Republic of Ireland's indoor workplace smoking ban

ON 29 March, in accordance with Article 8 of the World Health Assembly's Framework Convention on Tobacco Control, a ban on smoking in all enclosed places of work, including pubs and restaurants, was introduced in the Republic of Ireland. After 1 month, the Office of Tobacco Control found that 97% of premises inspected nationally were compliant with the smoke-free law. This compliance rate is similar to, or higher than, that achieved in California and New York. How has this come about — in anarchic Ireland of all places?

Firstly, a high level of knowledge and understanding about the reasons for the ban were critical to ensuring compliance. The year of often heated debate — in newspapers, on television, on national and local radio, through expert discussions and phone-ins — meant that no one in the Republic of Ireland remained ignorant of the impending ban, that everyone had an opinion, and that popular support strengthened over the course of the debate as people began to perceive the self-serving nature of the hospitality industry's economic arguments. The strident arguments of the hospitality industry were partially responsible for driving the debate. But the debate was also driven by a carefully managed communications campaign. Non-governmental organisations and government departments used the same few, simple, consistent messages: passive smoking causes serious harm to health, workplace smoking is a health and safety issue, and ventilation does not work.

The high level of knowledge achieved by the communic-ation campaign was indicated by a poll in December 2003, 11 months after the announcement of the ban (and 3 months before the ban came into force). Some 84% of the population knew not only that the ban was coming in, but also that it was for health and safety reasons. Public support has remained strong. A survey commissioned by the Department of Health and Children showed that 4 months after the ban, 82% supported the Smoke-Free at Work measure, 95% agreed that the ban is a positive health measure, and 90% agreed that going smoke-free is of benefit to workers. Most reported that the new legislation improved their experience in pubs (70%) and restaurants (78%).

But this has not been a short-term communication process. It has taken many years of advocacy led by non-governmental organisations — such as ASH (Action on Smoking and Health) Ireland, the Irish Cancer Society, the Irish Heart Foundation — and by public health to raise awareness in trade union and government circles. Eventually there was sufficient concern to lead to the commissioning of an independent scientific working group to assess the degree of consensus that existed among leading scientific authorities on the risk posed to human health by environmental tobacco smoke in the workplace. The Minister of Health and Children considered the findings of this report¹ so stark that he felt he had no option but to bring in the smoking ban.

Meanwhile, ongoing work at community level was critical to ensuring compliance once the ban was implemented. Polls had shown, in Ireland as elsewhere, that as well as non-smokers, many smokers would be supportive of a ban. Most smokers want to stop smoking and most have tried, usually more than once. Smokers know better than anyone that non-smoking environments help them to stop or at least to cut down. Cessation supports are required to help smokers make the best of such opportunities. A platform of smoking cessation structures had been evolving and these have supported the successful implementation of the ban. One important measure was that nicotine replacement therapy has been available since 2001 free of charge to medical card holders, that is, the poorest third of the Irish population, who also have the highest smoking rates. Quitlines and health board cessation clinics had been developed across the country and cessation training offered to GPs, practice nurses, and pharmacists. Links between health boards and environmental health officers and restaurants, pubs and other workplaces had been developed for various health and safety initiatives, which could then be used to support and monitor the new smoking legislation. These and various other measures, such as price increases and advertising bans, had led to declines in adult smoking prevalence in the Republic of Ireland from 30% in the late 1990s to close to 25% prior to the ban. Equivalent declines had occurred earlier in the United Kingdom (UK): adult smoking prevalence was 30% in 1990, 27% in 1994, and 26% in 2002.^2,3

The most widely trumpeted negative effect of the ban is on the profits of the hospitality industry. However, reports to date in Ireland are varied. Some publicans are claiming 20% declines in business due to a combination of the smoking ban and a new watershed time limit of 9 pm for under-18s; other publicans and many restaurateurs say that business is either up or unchanged. But reviews of objective data in other countries have indicated that although some sectors may suffer, particularly in the short term, overall there are unlikely to be long-term adverse economic effects.^4,5 Preliminary evidence from the Republic of Ireland indicates a small downturn, but this should be viewed in light of the downward trends that were evident prior to the ban. However, given the seriousness of the health consequences of exposure to passive smoke, the economic argument is hardly relevant. For example, would anyone seriously propose that because removing asbestos from buildings costs money and may put marginal businesses out of business, workers should continue to work in dangerously contaminated buildings?

Another concern is the possibility of increased smoking in the home, with the consequent increase in exposure of children to passive smoke. However, an Australian study showed that people who worked in places where smoking was totally banned were more likely to ask visitors not to smoke in their homes than those who worked where smoking was allowed.⁶ An ongoing survey of Irish and UK smokers being conducted as part of the International Tobacco Control Policy Evaluation Project (G Fong, International Congress of Behavioural Medicine, Mainz, 2004), will yield evidence on this important issue.

Significant declines in exposure to passive smoke as well as both short- and long-term health gains are anticipated in workers in workplaces where smoking was previously allowed. Various studies — for example, studies of passive smoke exposure and of respiratory health in bar staff, indoor air measurements in various work settings, secular trends in hospital admissions for myocardial infarction — are ongoing to assess changes in exposure and/or health status. The existence of a similar population in a neighbouring jurisdiction without a ban (Northern Ireland) provides a unique opportunity to strengthen these ‘before and after’ studies by conducting similar measurements in Northern Ireland to control for changes not related to the ban.

Although worker protection remains the main goal of the workplace ban, it has been shown that smoking bans also have a significant effect on cigarette consumption.⁷ Declines are anticipated in both the amount smoked by smokers due to fewer opportunities to smoke (both at work and socially in pubs and restaurants), and in the initiation and prevalence of smoking due to non-smoking becoming the norm in more and more situations. Long-term cessation rates remain disappointingly low — around 10–25% for 1-year abstinence rates using nicotine replacement therapy.⁸ As previously mentioned, smoking bans support smokers in their efforts to stop smoking. In the run-up to the ban, there were large increases in the number of calls to quitlines. Preliminary figures suggest increased sales of nicotine replacement therapy products, and reports from GPs of increased requests for help to stop smoking are an example of how public health measures can impact on general practice workload.

A predicted 16% decline in cigarette sales (based on figures from the Revenue Commissioners for the first 6 months of 2004 (Revenue Commissioners, 2004) is further evidence of the impact of the ban. This is the highest short-term reduction ever recorded in the Republic of Ireland — or anywhere else. The 13% decline in cigarette consumption in New York after its ban was attributed to a steep increase in tobacco taxes and a citywide antismoking campaign as well as the ban itself. As the recent price increases in the Republic of Ireland were unexceptional, the Irish decline may be largely attributable to the smoking ban.

Conflict of interest

Shane Allwright chaired the scientific working group that wrote the Report on the health effects of environmental tobacco smoke (ETS) in the workplace. She was subsequently appointed to the Board of the Office of Tobacco Control (2002).