Thursday, 15 March 2012
Joint Committee on Health and Children DebatePage of 4
Chairman: I welcome the Minister of State with responsibility for primary care, Deputy Shortall, and Dr. Tony Holohan, chief medical officer at the Department of Health and chairperson of the steering group on the national substance misuse strategy. I also welcome those in the public Gallery including members of the media. I congratulate Dr. Holohan and the Minister of State on their work to date on the national misuse of substance strategy. I commend Dr. Holohan on the report published. The committee also published a report, which we hope will dovetail with the work done by the Minister of State and Dr. Holohan.
Before I ask the witnesses to make their opening remarks I advise them they are protected by absolute privilege in respect of utterances at the committee meeting. However, if they are directed by the committee to cease making remarks on a particular matter and continue to do so, they are entitled only to qualified privilege in respect of their remarks. They are directed that only comments or evidence connected to the subject matter of this meeting are to be given. They are asked to respect the long-standing parliamentary practice to the effect that, where possible, they should not criticise or make charges against a Member of the Oireachtas or a person outside the Houses in such a way as to make him or her identifiable.
I thank the witnesses for coming before the committee. It is important that on the eve of St. Patrick’s weekend, one of the biggest weekends in the Irish calendar and a big weekend for binge drinking, we have this opportune moment to address the issue of alcohol misuse. I ask the Minister of State, Deputy Shortall, to address the meeting.
Minister of State at the Department of Health (Deputy Róisín Shortall): I thank the committee for the invitation to appear before it today. I am pleased to have another opportunity to discuss the problem of alcohol misuse in the country and how we might approach tackling it. The committee has produced a report which is a very welcome development. I read it with interest and I very much welcome the committee’s engagement on the issue of alcohol misuse. I know it has had extensive hearings on the matter. It is timely that the report was published shortly before the report of the steering group. We have two very comprehensive reports which will form the basis of future early action in this area.
Having two new reports raises the question of whether we have had too many reports over the years. For the past 20 years there has been a proliferation of reports and the difficulty has been that many of these lay on the shelf and were left to gather dust as very little action was taken on foot of them. I want to make a clear commitment that this will not happen to the steering group’s report or to the report produced by the committee.
The approach taken by the steering group, the Department and the committee has been to look at the problem of alcohol misuse from a public health perspective and to consider the very substantial damage done to public health physically and mentally by our unhealthy relationship with alcohol and the fact we consume such large volumes. The steering group’s report is very stark with regard to the public health and protection agenda. It reported that potentially 1.5 million people in Ireland drink in a harmful way.
At this point we have little choice but to deal comprehensively with the problem. As public representatives we have a clear picture of the damage alcohol does to our society. We see it first hand in our constituencies. We meet people who have problem drinkers in their families and whose families suffer various harms as a result of alcohol misuse. We also see it very graphically in the public order problems caused in our constituencies. Dr. Tony Holohan, the chief medical officer, will speak about the evidence on the harm alcohol misuse causes. This evidence in aggregate is quite clear; alcohol is the source of many harms and dangers to Irish society therefore there is no more room for equivocation on this matter. The evidence will be presented to us and the onus on us as public representatives is to take action.
We are all familiar with the situation in cities and towns throughout the country on weekend nights. We see excesses, raucous behaviour, damage to property and assaults as a result of the alcohol-fuelled activity in which so many of our young people engage. We are also familiar with the issues that arise on an ongoing basis at public meetings we attend about the misuse of alcohol and harmful alcohol imbibing causing major problems in local communities and housing estates. It is very intimidating for older people in particular and for young people who do not engage in this type of activity. In my experience one of the most common issues that arises at public meetings is antisocial activity associated with alcohol misuse.
Those of us who are parents are very conscious of the dangers that exist for young people. We lie awake in bed on weekend nights wondering how our sons and daughters are when they are out for the night, perhaps in town. We know the likelihood is alcohol will be involved, whether on their part or on the part of their friends, and we are worried about the real dangers where large amounts of alcohol are involved.
As public representatives we are familiar with the scale of the problem. I have no doubt through our earlier discussions and from the extensive nature of the work done by the committee that committee members share our concern about this issue and are determined to address it in a comprehensive way. The Department of Health intends to take very early action on this issue. The evidence exists and Dr. Holohan will speak to the committee about it. It is very sobering evidence and we have reached the point where we need to take action.
The public also has a strong view that we can no longer tolerate the damage being done by alcohol to society. It exacts at huge cost in economic terms, estimated to be approximately €3.7 billion through the health burden, the cost of alcohol-related crime, the cost of absenteeism from work and the loss of productivity. The human cost is even greater in terms of family breakdown. Alcohol is implicated in many social ills such as domestic abuse, rape and child abuse. Alcohol is a factor with regard to the behaviour of the parents of a significant number of children who are taken into care. Alcohol is also a significant factor in mental health issues and figures indicate it is implicated in approximately 50% of suicides and self harm.
The evidence is very clear and we can no longer ignore it. There is no room for equivocation on this. The committee and the wider public share the view that we need to take action. We have a strong mandate from our electorate, and we know this because the issue arises at meetings we attend. The public wants us to take action in this area.
We will speak about the specific recommendations of the steering group’s report. One key area is supply and I share the committee’s concern about the proliferation of outlets and the need to tackle this problem. Another key area is price and we must tackle the very low cost of alcohol. Alcohol is no ordinary commodity and it cannot be treated as such. This is why we need to tackle the problem of the normalisation of alcohol in Irish society. The chief medical officer will give the committee an overview of the evidence presented to the steering group on the adverse impact of alcohol on society. It is on this basis that the recommendations have been drawn up.
I pay tribute to the excellent work of the steering group. In particular I thank our chief medical officer, Dr. Tony Holohan, and all of the members of the group who put a lot of time, effort and work into drawing up this very valuable report. I hope this report, along with the report of the committee, will form the basis of a very clear action plan which is in development in the Department of Health. That will be brought to Cabinet in the coming months in order to move forward with a public health Bill later this year which will address all the many facets of the alcohol problem.
I very much value the input of public representatives, particularly in this committee, given the work done in recent months. I strongly believe that public representatives are in a unique position to understand the nature of the alcohol problem in society and the various aspects of the issue. That is why I want public representatives to be very closely involved in drawing up this action plan. The approach we will take is reasonable but effective and it will not pull punches in facing up to the scale of the problem before us. We must take our courage in our hands and agree to take significant action over the coming months to address the problem.
Chairman: I thank the Minister of State for her presentation and commitment to action. From a public health perspective, this committee has made tackling alcohol misuse a priority. The Minister of State is correct in that it must be tackled and it is important that the unhealthy relationship people have with alcohol can be met head-on for the first time. I very much welcome the Minister of State’s commitment and statement that we will not fudge the matter. We will take it on and the Minister of State is right in saying we must have the courage of our convictions. I compliment her on her input. I welcome Dr. Tony Holohan, chief medical officer from the Department of Health, and I ask him to make his presentation.
Dr. Tony Holohan: I thank the committee for the invitation to come before it. I greatly appreciate the opportunity to speak on the subject of alcohol. I commend the Chairman and his committee on the excellent report recently produced on alcohol which I have no doubt will resonate very closely over the course of this discussion with many of recommendations made by the expert group that I had the privilege of chairing. I would particularly like to talk to about the steering group I chaired, about alcohol and its effects and about the recommendations we have made. My presentation is grounded in the evidence base that underpins the report, particularly the effects of alcohol and what will work.
In 2009, the Government, on publication of the national drugs strategy, decided that policy on alcohol and other substances should be integrated. Therefore, an expert group was established to bring alcohol policy into line with policy on drugs as a single overall integrated policy. This group, initially under my co-chairmanship and that of the former Department of Community, Rural and Gaeltacht Affairs, was established in December that year. When establishing the group, a cross-departmental and cross-sectoral representation was required to reflect a whole-population approach effectively. The steering group comprised representatives from relevant Departments and agencies, medical professional bodies, the community and voluntary sectors and the alcohol industry. It included the Department of Justice and Equality, the Department of Education and Skills, the HSE, the College of Psychiatry of Ireland, the Royal College of Physicians in Ireland, the Irish College of General Practitioners and Alcohol Action Ireland.
