EHJ June 2004, pages 172-175
Ireland did it first, Norway was next and Sweden has plans to do it. Stuart Spear visits the first European country to ban smoking in public places to find out how the Irish government managed to pull off Europe's biggest public health coup

The biggest question public health groups are asking themselves at present is how did Ireland manage to pull off one of Europe's most successful ever pro-health initiatives?

It's not as though the Irish have a history of pioneering public health. They are better known for their hospitality and pub culture with red meat and alcohol the staples of Irish life rather than fruit, vegetables and oily fish. So when Micheal Martin TD, minister for health and children, stood up in Wagamama's restaurant in the centre of Dublin over a year ago and said he was introducing a nation-wide ban on smoking in public places, no one could quite believe it, least of all the Irish themselves. Their health minister had just announced probably the most radical public health initiative of the 21st century and no one was quite sure if they could pull it off.

Ann Marie Part, principal EHO at the South Western Area Health Board and deputy chair of the Environmental Health Offices Association (EHOA), was there. "It was a bit like where were you when Kennedy was shot? We could not believe we were hearing the minister announcing this ban. None of us thought this was going to happen, and from that moment there started a 12-month roller coaster ride that was just incredible."

Firmly on board that roller coaster were the Republic's 500 EHOs and in particular the EHOA. The profession found itself elevated to the top table when it came to working out how Mr Martin's vision could be made a reality in just 12 months. And as a result of the extraordinary success of the ban, the profession's profile in Ireland has never been higher or its influence stronger.

Back in 1970 when Ireland set up its regional health boards Irish EHOs went in the opposite direction to their British counterparts. Instead of joining local authorities they are employed by 10 regional health boards, responsible for housing, food safety, environmental protection and limited smoking legislation covering underage sales, advertising and smoking in a few designated areas such as cinemas.

Health and safety, however, went to the Health and Safety Authority, with its own inspectors. This has led to a split in enforcement responsibility. It is up to the HSA to deal with smoking in most work places, under existing health and safety legislation that has been amended to require tobacco smoke to be risk assessed.

This leaves 41 full-time equivalent EHOs, who are designated by the health boards as tobacco control officers, to enforce the legislation which has caused most of the stir. The Public Health (Tobacco Act) 2004, which came into force on the 29 March this year, bans smoking in public places, including pubs, restaurants, cafes, bookies and bingo halls under penalty of a 3,000 euros fine. It also bans smoking in all workplaces. Prisons and psychiatric hospitals are the only exceptions.

It was clear that with such limited resources the enforcement community was going to have to do as much preparation as possible over the 12-month run up to the ban or they would face mass non-compliance and be swamped. Hearts and minds were going to have to be won, the battleground was going to be the media and the opposition was already marshalling its troops.

The two main pub trade bodies, the Licensed Vintners Association covering Dublin and the Vintners Federation of Dublin, representing the rest of the country, immediately started warning of an economic melt down. A billion euros loss to the exchequer, pubs going out of business, 65,000 job losses, even the collapse of Ireland's tourist industry. The restaurant and hotel trade supported the ban privately but sat on the fence fearing that if the pubs negotiated an exclusion their profits would be severely hit.

A veteran of such campaigns is Professor Luke Clancy, associate professor of respiratory medicine at University College Dublin and chair of the Irish arm of the anti-smoking campaign group Ash. He remembers when exactly the same arguments were trotted out by industry in the run up to the introduction of clean air legislation in the late 1980s. Industry losses, unemployment, economic collapse. None of it happened in the same way that none of the dire predictions over the smoking ban have so far materialised.

But the pro-health lobby realised that if enough fear of economic hardship was created, it could threaten the ban. There were also signs that the tobacco companies were marshalling resources. A previously unheard of trade organisation, the Irish Hospitality Association entered the fray, making doom-laden predictions in the media. "I cannot believe that this organisation was not being funded by the tobacco companies," points out Prof Clancy. "Terms such as freedom of choice were being used and this was for me a byword for the tobacco industry. It is just not a phrase that we would use in Ireland."

The vintner companies were also punching above their weight. In Ireland, pubs are usually used as political surgeries, so there is often a relationship between publicans and politicians. Not only that but despite there being cross-party support for the ban, Mr Martin's own party, Fianna Fail, was known to have a particularly cosy relationship with the hospitality industry. Although they had strong ministerial support, this was not going to be an easy fight and the pro-health lobby was going to have to get organised.

One of the most important moves in cementing support for the ban came from the EHOA itself. The Department of Health and Children had already set up a health promotion unit, tasked with forming a smoking cessation action plan, setting up a national quit line and providing a media campaign so that employers and members of the public would know how and why the ban was being implemented.

Public health groups, among them the Irish Cancer Society, Irish Heart Foundation, the Asthma Society and Ash Ireland, along with major unions, had also joined forces to form a powerful lobby to counter the industry view. It provided the media with a coherent public health message that was seen as independent from the government line and represented around 1.1m people, almost a quarter of Ireland's population, of which 27 per cent smoke. In the run up to the ban, the pro-health lobby's message appeared in 65 per cent of the print media coverage. The pro-ban campaigners were also faster off the mark dominating 75 per cent of column inches compared to 25 per cent for the anti-ban lobby in the first month after the announcement.

