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Abstract
Aim Ireland will not meet the tobacco endgame goal set in its 2013 Tobacco-Free Ireland (TFI) policy of reducing smoking prevalence to less than 5% by 2025. Public opinion on tobacco endgame, a key lever to realise this goal, is uncharted in Ireland. This study aimed to measure public knowledge and attitudes to tobacco endgame.
Methods A telephone-administered cross-sectional survey of 1000 randomly dialled members of the general public was conducted in 2022. Prevalence of awareness, perceived achievability and support for the TFI goal and tobacco endgame measures was calculated and compared across tobacco product use status. Logistic regression identified factors independently associated with goal support.
Findings Although TFI goal awareness was low (34.0%), support was high (74.6%), although most (60.2%) believed it achievable beyond 2025. Product-focused measures were popular while support for supply-focused measures was mixed: for example, 86.1% supported nicotine content reduction while 40.3% supported user licencing. Phasing out tobacco sales was highly supported (82.8%); for most, this was contingent on support for currently addicted users. TFI goal support was independently associated with female sex (adjusted odds ratio (aOR) 1.47, 95% CI 1.05 to 2.07), higher education (aOR 1.80, 95% CI 1.21 to 2.66) and non-tobacco product use (aOR 2.67, 95% CI 1.66 to 4.30).
Conclusions Despite low awareness, tobacco endgame support is strong in Ireland. Public appetite for radically reducing tobacco product appeal and availability combined with public views on endgame achievability subject to extended timelines should be used to re-invigorate tobacco endgame discussion and planning in countries at risk of failing to meet declared targets.
- End game
- Prevention
- Public opinion
- Public policy
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Public support is important when considering tobacco endgame policies and is generally high in countries where it has been measured.
Ireland was an early adopter of tobacco endgame, but unfortunately it will likely become one of the first countries to miss its own endgame target. As endgame deadlines approach, a number of other countries are likely to find themselves in a similar situation.
WHAT THIS STUDY ADDS
This study identified timely evidence of strong public appetite among the Irish population for tobacco endgame, particularly for product, institutional structure and supply-side measures.
The findings reinforce how the public perceive tobacco endgame as being best achieved through system-level policy options which fundamentally tackle the structures and dynamics sustaining the tobacco epidemic as opposed to through measures targeting individual-level factors.
The suggestion of continuing support to pursue tobacco reduction goals beyond the current target has relevance for other countries at risk of failing to meet their own endgame targets.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This study adds to the body of evidence regarding which tobacco endgame measures are most highly supported within a country at risk of failing to meet its declared endgame target.
Introduction
Following strong progress in tobacco control, in 2013 Ireland was an early adopter of emerging tobacco endgame thinking, by setting a 2025 target for reducing smoking prevalence to less than 5% through government’s ‘Tobacco-Free Ireland’ (TFI) policy.1 Its bold tobacco endgame goal attracted media attention2 however, its recommendations were largely grounded in strengthening established tobacco control tactics, underpinned by the WHO MPOWER model.3 Since 2013, new measures introduced under TFI included graphic health warnings on cigarette packaging, plain packaging and transposition of the European Union (EU) Tobacco Products Directive.4
Despite these actions, as of 2023, with smoking prevalence stalling at 18% and no current plans for policy review,5 Ireland is on track to be the first country in the world to fail to meet its own endgame target. While precedents can have positive ‘domino’ effects in tobacco policy,6 this inauspicious mantle may provide sceptics with evidence against tobacco endgame achievability and have wider global implications.
Public support is a key lever for tobacco policy change—it creates a low-risk political environment for policymakers and mediates policy implementation.6 7 Support for tobacco endgame goals is high across international studies,8 9 but support for specific tobacco endgame tactics varies. For example, while there is high support across different countries for reducing nicotine content in tobacco products and for Tobacco 21 laws, support for additive bans is lower.10–14 Building and sharing evidence on public views can help identify gaps and priorities for tobacco endgame policymaking, and underpin successful negotiation of the complex policy process.
