.83 (11.21)\u003c/p\u003e\n \u003cp\u003e.71 (9.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6.99 (13.70)\u003c/p\u003e\n \u003cp\u003e1.34 (8.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAUDIT\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003cp\u003en harmful drinkers (%)\u003c/p\u003e\n \u003cp\u003en hazardous drinkers (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.99 (5.63)\u003c/p\u003e\n \u003cp\u003e3.00 (6.00)\u003c/p\u003e\n \u003cp\u003e83 (13.72)\u003c/p\u003e\n \u003cp\u003e15 (2.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.55 (4.53)\u003c/p\u003e\n \u003cp\u003e3.50 (6.00)\u003c/p\u003e\n \u003cp\u003e121 (23.18)\u003c/p\u003e\n \u003cp\u003e4 (.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.78 (5.15)\u003c/p\u003e\n \u003cp\u003e3.00 (6.00)\u003c/p\u003e\n \u003cp\u003e204 (18.05)\u003c/p\u003e\n \u003cp\u003e19 (1.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eAny Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e4 (.67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e4 (.77%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e8 (.71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eAsian - British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e25 (4.12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e19 (3.64%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e44 (3.89%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eAsian - Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e11 (1.82%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e5 (.96%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e16 (1.42%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eBlack - British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e29 (4.79%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e8 (1.53%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e37 (3.27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eBlack - Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e39 (6.44%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e4 (.77%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e43 (3.80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eMixed - Any\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e14 (2.31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e15 (2.87%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e29 (2.57%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eWhite - Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e50 (8.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e46 (8.81%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e96 (8.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e401 (66.17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e404 (77.40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e806 (71.33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e29 (4.79%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e13 (2.48%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e43 (3.80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eI prefer not to answer this question\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e4 (.67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e4 (.77%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e8 (.71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eRelationship Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eDivorced or separated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e28 (4.62%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e17 (3.26%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e45 (3.98%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eI prefer not to answer this question\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e2 (.33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e2 (.38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e4 (.35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eIn a relationship (not co-habitating)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e74 (12.21%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e46 (8.81%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e121 (10.71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eMarried or co-habitating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e367 (60.56%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e360 (68.97%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e727 (64.34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e97 (16.01%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e75 (14.37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e172 (15.22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eWidowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e4 (.66%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e1 (.19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e5 (.44%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e34 (5.61%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e21 (4.02%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e56 (4.96%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eDoctorate degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e40 (6.60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e19 (3.64%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e59 (5.22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eMaster\u0026apos;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e128 (21.12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e99 (18.97%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e228 (20.17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eBachelor\u0026apos;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e210 (34.65%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e200 (38.31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e410 (36.28%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eProfessional degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e16 (2.64%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e10 (1.92%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e26 (2.30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eTrade/technical/vocational training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e40 (6.60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e63 (12.07%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e103 (9.12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eSecondary School / College (e.g. A\u0026apos;Level)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e97 (16.01%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e77 (14.