The steering group met a total of 20 times in the period December 2009 to October 2011. A public consultation was undertaken as part of our work in December 2009, whereby an advertisement was placed in national newspapers inviting individuals and groups to submit their proposals in regard to alcohol. A total of 65 submissions were received and, along with a range of reports and policy documents and materials we pulled together, these were considered by the steering group in reaching conclusions and recommendations. The report of our steering group - I understand the members have this - sets out 45 recommendations organised in the five so-called pillars used by the national drugs strategy. These are supply, prevention, treatment, rehabilitation and research. This is to facilitate alignment between both strategies. The report also sets out in summary the evidence upon which these recommendations are based, both in terms of harm and in terms of likely effectiveness. The report was launched on 7 February.
The World Health Organization has stated that alcohol is the third most significant lifestyle risk factor for disease. Through research and study, we know much about it and its varied health and wider social consequences. Alcohol is no ordinary commodity. That is why we regulate its sale, availability and access to it by minors. It has major public health implications and it is responsible for a considerable burden of health and social harm at individual and societal levels. It is a psychoactive substance that impairs motor skills and judgment. It is a drug of dependence and acts as a gateway to the use of other substances for some people. The practice of polydrug use is now widespread among problem drug users as a consequence, and we also know binge drinking is also a common phenomenon in this country. The Chairman alluded to that in his introduction.
It is true that there are some positives relating to alcohol, including some level of social lubrication and some health benefits. These benefits are derived only from low levels of alcohol consumption and that is not the way we drink alcohol in this country. Somehow we have let ourselves believe that alcohol is not really a problem in Ireland and we are complacent about our consumption and its impact on lives. Individually and sometimes collectively, we choose to ignore evidence of the significant and avoidable extent of the problem that alcohol wreaks on our society.
A particular issue of concern for the committee I chaired is that in recent years a significant shift has occurred in the share of alcohol sales from pubs, which provide a controlled environment for the consumption of alcohol, to the off-trade, including dedicated off-licences and mixed traders. We were especially concerned about supermarkets and other mixed traders whose core business is not the sale of alcohol, given the increased availability of alcohol it provides and the fact this leads to the normalisation of alcohol among a range of other products, such as bread. A further concern which our recommendations address is that many of these outlets use discounting of alcohol products and alcohol-based promotions to encourage people - often younger people - into their premises.
Per capita consumption is considered a good indicator of alcohol related harm in a country, with the specific measure used being per capita consumption of litres of pure alcohol per year for every person in the population over 15. International evidence indicates that the higher the average consumption of alcohol at the individual level and in a population, the higher the incidence of alcohol related problems for both. There is a clear and proportional causal relationship, which justifies a population-based approach. This goes to the core of the issue. There are many people who would seek to define our problems with alcohol as being with an implied minority who misuse alcohol. They may not wish to support population-based measures as they may not wish, necessarily, for Ireland to consume less alcohol. They will say that they share the concern about alcohol misuse but they will argue against population-based approaches.
In 2010, the per capita consumption in Ireland equated to 11.9 litres of pure alcohol per adult, corresponding to 482 pints of lager, 125 bottles of ordinary strength wine or 45 bottles of vodka. That is almost a bottle of vodka per week, which is a stark statistic. Given that 19% of the adult population are abstainers, according to best estimates, the actual amount of alcohol consumed per drinker is considerably more than the figures suggest. It is important, therefore, to reduce the overall level of consumption across the population, and that is why the steering group recommendations set this target for alcohol consumption of 9.2 litres of pure alcohol per person over 15 per year by 2016. That is the single measure of success of this strategy.
This population-based approach to the problem of alcohol benefits not only relates to those who are not in regular contact with the health services but those who have not been specifically advised to reduce their alcohol intake as it also aids the prevention of drinking harmful or hazardous quantities of alcohol. Therefore, a population-based approach will automatically help harm-reduction and prevention with cohorts of the population, such as children, who are not in regular contact with the services.
I will speak to some of the impacts. At the outset, the steering group reported that alcohol was responsible for at least 88 deaths every month in 2008, and we have no reason to believe the data are much different now. In men between 15 and 34, it is estimated to be responsible for one in every four deaths, which compares, in that age group, with one in 12 deaths due to cancer or one in 25 deaths due to cardiovascular disease. It is a contributory factor in half of all suicides and in deliberate self-harm, and it also increases the risk of more than 60 medical conditions such as cancers. I will return to that point. Alcohol is associated with approximately 2,000 beds being occupied every night in Irish acute hospitals and a quarter of injuries presenting to emergency departments and almost 8,000 admissions in 2010 to specialised addiction treatment centres throughout the country. We know it is associated with harm to the baby if consumed by pregnant women. It is also a factor in unplanned pregnancies. We have seen a significant increase in foetal alcohol related syndrome disorders in this country in recent years. It increases the risk of children needing special care with an estimation that adult alcohol problems are associated with about one in six of child abuse cases. We know from data in 2005 that it has been identified as a trigger in approximately one third of domestic abuse cases.
As the Minister of State has alluded to, alcohol, through these mechanisms, has substantial direct and indirect costs. Based on data from 2007 it is estimated, in direct terms, to account for €1.2 billion of health expenditure and a similar amount for alcohol related crime. At that time the cost of lost economic output was estimated to be roughly €500 million. Alcohol related road accidents cost a similar amount. The total figure was €3.7 billion in 2007. There is no substantial reason for us to believe that the costs would be different now.
I will go into a little more detail on some of the health effects. We know that alcohol, even in small amounts, increases the risk of cancer of the mouth, oesophagus, breast, colon, liver and pancreas. We also know that alcohol in very low quantities spread over time can have a protective effect against certain conditions, including cardiovascular disease. Higher levels consumed over shorter periods not only have no protective effect against heart disease but will increase the risk. In epidemiology we call that a J-shaped curve. Alcohol, even at moderate levels, can lead to injury and death in the short term from accidental and non-accidental injuries. It can cause a wide range of family problems from marital breakdown to child abuse and domestic violence, on which I have given members data. We know that children of alcoholic parents can suffer the effects of alcohol throughout their lives. We know it has a wider societal impact through the loss of productivity from absenteeism in the workplace and school, and it is associated with crime.
An argument can be made, and is advanced by some, that the consumption of alcohol is the choice of the individual. Please consider the following. Children born to mothers who drank heavily during pregnancy may develop a range of disorders, known as foetal alcohol syndrome disorders, that can have a devastating effect on their entire lives. As I have mentioned, we have seen an increase in that spectrum of disorders in recent years in this country. One in six cases of child abuse in Ireland is attributed to alcohol and approximately half of perpetrators and victims of sexual assault were drinking at the time of the assault. The upshot is that there are innocent victims of hazardous drinking that must be protected from this preventable harm by the direct and sustained intervention of Government on a population basis, by regulatory and-or other means. This is simply the State acting to protect the vulnerable by preventing the occurrence of harm in the first place, and nobody could contest the aims of such intervention.
Everyone can see that alcohol has an enormous burden of harm. It is this burden that largely informed the steering group’s recommendations to tackle the widespread availability of alcohol, its marketing and advertising, along with strengthening our care and health promotion services and systems to tackle it. Of course, it cannot be denied that there are other agendas that do not prioritise the protection of public health and our social well-being. It is inevitable that such agendas will be critical of the process and will suggest bias, ask for more debate, research and evidence or use the latter, or certain forms of it, in a manner that is not conducive to achieving the aim of protecting public health. Often such agendas can be propagated to obfuscate and confuse the public debate.
There is no single intervention that can reduce the impact of alcohol on our society. If we take an àla carte approach to the report’s recommendations rather than seeing them as a whole, we will not succeed. The evidence about the amounts of alcohol we consume is clear. The evidence of how we consume alcohol is clear. The evidence about what will work to reduce alcohol consumption is also clear. It requires a sustained multisectoral approach to the alcohol epidemic backed by a strong political and cross-societal consensus.
Chairman: I commend Dr. Holohan on his work and thank him for his presentation. He will find that the committee agrees with him that no single measure will work and that we need a multifaceted approach to combat the problem. It is clear from the reports prepared by the steering group and the committee there has been a profound shift in the use of alcohol to the off-trade which is a source of concern. The statistics he outlined on the harm caused by alcohol are quite a revelation. I ask him to go through the recommendations before the other speakers commence. Is that okay?
Dr. Tony Holohan: As I have said already, the recommendations have been organised under five headings and are based on the five sections on which the drugs strategy was based. The first of the five headings is supply. In many ways it is the most important because the measures outlined are the ones that are likely to have the greatest effect and impact. They relate to some of the matters that have been prominent in the public debate in recent times and I will probably dwell on them in a little bit more detail.