Yet despite the early success, the EHOA started to notice a gap in the pro-ban strategy. Ms Part explains: "We had started working with the HSA and working alongside the Office of Tobacco Control through the health boards. But we could see gaps where groups were not talking to each other. We also became concerned that the message was getting confused in the media with the ban being presented as a way to get people to give up cigarettes. Which was not the case and we did not want to be seen as enforcement officers forcing people to give up smoking."

There were also fears that information being given to the public may at a later date have ham strung EHOs when trying to enforce the ban. A meeting with the minister was called where it was decided to set up a national implementation group, to work out exactly how this was going to be enforced. On the committee were the EHOA, Office of Tobacco Control, HSA, and principal EHOs from the health boards. The profession now found itself in a key position with direct contact to the minister. As the ban approached it would be the job of Colm Smyth, chair of the EHOA, and Ms Part to get out in front of the cameras and on the radio to explain how the ban would be enforced. "A lot of people have come back and said that it was this level of PR and media coverage that made it easier for them on the door step, because a lot of the questions had already been answered for them," said Ms Part.

Another key weapon in the pro-health arsenal was the Office of Tobacco Control, set up four years ago and headed up by Dave Malloy, a former EHO with 20 years' experience behind him. Its brief is to change Irish attitudes to smoking while helping smokers give up, and to protect people exposed to environmental tobacco smoke, especially children.

Its specific role in respect of the smoking ban is to coordinate enforcement across the health boards, give guidance to the hospitality industry and drive the pro-health debate with published research on the health risks of passive smoking. It is also carefully monitoring levels of compliance and is preparing a report to be published next month.

Mr Malloy agrees that the early signs are of a very high level of compliance: "One of the reasons is that we were pushing against an open door. Our research showed that 80 per cent of the population, which included 60 per cent of smokers, wanted the ban to be enforced in pubs. Of course, there was a lot of work going on in the background to achieve this. Also, we must remember that the ban empowers the non-smoker who can now stand up and say 'no, I don't want it any more'."

Public support for the ban was key, but it was not the whole story. According to Prof Clancy you also have to go back four years to a falling out between the Irish government and tobacco industry over its refusal to make public all the chemicals present in its products. "You have to remember that the tobacco industry is very rich and very powerful and if you engage with them you are likely to be contaminated," he explains. "Our ministers did not deal with them after they refused to reveal what was in their cigarettes. So in the last four years they have not met with the industry. We achieved that arms-length relationship which was so hugely important." This is not the case in other EU countries, he points out, where tobacco companies are hugely influential, including Britain where, he believes, a national ban will be much more difficult to achieve.

Another problem, he adds, is that the UK lacks a minister with the courage to champion the ban and campaigners from the medical profession. "You need medical support, not just from the British Medical Association but from individuals who will get out there and campaign."

One of the arguments against introducing a UK-wide ban is that it would be unenforceable. The Irish experience undermines this view. Ms Part heads up a team of tobacco enforce-ment EHOs covering Dublin's Temple Bar region, an area with more pubs and restuarants than any-where in Ireland. "As it turned out we had very few problems, life in Ireland as we know it did not stop, all prophecies of doom and gloom did not come about. Everyone just embraced it from day one," she said. One reason may have been that the penalties for non-compliance are severe. A 3,000 euros fine each for the smoker, bar manager, owner and person in charge at the time. Smoking one cigarette is one offence.

Under the legislation, five cigarettes smoked could produce total fines of 100,000 euros. The publican also risks losing the licence when it's up for renewal, not a risk worth taking.

EHOs can also just raid a premises or observe through the evening. "So at all times the pubs have to be on their toes, they never know when we will be there," explains Ms Part. There is also a phone line for reporting offences.

"There is between 95 and 100 per cent compliance in the premises, but there still are grey areas with people smoking around the porch, or in a shed out the back, which is not compliant. The next stage is for EHOs to get them out of the porches," adds Ms Part. The legislation states that if people are smoking it has to be in structure with no roof or with half its walls missing to allow through ventilation.

So given all the doom-laden forecasts, is there a downside to the ban? There have been some job losses, particularly in the cigarette vending machine sector, and it is too early to see what the long-term economic impact will be, although early signs are it will not be significant. Ireland's largest alcohol supplier Diageo, which owns Guinness, has noticed no significant downturn in sales.

Even the tobacco companies seem sanguine, announcing they have no intention of challenging the legislation. What is clear is that the Irish are enjoying the ban. Going outside to smoke is providing a focal point for strangers to meet. "People are taking up smoking just to be part of the craic, "is a typical response when canvassing views on the ban. The joke at present is that previously concealed smells are coming to the fore. Clubbers are complaining of the smell of sweat, pub goers about the furnishings and toilets, and women are buying deodorant for their men.

Most people you talk to can't understand why the ban was not imposed sooner. Around 7,000 people die a year in Ireland from tobacco-related disease. Also, an independent scientific review of evidence on passive smoking commissioned by the OTC concluded that secondhand smoke was harmful, that employees needed workplace protection and that legislative measures were needed. As Prof Clancy points out: "There is no middle ground here, tobacco is the only product which kills you and those around you if taken as directed and most people don't smoke." To answer the question: How did Ireland pull this off? The people wanted it and there was no credible argument put forward for not doing it.