I welcome the delegations. Witnesses are protected by absolute privilege in respect of evidence they give to the committee. However, if they are directed by it to cease giving evidence on a particular matter and continue to do so, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they do not criticise or make charges against any person or an entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing parliamentary practice to the effect that they do not comment on, criticise or make charges against a person outside the Houses or an official, either by name or in such a way as to make him or her identifiable.
Alcohol Marketing: Discussion (Resumed)
Dr. Declan Bedford
My name is Declan Bedford and I work as a specialist in public health medicine and act as director of public health in the north east. I am grateful for the invitation to attend the committee meeting today. I am joined by a number of my colleagues, including Dr. Eamon Brazil, consultant in emergency medicine in the accident and emergency department at the Mater hospital in Dublin, who will share with me in making the opening statement, and Professor Joe Barry, Department of Public Health, Trinity College and HSE addiction services. The committee has requested information on the health effects and consequences for the health service of problem alcohol use. It is considering alcohol marketing with particular reference to targeting young people and minimum pricing.
The committee has received a written submission, which we hope it found useful, and as such we will keep our opening remarks brief. The submission lists examples of the health-related harm caused by our consumption of alcohol. I reiterate that these are only examples. Report after report has been written on the consequences and the harm caused by our consumption of alcohol. I have some of the reports with me. These reports and other research do not adequately capture the true level of social harms to individuals, their families and their communities. These harms are often hidden from society but they are no less real. Few reports have delved into the stress caused to individuals, families and communities or to staff and other patients in the accident and emergency departments around the country each weekend. Dr. Brazil will talk more about this shortly.
It is worth reflecting on some of the facts. Alcohol kills at least one person in Ireland every seven hours, and alcohol-related deaths increased during the period 1995 - 2004. Alcohol is a contributory factor in half of all suicides in Ireland, it was consumed in four out of ten episodes of self-harm in Ireland in 2010 and alcohol-related admissions to acute hospitals doubled between 1995 and 2008. Some 2,000 acute hospital beds are occupied on average each night as a result of alcohol at a time when the recently passed budget had to cut funding to the health services as a necessity. Alcoholic liver disease rates and deaths almost trebled with a 190% increase, between 1995 and 2007, with figures also revealing considerable increases of alcohol liver disease among younger age groups. Among those aged 15 to 34, the rate of alcohol liver disease discharges increased by 247%.
Alcohol is a factor in one in four traumatic brain injuries and it was the main drug responsible for 7,940 admissions to specialised addiction treatment centres in 2008. There were 1,798 alcohol-related admissions to mental hospitals in 2010 and more than one in eight patients seen in the sexual assault unit in Dublin's Rotunda Hospital last year had so much alcohol consumed, the patient was unsure if there had been an attack. Alcohol is also a trigger in a third of cases of domestic abuse, and low levels of alcohol consumption is associated with a small increase in breast cancer risk, with the most consistent measure being cumulative alcohol intake throughout adult life. Alcohol intake both earlier and later in adult life was independently associated with risk. Binge drinking but not frequency of drinking was associated with breast cancer risk after controlling for cumulative alcohol intake. Consuming alcohol during pregnancy increases the risk of foetal alcohol spectrum disorder but despite this almost two thirds of women report drinking alcohol during pregnancy with 7% drinking 6 or more units per week.
These facts highlight the extensive alcohol problem we have in Ireland. It is worth noting that most of these harms occur not in alcoholics or people with alcohol dependence but rather among regular drinkers who drink at hazardous or harmful levels; unfortunately, this equates to over 50% of all drinkers in Ireland. To characterise Ireland's drinking problem as occurring in a small minority of irresponsible drinkers is incorrect.
The cost of the alcohol-related harm to the health care system has been estimated to be €1.2 billion a year, based on 2007 figures, with costs of €500 million in the acute hospital sector, €574 million in general practice and allied health services and €104 million in mental health services. The cost of alcohol-related suicides has been estimated to be €167 million and the cost of alcohol-related fatalities on the roads has been estimated to be €526 million.
