Nutrition cues on ready-to-drink alcoholic beverage containers sold in grocery stores in Québec City, Canada

**Background:** Alcohol consumption is associated with over 200 negative health conditions including cancers and liver diseases. The alcohol industry has created ready-to-drink alcoholic beverages (RTDs) to target health-conscious consumers, using nutrition cues on labels that may create a 'health halo' effect, leading consumers to perceive these products as healthier and potentially increasing consumption. In Canada, alcoholic beverages >0.5% ABV are not mandated to display a nutrition facts table (NFT) unless a nutrition-related representation is made, and no specific regulations prohibit nutrient claims on alcohol products. This study aimed to record the use of nutrition cues among RTD containers sold in grocery stores in Québec City, Canada.

**Methods:** In July 2021, all available RTDs (malt-, cider-, or wine-based pre-mixed beverages in single-serve containers) were purchased from three major grocery store banners in Québec City. Products <1.1% ABV were excluded. A total of 193 unique RTDs were identified (149 pre-mixed cocktails, 44 hard seltzers). Information on brand, container size, ABV, nutrient claims (sugar, carbohydrate, calorie), other food-related claims (natural flavour, gluten free, vegan, organic, no preservatives), and NFTs was systematically coded. Containers were photographed to estimate the percentage of surface area occupied by nutrition cues. Logistic regression models examined predictors of nutrition cue presence, adjusting for container size and purchase format. Chi-square tests assessed differences by ABV category.

**Key Results:** Overall, 68% of products had at least one nutrition cue, and 65% had at least one claim. Other food-related claims were most common (86% of hard seltzers, 49% of pre-mixed cocktails; X²=19.41, p<0.0001), followed by NFTs (91% vs. 22%; X²=68.29, p<0.0001) and nutrient claims (82% vs. 17%; X²=64.55, p<0.0001). Hard seltzers were significantly more likely than pre-mixed cocktails to carry any nutrient claim (AOR=19.08, 95%CI:7.47-48.70), sugar claims (AOR=3.66, 95%CI:1.64-8.17), carbohydrate claims (AOR=27.26, 95%CI:7.20-103.19), calorie claims (AOR=18.47, 95%CI:7.34-46.51), and NFTs (AOR=45.49, 95%CI:12.62-163.93). Light-strength beverages (1.1-4.0% ABV) were more likely to carry any nutrient claim (97% vs. 19%, X²=73.76, p<0.0001) and any other food-related claim (88% vs. 52%, X²=14.12, p=0.0002) than regular-strength beverages. The mean percentage of container surface occupied by nutrition cues was 6% overall, significantly higher for hard seltzers (13%) than pre-mixed cocktails (3%) (p<0.0001). Sensitivity analyses showed Québec-only brands were less likely to carry NFTs (AOR=0.3, 95%CI:0.1-0.7) and natural flavour claims (AOR=0.4, 95%CI:0.2-0.8) compared to Canadian/multinational brands.

**Clinical Implications:** The widespread use of nutrition cues on RTDs—particularly hard seltzers and light-strength beverages—may mislead consumers into perceiving these alcoholic products as healthier or less harmful, despite containing ethanol, an addictive psychoactive substance associated with serious health risks even at low consumption levels. This health halo effect could increase selection and intake of these products. The findings support the need for regulatory action to restrict health-oriented nutrition messaging on alcoholic beverage labels, standardize nutrition information across all alcoholic beverage categories, and consider implementing warning labels (e.g., 'Alcohol can cause cancer') to counter misleading nutrition cues. Current Canadian regulations requiring NFTs only when nutrient claims are made create inconsistent labelling that may further confuse consumers.