Dr. Patrick Doorley, Chairperson of ASH Ireland, Council of the Irish Heart Foundation submitted a letter to the Irish Times in response to an article on Vaping and Health on the 11th of February. The letter was published on Monday the 18th of February in the letters section of the Irish Times.
Dr. Patrick Doorley, chairperson of ASH Ireland, Council of the Irish Heart Foundation, spoke with the Times Ireland edition on the delayed introduction on e-cigarettes by the Department of Health and the risk this poses due to the potential impact it has for licensed retailers to sell to young smokers. The article featured in the Sunday Times newspaper on the 9th of December 2018 but you can find the link to the article here
The Lancet Global Health journal published an article in June 2018 stating that Ireland has the highest prevalence in the world of smoking in pregnancy. In November, they published this response from Dr Patrick Doorley and Dr Joan Hanafin, ASH Ireland.
Smoking and pregnancy in Ireland
Pat Doorley and Joan Hanafin
In their paper “National, regional, and global prevalence of smoking during pregnancy in the general population: a systematic review and meta-analysis”, Shannon Lange and colleagues report the results of a systematic review and meta-analysis of the scientific literature from 1985-2016 to estimate the prevalence of smoking during pregnancy by country, WHO region, and globally. Smoking during pregnancy leads to adverse effects for women and children and this much-needed report is welcome. Estimates for smoking during pregnancy were calculated via meta-analysis for 43 countries and via statistical modelling for 131 countries and, at 38%, Ireland was reported to have the highest estimated prevalence of all countries.
We enter a note of caution in relation to the figure for Ireland. The five studies (1992, 1996, 2006, 2008, 2011) used to calculate estimates for Ireland had small sample sizes (n=100; 127; 151; 450; 1011), and the two very high prevalence rates (62% and 60.6%) were published in 1992 and 1996 respectively. In recent decades, Ireland has introduced a suite of tobacco control measures leading to substantial decreases in smoking prevalence in the general population and among pregnant women, specifically as a result of the 2004 Smoking Ban. Smoking prevalence for women in Ireland was 32% in 1998 and had decreased to 14.7% in 2017, although it was highest in the 25-34 year age group at 26.1%.
Two recent Irish studies (2012, 2017)   from the time period of the study, with large sample sizes indicate that smoking prevalence in pregnancy is greatly less than the estimated 38% and continues to fall annually. Data from the national longitudinal study Growing Up in Ireland reported by McCrory and Layte (2012) show that 28% of mothers whose children were born between 1997 and 1998 reported that they smoked during pregnancy, and this fell to 18% of mothers whose children were born in 2007. A study of over 42,500 women who passed through the Coombe maternity hospital in Dublin (Reynolds et al. 2017) recorded annual decreases in smoking during pregnancy, with prevalence dropping from 14.3% to 10.9% between 2011 and 2015.
The decrease in smoking during pregnancy is a positive development for public health policy in Ireland but further efforts are needed, especially among disadvantaged populations, if smoking-related risk to pregnant mothers, their infants and children is to be further reduced.
Patrick Doorley & Joan Hanafin, Submitted June 2018; Published November 2018 in The Lancet Global Health
 Lange, S, Probst, C, Rehm, J, and Popova, S. (2018). National, regional, and global prevalence of smoking during pregnancy in the general population: a systematic review and meta-analysis. (published online May 30.) Lancet Glob Health. 2018; http://dx.doi.org/10.1016/S2214-109X(18)30223-7
 Kabir, Z, Daly, S, Clarke, V, Keogan, S, and Clancy, L. (2013). Smoking Ban and Small-For-Gestational Age Births in Ireland. PLoS ONE, 8(3): e57441. doi:10.1371/journal.pone.0057441
 Brugha, R., Tully, N., Dicker, P., Shelley, E., Ward, M. and McGee, H. (2009) SLÁN 2007: Survey of Lifestyle, Attitudes and Nutrition in Ireland. Smoking Patterns in Ireland: Implications for policy and services, Department of Health and Children. Dublin: The Stationery Office. p.8. https://health.gov.ie/wp-content/uploads/2014/03/slan_smokingreport.pdf. Accessed 24th October 2018.
