Alcohol Abuse: Discussion with Cluain Mhuire Services.

I welcome Dr. Siobhán Barry, clinical director of Cluain Mhuire Services, along with her colleague, Dr. Larkin Feeney, consultant psychiatrist, Cluain Mhuire Services, who are here to make a presentation on alcohol abuse in Ireland. We are dealing with this subject as the inclusion of alcohol in the national drugs strategy is part of our work programme.

It is timely that our guests are here today as the Minister for Justice, Equality and Law Reform today published the heads of the intoxicating liquor public order Bill 2008. In addition, a new report prepared for the Health Service Executive, Alcohol Related Harm in Ireland, has just been published and it makes for disturbing reading. I would like this committee to have an input into the entire process. I invite Dr. Barry, who is no stranger to this committee, to address us.

Dr. Siobhán Barry

My colleague, Dr. Feeney, and I work in a publicly funded psychiatric service based in south-east County Dublin. We are managed by the Hospitaller Order of St. John of God. Our reason for appearing before the committee today is in part because of the committee's kind invitation but also to bring to members' attention some facts we believe might be important in terms of the overall concerted effort in minimising the harm to society caused by our current alcohol use. We prepared slides but the system here is not showing them very well and members have been given handouts. We felt we should talk about rising to the challenge because we certainly are facing a challenge.

In the past two decades we have had a situation in Ireland where alcohol consumption has increased gradually. It is undoubtedly our favourite and most used legally available drug. Many of our cultural and sports events have been hijacked by sponsorship, especially from the alcohol industry, all of which would appear to have conspired to give rise to a huge increase in alcohol consumption in recent years because sponsorship must meet its targets.

As the alcohol consumption per capita in society increases, the degree of harm to each individual and to society in general also increases. We have seen that broad range of alcohol problems increase but in that period and out of a recognition of the problem, we have had many reports. Dr. Feeney and I have brought along some props, so to speak. We have the strategic task force reports of 2002 and 2004 the Health Research Board problem alcohol use report of 2007; the HSE report of two days ago--

Dr. Larkin Feeney

And the other earlier HSE report on alcohol consumption in Ireland, and the HRB report, Trends in Treated Problem Alcohol Use, 2004 to 2006. That is just this year.

Dr. Siobhán Barry

There are reports being issued that are indicative of concern. At this stage we have too many reports. It is time for concerted action and, as the committee is aware, this will take concerted action across many different Departments.

In terms of problem use of alcohol in Ireland, we have one of the highest rates of alcohol consumption in the European Union yet, curiously, 23% of the population are abstainers from alcohol. They tend to be older people in the main and largely more male than female but when we consider that 23% of those over 18 do not use alcohol at all, it is an indicator of the use of alcohol among those who drink.

That our drinking patterns are excessive and problematic is evidenced by a 2007 report which indicates that 54% of the Irish adult population are weekly binge drinkers whereas the figure for the EU citizens is 28%. We are top of the league where Irish school-goers are concerned. Students in school in Ireland are top of the European league in terms of their drinking patterns. In terms of the gender balance, while women tend to have less problem use at this point, their capacity to use alcohol is far different from males. There is a particular problem with women of childbearing years in terms of problems arising for their infants. The male-female ratio of problem alcohol use currently is four males to one female but that is taking the figure globally for those aged over 18. The younger the age with which one makes the comparison between males and females, the closer to unity one gets in terms of the ratio. Globally, the ratio is 4:1, but the ratio between younger males and females is much closer in terms of their problem alcohol use.

In terms of alcohol related mortality in the period 1995 to 2004, 3.8% per 100,000 were registered as having died of alcohol related problems in 1995 and that incidence increased to 7.1% per 100,000 in 2004. Alcohol also has been found to be a contributory factor in 36% of road traffic accidents, 55% of suicides, of whom 92% were aged under 30 years of age, 30% of drownings and 51% of fire deaths in the case of those aged 20 and over. The tentacles of problem alcohol use is spread throughout all facets of life.

We are among the leading binge drinkers in Europe and are in the overall lead in terms of under age drinkers. We need to measure the problem of alcohol use. In the past there was a sense that one was either an alcoholic or not one and everyone had a stereotypical image of an alcoholic as a person who had no control over his or her drinking, was generally to be found to be lying in the gutter and getting into all sorts of visible problems on the street. However, if one takes account of the overall public health message, it is much more sensible to categorise problem drinking with a stereotypical alcoholic at one end of the spectrum. Ranked before that person on the spectrum, there is the harmful drinker. In other words, a person who drinks to the extent that he or she is harming his or her physical or mental health. At a lesser point on the spectrum are ranked hazardous drinkers. Many of us in this room are hazardous drinkers. In other words, in the case of these people no particular problem has been identified but they drink to a level that they are entering a risk category by being hazardous in their drinking. Those who are low risk drinkers consume less than 20gof pure alcohol per day.

There are some general facts associated with problem alcohol use. It is important to note these as well as the problem alcohol use in Ireland. Physical dependence on alcohol does not happen with the first drink. When people consume alcohol it acutely brings about certain changes in brain chemicals, especially the chemicals related with having a sense of pleasure. However, over a period if people continually use those brain pathways, what started as a low risk pattern of drinking can develop into a hazardous, harmful pattern and reach the level of dependency.