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e174 (15.40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eSecondary school (e.g. GCSE)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e42 (6.93%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e39 (7.47%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e81 (7.17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003ePrimary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e2 (.33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e2 (.18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eOther, please specify\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e4 (.66%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e4 (.76%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e8 (.71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003ePrefer not to answer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1 (.17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e2 (.18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e26 (4.29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e11 (2.11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e37 (3.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e395 (65.16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e353 (67.62%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e749 (66.30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eSelf-employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e44 (7.26%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e36 (6.90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e80 (7.08%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eMaternity leave\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e30 (4.95%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e24 (4.60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e54 (4.78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eStay at home mum/homemaker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e39 (6.44%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e50 (9.58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e89 (7.88%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eRetired\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e27 (4.46%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e18 (3.45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e45 (3.98%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eUnable to work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e13 (2.15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e9 (1.72%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e22 (1.95%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e21 (3.47%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e20 (3.83%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e41 (3.63%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003ePrefer not to answer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e11 (1.82%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e5 (.96%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e16 (1.42%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e26 (4.29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e7 (1.34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e34 (3.01%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCountry of Residence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eUnited Kingdom\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e576 (95.05%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e513 (98.28%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e1090 (96.46%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e8 (1.32%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e3 (.57%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e12 (1.06%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e22 (3.63%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e6 (1.15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e28 (2.48%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSexuality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eHeterosexual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e497 (82.01%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e437 (83.72%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e935 (82.74%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eBisexual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e33 (5.45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e46 (8.81%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e79 (6.99%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eLesbian/Gay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e18 (2.97%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e13 (2.49%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e31 (2.74%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e9 (1.49%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e6 (1.15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e15 (1.33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003ePrefer not to say\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e14 (2.31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e11 (2.11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e25 (2.21%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e35 (5.77%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e9 (1.72%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e45 (3.99%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eWoman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e574 (94.72%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e509 (97.51%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e1084 (95.93%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eTransman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e4 (.66%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e4 (.35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eGender fluid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e1 (.19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e1 (.09%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eNon-binary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e3 (.58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e3 (.27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1 (.17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e2 (.38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e3 (.27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003ePrefer not to say\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1 (.17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e1 (.09%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e26 (4.28%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e7 (1.34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e34 (3.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eDescriptive characteristics of the sample, split by study and total, displaying means (standard deviations), median (interquartile range) and n (%)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerceived harm analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBetween subjects ANOVA was applied with independent variables of scenario (two levels: own and observed drinking scenarios), alcohol alcohol (three levels: no alcohol, lower alcohol, and standard alcohol) and drank in pregnancy (two levels: consumed alcohol, consumed no alcohol), and the dependent variable of perceived harm of the vignette\u0026rsquo;s drink choice on the unborn baby. There was a significant main effect of scenario on perceived harm, F(1,693)=22.35, \u003cem\u003ep\u003c/em\u003e\u0026lt;.001,\u0026nbsp;h\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep\u003c/sub\u003e=.03. Contrary to our hypothesis based on the unrealistic optimism bias, those in the \u0026lsquo;own drinking\u0026rsquo; scenario (M= 36.74, SD=35.01) reported higher levels of perceived harm than those in the \u0026lsquo;observed drinking\u0026rsquo; scenario (M=29.04, SD=31.85, \u003cem\u003ep\u0026lt;\u003c/em\u003e.001). Additionally, alcohol was a significant main effect, F(2, 693)=46.07, \u003cem\u003ep\u0026lt;\u003c/em\u003e.001,\u0026nbsp;h\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep\u003c/sub\u003e=.12. Against our hypothesis, both standard (M=45.17, SD=33.16) and lower strength alcohol (M=41.91, SD=33.05) were viewed as significantly more harmful to the unborn baby than non-alcohol drinks (M=11.78, SD=23.48, \u003cem\u003ep\u0026lt;\u003c/em\u003e.001), but there was no significant difference between lower or standard strength alcohol (\u003cem\u003ep\u003c/em\u003e=.373).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[Insert Figure 1 here]\u003c/p\u003e\n\u003cp\u003eOf participants who had experienced pregnancy but not currently pregnant (n=409), there was a main effect of drinking in pregnancy, F(1,693)=16.92, \u003cem\u003ep\u003c/em\u003e\u0026lt;.001,\u0026nbsp;h\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep\u003c/sub\u003e=.02. In line with our hypothesis based on the self-image bias, those who consumed alcohol during pregnancy (M=20.12, SD=27.18) viewed the consumption of alcohol as significantly less harmful to the unborn baby than those who had not consumed alcohol during pregnancy (M=32.96, SD=34.78, \u003cem\u003ep\u003c/em\u003e\u0026lt;.001).\u003c/p\u003e\n\u003cp\u003eSub-group analysis was carried out on those who were currently pregnant (n=296). Between subjects ANOVA was applied with independent variables of scenario (two levels: own and observed drinking scenarios) and alcohol (three levels: no alcohol, lower alcohol, and standard alcohol), and the dependent variable of perceived harm of the vignette\u0026rsquo;s drink choice on the unborn baby. There was a significant main effect of alcohol, F(2,294)=23.31, \u003cem\u003ep\u003c/em\u003e\u0026lt;.001,\u0026nbsp;h\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep\u003c/sub\u003e=.14, on harm perception. Standard (M=46.70, SD=33.51) and lower strength alcohol (M=43.35, SD=32.36) were viewed as significantly more harmful to the unborn baby than non-alcohol drinks (M=19.37, SD=31.98, \u003cem\u003ep\u0026lt;\u003c/em\u003e.001), but there was no significant difference between lower or standard strength alcohol (\u003cem\u003ep\u003c/em\u003e=.774). There was a significant interaction between scenario and alcohol, F(2,294)=4.07, \u003cem\u003ep\u003c/em\u003e\u0026lt;.05,\u0026nbsp;h\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep\u003c/sub\u003e=.03. Post hoc analysis showed a significant difference between perception of harm for no alcohol wine (0% ABV) based upon observing (M=7.92, SD=21.32) and own (M=29.33, SD=36.31), \u003cem\u003ep\u003c/em\u003e\u0026lt;.001, all other comparisons were non-significant (\u003cem\u003ep\u0026rsquo;s\u003c/em\u003e\u0026gt;.996).