 McCrory, C. & Layte, RJ. (2012). Prenatal Exposure to Maternal Smoking and Childhood Behavioural Problems: A Quasi-experimental Approach. Journal of Abnormal Child Psychology, 40(8): pp. 1277-1288.
 Reynolds, CME, Egan, B, McKeating, A, Daly, N. Sheehan, SR and Turner, MJ. (2017). Five year trends in maternal smoking behaviour reported at the first prenatal appointment. Irish Journal of Medical Science, 186(4), pp. 971-979.
Allen Carr‘s Easyway to Stop Smoking is a highly effective treatment to help smokers quit, according to a new study just published in the prestigious BMJ’s Tobacco Control journal. The study was carried out in Dublin by the Tobacco Free Research Institute Ireland and is the first published Randomised Clinical Trial (RCT) in the world about Allen Carr’s Easyway to Stop Smoking. RCTs are the most rigorous way of determining whether a cause-effect relation exists between treatment and outcome, and are considered the gold standard method of assessing effectiveness.
The Allen Carr method has been widely used for over 30 years and is available in 150 centres in over 50 different countries. It consists of a one-off 5-hour seminar which does not involve the use of any form of medication. Many celebrity testimonials endorse its effectiveness and there are claims that it has helped more than 30 million smokers quit. Despite this there has never been a published report from a scientific trial supporting its use in a general population.
This trial involved 300 adult smokers equally randomised to Allen Carr and the online HSE Quit.ie service and followed up for 1 year. Result showed a quit rate of 38% at 1 month, 26% at 3 months, 23% at 6 months, and 22% at 1 Year in the Allen Carr Group. This was almost twice the quit rate achieved in the Quit.ie group. These success rates are similar to those from the best available treatment programmes currently used for smoking cessation.
Close to 6000 of our citizens die annually from tobacco related disease, and smoking cessation is a very important element of Ireland’s plan to become Tobacco Free by 2025. In that context one of the study’s authors, Professor Luke Clancy, Director General, TFRI said that “Allen Carr is a hugely under-used treatment method which has great potential to help Ireland achieve its ambitious targets in Tobacco Control”.
The study’s first author, Sheila Keogan, TFRI’s Director of Research and Communications said, “We hope that our study showing the success of Allen Carr’s Easyway method of helping smokers to quit will be of great benefit, and may be especially useful for people who are reluctant to take any medication, for instance pregnant smokers”.
Smokefree policy, practice, signage and bye-laws in playgrounds in Ireland
A target date of 2025 has been set for Ireland to become tobacco free, i.e., less than 5% of the population smoking (Department of Health, 2013). This target requires reducing prevalence of adult and child smoking, and preventing children from starting to smoke. A key recommendation of Tobacco Free Ireland is “to further develop the tobacco free playgrounds initiative in conjunction with the local authorities by voluntary measures or by the introduction of bye-laws” (Department of Health 2013, p.42). Moving towards smokefree zones where children congregate is an important step in de-normalising smoking, increasing its social unacceptability, and reducing prevalence. International research demonstrates that there is strong public support for tobacco free children’s playgrounds (Department of Health, 2013). Ireland’s first smokefree playgrounds were introduced in Donegal in 2010 and, since then, many County, City and Town Councils have introduced similar initiatives in playgrounds under their control (Department of Health, 2013; ASH Ireland, 2018). A previous survey carried out by ASH Ireland showed that a high percentage of City and County Councils had introduced such measures. This follow-up survey seeks to update earlier findings about City and County Councils’ policies, practices, signage and bye-laws regarding smokefree playgrounds under their control.