Genetic factors also apply when considering problem alcohol use. The evidence for that scientifically is that in situations where people were separated at birth from their biological parents and raised in an entirely different environment, those who had biological parents who were problem alcohol users tended to develop problem alcohol use while raised in an entirely different environment at a far greater level than those who had stayed with their families. Therefore, there is a genetic vulnerability to problem alcohol use.

Some people take alcohol because of stress. At social and cultural events consuming alcohol is very much glamorised but it is also very much hijacked and embedded into the event, which can be among the factors that we know internationally give rise to problem alcohol use.

The state of our economy in the past decade or more has brought enormous economic prosperity and we have been living in an environment where we have had more money, alcohol has been relatively cheaper and it has been more available with the increase in the number of outlets. I pay tribute to the Minister, Deputy Brian Lenihan, on the legislation published today which, if enforced fully, will give rise to developments that international evidence suggests would ameliorate the problem. There has been a laxity of regulation. Many regulations are in place but they have not always been enforced as they should have been. We are living in an environment where the degree of social capital has reduced and, consequently, our involvement with each other. People have much more a sense of the right of the individual. With the growth in individualism there has been a certain lack of sense of the impact of alcohol use on other people. We would like to influence the committee in that regard.

The next slide relates to the consequences of problem alcohol use. Figures on the health consequences of alcohol show that in 2005 more than 5,500 people received outpatient treatment specifically for problem alcohol use and almost 3,000 people received inpatient care, the majority of those in psychiatric inpatient care. The Department of Justice, Equality and Law Reform has figures that relate to drunk driving, public order offences and crime. In society in general, we have reports from the Family Support Agency on domestic violence, consequent child abuse and relationship difficulties. Attendances at accident and emergency departments associated with alcohol use have risen considerably in recent years. In the work domain, a consequence of problem alcohol use is absenteeism. IBEC members speak about 12% of their male absenteeism and 4% of their female absenteeism being directly as a result of alcohol use.

The final slide I want to show members is taken directly from the Health Service Executive report published two days ago. It gives some indicators of the harm to the drinker and to others. We are not talking about a substance that only causes harm to the self and that the rest of society is untroubled by it, but a substance that causes increasing difficulty for the individual and also for society.

Dr. Larkin Feeney

I will talk briefly about solutions, which is more where we come into the picture. Our expertise is in providing health care to people with mental health problems, and alcohol impacts greatly on these people. We see many people with alcohol related problems. It is important to point out that the introduction of public health measures is critical to reducing problem alcohol use. We welcome the publication of the alcohol Bill today, but it possibly does not go far enough. There are many proven international measures which reduce problem alcohol use. If we accept that Ireland as a society has a serious problem with alcohol, we need to look seriously at the introduction of such measures.

We have listed them in order of proven effectiveness, which may be surprising to people because it is not intuitive. Random alcohol breath testing is the most proven measure for reducing problem alcohol use, followed by lower blood-alcohol levels for drivers. Our blood-alcohol limit at 80 mg, together with that of UK, Cyprus and another country, is the highest in Europe. The blood-alcohol limit in other member states has been reduced to 50 mg. We would be very supportive of a reduction in the limit that applies here. Strong arguments from publicans and others have been put forward to the effect that reducing the limit might affect the fabric of society because people would not be able to go to the local pub and have a drink. In truth, there is no reason somebody cannot drive, if they need to, or otherwise make their way to a pub, have one or two drinks, spend a few hours and go home. There is a strong lobby to encourage people to drink much more than that and that is problematic.

Reducing the availability of alcohol is also a key measure. Some measures towards that have been published today in terms of off-licence hours being reduced and supermarkets and garages being required to have alcohol in a separate area to ensure there can be more regulation as to who buys it. These places are selling alcohol in a way that it can be bought by under-age drinkers. There is inadequate enforcement of the law in that respect. Increasing taxation on alcohol is a well proven measure which reduces alcohol use. We have to be aware that alcohol is currently at its most affordable level ever because of increased income and the fact that, relatively, prices have not increased.

Advertising and promotion restrictions constitute a difficult topic. We have extremely lax advertising regulations on alcohol in this society. In France, for example, one cannot advertise alcoholic products on television. One can only advertise them in the written media by showing a picture of the bottle. One cannot show a glamorous model drinking. Even though people consume alcohol a lot in French society, they do not have the same degree of alcohol-related problems that we have. A statutory code of practice on alcohol advertising is essential.

At the bottom of the list, but also very important, is education. There is not as much proof of its effectiveness but it is clearly important to educate young people about alcohol-related problems. As regards developing alternatives, it is also important to provide young people with other things to do - alternatives to drinking high alcohol content beers and so on.

We have also included a slide about interventions that do not work. As regards the designated driver campaigns, our feeling is that the message going out is that if people have somebody with them who is going to stay sober, they can get completely trolleyed. I do not think that is helpful because it conveys the message that a person does not have to take any responsibility for their own state of sobriety if someone is going to drive them home. I do not think that is an effective public health measure.