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAgreement with choice analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBetween subjects ANOVA was applied with independent variables of scenario (two levels: own and observed drinking scenarios), alcohol (three levels: no alcohol, lower alcohol, and standard alcohol) and drinking in pregnancy (two levels: consumed alcohol, consumed no alcohol), on the dependent variable of extent of which participants agreed with the drink choice. There was a main effect of scenario, F(1,694)=11.65, \u003cem\u003ep\u003c/em\u003e\u0026lt;.001,\u0026nbsp;h\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep\u003c/sub\u003e=.02, those who observed Sarah drinking (M=42.49, SD=40.99) agreed with alcohol use significantly more than those who rated their own drinking (M=39.93, SD=39.59, \u003cem\u003ep\u003c/em\u003e\u0026lt;.001). There was a significant main effect of alcohol, F(2,694)=293.84, \u003cem\u003ep\u003c/em\u003e\u0026lt;.001,\u0026nbsp;h\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep\u003c/sub\u003e=.46. No alcohol drinks (M=84.02, SD=25.82) were significantly more agreeable than lower alcohol (M=22.85, SD=28.95, \u003cem\u003ep\u003c/em\u003e\u0026lt;.001) and standard alcohol drinks (M=17.23, SD=24.87, \u003cem\u003ep\u003c/em\u003e\u0026lt;.001), but there was no significant difference between lower and standard strength alcohol (\u003cem\u003ep\u003c/em\u003e=.181).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[Insert Figure 2 here]\u003c/p\u003e\n\u003cp\u003eThere was a main effect of drinking in pregnancy, F(1,694)=65.79, \u003cem\u003ep\u003c/em\u003e\u0026lt;.001,\u0026nbsp;h\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep\u003c/sub\u003e=.09, those who consumed alcohol during pregnancy (M=55.53, SD=36.09) reported higher levels of agreement with the drink choice than those who had not consumed alcohol during pregnancy (M=36.65, SD=41.16, \u003cem\u003ep\u003c/em\u003e\u0026lt;.001).\u003c/p\u003e\n\u003cp\u003eSub-group analysis was carried out on those who were currently pregnant (n=296). Between subjects ANOVA was applied with independent variables of scenario (two levels: own and observed drinking scenarios) and alcohol (three levels: no alcohol, lower alcohol, and standard alcohol), and the dependent variable of perceived harm of the vignette\u0026rsquo;s drink choice on the unborn baby. There was a significant main effect of alcohol, F(2,294)=147.06, \u003cem\u003ep\u003c/em\u003e\u0026lt;.001,\u0026nbsp;h\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep\u003c/sub\u003e=.50, on agreement perception. Standard (M=16.56, SD=22.74) and lower strength alcohol (M=21.29, SD=29.73) were viewed as significantly less agreeable to consume than non-alcohol drinks (M=77.25, SD=31.89, \u003cem\u003ep\u0026lt;\u003c/em\u003e.001), but there was no significant difference between lower or standard strength alcohol (\u003cem\u003ep\u003c/em\u003e=.454). There was a significant interaction between scenario and alcohol, F(2,294)=3.47, \u003cem\u003ep\u003c/em\u003e\u0026lt;.05,\u0026nbsp;h\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep\u003c/sub\u003e=.02. Post hoc analysis showed a significant difference between perception of agreeableness for no alcohol wine (0% ABV) based upon observing (M=86.00, SD=26.36) and own (M=69.63, SD=34.48), \u003cem\u003ep\u003c/em\u003e\u0026lt;.05, all other comparisons were non-significant (\u003cem\u003ep\u0026rsquo;s\u003c/em\u003e\u0026gt;.996).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eSupporting women to abstain during pregnancy is a public health priority which can substantially benefit both mother and child wellbeing and health (41, 42). Population-wide strategies have identified lower strength alcohol products as one way to reduce alcohol harms (27). However, it is possible that if lower strength alcohol is perceived as less harmful, then some individuals may be more likely to drink alcohol when, typically, they would choose to abstain (e.g., in pregnancy). It is also known that special occasions can be a time when drinking in pregnancy is more likely (21). This study used a novel vignette paradigm to explore perceived harm of drinking alcohol at varying strengths during pregnancy, and the extent to which women agreed with drinking choices during a special occasion.\u003c/p\u003e\n\u003cp\u003eIndicating that people draw distinctions between products when considering what to consume during pregnancy, we found (as expected) that both standard (11% ABV) and lower (7.5% ABV) alcohol products were perceived as more harmful than the alcohol-free beverage, and people agreed less with the drink choice when it contained any alcohol. Unexpectedly, there was no difference in perceived harm or agreement between the standard and lower ABV drinks. The precautionary principle of abstinence was introduced in the UK in 2016 and, as part of standard care, midwives should be providing this information at antenatal appointments. As such, our findings may be viewed as promising evidence that the recommendations to abstain entirely throughout pregnancy maybe influencing women, and that lower alcohol products are being placed in the same category of harm as products of standard ABV, even in the context of a special occasion (which is a known risk factor for drinking in pregnancy (21)). On the other hand, certain groups of women, e.g. those with alcohol use disorder, can find abstinence very difficult to achieve (33). Although controversial and beyond this study, future research may look at the potential for harm reduction strategies in complex needs group, which incorporate low alcohol products, perhaps as part of a stepped treatment approach towards the recommended abstinence goals.