The HSE provides a wide range of services in respect of alcohol-related harm. These include health promotion activities and campaigns, outreach and counselling services, addiction services, family support, treatment of patients presenting with alcohol-related harm in acute hospitals and support of voluntary organisations. The appendix to our main submission document includes a list of the range of services and supports provided. The more a population drinks the greater the level of alcohol-related harm. We are suffering seriously in Ireland from a health, social and economic viewpoint, and the committee heard in previous sessions how much we drink as a people. A large part of this harm and the effect it has on the health services can be prevented, and the evidence is available to tell us what must be done.
I will now hand over to Dr. Brazil, who will comment in detail about the accident and emergency departments.
Dr. Eamon Brazil
I thank the committee for having us here today. I will give a perspective of what happens in accident and emergency departments as a result of alcohol. Alcohol carries a significant burden for emergency services in our acute hospitals, taking in the number of people attending, the range of presented symptoms and the level of repeat attendees associated with alcohol abuse. It should be borne in mind that in excess of 1 million new attendances present to the accident and emergency departments every year.
In that context I will provide some facts that the committee may not be aware of. Up to one in four of our attendances in general is related to alcohol or alcohol is a significant factor in the presentation. Nationally, almost a third of patients presenting to accident and emergency departments with an acute injury have alcohol as a contributing factor, with the figure somewhat higher in inner city departments. My department has a figure of approximately 50%. These cases are primarily a result of the patient's drinking prior to the injury but in some cases it is caused by a third party who may be drinking. For injuries related to alcohol our busiest times are Saturdays and Sundays, with the peak time between midnight and 4 a.m. We have coined the phrase "nightclub medicine" for what we tend to do at that time. There is also association with recreational drug use, which adds to the disruption.
The majority of injuries are unintentional but it is noted that one in three alcohol-related injuries, compared to one in 20 non alcohol-related injuries, is intentional and perpetrated by somebody else. Approximately 60% of patients presenting to the accident and emergency department with alcohol-related injuries would have engaged in harmful drinking, which we define as 12 drinks or more in the previous six hours. Clinical assessment by our staff would demonstrate that three quarters of patients are under the influence of moderate or severe intoxication.
With regard to the environment which these people come to, accident and emergency departments in Ireland are busy clinical areas which experience significant crowding most of the time. We deal predominantly with an ageing population and the majority of patients waiting in the departments are elderly and frail, with high complex health care needs. Patients who have consumed alcohol and present to our departments also require specialist skills and place a big burden on our medical, nursing and security staff. The management of patients who have consumed alcohol is significantly more difficult than those who have not as the effect of alcohol on the brain can make a case more complicated. This is even worse in a crowded accident and emergency department.
It should be borne in mind that patients under the influence of alcohol, by and large, behave the same way in an accident and emergency department as they do in the street. Years ago people would behave when they came into a hospital but that is no longer the case. The aggression, emotion and threatening behaviour seen in public places would also be seen in an accident and emergency department, sometimes culminating in the assault of staff and patients. These are not infrequent events.
Dr. Declan Bedford
We will discuss some effective strategies to reduce alcohol-related harm. As I mentioned, the more a population consumes alcohol, the greater the degree of alcohol-related harm. Priority should be given to reducing the overall level of alcohol consumption. The most effective strategies have been identified by the strategic task force on alcohol, and we recommend the following as the evidence supports them.
There should be an increase in price through taxation. This is particularly important as it would reduce the alcohol consumption of young people and have a bigger effect on heavy drinkers than light drinkers. There should be a minimum price on alcohol, particularly for off-sales, and there should be a new tax on alcohol sold for consumption off the premises. We recommend a reduction in the number of premises available to sell alcohol, and research has also indicated that alcohol advertising is influential in adolescents starting to drink earlier and more if they are already drinking.
Given the high level of teenage binge drinking in this country compared to other countries, it is essential that the promotion of alcohol through advertising and other promotions is addressed through a ban on the advertising of alcohol, including a ban on sponsorship of sporting events by alcohol companies. Enforcement of drink driving laws in recent years has seen the implementation of mandatory breath testing and reduced limits. The introduction of mandatory breath testing has been very effective. However, we need to maintain highly visible enforcement of drink driving laws, given that a study in this country showed that the only real deterrent to Irish males is the fear of getting caught.