The first matter focuses on the price. We know that price is an effective means of controlling consumption. We have seen price increases for alcohol in this country and in other countries. The evidence that examines price shows that the less affordable alcohol is, the lower the level of consumption. We recommend, through a series of measures, that we maintain the price of alcohol at a high level. In other words, we should make alcohol less affordable. We know from evidence in this country over a period of many years that alcohol has become more affordable. There has been an estimated 50% increase in its affordability over recent years. That is the reason for our recommendation.
The second recommendation is to introduce a legislative basis for a minimum price per gram of alcohol. This is to ensure that the focus is especially on the alcohol available at the cheaper end. There is good evidence to support the effectiveness of such measures from other countries, including Canada. The measure is likely to have an impact on the availability, supply and access to alcohol at the cheaper end of the spectrum, particularly through non-pub related environments because it will set a floor level below which alcohol prices would not drop. That floor level would relate to the concentration of alcohol in the product because it would be linked to the price per gram.
The next recommendation relates to section 16 of the Intoxicating Liquor Act which provides for mechanisms that prohibit price-based promotions, of which there are many examples. I am sure members will be familiar with them and may have seen them in off-licences. They are often in pubs. Very often the promoters target third level institutions and such environments. There has been a lot of public discourse about them and this is why we made the recommendation.
The fourth recommendation identifies how important it is for us to work on an all-island basis, as we are now doing, at both a political and official level. We are doing very well. We want to move forward in common and we reflect the fact that we share a common land border and substantial media operations. The use of media on both sides of the island is often shared.
The next recommendation asks for the HSE to be named in the legislation as an organisation that can object to the granting by courts of new or renewed licences where the HSE is concerned, at a local level, about practices around an individual licence holder or proposed licence holder.
The next recommendation asks for the development of a statutory code of practice. It would simply seek to bring into line the off-trade with the on-trade in terms of the controls and arrangements that are in place for the sale of alcohol through the off-trade.
The next recommendation is on section 9 of the Intoxicating Liquor Act that provides for structural separation. The legislation exists on the Statute Book and its commencement would provide for a requirement to have structural separation in a shop or retail environment between alcohol, as a product, and all other products being sold. Members may be aware that the Minister for Justice and Equality has recently conducted a public consultation on its commencement.
The next recommendation is on the enforcement of licensing provisions and ensuring consistency across Garda areas. Some of the recommendations are on monitoring the implementation. They focus on the importance of measuring the extent of consistent nationwide enforcement by gardaí or other authorities of legislation we may already have on the Statute Book. It is regarded as important by our steering group that this would happen and it will be part of our public reporting on effectiveness and impact.
The next one is the importance of consideration. I am well aware, Chairman, that the committee went further than this in the recommendations it made in its report with regard to distance sales. Distance sales were a source of concern for many people in the steering group, and the difficulty of clarifying the point of sale is a substantial reason for the way that recommendation is now framed. It is important to develop server training programmes for the on-trade and off-trade and to connect that, potentially, to licensing and so forth, thus ensuring that particularly in the off-licence sector there are people who are trained and understand the harms of the product they are selling. Perhaps that is not always the case, particularly in mixed trading as distinct from pure off-licence or pub environments.
We refer to the importance of age authentication controls and advertising of alcohol websites. Quite an amount of our time was taken up with concerns about the shift there has been, and might be, in advertising and marketing into digital media and the capacity to regulate that. Some evidence was presented to us about the possibility of introducing strong age authentication controls around access to certain websites. As a minimum we should seek to try to introduce those types of controls, even if we are not in a position to control many other aspects of the digital media.
The next set of recommendations relates to the issue of advertising. This received much attention and time over the course of the committee’s work. Suffice to say there was a variety of different views. What is presented here as a final recommendation is a compromise view from the different perspectives around the table. As is noted in the footnotes to the full report, not every member of the group was in agreement with this recommendation. Some members of our committee would have wished to see a complete ban on advertising of alcohol in all forms. Other members would have been more comfortable if we had made no particular recommendations relating to restrictions on advertising.
What is presented in the report has the rationale of trying to ensure that we protect our young people, in so far as we can, from exposure to the advertising of alcohol. That is the reason we have a slightly different level of recommendation for different forms of media. It all relates to the likelihood of children being exposed through that medium. We recommend a 9 p.m. watershed for alcohol advertising on television, a cinema ban for movies that are suitable for those under 18, a proposal for a prohibition on outdoor advertising and a proposal that print media be subject to stringent code controls enshrined in legislation and independently monitored. That is a radical change from our current position with regard to advertising but it does not go as far as some members of the committee might have wished.
Another recommendation that has been subject to quite an amount of public discourse but which has the same broad intent is with regard to industry sponsorship of sport and other large public events by the alcohol industry and the recommendation that it be phased out by legislation by 2016 and not increased in the intervening period. Again, the intent is to try to protect young people from exposure to alcohol advertising.
There are some specific recommendations that will further strengthen our legislative provisions relating to drink driving. That is to try to copperfasten the very significant success we have had in that regard in recent years.
I will move quickly through the remainder of the report. The prevention pillar is largely focused on strengthening our prevention, clarifying our guidelines and improving and co-ordinating our preventative efforts across society. To bring our current public guidelines relating to safe levels of consumption into line with other countries, particularly the UK, we will be required to revise down what had been our public messaging, which was 21 and 14 units for men and women respectively. That is the recommendation in the UK. The difference is that a unit in this country has a different size and volume, and the recommendation is to bring it into line with that. However, our ultimate recommendation is that we move to per gram public messaging. The view of the committee is that whereas there is a great deal of public confusion about what a unit is, there is none about a gram. We believe that over time this would help to remove much of the confusion.
To move to treatment and rehabilitation, this is about bringing into line our addiction services, which have a role and remit with regard to both alcohol and substance misuse and harm arising from other substances, into line with each other and aligning them with our mental health and primary care services, and ensuring appropriate access and proper care pathways are developed to allow people who have suffered impact as a consequence of exposure to alcohol to be appropriately identified and provided with appropriate services.
The final set of recommendations relates to the issue of research and information. We consistently need to prioritise research and information. It is only through our efforts in research and information that we get the evidence on which to base the recommendations we have made. The Health Research Board, HRB, in particular, has done a great deal of good work through its drug and alcohol division to bring together data on a continuing basis to inform actions at a policy and practice level on the misuse of alcohol and other substances. Continuing to prioritise that is a particularly important recommendation and allows us to have confidence that we will be able to monitor on the basis that we have recommended.
The monitoring we are recommending in this regard would focus on a number of key performance indicators. If we track these performance indicators and we are making progress on them over time, we can have confidence that the broad impact of this strategy is as we would wish it to be. The first of those is the one I mentioned, the annual per capita consumption of alcohol. We have set a target for that over the years to 2016 of 9.2 litres. The others relate to enforcement of existing legislation, numbers of off-licences and other forms of licensed premises, and certain measures with regard to both mortality and morbidity.
I hope I have given a reasonable overview of the 45 different recommendations. I deliberately focused more on those that relate to supply on the basis that these are likely to be the most effective of the measures set out in the strategy.
Deputy Charlie McConalogue: I thank the Minister of State and the chief medical officer for attending this meeting and for the work they have done through the steering committee. They have obviously put a great deal of thought into it. It is the type of thing that takes a great deal of time and the report is comprehensive.
Some of the fact outlined by Dr. Holohan are evidence that ours is sick society when it comes to alcohol. We have become numb to it in many ways. We have grown up with it and become immune to it. However, when the figures are presented in this way in the report, it brings the issue home to us. One can see the crime related figures, the impact on health - 2,000 people in beds per night - the impact on society and the diseases. With regard to the actions that are recommended, the Minister of State will be aware that there have been many reports in the past but we need to see implementation. I am sure the Minister of State intends to implement this one but there should be a time line for it. In the case of some of the measures, it is important that we use a phased approach, rather than a big bang one. However, it is urgent that we make this happen.
Will the chief medical officer comment further on the supply issue, particularly the steering committee’s views on the sale of alcohol in supermarkets and so forth? My own view, which I expressed when we were compiling our report, is that I am not convinced it is a big issue, in the sense that those who abuse alcohol most will still access it. However, I accept the point that supply is a key issue. The problem over the last while is the price differential between off-licences and the pub trade. That has become very significant and it must be rebalanced so we can bring people into the social aspect of the pub where it is controlled. We are also very poor in this country in terms of tolerating and addressing drunkenness in pubs. That has been very damaging and we must improve in that regard. Will the chief medical officer comment on that issue?