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlso affording a somewhat optimistic view, while there were no differences in agreement with drink choice, participants who were asked to imagine their own consumption in the scenario reported higher levels of perceived harm than the participants asked to assess another person\u0026rsquo;s (Sarah\u0026rsquo;s) drinking. In a manifestation of the (unrealistic) optimism bias (36, 37), it has been shown that people tend to underestimate risk of harms from their own alcohol use, while judging other people\u0026rsquo;s drinking as more harmful (37, 38, 43), yet our current finding suggests this is not the case when judging pregnancy-related alcohol harm. This fits with a study that found a lack of unrealistic optimism bias in South African pregnant women regarding risks of drinking in pregnancy (44). Indeed, in the context of pregnancy, self-perceptions of harm may be magnified in contrast to perceived harm to others, perhaps because fetus protection is a primary motive for not drinking during pregnancy \u0026nbsp;(23, 45-47). Our findings therefore suggest that asking women to evaluate potential alcohol risks in a more personal way (i.e., harm to your own pregnancy) may be an effective strategy to magnify perceived potential harms and thus reduce AEP.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOf more concern, although expected, is our finding that respondents who had consumed alcohol during their own pregnancies tended to perceive the consumption of alcohol in the vignettes as less harmful and more agreeable than respondents who did not drink during their own pregnancy. According to the self-image bias, we judge others by our own yardstick (34) and this has been found to apply to assessment of other people\u0026rsquo;s drug use (35). Evidence suggests that some pregnant women and mothers are not convinced that low level alcohol use during pregnancy is harmful, they find the evidence and information given confusing, inconsistent and/or incorrect, and some believe that abstinence messaging is patriarchal (23, 24, 45). \u0026nbsp;Women, who had previously been pregnant but weren\u0026rsquo;t currently, judged drinking in pregnancy to be less harmful, they may be more likely to drink when pregnant but may also project that belief onto others in a similar situation. This is in contrast to women who were currently pregnant who viewed all alcohol consumption as harmful in comparison to no alcohol alternatives. This could have implications for pregnant women who may be subjected to social pressures during special occasions where normative affordances for consumption are particularly high (48, 49).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere are limitations to this study. First, we specified ABV % based on products that are currently on the market to make the results more applicable, however, it is not known whether there is a \u0026lsquo;tipping point\u0026rsquo; at which ABV % is perceived as significantly more or less harmful. If such a tipping point exists, this may differ across beverage type. For instance, we used wine in the current study, but some women perceive risk from wine consumption as lower than other types of alcohol when pregnant (19, 48, 50, 51), and use type of alcohol rather than strength to evaluate risk (19). Second, we focused on a single drinking occasion during a celebratory event, because special occasion drinking is a known risk for drinking in pregnancy. However, evidence shows that many women feel that low level, occasional alcohol use is acceptable during pregnancy (19, 23). Given the evidence that risk of fetal alcohol harms is greater as levels of consumption increase and is particularly associated with binge drinking (52, 53), these attitudes are understandable. It is therefore possible that perceived harm and agreement would differ if we had included more \u0026lsquo;every day\u0026rsquo; drinking scenarios. Third, we recruited women with and without experience of pregnancy. Although non-pregnant women are not the immediate target audience of this research, their inclusion is important. Better understanding of the factors that influence women\u0026rsquo;s attitudes and decisions around alcohol use behaviour during pregnancy can inform prevention strategies, either for women who become pregnant in the future and/or which incorporate components of social support/transmission of health information and advice. Last, we recruited a convenience sample which reported low levels of alcohol use, and we cannot assume heavier drinkers would respond in a similar way.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFuture research can overcome these limitations by assessing perceptions towards a wider variety of alcohol strengths and products (e.g., wine/beer/spirits), across different situations, and by comparing different subpopulations of drinkers to develop a more nuanced understanding of this issue. This is important given the finding that people who consume higher levels of alcohol use may underestimate how harmful alcohol can be (54). Future research could also use ecological momentary assessment tools to assess how drinking attitudes and harm perception may differ across pregnancy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe would highlight, that despite our participant group\u0026rsquo;s low level of current drinking, 19.42% reported some level of drinking in pregnancy. This finding confirms that alcohol exposed pregnancy in the UK is a significant public health issue and not something restricted to pregnant people with pre-existing hazardous or harmful drinking behaviours. We would also argue that any strategies to increase prevalence rates of abstinence during pregnancy carefully consider women\u0026rsquo;s perceptions of harm across drinking levels, and work with women to develop ways to justify the precautionary principle which focuses on supporting the health and wellbeing of the woman, as well as the child.\u003c/p\u003e\n\u003cp\u003eThis novel study suggests that lower strength alcohol products are still perceived as harmful when considering special occasion drinking during pregnancy. This means that lower strength alcohol products may not be a risk for alcohol use in pregnancy, although we have outlined recommendations for future research to confirm this. This work also reinforces the importance that public health campaigns to reduce AEP should be framed so that women can understand that potential harms are directly applicable to their own drinking behaviours and pregnancy, and aligns with efforts to ensure women do not feel judged or stigmatised for their behaviour, and that compassionate framing supports women\u0026rsquo;s wellbeing.