Second Stage Speech The Public Health (Tobacco) (Amendment) Bill 2011Dáil Eireann – Ms Róisín Shortall TD, Minister for State with responsibility for Primary Care’

A Ceann Chomhairle,

I move that the Public Health (Tobacco) (Amendment) Bill 2011 be now read a second time.

At the outset I would like to acknowledge the welcome given to this important legislation during its passage through the Seanad earlier this week and, in particular, the all party and across the board nature of the support that was accorded to the Bill in that House.

Tobacco packaging serves as a critical link to consumers. It has to be acknowledged that the brand imagery of the tobacco package is the foundation upon which all other marketing is built and plays an even greater role in jurisdictions such as Ireland where traditional forms of advertising, promotion, and sponsorship are restricted. It is, therefore, critical that health warnings on tobacco packages counteract the promotion of these products.

The first guiding principle of the World Health Organisation’s Framework Convention on Tobacco Control (FCTC) is that every person should be informed of the health consequences, addictive nature and mortal threat posed by tobacco consumption and exposure to tobacco smoke.

Tobacco packages are an excellent medium for communicating health information given their reach and frequency of exposure. Tobacco health warnings are also unique among tobacco control initiatives in that they are delivered at the time of smoking and at the point of purchase. As a result, the vast majority of smokers report a general awareness of package health warnings and pack-a-day smokers are potentially exposed to the warnings 7,300 times per year. Such health warnings on tobacco packages are among the most prominent sources of health information.

The 2010 global progress report on the implementation of the WHO Framework Convention on Tobacco Control reported that 44 Parties require health warnings to take the form of or include pictures. A total of six EU Member States have introduced combined text and photo warnings and a further four EU Member States are in the process of doing so.

Health warnings on the packaging of all tobacco products are guaranteed to reach all users. Health warnings on tobacco packages increase smokers’ awareness of their risk. Use of pictures with graphic depictions of disease and other health related and cessation images has greater impact than words alone, and are critical in reinforcing the warnings.

The recently published WHO Report on the Global Tobacco Epidemic (July, 2011) confirms that effective health warning labels increase smoker awareness of health risks and increase the likelihood that they will think about cessation and reduce tobacco consumption. The Report also considers that such warning labels shift the nature and value of packaging away from marketing and towards public health messaging.

The WHO Report also points out that, in Australia, the introduction of graphic health warning labels caused more than half of smokers to believe that they had an increased risk of dying from smoking-related illness, with 38% feeling motivated to quit. Other countries with pictorial warning labels, including Brazil, Singapore and Thailand report similar effects on smoking related behaviour.

Findings from Canada, Thailand, and elsewhere, indicate that considerable proportions of non-smokers also report awareness and knowledge of package health warnings. As a result, health warnings are an extremely cost-effective public health intervention and have a tremendous reach.

Full-colour picture-based health warnings on tobacco products are far more effective than text-only warnings. Pictorial health warnings on tobacco products make the product less attractive and target smokers by providing them with information on tobacco-related health risks. They are an essential component of a comprehensive tobacco control programme.

In introducing this Bill in the Dáíl today, it is appropriate to reflect on the comprehensive range of tobacco control legislation that has been introduced in Ireland since 2002, particularly the successful implementation of the smoke-free initiative in 2004, the ban on the sale of packs of cigarettes of less than 20 in 2007, the ban on in-store display and advertising and the introduction of the retail register in 2009. This comprehensive range of tobacco control legislation places Ireland in the top rank of countries internationally.

However, despite the significant tobacco control measures that have been put in place to date and the widespread knowledge of the harm caused by tobacco consumption, smoking prevalence in Ireland remains high.

The most recent SLÁN survey estimates that 29% of our population smoke – a prevalence rate that has remained stubbornly high for a number of years now – and a matter that was a cause of particular concern to members of the Seanad during its debate on this Bill earlier this week.

This prevalence rate is despite the comprehensive nature of our tobacco control legislation. We cannot, therefore, become complacent and must continue to build on the work that has already been done. This legislation is a further step in this regard.

Combined text and photo warnings (also known as pictorial warnings or graphic warnings) on tobacco products were developed by the European Commission for Member States that wished to adopt them. The Commission proposed a library of these warnings but, as their introduction is not mandatory, the legislation before the Dáil today is required prior to their introduction on the Irish Market.

We should not lose sight either of the health consequences of smoking and it needs to be remembered that smoking is the greatest single cause of preventable illness and premature death in Ireland, killing over 5,700 people a year. Half of all those people who continue to smoke for most of their lives will die of their habit, half of these before the age of 69.

Every year, premature deaths caused by tobacco use in Ireland are far greater than the combined death toll from car accidents, fires, heroin, cocaine, murder and suicide.

