Introduction
The first document from the Irish State that mentioned ‘Alcohol’ and ‘policy’ in its title was published in 1996 (Department of Health, 1996). It forecast, accurately as it transpired, a worsening of Irish alcohol-related problems, with no suggestion that this could be prevented. Six years later, when the later Taoiseach Micheál Martin was Minister for Health, a more robust policy document was published, followed on 2 years later by another policy document published by the Department of Health led Strategic Task Force on Alcohol (Department of Health, 2002; Department of Health, 2004). These two reports followed the World Health Organisation framework for alcohol policy. This framework found expression in a book called ‘Alcohol; no ordinary commodity’, authored by a collection of leading international alcohol researchers led by Thomas Babor of the University of Connecticut (Babor et al. Reference Babor, Caetano, Caswell, Edwards, Griesbrecht, Graham, Grube, Hill, Holder, Homel, Livinston, Osterberg, Rehm, Room and Rossow2003). The publication of the two Strategic Task Force reports was stimulated by European data which showed that for the decade of the 1980s Ireland’s per capita alcohol consumption had increased by 46% (Table 1). Only the United Kingdom, of the other than 13 countries of the European Union, showed a substantial measurable rise over the same period of 10%.
Table 1. Alcohol consumption per capita, in litres of pure alcohol, 1989–2000 EU countries
The thrust of the two Strategic Task Force reports was to reduce our per capita alcohol consumption, which in the past was as high as 14 l per capita per annum (https://www.drugsandalcohol.ie/25304/). The strategic task force had drinks industry representation, although some public health advocates had suggested that the alcohol industry should not have a position at a policy forum chaired by the Department of Health. Other developments around this time included intense public health advocacy to introduce random breath testing on Irish roads, with popular support of over 80% for such legislation (Alcohol Action Ireland, 2006). After some delays, random breath testing was introduced and likely resulted in significant decreases in annual road deaths (Garry et al. Reference Garry, Donnelly, Heffernan, McGarvey and Nicholson2018; Stevenson & Thompson, Reference Stevenson and Thompson2014). Also significant hikes in excise duty were welcomed in the past, but it was noted that minimum unit pricing would be needed to make a real difference in society (https://www.drugsandalcohol.ie/20737/).
Alcohol recognised as a drug and ‘No Ordinary Commodity’
Four years on from the second task force report another policy document, the Report of the Government Alcohol Advisory Group (Department of Justice, 2008), was published, under the political stewardship of the late Brian Lenihan, then Minister for Justice. It was in this report that alcohol was first described as a drug and also as ‘no ordinary commodity’; both landmark statements in the alcohol policy debate in Ireland. A backdrop to the report’s publication was the increasing ratio of off-trade versus on-trade alcohol consumption by 2008 with publicans’ dominance of alcohol sales being challenged. From 1998 to 2007, the number of wine off-licences in Ireland rose from 483 to 3691 (Revenue Commissioners, 2008). During a time when the stated aim was to reduce alcohol availability, this was yet another illustration of the weakness of a policy not underpinned by legislation.
Public health action
By the middle 2000s, the Irish media were increasing coverage of the alcohol industry’s influence (Irish Independent, 2006). In 2004, the Irish Government succeeded in banning smoking in pubs with the rationale being that it presented as a health and safety issue related to the damaging effects of passive smoking. It crucially had the support of Mandate, the trade union representing bar workers, although it faced significant opposition from some publicans. Various strategies were utilised by public health alcohol advocates to highlight alcohol-related issues such as introducing the concept of other people’s drinking, known as H2O (alcohol’s harm to others). In 2014, the HSE commissioned research into H2O (Hope & Barry, Reference Hope and Barry2018). There were three elements examined: the general population, co-workers and children. The key findings from this report were one in four people reported one or more harms due to other people’s drinking, 1 in 10 workers reported one or more harms from co-workers’ drinking and 1 in 10 children were exposed to one or more harms from others’ drinking.
The long political journey to the Public Health (Alcohol) Act
Much has been written about the journey to implementing an Alcohol Policy Bill in Ireland, with some authors suggesting that 2008/2009 was a key turning point where policy momentum shifted in a public health direction (Lesch & McCambridge, Reference Lesch and McCambridge2021a). The failure of earlier alcohol policies resulted in increased visibility of alcohol-related harm in society among key stakeholders, which increased demand for policy change. In 2012, the Department of Health published the National Substance Misuse Strategy (Department of Health, 2012); in effect this became Ireland’s public health alcohol strategy. It was produced after 3 years of tortuous discussion, expertly chaired by the Chief Medical Officer Dr Tony Holohan. The set of 20 recommendations was divided into four categories: supply control, prevention, treatment/rehabilitation and research.
