Abstract: Tobacco use remains Ireland’s leading cause of preventable death, with lung cancer the number one cause of cancer-related death in the country. Despite excellent progress through the Tobacco Free Ireland Programme (TFIP)— including the Tobacco 21 legislation and universal access to nicotine replacement therapy—smoking prevalence persists at 17%, and youth vaping rates are rising. National initiatives like Quitline, Quit4Youth, and We Can Quit have expanded cessation access, yet challenges remain in mental health settings, illicit supply, and youth uptake. While Ireland has achieved global recognition in tobacco control, intensified enforcement and innovative strategies are essential to realise a truly tobacco-free future.
Introduction
The evidence remains stark, with the WHO highlighting the following statistics;
Tobacco use is the leading cause of preventable death in Ireland with 4,500 smokers dying each year from tobacco-related diseases.1Tobacco kills up to half of users who do not quit.2,3,4
Tobacco is responsible for over 7 million deaths annually, including an estimated 1.6 million non-smokers who are exposed to second-hand smoke as well as disability and longterm suffering from tobaccorelated diseases.5
The younger you are when you start smoking, the more likely you are to smoke for longer and to die early from smoking.6
Despite the glaring data and devastating consequences of smoking-related lung damage, the tobacco epidemic continues to be one of the biggest public health threats faced by society. The 2024 Healthy Ireland (HI) survey reports that 17% of the Irish population are current smokers, of which 14% are daily and 4% occasional smokers. Smoking rates remain highest among the 25 to 34 age group at 20%, However it must be noted that this is a significant decline from 32% reported in the first Healthy Ireland Survey in 2015.
Cigarette smoking remains the most common form of tobacco use worldwide but there is growth in the industry of electronic cigarettes – the most common form of electronic nicotine delivery systems (ENDS), commonly referred to as ‘vaping’. Multiple forms exist including disposable vapes, pod systems, pen-style vapes and box mods. These contain varying amounts of nicotine and additional harmful emissions. The World Health Organisation (WHO) state that there is no safe level of tobacco use and calls for comprehensive bans on flavoured tobacco and nicotine products to prevent youth addiction. The current evidence reveals that these products are harmful to health, however unfortunately it is too early to provide clear data on the longterm impacts.
Overall 8% of our Irish population currently use e-cigarettes either daily (5%) or occasionally (3%) –this figure has not declined since 2023. Most concerningly, the central statistics office reported in 2024 that 9.3% of our young people aged 15-19 years of age use e-cigarettes daily, a staggering increase from 4.7% reported in 2022, having peaked at 12.3% in 2023. The prevalence of nicotine pouches which are strongly linked to oral cancer was as high as 8.1% in the Irish population in 2024.7
In 2004, Ireland became the first country to pass a smoke-free law, and furthermore in 2021 the WHO recognised Ireland as a global leader in tobacco control due to its innovative policies.
The HSE’s Tobacco Free Ireland Programme (TFIP) Implementation Plan for 2022–2025 set a national target to be tobacco free (i.e. with a smoking prevalence rate of less than 5%) by the year 2025. This policy focuses on a number of key pillars in smoking cessation and lays out a robust, multi-dimensional path toward achieving their goal by integrating governance, policy, clinical practice and public engagement Nationally.
The overall objectives of the TFIP are to support people in smoking cessation and treat tobacco dependence as a healthcare issue, prioritising the protection of children and contributing to the de-normalisation of tobacco use for future generations. As we approach the end of the current Tobacco free Ireland policy in 2025, we will critically appraise the areas addressed to highlight the key successes to date and offer an outlook on the next steps for efficient tobacco control in Ireland. Legislative Compliance and Regulating the Retail Environment.
Firstly it must be acknowledged that there are significant gains obtained from the major law changes delivered as part of the TFIP nationwide implementation plan. Under the Public Health Tobacco Amendment Act 2024; Ireland is increasing the minimum legal age for the sale of tobacco products from 18 to 21, thus becoming the first EU country to implement such a policy. US studies indicate that Tobacco 21 laws reduce both smoking rates among 15–20 year-olds and limit social supply, therefore this legislation which was passed by Dail Eireann in November 2024 (and taking effect from February 1st 2028), is seen nationally as a gamechanger in protecting our children and future generations from tobacco addiction. These law changes are predicted to have a major beneficial effect on our society. It has been shown that people who start smoking at a younger age are more likely to continue to smoke through their adult life.6 In addition, the 2024 Eurobarometer report demonstrated that children in Ireland start smoking at a younger age than the European average.8
In addition, the Public Health Tobacco Products and Nicotine Inhaling Products (TPNIP) Act 2023 has introduced phased commencements. The first measure, implemented in December 2023 introduced a ban on selling tobacco products and ENDS to individuals under 18. In addition the legislation restricts advertising near schools and on public transport.