Tobacco use is also a major cause of increased morbidity. Smoking is the main cause of chronic obstructive pulmonary disease (COPD) and causes nearly 90% of all cases of emphysema. There is also a causal relationship between smoking and acute respiratory infection including pneumonia and tuberculosis. Smoking increases the risk of cardiovascular disease with the risk of mortality from cardiovascular disease in cigarette smokers is 1.6 times that of never-smokers.

The impact of smoking on health care costs in terms of treatment services for cancer, cardiovascular disease and respiratory diseases is significant. In the next ten years, if we do not make progress on reducing the impact of tobacco, it is estimated to cost our health service in excess of €23 billion. This would pay the entire cost of running our health services for almost two years. Smoking costs the Irish economy at least €1m per day in lost productivity.

A concern could be that the use of shocking images is not the best way to inform smokers. However, qualitative research in the UK has shown that images tend to be most effective when they convey shock, immediacy and empathy. Smokers tend to favour ‘shock’ images that are disturbing or unpleasant to look at. Research in Belgium has demonstrated similar results. Warnings shown to have the most impact were those that were felt to be the most graphic and most disturbing.

In Ireland, pre-testing of the 42 images in the EU library was carried out by TNS_MRBI on behalf of the then Office of Tobacco Control and the 14 warnings to be used on the Irish market were identified. The research found that images impacted differently depending on age group and sex; for example the apple image particularly impacted on a very important target group – younger female smokers (18 – 35). They could readily see that smoking causes damage to the skin, predominantly around the eyes and the lips, whereas impotency was found to particularly impact on younger male smokers especially.

International research indicates that smokers are more likely to remember a health consequence of smoking, when smoking, if they have seen a picture1 . In Canada more than 50% of Canadian smokers say the warnings compelled them to smoke less around other people2 . Canadian3 smokers who discussed the combined text and photo warnings were significantly more likely to quit, attempt to quit or reduce their smoking, and 31% of Canadian ex-smokers participating in a study reported that combined text and photo warnings had motivated them to quit in the first place.

In bringing this legislation before the House I have taken particular note of general concerns raised with regard to children and smoking. Three quarters of all smokers in Ireland started smoking in Ireland before the age of 18 and half of all smokers before the age of 16.

1 Fong, Geoffrey. A review of the research on tobacco warning labels, with particular emphasis on the new Canadian warning labels. 2001.

2Hammond D et al. Impact of the graphic Canadian warnings labels on adult smoking behaviour. Tobacco Control, 2003, Vol12, 391-395

3Hammond D et al. The impact of cigarette warning labels and smoke free bylaws on smoking cessation. Canadian Journal of Public Health, May/June 2004, Vol95.3, 201-204

While research on school aged children does show that smoking rates for those aged 15 – 17 decreased between 2002 and 2006 for both girls and boys, the decrease was much smaller among girls in that age group. The fact remains that the earlier children start to smoke the more likely they are to remain smoking later in life.

The ban on the sale of packs of cigarettes of less than 20 since 2007 was introduced with young people, in particular, in mind. The 2009 legislation removing point of sale display and advertising in retail outlets ended the placement of tobacco products in close proximity to every day consumer goods – such as sweets and newspapers – and is a very comprehensive and far reaching body of legislation that will, over time, considerably assist ongoing efforts to de-normalise tobacco use in Ireland.

Already, by 2010, the proportion of children who recalled seeing retail tobacco displays had dropped by 60%. It is no co-incidence that one of the world’s largest tobacco manufacturers has now initiated legal proceedings in the High Court challenging key provisions in the 2009 legislation including the point of sale advertising and display ban.

The Bill before the House today is a further important intervention in our ongoing efforts to reduce smoking, particularly by young people. The recent WHO Report highlights that graphic warning labels are more likely to prevent adolescents from initiating smoking or, if they are already smokers, to think about cutting down or quitting.

Whilst an enabling provision allowing the Minister to make regulations was included in the 2009 Public Health (Tobacco) (Amendment) Act, which was enacted in July 2009, the Department was advised by the Office of the Attorney General (AGO) that this provision in the 2009 Act does not adequately empower the Minister to make the necessary regulations. The AGO advises that an amendment of the 2009 provision is, therefore, required to give the Minister the necessary authority to make the required regulations.

This Bill will allow for the introduction of regulations which will provide that all tobacco products sold in Ireland will carry a combined text and photo warning. This will, in turn, help to reduce the numbers of people smoking and, more particularly, encourage children and young adults not to start smoking.

In conclusion, I would again like to confirm this Government’s commitment to health promotion and tobacco control measures that support the aim of de-normalising tobacco and we will work constructively with all stakeholders to achieve this goal.

I recommend this Bill to the House.