Given the likelihood that TFI will not be achieved by 2025, reinvigoration of endgame planning is much needed. This study aimed to assess public opinion on tobacco endgame and component measures in Ireland.
Materials and methods
A nationally representative cross-sectional study was conducted to measure prevalence of public views on tobacco endgame using a literature-informed survey instrument refined through expert consultation (online supplemental appendix A).
Supplemental material
Sampling, recruitment and fieldwork
Sampling, recruitment and data collection were conducted by an Irish-based market research company (IPSOS MRBI) in February 2022. The target population was members of the Irish general public aged 15 years and older. Sample size was calculated based on the conservative assumption that 50% of the public reported support for TFI; 784 respondents was sufficient to measure this proportion with a 95% Confidence Interval (CI) of ±3.5%.
Overall, 1000 participants were recruited for computer-aided telephone interviewing via random digit dialling using mobile and landline prefixes from the Commission for Communications Regulation. In total, 3386 individuals were contacted. Participants uncontactable by phone, non-fluent in English and who did not complete the survey in its entirety were excluded.
Measures
The questionnaire assessed 29 primary outcome measures (online supplemental appendix B). Agreement with the TFI goal and component endgame tactics was elicited on a 5-point Likert scale, including a ‘don’t know’ option. Responses were dichotomised (‘support’/’no support’): ‘support’ was defined as agreement (‘strongly agree’/‘somewhat agree’); ‘no support’ was defined as absence of support (‘neither agree nor disagree’/‘somewhat disagree’/‘strongly disagree’/‘don’t know’).7 11
Sociodemographic characteristics and tobacco product use behaviours (online supplemental appendix C) were collected. Current tobacco and e-cigarette use status was combined into a new variable (‘exclusive tobacco product use/exclusive e-cigarette use/dual use of tobacco and e-cigarettes/non-use’); respondents with current product use included those using cigarettes/e-cigarettes either regularly or occasionally. Those who responded ‘don’t know’ (n=6) were excluded.
Analysis
Data were analysed using IBM SPSS Statistics V.26.0. Frequency-based weights for age, sex, region and social grade were applied. Prevalence of knowledge and attitudes were calculated as weighted estimates with 95% CIs. Pearson’s χ2 test compared differences in responses between respondents using tobacco only, e-cigarettes only, both products or neither product. Multivariable logistic regression modelling was used to explore respondent factors associated with TFI goal support.
Results
In total, 1000 adults completed the survey (response rate 29.5%). Weighted sample characteristics are provided in online supplemental appendix D and online supplemental table 1. Overall, 11.0% currently used tobacco products only, 5.7% currently used e-cigarettes only and 2.6% currently used both products.
Knowledge and attitudes to tobacco endgame
Most respondents (76.2%, 95% CI 73.6% to 78.8%) supported more government action tackling smoking-related harm. Participants were provided with a brief description of the TFI goal and asked about their support: ‘The “Tobacco-Free Ireland” goal aims to reduce the proportion of Irish adults who smoke to less than 5% by 2025.’ Although one-third (34.0%, 95% CI 31.1% to 36.9%) were aware of the goal, most (74.6%, 95% CI 71.9% to 77.3%) supported it and believed it was achievable (76.6%, 95% CI 74.0% to 79.2%). While few (16.5%) agreed the 2025 target achievable, most (60.2%) considered tobacco endgame achievable beyond the current target of 2025; however, a minority (16.3%) believed the tobacco endgame target was not achievable at all.
Support for tobacco endgame measures
Overall, there was majority support for 19 of 22 specific tobacco endgame measures assessed (table 1). Support was generally higher among those who did not use tobacco products and there were significant differences in support among those who used tobacco products and those who did not for all but three measures. Two-thirds (66.7%) of those who supported a sales phase-out believed this should occur within 10 years. For most (85.0%), that support was contingent on measures for people currently addicted: increased government assistance for quitting (74.8%) or allowing smokers to buy tobacco products using a licence (40.8%).