Advertising self-regulation has not been effective. On the one hand we have industry ads on the radio saying "Drink sensibly", while at the same time the same industry is promoting crates of beer at all-time low prices in every available outlet. It does not make sense. The industry should be made to be more responsible as regards promotion and advertising.

I will now move on to how one can treat alcohol problems and how we have traditionally done it in this country. It has traditionally been very poorly organised - a hotchpotch of voluntary organisations such as Alcoholics Anonymous, Sr. Consilio's organisation in various parts of the country, hospitals such as the St. John of God Hospital and St. Patrick's Hospital, which offer alcohol programmes for people with private health insurance, and the Rutland Centre. For the vast majority of the population there have been psychiatric hospitals. Traditionally a lot of people have gone into psychiatric hospitals with alcohol problems. It is Government policy but it does not make sense. In our experience, admitting somebody with an alcohol problem to a ward environment where, in the main, people are being treated for conditions like schizophrenia and bipolar disorder, does not address their problem. The Vision for Change document, which is Government policy, makes clear that alcohol problems will no longer fall within the remit of mental health services, except where there are co-morbid mental health problems such as depression or anxiety disorders. We need to recognise it is a wider problem than that.

It is important to identify the problem and address it earlier, before it gets to the point where people are admitted to psychiatric hospitals. Hence, services need to be organised so that they allow for the problem to be recognised and addressed earlier. Public awareness is a key point - awareness of what problem drinking is. It is not the severe alcohol dependency that we have traditionally recognised as problem drinking. If somebody is coming in on Monday morning boasting about having had 14 pints the night before, falling over and not being able to find their bedroom, that is not something one should be boasting about in Irish society, but at the moment it is.

We should be training professionals to recognise and manage the problem. When I say professionals, I am talking about everybody - teachers, prison officers, employers - anybody in any walk of life who has contact with people so they can recognise the problem early and be able to go some way towards addressing it.

Screening is important. A study has been published by colleagues of ours, John Sheehan and Ronan Hearne, which examined how often alcohol problems were picked up in an accident and emergency departments. We know that about half the cases in accident and emergency departments, particularly at the weekends, are alcohol-related, but less than a third of them, 30%, were picked up by doctors. Only a small proportion were referred on for appropriate treatment. We are not picking the problems up, partly because everybody is working flat out, they are too stressed and do not have readily accessible services to refer to. If people do not think they have something they can do for somebody, there is a kind of nihilism about bothering to pick it up. Research has shown, however, that even telling somebody "You're drinking too much. Drink caused you to be here today. You should think about cutting back. Here is some information", has been proven to be effective in reducing a person's alcohol intake over the following six months. That has got to be done.

The next slide is a pyramid showing how alcohol services should be organised for people who are drinking at a hazardous or harmful level, by having easily accessible and available brief interventions, advice and counselling at primary care level. More extensive services should be available for severe alcohol-prelated problems up to and including residential services. At the moment there is no real organisation at primary care level for alcohol-related problems.

We want to get to these problems early in a primary care setting. If we get them early there is much less impact on society and on the individual's subsequent health. We are trying to implement the primary care strategy at present by setting up primary care teams. Part of that strategy is to include addiction counsellors as part of those primary care teams. In the first instance, people presenting in all sorts of primary care settings need to have their alcohol problem identified. Primary care settings do not just include GPs, but also other areas where people might have their health problems identified. Accident and emergency services are probably the biggest area in which we are not addressing this problem. In units all around the city and country, people are presenting night after night having had all sorts of alcohol-related problems, including fights and falls. Such people are stitched up and sent home, yet nobody is asking "Are you going to do something about your drinking?" That is partly because people do not recognise it as being within their accident and emergency remit. It is important, however, to have professionals working in accident and emergency units who can deliver simple advice and information.

Following studies in London, they developed a test called the Paddington alcohol test. It takes one minute. Somebody presenting in certain situations is essentially asked two questions and gets a leaflet with information. Even that reduces drinking.

It is important to put the resources into accident and emergency departments to address alcohol-related issues when they arise. Very often that is the only opportunity we will get before that person is much more severely dependent on alcohol.

There are other areas where people might have particular needs. People in prison should have their addictions, including alcohol, attended to. Alcohol tends not to be considered as much a problem as perhaps heroin in prisons but often people going to prison have very severe alcohol problems. It is important the homelessness services have the resources to address alcohol-related problems. Perhaps there should be particular services for groups such as Travellers and asylum seekers which might not find it easy to access primary care health facilities. The specialist settings, such as mental health services like ours, general hospitals and drug treatment services, all need to address alcohol problems as part of what they do because there is a huge overlap.

Different treatment is required for different types of drinking. People who hazardously drink, that is, perhaps having 14 pints every Friday and Saturday night, need brief advice telling them they are drinking too much. Even that can help them to reduce the amount they consume. Counselling is required for people who engage in harmful drinking. Harmful drinking means not only harming one's physical or mental health but also harming one's family and society in terms of crime. Dependent drinkers, who are very physically dependent on alcohol, need a more comprehensive package which includes the availability of detoxification with medication such as Librium and specialised addiction counselling up to and including residential care.