Senator David Cullinane: I welcome the Minister of State, the chief medical officer and the publication of the report. It is interesting and good that there is much crossover between the recommendations in the steering committee’s report and the joint committee’s report. I also welcome the fact the proposals and actions are clear, pragmatic and deliverable and that there is a target in regard to reducing consumption because what should underpin any of the actions we take is reducing alcohol consumption. Many of the organisations which appeared before this committee have their own views, which is fine, but my primary concern is to reduce alcohol consumption.
I have a number of observations and questions in regard to the report. There are one or two issues on which I do not fully agree with the steering group. A minority view was expressed in this committee in regard to pricing. The document states that increasing excise duty is one of the most effective methods of reducing alcohol consumption. I agree with that because if one increases excise duty on alcohol, the Exchequer gets back 100%.
In terms of a hierarchy, our focus should be on prevention, treatment, rehabilitation and research. Obviously, pricing, advertising and codes of practice in regard to sale and display are important but in terms of a hierarchy, I would like to see more investment in prevention, treatment and rehabilitation. Increasing excise duty on alcohol would be the most effective way to get money into the Exchequer and that money could be ring-fenced for those purposes.
The report states that below-cost selling may be very difficult to deal with and it does not recommend that we do that, although that would be my preference. However, it supports the concept of minimum pricing. How would that work? One of the concerns I have is that if one sets a minium price for alcohol, who benefits if, for example, it increases the price of certain alcoholic products in certain outlets? Does the retailer, for example, get the extra revenue generated? We could end up bolstering the profits of some of the providers rather than reducing consumption because some of the people who appeared before the committee said that pricing, in itself, will not deal with people who are chemically dependant on alcohol. I believe increasing excise duty would be the simplest and most effective way if one believes pricing is an instrument which should be used to reduce consumption. How would minimum pricing work?
I do not believe minimum pricing would deal with the branded products because they are more expensive. Even if they dropped their price in line with the minimum price, they would still be in line so it would not make a huge difference to branded products. Perhaps the chief medical officer and Minister of State could deal with that.
I fully agree with the statutory code of practice on the sale of alcohol in the off-licence sector. That is important. The report also calls for developing a system to monitor the enforcement of the provisions of the licensing laws. A number of representatives called for mandatory training in identification. Has consideration been given to that?
I fully support the recommendations in regard to advertising and again the committee has taken a very pragmatic and common sense approach. I like the recommendations in regard to social media, which are necessary. It is something we need to do to strengthen that area. A very pragmatic view has been taken of the watershed of 9 p.m. That is the best way to deal with television advertising rather than a complete ban.
The report refers to implementing section 9 of the Intoxicating Liquor Act 2008, which is a bone of contention and on which there are different views. There are two aspects to segregation. There is section 9(1A) and section 9(1B). Section 9(1A) deals with complete segregation whereas section 9(1B) makes exceptions for wine and there is not complete segregation. I do not advocate any one position but it is not clear to me what part of the Act the group recommends. Does it recommend section 9(1A) and that we have complete segregation?
Deputy Denis Naughten: I thank the Minister of State and Dr. Holohan for their presentations. The Minister of State and I have been through this debate on a number of occasions because we have been Members of the House for a number of years. This issue has continually come up but, significantly, what we now see is a shift from alcohol consumption in public houses to the off trade. The problem has been compounded because of the type of shift that has taken place and because it has been so quick and so dramatic. Based on some of the evidence we have seen, we all accept the huge impact it is having on families. A number of cases of neglect, at which this committee has looked, really highlights that situation.
We cannot look at the issue of alcohol in isolation. We must also look at the impact on our health services. Based on Dr. Holohan’s figures, we are looking at three drunks presenting in accident and emergency departments every five minutes. That, in itself, is a scary statistic. Those involved in the emergency services or in the health services break out in a cold sweat thinking about St. Patrick’s Day falling on a banking holiday weekend because it will concentrate this problem. It is not so much dealing with the drunks presenting but the violence and assaults which come with them which the gardaí must deal with on the streets or the emergency service or medics must deal with in our hospitals. We cannot ignore that aspect of this debate.
It is sad to read the newspapers today, or any day this week, because the focus is not on the events taking place this weekend. There is wall to wall advertising in regard to specials and drink promotions in the run in to this weekend. One immediate step we need to take is to ban alcohol advertising and promotions in regard to bulk discounts and below cost selling, something which the Minister of State, as a Deputy, and I highlighted when the ban on below cost selling was removed.
Dr. Holohan made the point that the focus is very much on supply. We definitely need to deal with supply because we have seen the problem with that in the past couple of years but do we not need to place as much focus, if not more, on the attitude change to alcohol? We have seen what has happened in regard to speeding and drink driving, which are a complete no-no. No one would ever brag that he or she can travel from one point to another within so many minutes because of the attitude change. Is that not a huge issue in this regard?
In regard to the issue of supply, one glaring aspect, which the report mentions, is identification. We do not have a national ID card. If someone is consuming drink off site, he or she should provide ID whether 70 years of age or 18 years of age. That is a condition of purchase in the off trade in Canada, which was mentioned earlier, as well as in many other countries.
I refer to the recommendation in regard to prevention and using grams of alcohol. I question that from a consumer understanding point of view. In terms of talking about liquid and the weight of a liquid, does it not make more sense to revise our units and campaign on that basis rather than going down the grams route which I think would confuse people even more?
Dr. Tony Holohan: I will take the questions in the order in which they arose if that is okay and I will start with Deputy McConalogue’s questions. If I overlook something, members might let me know. In regard to sale of alcohol in the supermarket environment, we had much debate about this as members can imagine and there was much concern, as I outlined in my initial remarks about this issue. The desire of the group was to move to a situation where we made a recommendation that there would be a complete prohibition on the sale of alcohol through mixed trading premises - in other words, premises where the core business was not the sale of alcohol. However, a pragmatic view ultimately informed the final recommendation. If there is legislation on the Statute Book, the commencement of which would bring us substantially down the road of separating out the sale of alcohol from the sale of other products, then we should make a recommendation to commence those arrangements.
Dr. Tony Holohan: The Department of Health fed into the process that is under way through the Department of Justice and Equality. There is a voluntary code, which is overseen by the RRAI process, Responsible Retailing of Alcohol in Ireland.
Dr. Tony Holohan: We would prefer to see the structural separation commencing and to replace the voluntary code. That would be the view of the steering group. That is not to say that every single member of the steering group would have agreed with that view. There is dissent from one or two of the recommendations, and that is set out in the report. To clarify what I am talking about, a question arose in relation to 9(1A) versus 9(1B). The general intent of the committee would have been consistent with the provisions of 9(1A), namely, that all products that contain alcohol be separated from other forms of alcohol in mixed trading premises. The reason for that concern is twofold, first, the significant change that has taken place through the availability of alcohol in those settings. It is not to say that is the only thinking that has changed over a period but when that is coupled with the substantial reduction in price that we have seen, and that affordability of that product has greatly increased, it is much easier to buy and there are more locations in which one can get it. The controls in those locations, both formal and informal, are much less and the alcohol is much cheaper. We have seen a significant increase in the sale of alcohol through those premises. That is the reason that the sum total of our recommendations in relation to supply are based on that kind of analysis of the problem. It is not just one measure in relation to mixed traders as distinct from other measures in relation to price and-or to advertising. We see them as needing to be seen as a whole. That is the reason we have set out the recommendation in that way. All other things being equal, the committee would have wished to see us moving in the direction of a complete prohibition on mixed trading of alcohol, but as I say there was a pragmatic view that we should commence with legislation that was already on the Statute Book.
In our recommendations on minimum pricing, we were not saying either-or. The recommendation set out provisions for both, but there is a substantial evidence base on minimum pricing and that evidence base demonstrates its effectiveness in selectively benefiting people who are at highest risk. Therefore, the problem drinkers, the people who drink to the greatest extent to excess and young people are most sensitive to minimum pricing, as distinct from across the board population based increases in excise duty. One gets from minimum pricing, proportionally, a greater benefit in the people who are harmed most. That makes it a very useful intervention from the point of view of the Department.
Dr. Tony Holohan: That is an issue that received some attention during the work of our steering group. Where the Department is now taking it is to try to address the answer to that question. It is not necessarily our view that it would automatically follow that the person who is retailing the product or other people involved in the provision of that product would automatically benefit from this change, but this is still part of what we are exploring around the implementation of such pricing. The Department has taken legal advice on the issue and we have been in touch with the authorities in Northern Ireland. I know the Minister of State, Deputy Shortall, will comment further on where we wish to go in relation to it. We are mindful of the experience we have had on minimum pricing provisions in respect of tobacco, which I would have regarded as very good but were struck down in Europe.