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate:\u0026nbsp;\u003c/strong\u003eEthical approval was obtained from School of Psychology Research Ethics Committee, Liverpool John Moores University (reference number 22-PSY-020). Participants were informed, and their involvement was voluntary. Consent was obtained from all subjects. The study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003e Consent is given as the individuals in the study are entirely unidentifiable and there are no details on individuals reported.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eData can be accessed on the following link on the OSF repository https://osf.io/kpq63/?view_only=681f9a50c4f4429ea3219b9dc521e875.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest:\u0026nbsp;\u003c/strong\u003eNone to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis work received no funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003eConceptualisation SB, RM, ED, AKR: Data Curation SB, AKR: Formal analysis SB, Investigation: SB, RM, ED, MG, AKR: Methodology SB, RM, ED, AKR: Project administration SB: Resources SB, RM, ED, AKR: Software SB, AKR: Validation SB, RM, ED, AKR: Visualisation SB: Writing- Original Draft Preparation, SB, RM, ED, MG, AKR: Writing-Reviewing \u0026amp; Editing, SB, RM, ED, MG, AKR\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e None\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBaer JS, Sampson PD, Barr HM, Connor PD, Streissguth AP (2003) A 21-year longitudinal analysis of the effects of prenatal alcohol exposure on young adult drinking. Arch Gen Psychiatry 60(4):377\u0026ndash;385\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePopova S, Lange S, Probst C, Gmel G, Rehm J (2018) Global prevalence of alcohol use and binge drinking during pregnancy, and fetal alcohol spectrum disorder. Biochem Cell Biol 96(2):237\u0026ndash;240\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePopova S, Lange S, Probst C, Gmel G, Rehm J (2017) Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis. Lancet Glob Health 5(3):e290\u0026ndash;e9\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLange S, Probst C, Gmel G, Rehm J, Burd L, Popova S (2017) Global Prevalence of Fetal Alcohol Spectrum Disorder Among Children and Youth: A Systematic Review and Meta-analysis. JAMA Pediatr 171(10):948\u0026ndash;956\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLange S, Probst C, Rehm J, Popova S (2017) Prevalence of binge drinking during pregnancy by country and World Health Organization region: Systematic review and meta-analysis. Reprod Toxicol 73:214\u0026ndash;221\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSch\u0026ouml;lin L, Mukherjee RA, Aiton N, Blackburn C, Brown S, Flemming KM et al (2021) Fetal alcohol spectrum disorders: an overview of current evidence and activities in the UK. Arch Dis Child 106(7):636\u0026ndash;640\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEasey KE, Dyer ML, Timpson NJ, Munaf\u0026ograve; MR (2019) Prenatal alcohol exposure and offspring mental health: A systematic review. Drug Alcohol Depend 197:344\u0026ndash;353\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAddila AE, Azale T, Gete YK, Yitayal M (2021) The effects of maternal alcohol consumption during pregnancy on adverse fetal outcomes among pregnant women attending antenatal care at public health facilities in Gondar town, Northwest Ethiopia: a prospective cohort study. Substance Abuse Treatment, Prevention, and Policy. ;16(1):64\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChambers CD, Coles C, Kable J, Akshoomoff N, Xu R, Zellner JA et al (2019) Fetal Alcohol Spectrum Disorders in a Pacific Southwest City: Maternal and Child Characteristics. Alcohol Clin Exp Res 43(12):2578\u0026ndash;2590\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMamluk L, Edwards HB, Savović J, Leach V, Jones T, Moore THM et al (2017) Low alcohol consumption and pregnancy and childhood outcomes: time to change guidelines indicating apparently \u0026lsquo;safe\u0026rsquo; levels of alcohol during pregnancy? A systematic review and meta-analyses. Bmj Open 7(7):e015410\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang G (2023) Reducing Prenatal Alcohol Exposure and the Incidence of FASD: Is the Past Prologue? Alcohol Res 43(1):02\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorton Ninomiya ME, Almomani Y, Dunbar Winsor K, Burns N, Harding KD, Ropson M et al (2023) Supporting pregnant and parenting women who use alcohol during pregnancy: A scoping review of trauma-informed approaches. Womens Health (Lond) 19:17455057221148304\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbadir AM, Ickowicz A (2016) Fetal alcohol spectrum disorder: reconsidering blame. CMAJ 188(3):171\u0026ndash;172\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePaley B, O'Connor MJ, Frankel F, Marquardt R (2006) Predictors of stress in parents of children with fetal alcohol spectrum disorders. J Dev Behav Pediatr 27(5):396\u0026ndash;404\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSanders J, Buck G (2018) A long journey: biological and non-biological parents\u0026rsquo; experiences raising children with FASD. J Popul Ther Clin Pharmacol. ;17(2)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM\u0026aring;rdby A-C, Lupattelli A, Hensing G, Nordeng H (2017) Consumption of alcohol during pregnancy\u0026mdash;A multinational European study. Women Birth 30(4):e207\u0026ndash;e13\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuggli E, O\u0026rsquo;Leary C, Donath S, Orsini F, Forster D, Anderson PJ et al (2016) Did you ever drink