A list of the Chief Executive Officers (CEOs) and Postal Addresses for all City and County Councils in Ireland was sought from the Local Government Management Agency. An Excel file was received from the Research & Innovation section of the Local Government Management Agency. Using this list, ASH Ireland wrote by post to all City and County Councils in Ireland on 14th May 2018 (n=31) to ask them about their current policies, practices, signage, and bye-laws in relation to smokefree playgrounds under their control. Councils were informed that ASH Ireland continues to promote smokefree environments for children and adults. A follow-up letter was sent by email on 9th August 2018 to all councils from which a full response had not been received.
Fourteen full or partial responses were received from the first round and an additional 5 responses were received from the second round. A final response from 1 more County Council was received thereafter, giving a total of 20 out of 31 responses (65% response rate).
Each Council CEO was asked to reply to the following questions:
1. What percentage of the playgrounds under your control are entirely smokefree?
2. If not 100%, has a decision been made to make the others smokefree and when can we expect this to be in place?
3. You might also let us know please if your council has erected smokefree signage in the children’s playgrounds and, if not, we request that you would consider doing so.
4. Have any changes been introduced to the park bye-laws, so as to legislate locally for smokefree playgrounds?
1. What percentage of playgrounds under your control are smokefree?
Of the 20 responses received, 16 Councils replied that their playgrounds were 100% smokefree (52% of all Councils or 80% of those that responded). Two did not answer this question; one replied that they did not know what percentage of playgrounds was smokefree and were trying to find out; and one responded that none of the playgrounds under their control were smokefree.
2. If not 100%, has a decision been made to make the others smokefree and when can we expect this to be in place?
No council answered this question directly. One council replied that they were trying to find out the answer to this question (but more particularly to questions 1 and 3).
3. Has your council erected smokefree signage in the children’s playgrounds and, if not, we request that you would consider doing so.
Seventeen Councils (55%) reported that they had erected signage. Ten (32%) had erected signage in all playgrounds. Seven (23%) had erected signage in some of the children’s playgrounds. Two Councils reported that all playgrounds would have signage completed during the coming months. One Council reported that 10 out of 14 playgrounds under their control had signage and that the Council “will consider extending the Smokefree Policy to the remaining 4 playgrounds”. One Council reported that all new signage includes “no smoking information”, and they included with their response an image of their signage which incorporates a no-smoking icon (no text). One Council did not know but was trying to find out what percentage of children’s playgrounds have no-smoking signage.
4. Have any changes been introduced to the park bye-laws, so as to legislate locally for smokefree playgrounds?
i. Five Councils (16%) reported that they had introduced bye-laws to legislate locally for smokefree playgrounds.
ii. Two councils reported that they did not have any bye-laws.
iii. Twenty-seven Councils did not provide any information about bye-laws to legislate locally for smokefree playgrounds. This low response rate included Councils that provided information about the other questions asked.
iv. One Council reported that they were working towards “having revised Bye-Laws being introduced which would ban smoking at public playgrounds”.
v. One Council reported that they employ Community Wardens who have the power to enforce the Litter Pollution Act 1997 and provides a LoCall Environmental Hotline for members of the public to report littering.
vi. Additionally, that Council reported that their Environment section “receives complaints from time to time re littering (including cigarette butts) in playgrounds”.
vii. One other Council reported that Parks Bye-Laws have been enforceable since 1st September 2014 which apply to all Parks, Playgrounds, playing pitches and MUGAs and that appropriate signage has been erected in all of the parks and playgrounds with a view to notifying the general public of the bye-laws.
Summary, Conclusion, Recommendations
Of 31 City and County Councils surveyed by ASH Ireland during the period May-August 2018, 65% (n=20) responded, in three rounds. City and County Councils that responded to the survey were positive about implementing Smokefree playgrounds under their control.
· 52% (n=16) reported that playgrounds under their control were smokefree.
· 55% (n=17) had erected signage; 32% (n=10) in all playgrounds and ~23% (n=7) in some or most playgrounds under their control.
· 16% (n=5) said that they had bye-laws in place to prohibit smoking in playgrounds.
