Professor Des Cox:

I thank the Chairperson for the invitation to appear before the committee. I am a consultant in paediatric respiratory medicine at Children’s Health Ireland, Crumlin. I represent the policy group on tobacco of the Royal College of Physicians of Ireland. The RCPI is a postgraduate medical training college with a membership of over 12,000 doctors across 29 different specialties in more than 90 countries.

In addition to leading in training and postgraduate education of specialist doctors, RCPI’s members and fellows offer a clinical perspective and expert knowledge to inform and influence national policy on public health. The RCPI policy group on tobacco was established in 2014. Since 2020, we and the IPH have collaborated to increase the impact of research and advocacy in the area of tobacco use.

Tobacco smoking remains the biggest long-term public health issue in Ireland. Smoking causes over 6,000 deaths and 1,000 hospitalisations each year. Every day doctors and other healthcare professionals have to pick up the pieces – breaking bad news to patients and their families about cancer caused by smoking, arranging care for preventable illnesses caused by smoking, such as heart attacks and stroke, and supporting people living with ongoing disability, such as chronic lung disease. Everyone has seen and supported healthcare professionals on the front line tackling the Covid-19 epidemic. We must remember that healthcare professionals in Ireland are still on the front line tackling a continuing epidemic of harm caused by smoking. We have a target of 5% smoking prevalence by 2025, as set in the 2013 Tobacco Free Ireland action plan. Despite declines in prevalence – from 23% in 2015 to 18% in 2021 - there are concerns that progress is now stalling. Worryingly, there has been a slight increase in children tobacco smoking since 2015.

Nicotine inhaled products are commonly used today in Ireland, often promoted as a safer alternative to tobacco smoking. When doctors recommend or provide healthcare, we need to have confidence that the care is safe and effective. Patients expect nothing less. This is the standard against which nicotine inhaled products need to be assessed. What we know about these products from independent scientific studies, including randomised controlled trials, and in Ireland from a review by the Health Research Board, is that they are no more effective than approved, regulated, safe and clinically sound nicotine replacement therapies. Studies also show that nicotine inhaled products are a gateway to tobacco smoking. Adolescents who ever used nicotine inhaled products are between three and five times more likely to start smoking compared with adolescents who have never used nicotine inhaled products.

Numerous scientific studies demonstrate that nicotine inhaled products have harmful effects. Although they contain fewer harmful substances when compared with tobacco smoking, research on their long-term health effects, particularly from animal studies, suggests that substances contained in these products can cause brain, heart and lung damage. To enhance the health gains of this Bill, we would like the committee to consider our recommendations for modification to the existing heads of Bill, recommendation 1, and for future amendments or legislation, recommendations 2 to 4.

Our first recommendation is inclusion of nicotine inhaled products under selected existing heads of Bill. In respect of the prohibition on the sale of tobacco products from temporary or moveable premises, head 16, counter or point of sale, head 17, events where children are present, head 21, and vending machines, head 35, we recommend extending these measures to include nicotine inhaling products. As we do not wish to delay the passing of the Bill, we recommend that measures be added as amendments to the Bill in the near future.

Our second recommendation is to increase the prohibition of the sale of tobacco and nicotine inhaled products from 18 to 21 years of age. Countries such as the US and Singapore have implemented a Tobacco 21 policy and recent evidence suggests that tobacco smoking reduced among 18- to 20-year-olds as a result.

Recommendation 3 is to prohibit the sale of nicotine inhaled products flavourings apart from tobacco flavoured products. Adolescents are more likely to initiate nicotine inhaled products use through flavoured products relative to other age groups. While adults may also enjoy flavours, the risks of nicotine inhaled products initiation in adolescents and young adults outweigh the benefits of ex-smokers using flavoured products. Finland’s 2016 ban on flavours did not result in fewer smokers using nicotine inhaled products as a quitting tool.

Recommendation 4 is that the same restrictions on advertising and marketing of tobacco products should be applied to nicotine inhaled products. Currently, point of sale and billboard advertisements have the potential to attract non-smokers to try nicotine inhaled products. Marketing across social media platforms for nicotine inhaled products remains unregulated. It often appears that these products are being sold as an alternative to tobacco smoking rather than solely as a stop smoking aid.

We wholeheartedly support this proposed Bill as an important milestone in tobacco control legislation in Ireland. Enacting this proposed legislation into law would align Ireland with many of our counterparts across the EU and with the UK. It will lead to a reduced prevalence of tobacco smoking and deliver a significant child protection measure against nicotine addiction. We encourage the committee to pass the proposed Bill without delay and also to consider our additional recommendations.

I declare no conflict of interest personally, or on behalf of RCPI, in respect of any direct or indirect financial assistance or funding or any professional relationship with the tobacco industry or any entity working to further its interests.