more? A detailed description of pregnant women\u0026rsquo;s drinking patterns. BMC Public Health 16(1):683\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBakhireva LN, Leeman L, Roberts M, Rodriguez DE, Jacobson SW (2021) You Didn't Drink During Pregnancy. Did You? Alcohol Clin Exp Res 45(3):543\u0026ndash;547\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeurk CS, Broom A, Adams J, Hall W, Lucke J (2014) Factors influencing women\u0026rsquo;s decisions to drink alcohol during pregnancy: findings of a qualitative study with implications for health communication. BMC Pregnancy Childbirth 14(1):246\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSch\u0026ouml;lin L, Hughes K, Bellis MA, Eriksson C, Porcellato L (2018) Exploring practices and perceptions of alcohol use during pregnancy in England and Sweden through a cross-cultural lens. Eur J Public Health 28(3):533\u0026ndash;537\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsang TW, Kingsland M, Doherty E, Anderson AE, Tully B, Crooks K et al (2022) Predictors of alcohol use during pregnancy in Australian women. Drug Alcohol Rev 41(1):171\u0026ndash;181\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerrer R, Klein WM (2015) Risk perceptions and health behavior. Curr Opin Psychol 5:85\u0026ndash;89\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUjhelyi Gomez K, Goodwin L, Chisholm A, Rose AK (2022) Alcohol use during pregnancy and motherhood: Attitudes and experiences of pregnant women, mothers, and healthcare professionals. PLoS ONE 17(12):e0275609\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHammer R, Rapp E (2022) Women's views and experiences of occasional alcohol consumption during pregnancy: A systematic review of qualitative studies and their recommendations. Midwifery 111:103357\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElek E, Harris SL, Squire CM, Margolis M, Weber MK, Dang EP et al (2013) Women's Knowledge, Views, and Experiences Regarding Alcohol Use and Pregnancy: Opportunities to Improve Health Messages. Am J Health Educ 44(4):177\u0026ndash;190\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErng MN, Reid N, Moritz KM, van Driel M (2023) Prenatal alcohol exposure risk perception dimensions and influencing factors: A systematic review and conceptual model. Aust N Z J Public Health 47(3):100047\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGovernment H (2019) Advancing our health: prevention in the 2020s. UK\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCare DoHS (2018) Low Alcohol Descriptors Guidance. UK\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorfe S, Hyde R, Shepherd J (2020) Alcohol-free and low-strength drinks. Understanding their role in reducing alcohol-related harms. UK\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolmes J, Angus C, Meier PS (2015) UK alcohol industry\u0026rsquo;s billion units pledge: interim evaluation flawed. BMJ: Br Med J 350:h1301\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang M, Liu S, Zhan Y, Shi J (2010) Daily work-family conflict and alcohol use: testing the cross-level moderation effects of peer drinking norms and social support. J Appl Psychol 95(2):377\u0026ndash;386\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRosenquist JN, Murabito J, Fowler JH, Christakis NA (2010) The Spread of Alcohol Consumption Behavior in a Large Social Network. Ann Intern Med 152(7):426\u0026ndash;433\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePopova S, Dozet D, Akhand Laboni S, Brower K, Temple V (2022) Why do women consume alcohol during pregnancy or while breastfeeding? Drug Alcohol Rev 41(4):759\u0026ndash;777\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHill T, Smith ND, Hoffman H (1988) Self-image bias and the perception of other persons' skills. Eur J Social Psychol 18(3):293\u0026ndash;298\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMonk RL, Heim D (2011) Self-image bias in drug use attributions. Psychol Addict Behav 25(4):645\u0026ndash;651\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeinstein ND (1980) Unrealistic optimism about future life events. J Personal Soc Psychol 39(5):806\u0026ndash;820\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShepperd JA, Klein WMP, Waters EA, Weinstein ND (2013) Taking Stock of Unrealistic Optimism. Perspect Psychol Sci 8(4):395\u0026ndash;411\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGual A, \u0026Aacute;ngel Arbes\u0026uacute; J, Zarco J, Balcells-Oliver\u0026oacute; MdlM, L\u0026oacute;pez-Pelayo H, Miquel L et al (2017) Risky Drinkers Underestimate their Own Alcohol Consumption. Alcohol Alcohol 52(4):516\u0026ndash;517\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSobell LC (1993) Timeline followback: A technique for assessing self-reported alcohol consumption. In: Litten RZ, J. A, (ed) Measuring alcohol consumption: psychosocial and biological methods. Humana, New Jersey\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBabor T, Higgins-Biddle JC, Saunders J, Monteiro M (2001) AUDIT. The Alcohol Use Disorders Identification Test. Guidelines for Use in Primary Care. Second Edition\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEngland PH (2020) Maternity high impact area 4: Reducing the incidence of harms caused by alcohol in pregnancy. London UK\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEngland PH (2020) Early years high impact area 2: Maternal mental health. London UK\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorris J, Tattan-Birch H, Albery IP, Heather N, Moss AC (2024) Look away now! Defensive processing and unrealistic optimism by level of alcohol consumption. Psychol Health. :1\u0026ndash;19\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLouw JG, Tomlinson M, Olivier L (2018) Unrealistic optimism with regard to drinking during pregnancy among women of childbearing age in a South African community. South Afr J