Services to screen and treat individuals with alcohol-related problems need to be reviewed with a view to developing a comprehensive service with integrated care pathways and accessible services. Treatment and support for persons with alcohol-related problems can provide benefits not only to the patient but also at a societal level.
The need for alcohol companies to increase profits for their shareholders is a barrier to reducing consumption. Alcohol is a psychoactive drug and for some is an addictive substance. For a national strategy to be effective there must be an acceptance by Government that alcohol is no ordinary commodity and that it is a legitimate health concern, not just an industry. As alcohol-related harm affects every sector of the population there is a need for strong leadership and a co-ordinated approach at Government level across all Departments.
I thank both speakers for their strong presentations which offer profound reading. We will take questions in a moment. I welcome Dr. McCarthy from the College of Psychiatry of Ireland who will make the presentation on behalf of his colleagues.
Dr. Anthony McCarthy
I thank the committee for inviting us. I will say a few words before introducing my two colleagues who are the experts in this field. Dr. Flannery is the chair of the alcohol faculty of the College of Psychiatry of Ireland and Dr. Cooney is the chair of the faculty of liaison psychiatry. Our college is three years old. We merged together the three bodies that represented psychiatry in this country into one single body three years ago so it represents the entire body of psychiatrists. Our main objective, and the main theme we addressed this year was the problem of alcohol. For World Mental Health Day this year we ran a number of lecture sessions and teaching sessions on the subject of alcohol and its abuse, the sick effect of alcohol on society and how we already have a sick society with regard to alcohol and how alcohol exacerbates that sickness further.
I work in the National Maternity Hospital in Holles Street and I also work in St. Vincent's Hospital. In the National Maternity Hospital in the last year for which we have absolute figures there were 20 babies with alcohol withdrawal and the DTs in our neonatal intensive care unit. DTs in a newborn baby is a very distressing thing to see. Being against alcohol abuse is not to destroy fun. We are not against fun or joy but what really destroys joy is seeing children in such a state. Children with the DTs are just the tip of the iceberg. The mother must be drinking vast amounts to have a baby with DTs so one can imagine how many mothers there are in the hospital drinking less than that whose babies do not get the gross DTs but have some withdrawal or behavioural effects, and where the mothers continue to abuse alcohol through pregnancy.
The other part of my job is in St. Vincent's Hospital where one of my tasks is to assess psychiatric and alcohol issues in patients waiting for liver transplants. Again, we are not killjoys but what would kill anybody's joy is seeing the level of sickness, distress and resources being consumed by people who have drunk to the stage that they are in that state of illness. Sometimes, no matter how sick they are, once we get them slightly better they leave the hospital to get cheap beer across the road in Tesco's supermarket, force the drink down and then they come back to us with their illness again. It is a sick state.
We would completely support everything that has been said about alcohol advertising, minimum prices for alcohol and banning below-cost selling. My colleagues will take the issue further.
Dr. William Flannery
As Dr. McCarthy said, I am a consultant psychiatrist specialised in the treatment of addictions. I run a HSE addictions team based in the midlands. I thank Dr. Bedford who has given a thorough overview of the effects of problematic alcohol use. In 2008 this so energised the college, in particular the effects on adolescence, that we issued a position paper calling for a ban on all alcohol advertising and sponsorship of events by alcohol companies. That continues to be our position. The college would strongly support the recommendations outlined in my colleague's statement, in particular, since it has been much featured recently, the call for minimum pricing for alcohol.
I am a psychiatrist so my job is to prevent suicide. Again, there is a wealth of distressing literature about the association between alcohol and suicidal behaviour. A stark pattern of how this presents was in a recent report by the National Suicide Research Foundation which looked at suicidal behaviour in the form of deliberate self-harm where presentations peak at weekends and on public holidays. We all know the reason behind that. The report correctly points the finger towards alcohol.
