Policy researchers have long been interested in the processes that facilitate major policy change.1 A 2021 study2 explores the role of the public health advocacy coalition in promoting the passage of the Public Health (Alcohol) Bill in Ireland. Following a five-year campaign, the Public Health (Alcohol) Bill was approved by the Government in December 2015 and after a protracted and contested process the legislation was signed into law on October 2018.

The alcohol industry and the public health community formed two opposing coalitions during the policy debate.3 The alcohol industry’s success in resisting population-level approaches to alcohol policy has been identified in Ireland4,5,6,7–11 and elsewhere.12–20 In contrast, public health advocates have typically had limited success. Yet in this case, public health advocates in Ireland have developed sophisticated political strategies to foster major alcohol policy change.

Methodology

The study constructed a record of the public health advocacy coalition and its campaign to promote the Public Health (Alcohol) Act 2018 in Ireland. To identify the key actors and issue frames, a thematic analysis was undertaken using primary documents produced by advocates, newspaper articles, and semi-structured interviews with key advocates, public health experts, and elected officials.

This analysis documented the growing political sophistication and effectiveness of public health advocates in Ireland. First, a broad-based coalition enabled advocates to pool resources and coordinate their strategy and messaging. Second, issue-framing was critical in shifting the focus of the debate to alcohol-related harm. This placed pressure on politicians by making available evidence on the extent of the problem. Finally, evidence of political learning was presented, where advocates’ knowledge of the political system spurred innovations in campaigning.

These three strategies – coalition-building,21 issue-framing,22 and political learning23,3 – are discussed in more detail below.

Coalition-building

The public health alcohol advocacy community in Ireland had traditionally comprised a relatively small group of non-governmental organisations (NGOs), public health experts, and public health officials. However, a concerted push to professionalise advocacy since the 2000s saw Alcohol Action Ireland (AAI), a national advocacy organisation, participating in numerous policy deliberations including the National Substance Misuse Strategy (NSMS) Steering Group. When the Government announced it would be acting on the policy recommendations of the NSMS report, AAI mobilised a cross-party group of senators and TDs.

Interest in alcohol policy also extended to the Irish medical establishment, leading to the formation of an alcohol policy group in 2012. Key figures in the Royal College of Physicians of Ireland (RCPI) and AAI decided to mobilise other organisations who supported the key principles of the Bill. This Alcohol Health Alliance Ireland brought together 62 organisations.

The establishment of this broad coalition allowed members to effectively pool their limited resources. Drawing ‘on the strength and the reputations’ of its membership helped to strengthen the advocates’ credibility giving them ‘more clout with the public, with politicians, and with the media’.2 As one advocate explained, AAI had been ‘a small charity, a small voice, [and] a lone voice, with a limited budget’, and so the inclusion of organised medicine enabled the alliance to ‘speak with more authority’ on alcohol harms.

The coalition coordinated its strategy and maintained message discipline by advising experts ahead of their media appearances. As one member remarked, traditionally there were ‘lots of disparate voices shouting out in an uncoordinated way’.2 The alliance ensured that when an issue was raised in the media, the most effective voice articulated the public health position.

The alliance also recruited individuals from member organisations who possessed a background in public affairs, including those with prior roles as journalists and as political advisers, thus possessing an intimate knowledge of the political system. The close working relationships with politicians and key officials within the Department of Health allowed the alliance to keep ‘on top of what was happening in government … and what … might have been said in the media’.2

Issue-framing

A key framing strategy was to focus on the content of the problem – the health harms – rather than the particular measures within the Bill itself. Advocates made extensive use of social media and developed multimedia strategies to establish their preferred framing. The alliance used its website and other communication materials, including infographics, to highlight the harms caused by high levels of alcohol consumption. Advocates released hundreds of documents, including reports and press releases, to generate media coverage. Advocates also used social media, press interviews, and editorials at key stages of the Bill’s progression to underline the principal harms frame.24–27

Although it faced entrenched alcohol industry positioning, it found ways to pivot when confronting less advantageous frames. For example, when industry identified the economic costs of the Bill, advocates responded by highlighting the healthcare costs associated with the status quo. According to one citation, the alliance’s ‘expert stakeholder alliances and evidence-based communications’2,28 succeeded in keeping alcohol on the agenda for more than three years, despite facing a ‘well-resourced and culturally-embedded opposition’.28

Political learning

There is evidence of political learning23 where advocates’ prior experiences and knowledge of the political system in Ireland spurred innovations in campaigning. Key lessons had been drawn from other successful public health campaigns including the smoking ban.

The specific expertise of the advocates was critical to the Bill’s passage, including experience in politics, journalism, and in campaigning organisations. Politicians were targeted and close relationships were formed with those who were sympathetic, broadening the coalition, and leveraging these interactions to shape the legislative process. Local grassroots organisations also played a key role in reinforcing this tactic at a local level. These strategies were interdependent and mutually reinforcing, and succeeded in building support for public health advocates’ preferred policies among politicians and the general public.

Advocates exhibited sophistication throughout the debates over the Bill. One expert, who was not formally involved in the coalition, had this to say about its influence:

[The alliance] was pivotal because they made it a campaign and they ran it like a campaign ….Campaigns are not accidental things … they have to have many arms … they have to have a communications arm, a political arm, a policy arm, [and] a civil service arm … I think they covered all the bases … I think the public health side [was] strong and … more savvy than before.2

Discussion

These findings provide insights into the developing capacity of advocates to drive major policy change. The success of the alcohol advocacy coalition in its campaign to pass the Public Health (Alcohol) Bill was a hard-fought campaign but other equally hard-fought advocacy campaigns preceded it, including the ban on smoking in public places as well as national referenda on divorce, abortion, and same-sex marriage. Such successes generate momentum and are relevant to appreciating how the broader advocacy community has professionalised over time.

Ireland’s long-standing problematic relationship with alcohol as well its failure to get to grips with the problem is another important consideration.4–6,8 Several Irish experts have been instrumental in generating high-level awareness of the existence of a problem, gradually reframing the problem away from an issue affecting a subgroup of ‘alcoholics’ towards a fuller population-level understanding of alcohol harms. Politicians were receptive to major policy change due in part to sustained public attention to alcohol as a problem.8

This study contributes to a broader research programme on the alcohol industry and the role of evidence in alcohol policymaking.18,29–31 A recurring finding on the alcohol industry is the advantages it holds over its opponents with respect to resources and lobbying efforts.28 This study, however, shows that experts often possess unique capabilities or attributes – such as public trust – which can help to mitigate the industry’s resource advantage.

Finally, the prolonged development of alcohol policy innovation in Ireland underscores the perennial role of conflict. The Irish advocacy coalition saw itself as fighting a war with industry in pursuit of rational policymaking, based on using high-quality scientific evidence to reduce avoidable harms caused by alcohol. In such terms, an important series of battles have been won, culminating in the passage of what has become the Public Health (Alcohol) Act 2018. However, the political war will not end with legislative enactment. Researchers will need to focus on policy implementation, examining how each coalition seeks to advance its interests and ideas in this next stage of the policy process.

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