In response to Deputy Naughten, we must emphasise our health promoting messages and seek to try to bring hearts and minds with us. The Deputy alluded to the relationship between drinking and driving. If one looks at the issues of drink-driving and of tobacco, we have had significant legislative changes on both of these issues, which are not the only things that have happened in relation to both and we have seen the outcomes. The orthodox view might be that the attitude change comes first and that it is followed by the behaviour change, but we imposed in a sense through legislative means a behaviour change in smoking and within a very short period, we saw significant changes in attitude as a consequence. Let me illustrate the extent of that change. After we introduced the smoking ban Irish people holidaying abroad would find it completely repugnant that they would be exposed to tobacco smoke, whereas two or three years previously they were quite happy to sit in a restaurant and not complain about it. The attitude seemed to change very quickly. The same behavioural change happened in relation to drink driving. We strengthened substantially our provisions on drink driving, improved our enforcement and nowadays it would be abhorrent for people to hear somebody bragging about speeding or drinking while driving. In a sense it is not a case of either-or in relation to the way we view the recommendations, we need to do both. In some respects, however, the attitude change almost follows the mandated change as opposed to the other way round.
On the question of measuring intoxication by the number of grams of alcohol, I take the point, and it is quite clear that we will have to engage in a process of education and messaging so that we try to develop a process so that people can work out their level of consumption based on the number of grams of alcohol. Our concern is that as things stand we use different units in different countries and there is different messaging around use. There is a great deal of marketing and research evidence to support the view that the public does not understand units very well. There are certain organisations who are quite happy with that.
Deputy Denis Naughten: I accept the point Dr. Holohan is making but I wonder if grams of alcohol is the way to go in measuring consumption, as this is the comparison of volume versus weight. I am only throwing out the question. I do not have the answer.
Chairman: Are we confusing people further by changing to grams as opposed to measuring it by volume? People use the measure of a pint, a glass or a shot. Would we dilute the message by making that change?
Dr. Tony Holohan: If we are going to make the change, we will have to do it on the basis of a public information campaign and messaging that explains not just what we are doing but why we are doing it and how people can go about computing their individual risk based on this information.
Dr. Tony Holohan: The concern is that most people, and there is a great deal of research evidence to back this up, are unable to turn their own level of consumption, that is I have had X number of pints into units, into the question of whether they are drinking to excess or not. While they will need to go through a process of developing an understanding on how to do that with grams, ultimately the message will be easier to understand and less likely to be confusing, because it will not be a question of whether a gram is a different measurement in this country, in the UK or in another country.
Deputy Róisín Shortall: A question was raised by Senator Cullinane who is not here at present. The idea of proposing the minimum pricing approach is to deal specifically with the problem that has emerged over recent years, the switch from drinking on trade to off trade and to deal specifically with the very low cost sales of alcohol, and the selling of alcohol in supermarkets in particular. It does not preclude us doing something on the excise front. The steering group recommends that we consider doing something on that front on particular high volume alcohol drinks. That is a possibility and we will certainly be looking at it.
I agree with Deputy Naughten that what is happening in relation to advertising at present is shocking. There is reinforcement of the association between alcohol and every celebratory occasion, national or public holiday. I noticed in one of the newspapers, that one of the main supermarkets has very prominent alcohol advertising. One will see all the supermarkets doing that this week in the run up to St. Patrick’s Day, our national holiday. We are trying to break that cultural link between celebration and alcohol and these types of advertisements do not help in that regard. In fact, one of the major supermarkets is advertising bottles of vodka and whiskey and so on with shamrocks on them. This type of practice is unacceptable and needs to be stamped out.
Deputy Róisín Shortall: The issue first came to my attention this morning. As Dr. Holohan pointed out, we must move towards a position where voluntary codes are replaced by statutory codes. That is a key part of the recommendations and an issue I certainly intend to pursue.
The other point that arises in respect of advertising is the proposal in the steering group’s report to introduce a social responsibility levy which could be used for positive social marketing. This recommendation will be given serious consideration.
A point was also raised about the emphasis on supply rather than prevention and demand. While education programmes on prevention are very important, we know from the evidence that they do not work on their own and need to be backed up by strict laws and strict enforcement. Deputy Naughten referred to drink driving. Everyone knows it is dangerous to drink and drive. However, despite many education and awareness programmes on the issue, behaviour did not change substantially until strong laws were introduced and, more important, these laws were enforced. These changes brought about an overnight change of behaviour in respect of drink driving.
On the issue of monitoring, an important point to emerge from the steering group’s report was that addressing this issue will not be about a report or set of actions to be taken, at which point people will move on, but about ensuring we take action now and continue to monitor the situation to ensure we are reaching the targets being set, whether in overall consumption levels, enforcement of the law or the application of the law across the country. The performance indicators built into the recommendations are very important.
On the next steps, I have taken the steering group’s report - I am also very conscious of the recommendations in the joint committee’s report - and I am developing an action plan. I am engaging in consultations with the joint committee because this is the most appropriate forum to consult public representatives and allow them to make a direct input into the action plan. I am also meeting individual Cabinet Ministers on issues of concern to them. This process is not all plain sailing, nor is it straightforward. Some of the issues involved are difficult to address and the impacts of all proposals will require discussion, negotiation and careful consideration. For example, we do not want to take action that has a highly negative impact on jobs. For this reason, we must examine the proposals in the round to ensure we bring people along with us. However, there is potential for securing cross-party support to move forward on this issue.
It is intended that, based on the reports and evidence available to us, we will develop a set of actions. We are working closely with Dr. Holohan and others in the Department on this issue. The actions will then form the basis of a public health Bill to be produced later this year. I am aiming to have the legislation prepared by the middle of the year. Those are the next steps and I hope in the months ahead, while the legislation is being prepared, to engage in continuous dialogue with representatives of the joint committee. I would like to work closely with members and have their inputs throughout the process. With the agreement of the Chairman, therefore, we could establish a reference group consisting of members from all parties. I could then tick-tack regularly with the group on how we move forward on the issue and prepare the Bill.
Chairman: Members would be anxious to participate in such a reference group and collaborate and work with the Minister of State and Dr. Holohan. The Minister of State made a very important point. We need to reclaim our national holiday. It is imperative that we work on the concept of a festival and change the image and perception of Irish people on St. Patrick’s Day both at home and abroad. The Minister of State has the joint committee’s full support on this issue. If the joint committee does nothing else, it should try to achieve such a change. We will work with the Minister of State on establishing a reference group. I ask Dr. Holohan to respond on the issue of the national identification card.
Deputy Denis Naughten: My question was whether it should it be mandatory for everyone to show identification, rather than making it an age related requirement. In countries where alcohol is more tightly regulated and the approaches to alcohol consumption appear to be much more successful, for instance, the United States and Canada, no one can purchase alcohol, even a person aged 70 years, without showing identification. It should be noted that we are all compelled by law to carry a driving licence.
Deputy Eamonn Maloney: I welcome the Minister of State back to the joint committee. I also welcome Dr. Holohan to the meeting. This is a detailed, clear and alarming report and a great deal of time went into it. Reading it over the past two or three days I asked myself how things got so bad. Leaving aside medics such as Dr. Holohan and politicians such as the members present, a layperson reading this report would quickly come to the conclusion that there is something desperately wrong. The national drug, alcohol, inflicts untold misery on the society in which we live. For my part - others may disagree - I know where the blame lies. As I have stated at previous meetings, despite umpteen reports being written on this issue, Deputies run for the hills when it is left to the Dáil to make decisions on foot of them. That is the reason the position has become so bad. People divide on the issue of alcohol and the drinks lobby - the vintners and so forth - has considerable power which it exercises when necessary.
I hope this Dáil will be different and parts, if not all, of the report will be acted on or implemented. In light of the many previous reports published over the past 60 or 70 years, several of which I have read, the inaction of previous Members of the Oireachtas is responsible for the position in which we find ourselves today. If one speaks to a nurse in an accident and emergency department of a hospital, a member of the Garda Síochána or someone working in the Courts Service, he or she will tell one very quickly where the real problem lies. We have a national drug, alcohol, which has a special place in society. To borrow Deputy McConalogue’s phrase, alcohol’s position in society has become so entrenched that we have become immune to it.
If this meeting with Dr. Holohan and the Minister of State had been arranged to discuss a report from a steering committee on cocaine, hashish or heroin, we would not have been able to get through the throngs of concerned citizens on Kildare Street. Dr. Holohan can correct me if I am wrong but I believe all the illegal substances combined have not inflicted the same level of misery on families across the length and breadth of the country as alcohol.