Residential treatment is really only available in the private and voluntary sectors at present. It is not necessary in most cases. Most cases can be dealt with on an outpatient, community basis. There is as good an outcome if somebody can address his or her problem on an outpatient community basis as there is if he or she is in an inpatient setting, even though traditionally we think that somebody addresses his or her alcohol problem by going into hospital and getting dried out. Very often that only results in a person being dried out in order to leave and do the same thing again. It feeds into a dysfunctional cycle and the person does not actually address the problem.

I refer to the steps to be taken to address this. The public health measures are the critical way forward. The strategic task force on alcohol made all these recommendations which need to be implemented, as they are all sensible. In the primary care and other health care settings I mentioned, there should be screening, brief advice and education from professionals whose job it is to address alcohol problems and access to more specialised addiction counselling and detoxification, as required.

The last slide I have states: "Time for action, no more reports." It suggests there is a need for an office that involves everybody along the lines of the Office for Tobacco Control, to deal with alcohol. Many Departments have an interest in alcohol, including the Departments of Justice, Equality and Law Reform, Finance, Education and Science, Health and Children, Community, Rural and Gaeltacht Affairs, Social and Family Affairs and Transport. With so many Departments with an interest in one area, perhaps there is a need for a joined up task force. We came up with a slightly tongue-in-cheek acronym - bureau for alcohol regulation - but perhaps we can come up with a better one than BAR. The strategic task force's recommendations should be implemented.

Dr. Siobhán Barry

Nuair a bhíonn an t-ól istigh, bíonn an chiall amuigh. When drink is in, sense is out. What we would like to have is "nuair a bhíonn an chiall istigh, bíonn ant-ól amuigh".

I welcome Dr. Siobhán Barry and Dr. Larkin Feeney. I refer to the fragment of places to assist alcoholics, such as Sr. Consilio's, St. John of God, and so on. Considering that fragmentation, could they be combined into a unit? Some people go to St. John of God while others go to Sr. Consilio's. What is the link between all of them in regard to the treatment of alcoholics? I have seen Sr. Consilio's grow from small beginnings in Athy to a wonderful place of assistance for alcoholics. Is there a link between Sr. Consilio's, Bruree, the other places in Galway and elsewhere and St. John of God? If there is none, do Dr. Barry and Dr. Feeney see the need for a link between them all so that they have the one thing in common when dealing with alcoholics?

I recently met representatives of the Vintners Federation of Ireland who question the definition of a "binge drinker". Is it somebody who has three or four pints? What is Dr. Barry's and Dr. Feeney's definition of a "binge drinker"? The Vintners Federation of Ireland seem to say that the definition of a binge drinker is somebody who takes only three or four drinks. When one says we are the biggest binge drinkers in Europe, one is talking about a person taking two or three drinks, therefore the situation is not as bad as the picture being painted. Do Dr. Barry and Dr. Feeney see alcohol as an introduction to the use of illegal drugs, especially among young people?

I welcome Dr. Barry and Dr. Feeney and am delighted to see them. I am glad the views they expressed are the same as those I have expressed for many years in the Dáil. We have a very serious drink problem in this country but we are always afraid to say so because of all the vested interests. There are so many vested interests, including the vintners and the Government. There are 6,000 outlets selling drink here. Judges gave out 91,000 licence extensions. That provides a huge amount of revenue to the State. We must tackle the vested interests, including the Government. The people will have to speak out. The fact that 23% of people do not drink alcohol at all shows the seriousness of the problem given the amount drinkers consume. I do not agree with the doctors on the rural driving issue and I will explain the reason before I finish.

I raise the issue of people seeking treatment when they have a problem. I was glad to hear the doctors talk about accident and emergency departments. Accident and emergency departments are not the place for people with drink-related problems. A lady came to my clinic a fortnight ago and we wrote a very strong letter to the HSE. Her husband has gone into an accident and emergency department 15 or 16 times. He left an accident and emergency department at 3 o'clock or 4 o'clock one morning with 30 or 40 tablets in his pocket. He went home and drank a bottle of whiskey. With the whiskey and the tablets, he was a lethal cocktail for that family which suffers as a result. She cried and begged for assistance from the State for her husband. There is no point in bringing a person into an accident and emergency department, handing him a box of tablets and sending him home telling him that everything will be fine. There was another reason he was brought in. It was not because he was so nice at home. He was sent home worse because the State sent him home with a lethal weapon of drugs. They gave him tablets going home and they are like a bottle of whiskey to him. We need to deal with that.

I do not believe there are services available, in particular, for the poor. If one is rich, one can go to places to get dried out. That is happening all the time. People on middle incomes, low incomes and social welfare have no hope at all because there are no services for them.

To take the case of that man, there is a good place in Mayo called Hope House but the problem there is that before one goes into it one must be dried out. He was not dried out and his wife could not even get him in there. Even if she wanted to pay for it, she could not afford it. That is one issue.