Psychol 48(2):219\u0026ndash;229\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFleming KM, Gomez KU, Goodwin L, Rose AK (2023) Identifying the motives for and against drinking during pregnancy and motherhood, and factors associated with increased maternal alcohol use. J Public Health\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartinelli JL, Germano CMR, de Av\u0026oacute; LRS, Fontanella BJB, Melo DG (2019) Motivation for alcohol consumption or abstinence during pregnancy: A clinical-qualitative study in Brazil. PLoS ONE 14(10):e0223351\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones SC, Telenta J (2012) What influences Australian women to not drink alcohol during pregnancy? Aust J Prim Health 18(1):68\u0026ndash;73\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrawford-Williams F, Steen M, Esterman A, Fielder A, Mikocka-Walus A (2015) My midwife said that having a glass of red wine was actually better for the baby: a focus group study of women and their partner\u0026rsquo;s knowledge and experiences relating to alcohol consumption in pregnancy. BMC Pregnancy Childbirth 15(1):79\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFletcher T, Mullan B, Finlay-Jones A (2022) Perceptions of two different alcohol use behaviours in pregnancy: an application of the prototype/willingness model. Health Psychol Behav Med 10(1):1071\u0026ndash;1085\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDumas A, Toutain S, Hill C, Simmat-Durand L (2018) Warning about drinking during pregnancy: lessons from the French experience. Reproductive Health 15(1):20\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorrales-Gutierrez I, Mendoza R, Gomez-Baya D, Leon-Larios F (2019) Pregnant Women\u0026rsquo;s Risk Perception of the Teratogenic Effects of Alcohol Consumption in Pregnancy. J Clin Med 8(6):907\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePopova S, Charness ME, Burd L, Crawford A, Hoyme HE, Mukherjee RAS et al (2023) Fetal alcohol spectrum disorders. Nat Reviews Disease Primers 9(1):11\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMukherjee R, Cook PA, Fleming KM, Norgate SH (2017) What can be done to lessen morbidity associated with fetal alcohol spectrum disorders? Arch Dis Child 102(5):463\u0026ndash;467\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSanchez-Ramirez DC, Franklin RC, Voaklander D (2018) Perceptions About Alcohol Harm and Alcohol-control Strategies Among People With High Risk of Alcohol Consumption in Alberta, Canada and Queensland, Australia. J Prev Med Public Health 51(1):41\u0026ndash;50\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Liverpool John Moores University","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 exposed pregnancy, Alcohol by volume, Risk perception, Alcohol harm","lastPublishedDoi":"10.21203/rs.3.rs-6921157/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6921157/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSpecial occasions are a risk factor for drinking during pregnancy. This study determined the impact of alcohol strength on attitudes around, and perceived harm of, drinking in pregnancy. If perceived harm decreases with lower strength alcohol, this may promote drinking when abstinence is recommended.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eTwo online \u0026lsquo;special occasion\u0026rsquo; vignette studies randomised female participants to one of three drink strength conditions (11%, 7.5%, 0% alcohol beverage volume [ABV]). In the study (N\u0026thinsp;=\u0026thinsp;1030), participants were asked to imagine themselves or someone else choosing to consume the beverage when pregnant. Outcome measures assessed how harmful participants thought drink choice was, and the extent to which they agreed with the drink choice.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe standard and lower strength alcohol beverages were viewed as more harmful than the alcohol-free drink (\u003cem\u003ep\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.001), and participants agreed with the alcohol-free drink choice more than the standard and lower strength beverages (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Perceived harm was greater in when rating own hypothetical alcohol use in comparison to rating observed hypothetical alcohol use (\u003cem\u003ep\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.01). Participants who reported drinking in their own pregnancy rated the alcohol choices as less harmful and more agreeable than participants who had not consumed alcohol in their own pregnancies (\u003cem\u003eps\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.001).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ePerceived harm, and the ability to apply the potential harms of drinking during pregnancy to one\u0026rsquo;s own circumstances, may be crucial in reducing the risk special occasions pose to alcohol exposed pregnancies. Public health campaigns should focus on facilitating this, compassionately explaining the risk of harms across a range of drinking behaviours, while explicitly tackling the stigma and shame women may experience around this public health issue.\u003c/p\u003e","manuscriptTitle":"Impact of alcohol strength on attitudes and decisions concerning special occasion drinking during pregnancy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-20 15:40:02","doi":"10.21203/rs.3.rs-6921157/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":"709fe959-38c3-4dd5-a1eb-c0d2067e73bb","owner":[],"postedDate":"June 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":50228933,"name":"Psychology"}],"tags":[],"updatedAt":"2025-06-20T15:40:02+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-20 15:40:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6921157","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6921157","identity":"rs-6921157","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}