As the Minister of State noted, notwithstanding that alcohol costs taxpayers €4 billion per annum, the more important aspect of this issue is the human side. The figures for child abuse are shameful and no EU member state compares with Ireland in terms of percentages. We have a major problem which we have a difficulty facing up to.
I may have missed it in the 40 plus recommendations but I am convinced - I have been a member only for 12 months and, therefore, I plead not guilty - that one of the greatest mistakes for a generation in respect of alcohol in this jurisdiction has been that nobody, including the Oireachtas, ever stood up to supermarkets selling drugs. That is the real problem. There may be good reasons for that but I am white and black about it. Supermarkets should not be allowed to sell alcohol. It is not the children’s fault. They are taken to a supermarket to buy their bread and butter and it is desperately wrong that one can buy the national drug beside those items. The other issue is advertising.
Deputy Eamonn Maloney: With all due respects to previous speakers, this is nonsense. Advertising of alcohol must be banned in the same way as cigarette advertising was banned. It is simple. Pampering around the issue, because one is afraid of the drinks industry, is cowardice but we must stand up to that.
The next issue is personal. The vast majority of those who make up the membership of this new committee have a sufficient degree of courage, including the esteemed chairman. Our report deliberately refers to alcohol and other drugs. I wish medics would use that term. One can hear people say they do not want coke or their son on cocaine but they do not mind him coming home plastered seven nights a week. That is a complete contradiction. It must be put in perspective. It is the national drug.
I am a user. I am not a full-time user and do not have a love affair with it but as John Prine, the American song-writer, said, it helps one to escape from reality. Given where we are in Ireland, occasionally, I make no apologies for escaping from reality.
Deputy Peter Fitzpatrick: Some 1.5 million people in Ireland drink in a harmful way. Last weekend in Dundalk about 150 to 200 people attended a house party in Mullaharlin Road in Dundalk. They were drinking and urinating on the street. They broke glasses and caused much noise, and people were afraid to come out of their homes. Three people were stabbed in Dundalk last weekend. All the incidents were alcohol related. If something is not done soon, the situation will get out of control. This happens not only in Dundalk, but all over Ireland. While it has been said that people harm themselves, they also harm the whole community.
In 2010, consumption per adult of pure alcohol was 11.9 litres, that is, 482 pints of beer or ten pints per week, 125 bottles of wine or three bottles per week, or 45 bottles of vodka, which is one bottle of vodka per week. Children born to mothers who drink heavily during pregnancy develop a variety of disorders and one in every six cases of child abuse in Ireland is attributed to alcohol.
We need to reduce the impact of alcohol in society. We must reduce the amount of alcohol consumed. We have a problem with alcohol in Ireland and we must sort it out. Given this information we must react because, if we do not, we let society down.
Deputy Robert Dowds: I thank Dr. Holohan and the Minister of State for appearing before the committee. I support the thrust of their aims. I am concerned that two or three senior members of Government appear to have a difficulty confronting the issue. I appeal to them to examine the issue in terms of the harm caused to society. When the legislation is enacted, it is important that it is as strong as possible.
If the Intoxicating Liquor Act 2008 was implemented in respect of separate entrances for establishments selling alcohol, would it have the effect of closing down many suppliers of alcohol and, if so, would that be a good thing? It is important to put strictures on sales from off-licences brought to people’s homes. That is a source of considerable problems in the city and probably elsewhere throughout the country. I noted that Dr. Holohan said there were certain difficulties but I ask that the issue be examined to ensure such a stricture is introduced.
I am interested in a conversation on the next issue because I am not sure of my own view on the issue. While there is clearly a case for minimum pricing, is there a case to use minimum pricing to reduce the prices in pubs on the basis that it is socially more desirable that people drink in public houses than in their private homes?
Deputy Róisín Shortall: I thank members for their support. It is clear there is a wide measure of agreement at the committee to take comprehensive steps to deal with the problem. The points made by Deputy Peter Fitzpatrick in regard to the scenes in Dundalk last weekend are, as he said, replicated all over the country each weekend. Extraordinary damage is being done to our young people, in particular, through the misuse of alcohol. We all have a responsibility to take action and it is not a question of leaving it to the individual. We have allowed a situation to develop where people are bombarded with alcohol. It plays a very central part in our lives. I do not know how many pages of today’s newspapers are full of advertisements from supermarkets, many of which emphasise alcohol. It is all around us.
It is in small shops and hits one as soon as one walks inside the door. There are large window displays and so on. The advertisements in cinemas and on television tend to be the best. It is clear from research on advertising that young people are particularly susceptible to the messages coming across and are familiar with all the brands. Much is invested in high quality advertising of alcoholic drinks. Advertising and sponsorship works, and that is why the industry invests so much in both. We need to address all those issues. I welcome the clear support to address the issues.
Dr. Tony Holohan: On the structural separation issue, there is no doubt that implementation would lead to a number of people providing alcohol in mixed trading environments having to make a strategic decision on whether to continue in the alcohol business. That is likely to lead to a significant number deciding not to continue in the business and that would reduce the number of outlets. However, it may be difficult to estimate the precise number but there is no doubt that would happen.
Dr. Tony Holohan: If we look at the shift that has taken place on the sale of alcohol, more than 50% of alcohol sold in Ireland is sold through the off trade as opposed to the on trade. It is far less job intensive to sell alcohol through the off trade. One does not need very many people to sell by the pallet or multi-packs such as are sold in an off-licence environment. If one is going to provide alcohol through a pub environment, it is fairly resource intensive and supports far more in terms of jobs. We have done some back-of-the-envelope style calculations, although I would not want to hold them out as a robust analysis. If we take the issue of the number of litres of pure alcohol sold per year, it was 11.9 in 2010. For every litre of that sold in the off trade, we estimate that it represents something in the region of a loss of €150 million to the State in income tax because of the lower level of employment it supports, and in terms of VAT receipts. That is a rough calculation and I would not want to be held to it but it is a significant difference.
In general terms therefore, the way in which we sell alcohol - and not just the issue of how much we sell - has a big bearing on the number of jobs. If we saw any reversal of that trend from the sale of alcohol through off-licences back to on-trade, it would benefit jobs.
Deputy Róisín Shortall: There are a number of issues we need to be aware of in terms of moving forward on this, and jobs is one of those. The proposal concerning minimum pricing, as Dr. Holohan said, has very minor implications for jobs - negligible, in fact. That is because we are talking about the shift in drinking patterns where most drinking is now done as a result of buying in the off-licence sector. Also, 95% of that alcohol is purchased in supermarkets. Senator Cullinane asked earlier who would get the profits if we introduce minimum pricing. The fact is, however, that if supermarkets are using alcohol as a loss-leader, then we are paying higher prices for our groceries. It would be much better if supermarkets engaged in price wars on grocery products rather than on alcohol.
As I said at the beginning, the price of alcohol misuse is costing us all very dearly. In addition, if we look at what is happening in the workplace - which is a significant issue and was the subject of a recent conference - in terms of job losses, absenteeism and lack of productivity generally in industry, alcohol misuse is a huge factor in that. Jobswise there are benefits to be had if society tackles this problem, thus becoming healthier and having a more balanced relationship with alcohol. While it is understandable that there are concerns about different aspects of proposals, we must examine the issues in the round. That is why I welcome the comprehensive nature of the steering group’s report.
Dr. Tony Holohan: I might add to what Deputy Fitzpatrick said by way of information on the volumes of alcohol that are consumed. In some of the submissions made to the committee by various parties much was made of the reduction that had been seen in the amount of alcohol consumed over a period up to 2009.
Dr. Tony Holohan: I did not hear that myself, to be honest. We know that in 2009, according to the metric we use, it was 11.3 litres of pure alcohol per year. That went up in 2010 to 11.9 litres. I have provisional data for 2011 which indicates a further, albeit smaller, increase to 11.97 litres. That is a provisional figure from the CSO but it suggests that, against the background of a reduction, we have now seen two years of increases since then. That is in the context of the affordability of products being much less generally in society because of the impact of the economic downturn.
Dr. Tony Holohan: If everybody in the population was to consume up to what is regarded as the safe level, and one was to work out the target from it, that is where it comes from. Our average consumption at the moment puts each on average above that safe level. The figure of 9.2 approximately equals the OECD average consumption.