If, tomorrow morning, either Dr. Barry or Dr. Feeney were Minister for Justice, Equality and Law Reform, Minister for Health and Children or Minister for Education and Science, what is the one thing they would want done to curb alcohol abuse in this country?

It is outrageous that there are sporting organisations such as the GAA taking sponsorship from Guinness. I hope Dr. Barry and Dr. Feeney will speak out on this as well because I saw it in their presentation. It is outrageous. That is a matter for legislation.

The witnesses are correct in what they have stated. I am fed up of reports. We know what the problems are. We know we have the biggest alcohol problem in Europe and it affects many families. We are hypocritical about it in this country. People do not have as much sympathy for somebody suddenly diagnosed with cancer as they do for somebody who is drunk. One would refer to such a person going down the street as a poor devil, but he might go home and beat up his wife and family. There is great sympathy for such a person. When it comes to people misbehaving with alcohol we must take the same view as with drink driving. One must be cruel to be kind. In this country there is a tolerance for and sympathy towards alcohol abuse and we must take a stronger line on what is happening with alcohol abuse.

Mention was made of drink driving. I cannot condone it and never will. I have a simple word for people who get caught and come into my clinic looking for support because they know what they are doing. I cannot use that word here today because I do not wish to be vulgar.

However, there is a problem in rural Ireland in particular and the delegation touched on it. There is a section of society who go out for one or two drinks. They are not the people the delegation are talking about but they are the ones being affected by it. They are law-abiding citizens. They do not want to break the law. The guy who takes 15 or 16 pints to whom they referred does not really care about drink driving. If he wants to drive after drinking 15 or 16 pints, he will do that. There certainly is a very serious trend developing, and particularly in rural Ireland where people have no social outlet. The other problem is where people are buying alcohol and bringing it home. This results in more violence and more problems and we are not able to control it. There is a need for balance.

I have asked the questions. I am glad to see the delegation here today. It is matter I feel strongly about. I am one of the few who spoke in the Dáil opposing the new opening hours, which were a disgrace. It is a matter the Government should look at. After extending the opening hours, they still gave 91,000 exemptions. There is no real leadership in this country on alcohol.

I am glad to hear the delegation speaking out about it here. I note from personal experience that alcohol is the biggest destroyer of families in this country and we have been too tolerant too long about it.

I welcome Dr. Barry and Dr. Feeney. It is nice to see Dr. Barry again. I will play devil's advocate here because it seems that as long as I have been in this House, and, indeed, long before it, we have been passing legislation to deal with alcohol and, as the delegation correctly stated, the problem has, if anything, got worse rather than better. It seems we may not be hitting the right targets at all.

The delegation mentioned that the causes are not what one might intuitively think they are, but do we have a clue what the causes are? They mentioned advertising. Ireland and Irish people were associated with excessive drinking, binge drinking and alcoholism long before there was sophisticated advertising. Obviously, companies advertise because it works but a great deal of advertising, as I am sure they know, is aimed at pushing one brand ahead of another. I do not know whether it actually makes one drink alcohol or not, but it certainly might make a person drink one product rather than another. I am not playing down the role of advertising. I am sure it does play a role but since we had alcoholism long before we had sophisticated advertising, I wonder whether it is the big deal we make of it.

Is it a matter of cost? The delegation stated tax plays a role. Perhaps it has some role. They correctly stated that alcohol is relatively cheaper now than it ever was, but it is still a great deal more expensive than it is in many other countries where they drink less than we do.

Is it a matter of availability? There have been all these licence extensions but alcohol is far more available in countries such as Spain, Italy and France which do not have our problems. I accept such countries may think they have problems and they probably do have them but, nevertheless, they do not seem to have the same kind of problems as we do.

It does not seem to have anything to do with poverty and whether one is poor or rich. We drank when we were poor and when we were rich.

What is the cause? The delegation mentioned a genetic vulnerability. Could that be it? Are we missing the target altogether? Is there something else we should be doing in terms of response rather than treatment? Obviously, the treatment problem must be tackled, but in the legislative areas such as justice and education, are we hitting the target or are we missing it completely? For instance, they mentioned that random breath testing works. I am convinced it works to reduce the harm associated with alcohol in terms of road accidents and I was very involved in promoting that legislation, but I am not sure it reduces the amount people drink. I notice that since people know they cannot drink and drive, they make arrangements and drink their heads off. They know they do not have to drive home and are free to drink, or they drink at home where there is no limit on what they can drink. When it comes to alcohol do we actually know what we are dealing with at all?

I hate to suggest to two experts who have told us what it is all about that perhaps they do not know, but do we really know? I accept everything they said about treatment, the need for the different types of treatment and the need to use all sorts of opportunities.

I am especially interested, for instance, in at least trying to postpone the day when kids start to drink. Intuitively, I feel that if one could keep kids away from alcohol - even from the point of view of it affecting their brains - and they started the binge drinking at 20 rather than at 12, it might be better for them. It might be better if we put more energy into creating a rigid identity card system or some system of keeping young children away from alcohol rather than into other areas.

Perhaps I am completely wrong. The presentation states the steps to be taken and research is one of them. Perhaps there is a need for research. Perhaps it is something within us and we should be tackling it from another perspective altogether.