Support for tobacco endgame measures*
Factors associated with TFI support
Females (adjusted odds ratio (aOR) 1.47, 95% CI 1.05 to 2.07, p=0.025), higher social grade members (aOR 1.47, 95% CI 1.00 to 2.15, p=0.049), those of higher education (aOR 1.80, 95% CI 1.21 to 2.66, p=0.004) and those who did not use tobacco products (aOR 2.67, 95% CI 1.66 to 4.30, p<0.001) were significantly more likely to support the TFI goal than their comparative counterparts, as were older respondents (online supplemental appendix D; table 2).
Discussion
Public support can translate bold tobacco endgame ambition into reality. This is especially important for early adopters, like Ireland, where fast-approaching declared endgame targets may be missed. Besides protecting national efforts, re-invigoration is needed to avoid setting a negative precedent for global efforts. Strong public support delineated in this study confirms how much success in tobacco control has changed social norms about tobacco use and helps consolidate tobacco endgame as a legitimate concept for viable policy discussion and action in Ireland.8 9 15 This study indicates that the public see tobacco endgame as being achievable, but only beyond the current policy target of 2025. However, Irish public awareness of the TFI goal was lower than was found in recent New Zealand studies,10 suggesting that public support coupled with awareness may add mandate for action.10 16 This underscores the urgent need to raise the profile of tobacco endgame through public engagement and discussion in order to advance policy action as a political priority.
This study consolidates the emerging conceptual framework for tobacco endgame.17 Levels of support for many of the endgame measures assessed in this study are well above levels of support observed both before and after implementation of Ireland’s 2004 smoke-free law, where, contrary to prevailing narrative, a dramatic increase in support (from 13% to 46%) was seen for a total ban on smoking in bars/pubs.18 This reference point underscores the significance for policymakers of the public’s current support for tobacco action in Ireland.
Similar to other studies, product-focused measures were popular,11 12 making tactics targeting nicotine content, for example, early policy options. There is already strong evidence to guide policymakers on implementation of a very low nicotine standard for cigarettes.17 Both institutional structure-focused measures had majority support. Recent plans in Ireland through implementation of the EU Single-Use Plastics Directive to make the tobacco industry pay for its waste should be used to set the stage for discussion on extending industry accountability to healthcare costs.19 20
Support for banning smoking in public places (the single user-focused measure assessed) was high, although lower among those who used tobacco products. Support for supply-focused measures varied—a tobacco retail phase-out had higher support than international findings,16 21 22 and previous Irish studies,23 underlining rapidly changing norms. New legislative plans for tobacco retail licencing announced in Ireland present a window of opportunity to better regulate tobacco retail in a way which is more proportionate to harm.24 To date, TFI policy has been characterised by strengthening ‘business-as-usual’ tobacco control. High support identified in this study for specific endgame measures, especially for a tobacco retail phase-out, presents an opportunity in Ireland to critically review, augment and truly orient planning to TFI’s endgame goal.
Conversely, less supported measures included prescription-only e-cigarette sales and tobacco-user licencing. In general, support for most measures was lower among those who used tobacco products, particularly for filter bans, substantial tax increases and restricting tobacco sales hours (online supplemental appendix E). While reasons for this were not explored, measures which were less popular with those who used tobacco had an individual-level focus. Measure support across product-use categories varied. High support for measures targeting system-level factors, and the contingency of support for a tobacco retail phase-out on supports for people who currently smoke, suggests that public opinion in Ireland aligns with endgame principles emphasising action on systems-factors perpetuating the tobacco epidemic over individual-level factors.25 Those leading tobacco endgame discussion seeking to leverage public support should carefully consider this important feature. New Zealand’s endgame plan which translates these principles into action should be a key reference for Ireland, and other countries where progress towards endgame targets is faltering. Lower tobacco endgame support in this study among social groups bearing the heaviest burden of smoking-related disease is also an important consideration since it emphasises a need to lead equity-responsive and inclusive tobacco endgame discussions.