As to what we can do about it, it is interesting to look at the example of the national drugs strategy which has been successful. Three or four years ago regional and local drugs task forces fed back that they were seeing many patients presenting with alcohol problems and passed that information up the line. That led to the setting up of the national substance misuse strategy steering group, the aim being to set up a combined alcohol and drugs strategy, which I and the college would strongly support.
The report of the group is in its final draft stage but it is reasonable for me to bring it up as there are some points I would like to get across. There has been considerable work in the past two years involving considerable compromise from everyone involved. The drinks industry is involved. Originally, the college expressed a view that the drinks industry should not be involved and to some degree I am not surprised at the recent developments where the drinks industry has sought to scupper the report by requesting that it would have a minority report included in the final report of the steering group. The minority report would take up one third of the total report. It is an attempt to undermine the recommendations of the report, many of which I am happy to stand over. For example, a compromise from our point of view is that there is tighter regulation on alcohol advertising and a phasing out of sponsorship of alcohol by 2016. That is not our position but nevertheless it is a compromise. That is something I would welcome.
Treatment and rehabilitation are my specific area of responsibility. Again, there is much to be welcomed in that regard. The office of the Minister with responsibility for drugs should become the office of the Minister with responsibility for drugs and alcohol. The draft report makes a good call to seek a forum for those involved in overseeing services. For example, the strategy underpinning the psychiatric services is, A Vision for Change, but how that links in with addiction services, primary care and hospital services is unclear. Having a forum to discuss those pathways would be very helpful.
Given the current economic situation, the national drugs strategy and its structures have worked very well. This is an opportunity to suggest to the Department of Health that those structures would be extended to include alcohol. Those involved meet patients on the ground and treat them so it is not unreasonable to consider extending the remit to include alcohol. However, that is ultimately the call of the Minister and the Department of Health.
David Higgins is a young man who took his own life at the beginning of this year in Mayo. His father summed up the situation eloquently and accurately and it is a useful one to reference.
Dr. John Cooney
I thank the committee for its invitation. I am a liaison psychiatrist in St. James's Hospital which basically means that my catchment area is the general hospital. I am not an addiction specialist per se but by default I end up seeing a huge amount of people with alcohol problems. I take a lead in looking at the issue of alcohol in the general hospital. That includes the emergency department where we see a huge amount of people presenting with self harm, alcohol problems and a whole variety of other behavioural disturbances our emergency department colleagues ask to help disentangle. I also see patients in the general hospital through oncology, heart disease and general surgery. The most common problem across all specialties is alcohol. This is true of presentations throughout the hospital.
I have prepared a background document on behalf of the liaison group. I do not want to go back over all the statistics on presentations. They are so well documented there is no point in head counting any further. We know what they are and their costs. How many more times does it need to be said? I am grateful for the opportunity to speak to this committee and for the fact that members are here to hear what it is like to be a practitioner facing the difficulties of people who present with alcohol problems in hospitals.
The emergency departments are replete with them. We are doing another audit at present. I said I would not cite statistics, but one of my colleague has done a recent study. This colleague is a new intern, which is good news because we do not get many new resources but we did recently. This new intern looked at deliberate self-harm over the last three months. The study found that 70% of those presentations were associated with significant alcohol use. This is just another snapshot of the presentations. Members do not need to be convinced about this.
When I started in St. James's Hospital a number of years ago one of my senior colleagues, who I remembered from my training, said, "Cooney, what are you going to do about alcohol in St. James's?". I gulped, shrank away into a corner and thought about the question a lot. Alcohol is such a ubiquitous problem in the health service that it cannot be dealt with by just one agency. Dr. Bedford talked about the societal and preventative approach and all the measures the experts who know about these things would endorse. Clearly, those things must change.
For legislators, the notion of leadership regarding attitudes to alcohol is important. I once did a course in the United States where one of the suggested screening questions for alcohol problems was, "Have you consumed more than five drinks at one sitting in the last month?". When I say this to medical students and to Irish groups generally I see much folding of arms, sheepish grins and the like. That is where the standard of tolerance is, and we are way over the limit across the board. There is that societal problem. Our permissive attitude to alcohol is a significant issue.