I welcome Dr. Barry and Dr. Feeney. I am most impressed with their presentation because it is quite stark, it pulls no punches and it sets out the matter exactly like it is. It is important for us all to take note of that. It contains a great deal of concise detail spelling out the horrific short-term and long-term implications of alcohol abuse.

The witnesses made a couple of interesting points about the reports. It is interesting that they were able to produce so many of them from 2006 and 2007. We cannot stop producing reports. We never will and I do not think we should. We are not doing anything about the reports - this is true right across the board - and, as far as I can see, we are reinventing the wheel every time.

My background is in research. While I would welcome the research, we might almost have enough telling us what is wrong. We are not doing what we need to do, however.

It is interesting that among the causes of the recent increase in alcohol problems in Ireland is the greater number of outlets available. In my constituency of Dublin South-Central there were 11 applications last year. Ten of those were awarded, two of which were cheek by jowl. It is not as if there was need for another one. It was not a matter of access.

The second change I have noticed relates to supermarkets. I was sitting in a traffic jam yesterday and had the opportunity to look in the window of one such establishment. There was nothing on display except endless cans of alcohol. Many establishments are offering six free cans with every six purchased and they are also engaging in price cutting. The key point is that availability is hugely important. Alcohol is available and is promoted everywhere. If one intends to have a drink, there is little to stop one from doing so.

I am interested in hearing our guests' views on café bars. Deputy Mitchell referred to the availability of alcohol on the Continent. I accept that it is part of our culture that people drink in pubs. We debated the idea of introducing café bars and many people were opposed to it. However, perhaps it is worth revisiting. People should not just go out to drink; they should go out for a meal and have a glass of wine or beer. The entire focus in Ireland is on going to the pub. One does not necessarily even go out for a night's entertainment; one goes to the pub to drink. That merely encourages people. It all comes down to promotion.

One group which was not referred to in the context of under age drinking is parents. There is a strong case to be made for encouraging people to be responsible for their children. One hears stories about junior certificate students going out on the town to get drunk. I do not want to sound old fashioned but it is appalling that 15 year olds are planning to go out and get drunk. Clearly, their parents are in some way complicit in this. From where do their children obtain the money for alcohol? Why is it that no one seems to take responsibility, especially if children are not returning home until 3 a.m. or 5 a.m.? We need to impress upon parents that they have a responsibility to their teenage children and to other members of society who, indirectly perhaps, become damaged by the binge drinking in which these youngsters engage.

Our guests' final point related to a single task force. They are quite right. Responsibility in respect of this matter is spread all over the place. It might be useful to put in place a single task force or group.

I remind members of the time constraints. We are supposed to vacate this room within the next ten minutes. Six members are offering and our guests must be given the opportunity to reply. I ask members to be brief.

Tá fáilte romhaimh. Today I learned the Irish for Celtic tiger. Is officialdom in a position to provide answers in respect of the problems we face? It can assist but I do not believe it can provide the necessary solutions because we are dealing with a particular mindset.

Our guests' presentation was excellent, containing a minimum of waffle and a great deal of wisdom. I genuinely believe that what we need is a crusade which must be led by role models with whom those in certain age groups can identify. If one in every two adults is involved in weekly binge drinking, then half the population is involved. Those who engage in this behaviour obviously do not see anything wrong with it. The need to communicate to them the seriousness of the situation is apparent.

When major anti-social incidents occurred, some of which involved deaths, there was an outcry for two days afterwards and editorials appeared in newspapers, etc. I stated in the Seanad that the outcry would not last. The only way we can proceed is to instigate a crusade and that will require leadership. However, I am not taking from the official input in that regard.

Many years ago, cigarettes were an integral part of films because most actors and actresses did not know what to do with their hands. They were also integral to amateur productions and on television. One need only watch the films of Humphrey Bogart to understand what I am saying. Later, it became socially unacceptable to smoke cigarettes in films. If one watches "Fair City", "Coronation Street" and other soaps, one will realise that a major part of the action is based in pubs. These programmes do not depict social drinking and characters will often state that they are going to the pub to drink for three or four hours. That is the culture to which people are exposed.

The only hope we have is to change people's mindset. I do not believe that reports or statistics will help. We must shock people into realising what is happening and what needs to be done.

I thank both of our guests for their presentation. I agree with Senator Ó Murchú that we need to change the culture. I have spent a fair amount of time in America with one of my nephews. He is 28 years old but looks much younger and on each occasion we went out for something to eat, he was asked to provide an identity card when he tried to order drinks.

We must take action to change the drink culture in Ireland and also to alter the style vocabulary. As a mother of young people, I am familiar with the terms "trolleyed", "hammered", "sloshed" and "plastered". The drinking of alcohol is glamorised to a huge degree. We must protect our children and their friends. As public representatives, we must send out a strong signal that to be hammered, trolleyed or sloshed is not pleasant; it is terrible. I do not want another report to be compiled. There must be a shift in our mindset. Why are Irish people the leading binge drinkers in Europe? How did this come about in such a short period? Why did Irish youngsters become the leading under age drinkers in Europe in the same period?