More needs to be done to increase the number of City and County Council-controlled smokefree playgrounds. Efforts to increase smokefree outdoor areas should be informed by research findings asserting that, for policy implementation and compliance, establishing the public health evidence for policy change is critical to engaging diverse stakeholders with varied tobacco-related interests (Leung et al., 2013).
Benefits of Smokefree playgrounds
Research from the UK, US, Australia, Canada and other countries suggest many benefits of smokefree playgrounds. Smokefree playgrounds are desirable for reasons of denormalisation and positive role modelling, reducing the prevalence of smoking, avoidance of secondhand smoke dangers, and environmental benefit. Smokefree playgrounds are justified as the toxicity of smoke is a nuisance to many and poses a health risk to others. Smokefree playgrounds help users to quit smoking. There is wide public support for smokefree legislation in general and for smokefree playgrounds in particular. Smokefree playgrounds:
· continue the denormalisation of tobacco and help reduce smoking prevalence among adults and children.
· communicate a positive message that tobacco use is not compatible with an active, healthy lifestyle and that tobacco use and sports do not mix.
· protect children and their carers from the harmful effects of exposure to secondhand smoke. Secondhand smoke is a human carcinogen for which there is no safe level of exposure. Even in outdoor settings, secondhand smoke levels can reach levels as high as those found in indoor facilities where smoking is permitted. Secondhand smoke causes heart disease, cancer, respiratory problems, and ear infections, and worsens asthma. Exposure to secondhand smoke is especially harmful to children and adults with asthma or other chronic conditions. Children, older adults, people with special health needs, and pregnant women are particularly vulnerable to the health risks caused by secondhand smoke exposure, even in outdoor environments. Tobacco-free parks and beaches provide families and children with healthy environments in which they are not exposed to the negative health effects of secondhand smoke.
· enhance support for community users to quit smoking.
· enhance users’ enjoyment of clean air and health activities.
· reduce cigarette litter. Discarded cigarette butts pollute the land and water and are highly toxic and dangerous to children, domestic animals, and wildlife. Small children are at risk of swallowing, choking or burning themselves with discarded butts and suffering nicotine poisoning.
· reduce maintenance costs and fire risks. Cigarette butts are the most littered item in the world and they are not biodegradable. Carelessly discarded cigarette butts are a frequent cause of fires, especially during periods of dry weather.
Recommendations for promoting smokefree playgrounds in Ireland
· Public health campaigns should include a focus on the benefits of smokefree playgrounds to children, parents and others using these facilities (see above).
· City and County Councils that have made efforts to make playgrounds under their control smokefree should be noted and commended.
· Examples of good practice regarding smokefree playgrounds should be collated and circulated.
· Those Councils that have not yet made playgrounds under their control smokefree should be encouraged to do so.
· Those Councils that have not yet erected smokefree signage in playgrounds under their control should be encouraged to do so.
· Councils appear to be receptive to guidance regarding signage. Several Councils attached with their survey responses examples of their signage. A range of signage suggestions could be made available to all Councils based on best practice. This would help Councils to avoid “re-inventing the wheel” and perhaps facilitate wider implementation of smokefree signage in playgrounds.
· Some Councils appear to be receptive to guidance regarding bye-laws. Examples of good practice could be circulated to all Councils.
· Playgrounds not under the control of City and County Councils should be informed of good smokefree practices and encouraged to implement smokefree playgrounds and to erect appropriate signage.
· Regarding health inequalities, social class differences persist in smoking prevalence and may also exist in how playgrounds are used. Evidence from other countries suggests that consideration should be given to ways of allocating sufficient resources to enhance voluntary compliance so that smokefree playground policies and bye-laws do not contribute to health inequalities.
 On the Excel mailing list received from the Local Government Management Agency, 5 assistant chief executives of Dublin City Council were listed in addition to the chief executive. These 6 officers of Dublin City Council were included in the mailing in the interests of communicating with all officers named on the list. A total of 36 surveys were sent out, therefore, to a total of 31 City and Council offices. (No response has been received to date from any of the offices of Dublin City Council.)