Vending machines are consistently more accessible to minors than over-the-counter sales. To combat this, the Act has implemented (in September 2025) a ban on selfservice sales of these products from vending machines. At the time of writing, 2/3 of signatories to the WHO Convention have already banned the sales of tobacco products from vending machines, with Scotland, England, Wales and Northern Ireland introducing the ban over 10 years ago.
A national licensing regime was announced by Minister Donnelly in January 2025 – strengthening compliance leverage – and will come into operation in February 2026 with annual licences legally required for the sale of tobacco and nicotine inhaling products for each premises from which either product is sold. The law prohibits the issue of licences for temporary or mobile premises including festival popups, emphasising that a product that kills one out of every two of its users is not to be treated like other consumer products.
These legislations will have a knock-on effect in prohibiting ease of tobacco access for the younger population and preventing the start of a lifelong habit.
Challenges remain in the form of illicit supply, which undermines price-based deterrence and compliant retailing. A survey from the Irish Revenue in 2024 found that 26% of cigarettes packs held by smokers were illegal and a further 11% were non-Irish duty paid. The ability of under21s to source tobacco through informal and illegal channels will indeed blunt demand-reduction and compliance gains unless enforcement and cross-border controls keep pace.
Denormalisation of Tobacco Use and Promotion of Tobacco-Free Environments
With 9.3% (almost 1 in 10) of our 15-19 year olds now vaping daily in Ireland, the need to protect our youth from tobacco addiction has never been more important. Childprotection and denormalisation steps have advanced significantly with the legislation changes outlined above.
The implementation plan has also rolled out an awareness training programme for youth workers on nicotine addiction, the prevention of E-cigarette and smoking initiation – for example, the HSE Youth Prevention Toolkit and the Quit4Youth 7 week programmeprovide behavioural support from advisors and other participants to promote vaping and smoking cessation. The tobacco free Ireland team have engaged with mental health service Spunout who actively highlight and link young people with these available supports.
The HSE’s Tobacco Free Campus Policy has mandated that smoking by employees, patients, visitors and any other parties is prohibited on all HSE campuses since December 2015 (9). However, compliance with this policy is poor with a recent audit showing that up to 11% of people observed on hospital grounds had a cigarette in their hand.
In addition, Tobacco-free campus compliance is uneven – in particular, there is major difficulty in inpatient mental-health settings reported in the literature. Tobacco Free Campus policy implementation across the Mental Health service is vital as smoking rates are disproportionately high throughout all areas of the mental health service with the highest rates in people with substance use disorders.10 Implementing strategies such as smoking cessation becoming a routine part of psychiatric care plans will not only have a positive impact on quality of life; both the physical and mental health needs of our patients, but also has the potential to realise significant cost savings for the HSE.10
Further work is required with Mental Health Services to advocate for and support the development of on-site smoking services for acute and community mental health services. In addition, tobacco-free campuses must be properly enforced. This should include the removal of designated smoking areas and active policies to support patients to take up nicotine replacement therapy (NRT) and ultimately to quit smoking.
HSE Leadership in Treating Tobacco Dependence as a Healthcare Issue
The TFIP implementation plan, developed in 2022, outlines a clear national clinical framework for smoking cessation In Ireland. The National Clinical Effectiveness Committee’s (NCEC) Stop Smoking Clinical Guideline 2022 is a document that sets out best practice for treating tobacco addiction in the Irish healthcare system. This guideline focuses on health professionals to improve interventions for the general adult population, especially pregnant women and those with mental health issues as mentioned. It recommends an approach which combines pharmacological support and enhanced behavioural support services, with the goal of increasing successful quit attempts by providing evidence-based strategies and resources for smokers.
All of the commercially available forms of NRT are effective as part of a strategy to promote smoking cessation, with proven increased quit rates by 50-70% regardless of setting with NRT compared to no treatment.11 Interventions that combine pharmacotherapy with behavioural support also increase smoking cessation success at 6 months or longer compared with no support.12 This effect is consistent across trials.