I take Deputy Upton's point in respect of advertising. As a rural Deputy, however, I am aware that one of the major shifts in the social life of the country is the lack of community. Some children in my constituency return home alone to empty houses at 4.30 p.m. on each school day. Some of them drink alcohol while they are there. As a result of the fact that their parents might not return to Carlow or Kilkenny until late in the evening following their commute from Dublin or Waterford, these children have a great deal of free time. These children have a great deal of money because their parents make up for their guilt at being absent by overindulging them. We understand the pressure on parents who are trying to pay their mortgages and maintain their lifestyles and images. Unfortunately, overindulging children is having a negative effect on family life and on society in rural areas and small towns and villages.

I want to see the culture being changed. I want young people to be protected from the glamorisation of drink. If we could remove sponsorship by alcohol companies from our sporting arenas, it would be a step in the right direction.

I thank our guests for their informative presentation. I wish to inquire about some of the genetic factors that may possibly contribute to problems in this area and the concept of linking these back into some of the solutions our guests suggest such as screening. Reference was made to schools, the workplace, etc. Is it possible to obtain, through genetic screening, an idea of how someone might develop?

Dr. Larkin Feeney

Not yet.

I have heard Dr. Joe Barry suggest on numerous occasions that there is a direct link between the increase in taxation and the reduction in alcohol sales.

He stated that there is a correlation.

No, he indicated that there is a direct link.

There is a correlation, not necessarily a direct link.

As regards the inclusion of alcohol under the national drugs strategy, prevention is one of the elements of the latter. If we go down the road of prohibition, alcohol abuse will be driven underground and other problems will arise as a result.

Our guests referred to how certain groups could be targeted and mentioned asylum seekers. There are large numbers of migrant workers in my constituency who come from countries where the drink culture is different, which creates its own problems. What action can we take to address that matter?

I thank Dr. Barry and Dr. Feeney for their enlightening report. They pointed out in their earlier contribution they had half a dozen reports on alcoholism, which have made no difference. Another ten reports could be written but they will not make a difference. This issue comes down to people taking responsibility. As Senator Ó Murchú said, role models are needed to ensure a better approach to drinking so that we are more moderate and so forth.

Teenage binge drinking is the responsibility of family, which is the most important element in tackling underage drinking. If the Government went down the taxation route as proposed, cigarettes and alcohol would have to be taken out of the inflation basket. These taxes would add significantly to inflation if we went down that route.

Reference was made to random breath testing but not to drug testing. The Garda should test drivers for both alcohol and drugs, as is the case in Spain. I take a drink and the proposed reduction in the blood alcohol limit from 80 mg to 50 mg will not make a difference to one's driving. It has no value. Moderation in drinking is the core issue.

I thank the witnesses for their articulate and concise presentation. I refer to the solutions they listed that do not work, such as the designated driver initiative. It makes the roads safer but it does not solve the drinking problem. Perhaps initiatives intended to solve some problems do not. For example, reducing the blood alcohol limit from 80 mg to 50 mg will lead, as Deputy Ring said, to more drinking in the home in rural areas. People are afraid to have a drink or two and drive in their tractor or car and, therefore, they drink at home instead. They can buy alcohol more cheaply in supermarkets and they drink more at home than they would in the pub. Road safety has improved but the drink problem has increased.

I refer to the sponsorship issue and drinks companies hijacking sporting events. I agree with that comment but I would introduce an outright ban that would affect all sports, not only the GAA. For example, we have the Heineken Cup and the Budweiser Derby. I am involved in the GAA and the association was unwise to accept the recent sponsorship when it was globalising it. That is an issue for another day. However, the great work done by sporting organisations should not be forgotten in preventing thousands of young people from abusing alcohol. A substance abuse officer will be appointed in every GAA club shortly to guide young people. This is a balancing act and I would be interested in the delegation's comments on these issues.

I thank Dr. Barry and Dr. Feeney. The issue comes down to responsibility and parents setting an example. For example, every time I have passed a public house in the past three or four months, a Holy Communion or Confirmation celebration was under way. We have come to accept that as a society but, ultimately, it is not acceptable. I was astonished to discover two weeks ago that it is as easy to order alcohol for delivery to one's door as a pizza or chips.

I recently heard a group of teenagers, one of whom was my daughter, debating how they would get into a night club or disco and whose driving licence or passport they would use. Many of the venues that allow young people in using false identification should be shut down. That is the only way to prevent young people accessing clubs they should not be in. The issue of people handing over their passports or driving licences to younger people to gain entrance to clubs must be seriously addressed.

Education of young people must begin in the home and continue in our schools. Schools do not have an appropriate programme in this regard. The Walk Tall programme comes up now and again. We should be in there telling young people what alcohol and drugs do to their brains, lifestyle and longevity. Supports for young people in the community must be examined. I was involved recently in two youth cafés that opened in my area. Young people who used to stand on the corner of the road because they could not gain entrance to clubs are fully participating in these cafés. We must examine how additional facilities can be made available to young people at weekends that are not alcohol-led. That is the way we should go. I thank the doctors for their report.