It took 3 years from the publication of the National Substance Misuse Strategy to the publication of the Public Health (Alcohol) Bill (Houses of the Oireachtas, 2015). The challenges of bringing forward a Bill to reduce alcohol were highlighted at this time in spite of advocacy from Public Health Doctors (Butler, 2015). At its launch in December 2015 in the Royal College of Physicians was the then Minister for Health, Leo Varadkar, the Chief Medical Officer Tony Holohan and the President of the Royal College of Physicians of Ireland Frank Murray. The bill drew heavily on the recommendations of the National Substance Misuse Strategy, particularly in relation to minimum unit pricing, labelling, restrictions on marketing, regulation of the sale and supply of alcohol in certain circumstances, and also separation of alcohol from other goods in mixed trading stores, large and small.
The next phase in this long campaign to get public health law on the Statute books lasted a further 3 years when the President of Ireland Michael D Higgins signed the Public Health (Alcohol) Act into law in November 2018 (Houses of the Oireachtas, 2018). There was significant lobbying by the members of the Oireachtas throughout the period, as was evident on the lobbying register (Table 2). As we moved into 2018 and it was clear that the Government was fully committed to getting the Act passed. It was led politically by the Minister for Health Simon Harris and Taoiseach Leo Varadkar. Through September and October 2018, there was some opposition to passing the Act in the Dail, although eventually when the vote was called on October 17th 2018, the Bill was passed by a large majority. The President subsequently signed the Public Health (Alcohol) Act to the Statute Books. This Act originated from the Department of Health, while previous legislation and regulations that made a positive contribution to public health emanated from the Department of Transport (Mandatory Alcohol Testing) and the Department of Finance (Taxes on alcohol).
Table 2. Sample of groups lobbying in health a and their number of returns on www.lobbying.ie (Source: The Medical Independent February 18th 2018)
a Not all the above groups lobby exclusively in the health policy area.
The end of the beginning: commencement, implementation and monitoring
The implementation of the Act did not end there. Once an Act of the Oireachtas has been passed into law, commencement dates must be set by the relevant Minister to bring the various provisions of the Act into effect. Several elements of the Act have now been implemented. On November 12th 2019, a prohibition on advertising in certain places (Including the cinema) and promoting alcohol on children’s clothing came into effect. On November 12th 2020, restrictions on advertising in certain licenced premises were introduced. On November 12th 2021, restrictions on advertising during sporting events and restriction on alcohol sponsorship in events aimed at children began. On January 4th 2022, minimum unit pricing was introduced, which is seen as a key element of this Bill.
Another positive outcome of public health advocacy was that the Minister for Health established a Public Health Alcohol Research Group, with international as well as Irish representation, the terms of reference of which were:
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a. To monitor the progress and evaluate the impact of The Act
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b. Review existing data and research and consider its relevance to implementing The Act
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c. Identify gaps in existing data and research and examine how they might be filled
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d. Liaise with relevant organisations and stakeholders, including other Government departments, international bodies, and relevant organisations as required to review the adequacy of existing data
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e. Provide advice to the Department of Health on further research and action that may be required.
In spite of all this progress, there remains the very practical issues of enforcement, monitoring and future amendments, so the importance of advocacy remains (Critchlow et al. Reference Critchlow, Moodie and Jones2021). This remains particularly important given the frustrations expressed for implementing the legislation at times (Pope, Reference Pope2020). Furthermore, concerns have already been expressed about the deficiencies that are evident in the new Act and the importance of ongoing review of alcohol policy (Houghton & McInerney, Reference Houghton and McInerney2020).
Overall the enactment of this Public Health Alcohol Policy Bill can be viewed as a significant success for public health advocates in Ireland, and the journey highlights some key issues such as the importance of political leadership in delivering on legislation in Ireland (Lesch & McCambridge, Reference Lesch and McCambridge2021b). Furthermore, the crucial importance of co-ordinated advocacy among healthcare providers should not be underestimated in future public health endeavours (Lesch & McCambridge, Reference Lesch and McCambridge2021c). There is ongoing research in relation to alcohol-related harm across the United Kingdom and Ireland, and advocacy efforts should be sustained to ensure ongoing public health initiatives in this area (https://publichealth.ie/new-alcohol-policy-research-network-launched-across-ireland-and-the-uk/).
Conclusions
Advocating for public health alcohol policy in Ireland is complex and poses significant challenges. Huge efforts are needed on the journey from advocacy to enacting legislation; however, the tide of public opinion can turn and positive change is possible with significant efforts. These efforts can strongly influence our national response to the harms of alcohol consumption thereby reducing the health damages of drinking habits in Ireland long into the future.
Financial support
This research received no specific grant from any funding agency, commercial, or not-for-profit sectors.
Conflict of interest
The author has no conflict of interest to declare.
Ethical standards
The author asserts that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008.