Limitations
While this cross-sectional study provided a timely and efficient assessment of public views, interviewer administration potentially introduced social desirability bias and the low response rate (29.5%) means that non-response bias may affect representativeness. There was low tobacco endgame awareness, and the information provided about each policy was very brief. Lack of information on rationale and effectiveness of specific measures, particularly for less straightforward policies such as nicotine reduction or increased tobacco product regulation, may have impacted respondent’s interpretation of questions and views on acceptability.26 Lastly, small numbers of participants reported that they exclusively used e-cigarettes or used both tobacco products and e-cigarettes limiting analytical power to examine differences between subgroups.
Conclusions
As global momentum gathers, this study exemplifies how involving the public in tobacco endgame discourse can inform priority-setting and help design an approach which sustains support. There is high public support in Ireland for measures that radically and finally address tobacco product design and availability rather than just increasing incremental focus on people who smoke. This demonstrates a public vision for tobacco endgame based on policies targeting systemic factors underpinning the tobacco epidemic. For early endgame adopters like Ireland, now at risk of missing declared targets, strong public support should encourage policymakers to translate aspirational goals into urgent, comprehensive planning to deliver tobacco endgame. Findings on public opinion should be shared to re-inforce international collaboration to realise collective tobacco endgame ambition.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by the Royal College of Physicians of Ireland Research Ethics Committee (RECSAF 157). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The following colleagues gave input on the formulation and design of the survey: Professor Ruth Malone, University of California San Francisco Center for Tobacco Control Research and Education and Editor of Tobacco Control; Dr Elizabeth Smith and Dr Patricia McDaniel, University of California San Francisco Center for Tobacco Control Research and Education; Dr Rebecca Williams, Ms Elizabeth Anderson-Rodgers and Dr David Stupplebeen, California Tobacco Control Program, California Department of Public Health; Dr Fenton Howell, former National Tobacco Control Advisor, Department of Health; Ms Claire Gordon, Tobacco and Alcohol Control, Department of Health; Dr Helen McAvoy and Dr Ciara Reynolds, Institute of Public Health in Ireland; Dr Sara Burke, Centre for Health Policy and Management, Trinity College Dublin; Dr Daniela Rohde, Health Information and Quality Authority; Professor Des Cox and Members of the Royal College of Physicians of Ireland (RCPI) Tobacco Policy Group; and staff of the Department of Public Health, Health Service Executive South East. High-level and summarised content of the study has been published as a policy brief and shared by the Health Service Executive Tobacco-Free Ireland Programme with key national stakeholders; in addition, the lead author has presented the findings orally at the European Public Health Meeting in 2022 (an abstract based on the conference proceedings was published here: Cosgrave, E., Blake, M., Murphy, E., Sheridan, A., Doyle, F., & Kavanagh, P. (2022). Is Ireland ready for tobacco endgame? A national survey of knowledge and attitudes to tobacco endgame: Ellen Cosgrave. The European Journal of Public Health, 32(Suppl 3), ckac129.034. https://doi.org/10.1093/eurpub/ckac129.034). The author was also invited to present at an online seminar organised by the Centre of Research Excellence on Achieving the Tobacco Endgame (https://tobacco-endgame.centre.uq.edu.au/event/session/780).
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors EJC and PK conceptualised and designed the study; led the acquisition, analysis and interpretation of data; and drafted the manuscript based on the work. EJC conducted the background literature research and conducted the analyses and PK provided oversight of data analyses. AS, EM and MB made substantial contributions to the acquisition of data and analysis of the work. FD made substantial contributions to the conception, design and interpretation of the work. All authors provided final review and edits of the manuscript.
Funding The fieldwork for the survey was funded by the Health Service Executive Tobacco-Free Ireland Programme and conducted by IPSOS MRBI.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.