I welcome both doctors and congratulate them on their interesting presentation. I also compliment members on their contributions because this issue affects all of us. Disposable income is an issue because people have more money now. I am 43 years old and I do not drink, but when we went out for a night 15 or 20 years ago, we had £15 or £20 in our pockets. We pooled together to buy petrol for the car, the admission fee for the disco was £3 or £5, £2 was kept for chips and we had £7 or £8 to spend on drink. Now people go out with €150 in their pockets for a night and they drink 14 or 15 pints followed by a few shots before emerging on to the street.

I am surprised that in the context of the public health measures that work, the first seven are punitive and education is well down the list. Like Deputy Mitchell, I wonder about advertising. For example, 150 years ago we were known as the drunken "Oirish" and we did not have a great reputation, but we did not have access to advertising. The mass advertisements promoting just one drink are good. Perhaps the delegation has research on this.

It is time we were tougher on alcohol abuse. We have all been on foreign holidays and drunkenness is not tolerated abroad. Forceful policing is used. People are picked up and taken away because it is not accepted that they fall around the streets or hassle other people. I have witnessed this on numerous occasions. It is well past the time mandatory identification cards were introduced. This would involve a change of mindset and an attempt to enforce personal responsibility.

As Deputy Byrne said, Holy Communion and Confirmation ceremonies are taking place everywhere and the parents and children travel from the church to the pub. As one drives past in the evening, the children are outside in their communion dresses and so on playing while the parents have been inside for the day drinking. This culture needs to change, but that is a difficult job because disposable income is so high. People have the money in their hands and it is their choice what they do with it. The issue is how we prevent them from spending it on alcohol and forcing them into alternatives.

Dr. Siobhán Barry

I will respond briefly. The committee members have covered a wide range of areas. It is interesting for us to have dialogue about the situation. Our sense of the problem is that there is a tap running which has created a waterfall and we are at the bottom of that waterfall, running with little buckets trying to draw off water, help people and do whatever is necessary to glue them back together. We need the tap to be turned off. That is where this committee, as legislators, comes in. The problem is cross-departmental.

The various questions asked were all very interesting and relevant, but it will need a response to all of them to solve the difficulties. Deputy Wall, for example, asked about services, but these come at the end of the waterfall, when the water is flowing strongly. Services are very fragmented. We want to interest and influence the committee towards providing treatment at an earlier stage, rather than at the latter end of the problem when people are at the top of the graph and are stereotypical alcoholics falling around the place. There must be earlier recognition of the problem. Less severe intervention could be made then and it would not be as costly. This intervention should be available in casualty departments and in general hospitals, for poor and rich alike. What is available currently comes at the more serious level of the problem and is available mostly for people with incomes.

The committee's brief today concerns drugs and alcohol. Anybody who is an opiate user - at the end of the spectrum in terms of substance use - is always a drinker as well. People do not go straight to heroin. The sequence is cigarettes, alcohol, cannabis. At every hop, some people stop and do not go beyond it. However, one does not move from nothing or complete sobriety to opiates. One takes a series of steps to get there.

It will be necessary for many of the suggestions put forward by the committee members to happen together to solve the problems. It will take treatment and intervention, but first the tap must be turned off, and that will be done by the legislation. The well prepared and costly recommendations - it took hours of work, significant numbers of people and quantities of paper to draw them up - need to be implemented at the right level, for example, the recommendations with regard to driving, pubs and off-licences. The legislation must be enforced.

Several committee members mentioned that our children are following our example. We can wring our hands and talk about young people, but they follow our example. We are the most important educators. It is convenient to talk in terms of the schools doing the educating, but we need to do it ourselves.

Deputy Upton mentioned café bars. These were a wonderful suggestion, but the legislation that included café bars was a lot wider than café bars. Unfortunately, when people discussed them, they focused on the narrow viewpoint. There was also concern about the importation of alcohol through use of the Internet. The legislation was, of course, much wider than this. Of itself, the café bar proposal was good.

Our major recommendation today, apart from the availability of facilities for early intervention when people end up in casualty and general hospitals, is that the committee should consider strongly the creation of an office of enforcement. Dr. Feeney mentioned the Office for Tobacco Control. We suggest there should be a similar office or bureau for the regulation of alcohol and drugs. This could draw from all Departments, set out regulations and ensure enforcement of legislation. It could also consider the evidence from other European countries and ensure measures in those countries are introduced and enforced here.

This is what happened with regard to tobacco. When the Office for Tobacco Control was set up it was in imitation of what was in other European countries, but we ended up way beyond them in terms of our legislation. Other European and international countries have followed us. We now have the opportunity to do something similar in terms of what happens with regard to alcohol.

I thank Dr. Barry and Dr. Feeney. The level of interest shown in this issue, with 12 members contributing, is significant. In view of the fact that the legislation is imminent, I propose, therefore, that we send a transcript of our meeting today to the Minister for Justice, Equality and Law Reform. It would do no harm to make him aware of the committee's views. Is that agreed? Agreed.

The joint committee adjourned at 5.40 p.m. sine die.