The clinical guideline framework encourages all healthcare professionals to utilise the proven ASK–ADVISE–ARRANGE approach when assessing smoking status, advising on the best way to quit and finally recommending suitable medications while referring patients to specialised behavioural support services / a HSE stop smoking advisor. As smoking cessation without professional help is achieved only in 3-5% of smokers in the longterm, this guideline is key in providing our health system with a common strategy to establish sustained cessation.
The development of an effective smoking cessation framework in the acute hospital setting has been proven by the Ottawa Model in Canada and the CURE project in the UK.
A Smoking Cessation Proforma as part of the patient admission bundle was introduced on a pilot ward in Galway University Hospital in 2023. Supported by a poster campaign, the simple interventions included the introduction of a standardised approach to identification of smoking status and an optout referral of active smokers to smoking cessation services. Patients were easily identified this way with 19.7% of audited inpatients active smokers. During the 5 week pilot programme, smoking documentation rate increased from 64.4% to 85.7%, and 95% of tobacco users were referred to local smoking cessation services, a significant improvement from the reported pre-intervention results (13%). These policies can be implemented successfully throughout Irish hospitals.
HSE Quit Resources now include the National Quit website, the Quitline (1800 201 203), open 7 days a week, and the successful provision of free NRT.
These services are all standardised with national Quality Assurance (QA) standards and implemented across settings; digital QUIT plans and advisor-led programmes continue to attract users. The HSE moved to provide free NRT through stop-smoking services from 2023, with ongoing promotion and operational guidance in 2024–2025 focussed on providing universal access to pharmacotherapy in the form of gum, sprays, inhalers, lozenges and patches. Early evaluations have indicated increased NRT uptake, with record numbers of people using the QUIT service since it began providing free NRT in 2023. The HSE reported a 50% increase in NRT use among people using their service.
Another successful service is the ‘We Can Quit’ Programme, delivered by community partners under the auspices of the Sláintecare Healthy Communities Initiative. This programme is a free, community-based, group support programme run by the HSE and partners to aid smoking cessation. They run for between 7–12 weeks, offering weekly group sessions and free NRT, with one-to-one facilitators providing
encouragement and advice in a non-judgemental environment. Numerous groups are run by community organisations in every county throughout the country, focusing on community health inequalities, with further sites continuing to be developed.
Smoking in pregnancy is a leading public health challenge with both national and international studies highlighting the urgent need to improve stop-smoking care in pregnancy. This care gap was highlighted in the National Maternity Strategy (2016–2026) and an evidence-based care pathway was established in the 2022 new National Stop Smoking Clinical Guidelines.
A pilot implementation of the new care pathway was undertaken in two Irish maternity hospitals and found that 691 women were referred to a specialist Stop Smoking Midwives. Referrals were accepted by 81.6% of women and 23.4% set a quit date, with 14.5% of women delivering a smoke-free baby. This qualitative research highlights the importance of a non-judgemental approach in recruitment and engagement with women in the programme throughout the country, an important initiative which again should be targeted as an area we can continue to make important gains.
Monitoring Tobacco Prevalence and Evaluating Effectiveness of All Interventions
The HSE Health & Wellbeing Reports have maintained smoking cessation activity on the radar via a suite of key performance indicators developed to monitor the impact of HSE funded tobacco control interventions. For example at the end of quarter 1 of 2024; HSE metrics show that nationally 5,909 smokers received intensive cessation support from a cessation counsellor which is -5.4% below the target of 6,246 but +8.3% ahead of the same period in 2023. The HSE has provided accountability via the QUIT Service Monitoring reporting quarterly and annual outputs (QUIT plan activations, advisor sessions delivered, NRT provision).
Ongoing surveillance of tobacco and e-cigarette use through the HSE Tracker Survey, Healthy Ireland Survey, Health Behaviour in School Children Surveys and the European School Survey Project on Alcohol and Other Drugs have been vital implementation tools to monitor where we stand. Regular, transparent prevalence tracking works well to monitor progress, however, despite these interventions, the overall smoking prevalence is not on a trajectory to reach the eradication goal of <5% by 2025. The 2024 HI Survey provides up-to-date national data on smoking rates in Ireland. The data shows that 17% of the Irish population continues to smoke and the reality remains that Ireland won’t meet the desired target without extra measures.