Deputy Róisín Shortall: Home deliveries of alcohol is an issue of concern to me and I am familiar with it. It is common practice now and it is not just off-licences that are doing it because there are “dial-a-can” campaigns also. In addition, take-away food outlets will deliver a six-pack or a naggin of vodka with a chicken curry. In recent months, I have spoken to the Garda Commissioner about this matter which he is examining before coming back to me about it. We need to examine whether we need a change in the law or if it is an enforcement issue. There are questions concerning the method of payment and whether it is legal to pay cash on delivery in those circumstances. It is something we can deal with in the short to medium term rather than waiting for legislative change. Nonetheless I am very conscious of the matter and am moving on it.
Deputy Róisín Shortall: Given the place we are at in this country at the moment concerning alcohol and the central role it has, I think it would send out a negative or destructive message if we were to consider reducing the price of alcohol in pubs. I fully understand that it is a safer environment with the sociability aspect in coping with isolation. In addition, if somebody is going to have a few drinks it is preferable that they would do so openly in company. Ideally it would be better if, by and large, people had their alcohol in moderation with food. It is interesting that across most of continental Europe about 80% of drinking is done with a meal, whereas it is the reverse here - about 80% is just drinking on its own. There are therefore advantages in encouraging people to socialise in a pleasant and moderate way in pubs, rather than at home. However, the particular problem of current concern is the huge increase in off-trade sales. It is about availability and price, so we want to target that problem specifically, which is why we are going for the minimum pricing.
Chairman: I have a question based on Deputy Dowds’s comment regarding home deliveries of alcohol. I do not want to name any particular organisation or retail outlet, but is it possible to make a differentiation between the type of organisation that Deputy Dowds spoke about and, for the sake of argument, a wine delivery company that is not necessarily doing the same thing to which the Deputy referred?
Deputy Róisín Shortall: It would be difficult enough to distinguish between those two. If there were to be a ban on distance sales and somebody wants to buy a bottle of wine with their supermarket shopping-----
Senator Colm Burke: I thank the Minister of State and Dr. Holohan for their good presentations. I apologise for having stepped in and out of the meeting, but unfortunately there were votes in the Seanad. When citing the report, Dr. Holohan referred to the consumption of alcohol during pregnancy. Reports have been produced over the years and the big complaint has been that they are put on a shelf and not acted upon. One of the things about this report, however, is that a number of immediate actions can be taken without requiring legislative change. One such step concerns the consumption of alcohol during pregnancy. There are approximately 75,000 deliveries per year, so we have access to an immediate market as regards an education programme. I am not too sure whether that is happening, although it may very well be. I wonder if it could be improved upon. For instance, I remember putting in a request about eight months ago for figures on new-born babies going into the DTs. In one Dublin hospital alone, 44 babies went into withdrawal symptoms because their alcohol supply suddenly ceased after they were delivered. That indicates that there is a particular problem in this area. It is not just about pregnant women, it also concerns their partners and an education programme for them. Could something be done immediately in that area to take a more proactive approach to education? In the report referred to earlier, Dr. Holohan set out the knock-on effects on children of excessive consumption of alcohol during pregnancy, but that is just one issue.
Another issue concerns a more proactive approach by employers. I understand that one of the major employers in this country, Hewlett Packard, has inserted a condition in employment contracts whereby employees can be tested for drugs. I am not too sure if it also covers alcohol consumption because I have not seen the exact employment contract terms. Could we be more proactive with employers as regards this issue? For example, the HSE employs over 100,000 people, but do its staff contracts contain such a condition? If an employee has a problem and there are obvious signs, what action can the HSE take as an employer? If patient care is at risk the HSE can take immediate action, but I am talking about HSE staff generally. There are 100,000 people employed there but what are the employer’s obligations and rights in dealing with that issue? Those are examples that come to mind where immediate action could be taken without any major legislative changes, while at the same time having a beneficial effect.
Senator John Gilroy: I welcome the Minister of State and Dr. Holohan to the joint committee. I spent nearly 30 years as a psychiatric nurse, working mainly in acute services. Up to a few years ago, the general mental health services offered detox programmes, although they have been moved from the general services since. I am aware at first hand of the individual and social damage that alcohol does. The whole response to this matter should involve effecting a cultural change.
The scale of the problem facing us can be gauged from our two highest profile visitors last year. President Obama was brought to a pub in Offaly, while Queen Elizabeth was brought to the Guinness Hop Store. The very first image of Ireland, and the first thing that was almost expected of people, was to be seen in the company of alcohol in Ireland.
The consumption figure of 482 pints of lager per person per annum, which Dr. Holohan says has now been exceeded, is startling in itself. Are those figures calculated on the consumption of alcohol or otherwise? Is there any research to show the changing patterns of drinking among different cohorts of the population? Are such figures available? We see young people in every town heading into parks or local forests for “gatting”, which I think is the term they use for drinking.
Senator John Gilroy: Are those figures credible? According to the statistics, most people in this country are above the minimum harmful levels of drinking, if we can cross-reference one to the other. If these figures are to be believed, having one pint per night, or a can of beer with dinner, would almost put a person into a low-risk category of drinking. The public would be surprised to discover that if they were to drink like that, they would be putting themselves into a low level of risk with regard to alcohol. I am just wondering about that.
As regards minimum pricing of alcohol, how will we differentiate between standard and premium lagers? Standard lagers are seemingly the cause of problematic drinking for the younger cohort of the population. The quality and alcohol volume of standard and premium lagers are not differentiated at all, because branding and marketing determine which category they fit in to. How therefore can we affect one without affecting the other?
Deputy Charlie McConalogue: Did the chief medical officer consider increasing excise duty on drinks sold through the off-trade? Deputy Dowds suggested lowering prices in pubs but a lower rate of excise in pubs is not possible to police. It would, however, be easy to police an increased excise in the off-trade. Anything that is sold in off-licences is fully-corked and unopened. It is quite easy to monitor and one could have a separate stamps for off-trade sales. At the moment, the big problem is that it is cheaper by half to drink at home via off-licences, than in pubs. Meanwhile, pub staff are trained how to serve drink and, in addition, there are bouncers at the door providing security and control. The situation outlined earlier by Deputy Fitzpatrick concerning a house party in his area, involved no such controls or security. Nobody was there to monitor what was dished out. One could effectively have a night-club in a large house at the weekend where no such controls apply and the drink is a lot cheaper. That is the direction in which we have been moving and will continue to move unless action is taken.
It does not make sense that it is so cheap to buy alcohol through off-licences, considering the way people currently tend to drink. Have the Minister of State and the chief medical officer considered that? If not, it is something that definitely merits consideration. That is the key point I wished to make.
Senator John Crown: I am sorry for having had to step outside for a few moments. I thank the Minister of State and Dr. Holohan for their presentations. I am delighted that this important issue is receiving such focus within the Department of Health and the Government generally.
Alcohol is an addictive cancer-causing toxin. It is as simple as that. There is no other way to dress it up. It is an addictive cancer-causing toxin that many of us choose to use and abuse. If we all stopped drinking completely, we would be better off. Society would be better off if all alcohol consumption were to stop. There are no “ifs”, “buts” or “maybes” about this - the following things would happen: there would be a decrease in cancer of the head, neck, oesophagus, pancreas, breast and colon. In addition, there would be a decrease in liver disease, along with less violence - including domestic violence - fewer rapes and fewer unwanted pregnancies.
The opportunity lost through the money we spend on alcohol is colossal. There would be more money available for schoolbooks, family holidays, food, clothing and children. The cost of the time we spend drinking in our families is also colossal, so therefore there would be more time for good parenting and better example. There can be no ambiguity about this - it is a bad thing, although most of us do it. If we could push a magic button and make this chemical disappear, as if it had never been invented, the world would be a better place.
I do not wish to take anything out of context and I agree with the broad thrust of what the Minister of State and Dr. Holohan are saying. However, I am a bit nervous about leaving a line in there which refers to some health benefits from alcohol, because there are no such benefits. The reality is that one may define some individual person who - by a bizarre quirk of circumstances, not having had the diseases which a low level of alcohol could cause - might have had some particular health outcome of benefit to them. However, if a person who does not drink asks, “Will I drink in moderation because there may be some health benefits, or will I not drink at all?”, the correct answer is not to drink.
Epidemiologically, the chance of all kinds of bad stuff happening to a person who drinks will be higher. There is no safe lower level of alcohol consumption. Every drink one takes increases the risk of some cancers. In the case of some of the aforementioned cancers, the increase in risk is tiny for what is called a moderate amount of drinking. However, one should be aiming for a low tolerance of people having any alcohol. This is the reason I agree with the strategic thrust and the best short-term metric for doing this is to decrease the numbers of litres drunk per citizen and to try to get Ireland’s ranking in the league tables right down. This would give us something for which to aim. Our society is full of people who, while they may espouse high-sounding principles, have precisely the opposite ambition as they seek increased consumption of alcohol because they sell it. In particular, I am slightly troubled by a notion that appears to have crept through in both this joint committee and the Houses, which is that somehow, the alcohol one buys in an off-licence or in a garage somehow is bad alcohol, whereas the alcohol sold to one in a pub by the publican, who according to such thinking is a kind of social worker, is less dangerous.