 See, for example, Cancer Council Queensland (2018); Capital District Tobacco-Free Coalition (2018); Leung et al. (2016); NHS Glasgow (2009); Pederson et al. (2016).
 See, for example, Pederson et al. (2016).
ASH Ireland Response to Budget 2019: 50c increase welcomed
Ash Ireland welcomes the announcement by Minister Donohue in the 2019 Budget statement today to increase the price of a pack of cigarettes by 50c. Price is widely recognised internationally, and by the World Health Organisation, as the most important way of encouraging smokers to quit and discouraging young people from experimenting with tobacco. The possible links being raised between ‘smuggling and price increase’ are totally misguided and mainly fuelled by a major vested interest, the Tobacco Industry. Smuggling must be tackled as a separate and very serious criminal issue but it should not impinge on health policy and related decisions. ASH Ireland called for a 1 euro increase in price in its pre-budget submission.
Dr Patrick Doorley, Chairman of ASH Ireland said today, “Significant inroads have been made in regard to smoking prevalence over the past 15 years with current levels down to less than 20%, down from 29% in 2003. However, if the Government is to achieve its stated objective of establishing a smoke-free Ireland by 2025 then it must commit to significant annual increases in the price of tobacco, including Roll Your Own tobacco. We call on the government to ring-fence funding for the purpose of supporting smokers to quit, particularly smokers in lower socio-economic groups who have higher levels of smoking.”
Dr Doorley went on to say, “Smuggling of tobacco into this country is a major issue for Government. However, we must be wary of Tobacco Industry efforts to use smuggling as a reason for not introducing effective measures which can improve the nation’s health. There are many examples of jurisdictions where tobacco price has been increased for health reasons, and smuggling simultaneously tackled and reduced – such as Australia, New Zealand, UK and Spain.”
“Ireland is seen as a world leader in tobacco control. I ask the Government to intensify the public-health battle against tobacco, especially in relation to expanding smoke-free spaces. The toll to our citizens from smoking is a heavy one in terms of disease, disability and death. Smoking causes unique and catastrophic consequences for families all over Ireland as, every year, close to 6000 of our citizens die from smoking. We must do all that is possible to reduce this dreadful statistic by de-normalising smoking, and above all introducing pro-health legislation”, Dr Doorley said.
Dr Patrick Doorley, Chairperson ASH Ireland has been elected to the Board of the European Network for Smoking and Tobacco Prevention (ENSP). Dr Doorley is a specialist in Public Health Medicine and a fellow of the Faculty of Public Health Medicine of Ireland.
ENSP is an international non-profit organisation whose mission is to develop a strategy for co-ordinated action among organisations active in tobacco control in Europe by sharing information and experience and through co-ordinated activities and joint projects. ENSP aims to create greater coherence among smoking prevention activities and to promote comprehensive tobacco control policies at both national and European levels.
ENSP’s top priority objectives are:
· to implement the Framework Convention on Tobacco Control (FCTC) in Europe by 2020, and
· to reduce the prevalence of tobacco use in Europe to less than 5% by 2040.
ENSP’s vision for the future is to eliminate health inequalities among European citizens and suffering caused by ill health and early death due to tobacco-related diseases.
To attain its purpose, ENSP undertakes to conduct the following activities;
· to focus in priority on co-ordination and consensus-building, education, prevention and cessation;
· to facilitate the creation and development of national and international alliances for smoking prevention and tobacco control in Europe, as well as support for their actions;
· to promote collaboration amongst member organisations and support their actions;
· to stimulate and participate in joint projects at national and international levels;
· to undertake the collection, distribution and exchange of information relevant for tobacco control to the members of the network, non-governmental organisations, intergovernmental organisations, national governments all over Europe and the institutions of the European Union;
· to sponsor, promote and organise education and training seminars, conferences, missions and exhibitions on matters relevant to smoking and tobacco prevention and cessation.
Ms Norma Cronin Board Member, ASH Ireland was previously a member of the Board of ENSP.