The TFIP rollout included additional plans to develop and produce new media & public campaigns such as the QUIT TV and Radio campaigns which were revamped in 2023. Media outreach is a vital cornerstone in raising awareness of the importance of smoking eradication and in normalising cessation efforts. However, this outreach now needs to be sustained. These campaigns should be tested and tailored for different demographic groups, especially younger adults, where smoking remains high and multiplatform approaches including utilisation of young influencers on social media may enhance reach to this cohort.
Conclusion
As we approach the final quarter of 2025 and the end of the current plan, it must be acknowledged that there have been massive structural wins to celebrate from the TFIP implementation plan – primarily in terms of our legislative reforms.
As mentioned, TPNIP 2023, Tobacco 21 – 2024 and retail licensing laws launching in 2026 all show a clear commitment to continuing to denormalise tobacco and vaping by reducing their appeal and accessibility of products, particularly to young people.
In addition, service access has undoubtedly improved, most notably with universal access to free NRT which continues to support the reduction of smoking rates, alongside many other innovative services including We Can Quit, Quit4Youth, the National QUIT website and a 7 day-a-week Quitline. The clinical guideline dissemination and QA framework align well with the National Implementation Plan. These strategies implemented to date highlight the commitment of the Tobacco Free Ireland team to enforcing smoking cessation, saving preventable deaths and taking a significant step towards achieving a Tobacco Free Ireland.
However, the data unfortunately shows a definite loss of momentum in that we are not reaching the perhaps overambitious target of a tobacco-free Ireland by the end of this year. Meeting this goal in the near future will be dependent on accelerating the progress of our smoking cessation programs across all healthcare settings. Additional challenges have arrived including the evolving smoking habits of Irish people with the increasing popularity of ENDS, which will require ongoing adaptation of current smoking cessation practice and legislation. It is worth remembering that some of the aforementioned legislation announced will not come into practice until as late as 2028 and it will require additional time to fully bear the fruits of these new laws.
Unfortunately significant challenges remain. The annual HI Surveys suggest that denormalisation among adolescents/young adults is not yet decisively improving despite the best efforts of the National Implementation programme. The overall population prevalence remains concerningly static at 17% and youth vaping with e-cigarettes remains at 8%.
Of Note, the UK government has placed a complete ban on the sale of disposable / single-use vapes, implemented in June 2025, with e-cigarettes and e-liquids also subject to these regulations, including restrictions on the maximum nicotine strength – a policy that should now be strongly considered in Ireland.
Further progress can also be made with an increased focus on high-prevalence groups including tailored supports as discussed for both mental health and maternity sites. Campaigns utilising social media and influencers can target the under-25 population.
Smoking cessation policies should be implemented throughout our Irish hospitals, in line with the successful international Ottawa and CURE projects. Mandatory
Hseland training on smoking cessation for all healthcare staff across the board should be instated to emphasise the importance and remind us of the fact that it is all of our duties as healthcare professionals to continue to Ask-Advise-Arrange on a daily basis.
Expanding our Slaintecare communities is vital as is integration of the GP Healthlink IT system to provide direct referrals to the QUIT service, so that patients are prescribed NRT and swiftly linked with the available counsellors nationwide providing continuity. Publicising seizures to deter illicit supply may also be necessary.
In conclusion, we have much to be proud of as a leader in global tobacco control. However, despite admirable progress and unquestionable accountability from the HSE TFIP, the end of the epidemic of smoking-related harm in Ireland is not yet in sight. Tobacco use still remains the leading cause of preventable death in Ireland with a staggering 4,500 smokers dying each year from tobacco-related diseases. Lung cancer remains Ireland’s leading cause of cancer-related death in both sexes with 1950 deaths per annum, accounting for 19.5% of cancer deaths in women and 20.6% in men.13
The reach, intensity and enforcement of the TFIP simply must be accelerated—especially in particular groups such as youth, disadvantaged groups, and hardto-regulate environments such as the illicit tobacco trade and inpatient settings.
It is vital to maintain and grow these initiatives if – both as a society and a health service – we want to close the gap and obtain the desired goal of a Tobacco Free Ireland.
References available on request
by: Foley E1, MB BCh BAO MRCPI, Respiratory SPR Interventional Respiratory Unit, Galway University Hospital, Lead Galway University Hospitals
1. Interventional Respiratory Unit, Department of Respiratory Medicine, Galway University Hospitals, Galway, Ireland.
Corresponding author: Dr Eimear Foley: Interventional Respiratory Unit, Galway University Hospital, Newcastle Road, Galway, Ireland, H91 YR71. Email: Eimear.foley3@hse.ie Phone: 087-9704990
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