Senator John Crown: My question is whether the Department would consider the following measures. First, will it aim towards a total ban on advertising? While I do not advocate prohibition, why should we allow anyone to advertise an addictive cancer-causing toxin? Second, will it consider a complete ban on lobbying? No one who works for the alcohol industry in a public relations or lobbying capacity should be allowed come near anyone who makes decisions in this regard. If people who sell alcohol wish, as citizens, to make submissions to an expert body, that is fine. However, paying people to put a gloss on their message should be banned. Similarly, if health, social or punitive taxes are to be introduced or charges increased, some attempt should be made to ensure the money raised from them goes specifically to health-related issues and to research. I am terribly troubled by the idea that we may be raising more money from such taxes to be given on the next promissory note payout. Such money should be ring-fenced for the purposes of health preservation and protection.
Chairman: Before the Senator leaves, I make the point that neither I, as Chairman of the joint committee, nor other members make a distinction between the types of alcohol consumed or sold. I assure the Senator I certainly do not consider a publican to be a social worker.
Chairman: I did not take it that way but I make the point that in its report, which the Senator participated in drawing up, the joint committee does not make such a distinction. I would hate for a message to emanate from the joint committee that it does. Publicans are not social workers and as the Senator is aware, their sole aim is to sell alcohol and to look after their own businesses. This point applies to both the on-trade and the off-trade. Our job as members of the joint committee is to promote public health.
Senator John Crown: I understand but individuals have made a point that there somehow is some kind of a distinction and that alcohol which is consumed within the warm embrace of the pub, with someone keeping a fatherly or motherly eye on one’s consumption, somehow is safer than the alcohol one has at home while watching “The Late Late Show”.
Dr. Tony Holohan: As for Deputy McConalogue’s specific question on excise duty, some consideration was given to that proposal. The way in which excise duty works relates to the concentration of alcohol in the product and irrespective of where it is sold, this is what determines the level of excise. This is the reason we are not able to use that mechanism to achieve what we would wish to see, which essentially is the same objective being set out by the Deputy. The measures on minimum price would, in the round, increase the price in off-licences relative to pubs because the alcohol sold in the pub environment already is at a price where it is unlikely to be affected by a minimum price, whereas in many cases in the off-trade, it is not. Consequently, the effect would be to increase the price in the off-trade as opposed to the on-trade, which would narrow the gap. There also are more specific recommendations concerning matters such as the price of licences and so on for the off-trade that also would have an impact on increasing price. We share the same objective.
Deputy Charlie McConalogue: It still would leave a significant price gap between the two. The Minister of State made an interesting point earlier that on the Continent, 80% of alcohol is consumed with food, whereas the opposite is the case in Ireland. However, I note the imposition of the plastic bag tax certainly had an impact on the use of plastic bags. It is a consideration that a tax separate from the excise duties but administered in a similar way could narrow the gap between the off-trade and the pub trade.
Dr. Tony Holohan: Some other questions were asked by Senators who are not present. However, I agreed with Senator Colm Burke’s point regarding the case for a more proactive approach to the use of pregnancy as an opportunity to get across a series of positive public health messages, including on this issue. Moreover, his point was well made in respect of the workplace as an important setting for all forms of health promotion, including on this topic. Many multinationals are highly proactive in this regard and have good programmes of health promotion for their staff.
Dr. Tony Holohan: It would. The Senator specifically asked whether the HSE, as matters stand, included alcohol consumption clauses in its contracts. I believe he was implying it does not and I can confirm there is no such requirement. However, this is a direction in which we should be moving, as with so many people working in the public health service, there is no reason we should not be using employment as an opportunity to create positive health promoting messaging.
Senator Gilroy asked some questions about detoxification programmes and the patterns of consumption. In particular, he asked how we acquire these data. We have good data on the differential patterns of consumption in different age groups. I did not have an opportunity up to now to state that some of the data show us that we have seen significant decreases in the age of initiation of consumption of alcohol. In other words, children are starting to drink alcohol at increasingly younger ages if one looks back over the last number of decades. Members will be aware of this as they have set out some of this information in their own report. Our evidence in respect of low-risk drinking guidelines comes from international evidence and a consensus that develops around expert views in this regard. While it does appear surprising that if one puts it in those terms, it equates to something in the region of a pint a day, in general the recommendation from a health point of view is that even at low levels, one should not necessarily drink alcohol every day. One should always have at least a couple of days in which one gives oneself and one’s body time to adjust. Even at low levels, one should not expose one’s body to alcohol every single day.
The Senator also asked a question in respect of minimum pricing and whether one could classify and differentiate between branded and non-branded products. However, we would not necessarily seek to do so through that particular measure. I have had personal experience where what would be regarded as premium branded products still were being sold at extremely low prices. Irrespective of the product and the brand that might attach to it, if it is being sold below a certain minimum, it would be captured by an approach to minimum pricing. I believe this deals with most of the questions raised by the Senator.
Deputy Róisín Shortall: I believe that a lot more could be done in the workplace. We have a very high tolerance of people being absent on a Monday or Friday morning or of being in work but not really being present or being under the weather. Everyone has experienced this in their own workplaces and in different settings. There is an obligation on employers to have active alcohol strategies within their organisations to address such problems of absenteeism and to meet employees and discuss this issue with them. In addition, in circumstances in which people have particularly serious problems with alcohol misuse, it should not simply be left at the point at which people merely state they are aware that so-and-so has a problem but something actually should be done about it. As part of this approach to tackling the problem in a comprehensive way, different sectors, such as employers’ organisations, trade unions and other groupings, should have in place those active policies and should promote them within their organisations. This is not a matter which is simply the concern of politicians or the health sector as this is an issue that involves all of Irish society. All sectors must play their part in tackling the problem but certainly, our tolerance in this regard is far too high at present.
As for the points made by Senator Crown, I very much share the views he expressed with regard to lobbying. The industry is very well resourced and is very clever in the manner in which it goes about lobbying and this should be tackled. As for the question of where savings are made or of finding a way in which money can be invested into prevention services, the whole idea of the social responsibility levy is in that space. A levy could be imposed on the industry and the money raised could be used to fund various initiatives to help to tackle the problem.
Chairman: One point from Dr. Holohan’s report was most disturbing. It relates to the prevention pillar. The World Health Organization reviewed 32 alcohol strategies in schools. The specific reference is No. 6 on page 27 of the report. The report suggests the strategies did not have a direct positive effect on the drinking patterns. This is a source of concern. Dr. Holohan also made reference to social media and marketing and so on. We all saw the signs with Facebook and Diageo last year. This is another source of contention.
My final point relates to one of the elephants in the room, namely, the issue of alcohol sponsorship of sports. The report is strong in recommending a phasing out of this by 2016. I realise the Minister has encountered difficulty with some other elements of Government because the report makes reference to the Department of Transport, Tourism and Sport. Is there a recognition by sporting organisations and some of the festivals that there may have to be a movement away from a reliance on alcohol sponsorship?
Deputy Róisín Shortall: I am keen to meet with each of the sports organisations. I believe there is a need to bring people into the debate. I realise it is difficult to get sponsorship, especially in a time of recession. Sporting organisations and arts bodies find it easy to get sponsorship from the drinks industry because those involved are willing to provide it. One need not work too hard to get it. However, alternatives are available. Other companies are keen to get involved in sponsorship. We have seen the GAA leading the way in this regard, especially in the case of the All-Ireland sponsorship. One particular drinks company had been the sole sponsor but now it represents only one third of the sponsorship. Other companies are keen to get involved in sponsorship. It might take a little more work but I believe we can get there eventually. It is about being reasonable and setting out a timescale for the substitution of alcohol sponsorship by other forms of sponsorship. We should do this in a phased way over the coming years.
Chairman: I thank the Minister of State, Deputy Shortall, and Dr. Holohan for their attendance today. I commend them on their work. It is clear that this is another step in the process towards the publication of a public health Bill. I thank the Minister of State and Dr. Holohan for their stewardship. The committee looks forward to working with them to curb the misuse of alcohol and to change our attitudes towards alcohol in society. I thank the members of the committee and the members of the media for being here. I wish you all a safe and enjoyable St. Patrick’s Day.
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