We see two main groups presenting at hospitals. The first are those who present with alcohol problems. In my case I am asked to see these patients when there are complicating mental health problems or significant behavioural disturbance, and we try to disentangle what is going on. It is often said that one cannot assess someone's mental state properly when they are intoxicated with drugs or alcohol. The reality is that one has to make some attempt to do so, in order to try to manage risk, look after the patient or manage risk to other people who present. This is the province of Dr. Brazil and of every emergency department up and down the country. They can be chaotic environments with gross levels of abuse, violence, aggression and horrible behaviour. Sometimes people come back afterwards, sheepishly acknowledge their behaviour and express remorse for what they have done. This is very marked in the front line and what it is doing to people is very nasty. The contamination of mental illness which is my main province, as a psychiatrist, is a significant factor.
The national policy document produced by the addiction faculties makes an interesting observation regarding A Vision for Change. The latter document seems to accept the notion that alcohol and mental health should be regarded as two completely separate issues. That is rubbish. Like every area of health, mental health has alcohol abutting onto it and co-existent with it. The term used is, "co-morbidity with mental health problems". Unless we acknowledge that and have a capacity to deal with the different components of a person's presentation we will not get very far.
Earlier, I mentioned my colleague who asked me what I was going to do about alcohol in St. James's. It is such a ubiquitous problem that it is not what I, as an individual practitioner, can do that is important but what medical, nursing and social work staff can do in our approach to our patients, clients, service users and people who come along to us with alcohol as part of their presentation. We need to be able to address that. There are many reasons why we do not do so. Junior doctors are trained in very technological medicine. They are very good at it and are very bright and smart people. However, alcohol is a messy issue and a behavioural problem. It is less easy to define in terms of pathology or to delineate in terms of interventions and outcomes. It is harder to look at, influence and affect.
When we were taught, as medical students, about alcohol problems people were dichotomised. You were either an alcoholic or you were not. We now recognise that while alcohol dependence is at the tip of the iceberg there is a whole spectrum of alcohol problems and problematic alcohol drinking underneath that. We need to look at the group of people for whom alcohol is causing problems, or is likely to cause problems, because they are drinking in a hazardous way. These are people we see for whom alcohol has already caused a problem. We need to be able to address them, and I talk about that in my document.
Then there are people for whom alcohol is not a problem yet, but who are at high risk of developing consequences of their alcohol abuse. One of the difficulties with this group is that the system - I hate to have recourse to that term - is under pressure and the idea of grafting on another task, like screening, identification and intervention for people who are drinking in a hazardous way, seems onerous. The literature shows that screening and brief intervention for people who are drinking in a potentially harmful, or hazardous, way is effective. However, it calls for more resources.
It could be done more efficiently by training and by looking at what we already have and trying to deploy it more efficiently. There is one proviso which makes this very difficult. If one identifies an alcohol problem and someone is willing to go for treatment, where do they go? The contrast between the drugs and alcohol services is extraordinary. The drugs services, certainly in Dublin, are co-ordinated, integrated, well run and well managed. One can telephone facilities, everyone knows where they are going and so on. Alcohol services are disparate little islands, and only effective because of the good will of the people who slave away in these places. They are appalling. Recently, we tried to do a study of what happened to people we had advised to go to alcohol treatment services and we visited some. In a facility in Baggot Street, for example, they did not even have stamps to post us information. They had no record of the people who were coming and no secretarial support. A number of counsellors were operating in splendid isolation. That is not good enough.
The other marked aspect is the disparity between the public and private systems. If someone who presents has private health insurance one goes down on one's knees thanking God. At least they have a chance of getting into one of the alcohol treatment clinics. For a public patient who has severe alcoholism and needs residential care there are a number of voluntary organisations run by stalwarts such as Sr. Consilio, who does a fantastic job. The places are so limited and access so difficult that it is horrendous for people going into that system.
Those are my main issues. As a liaison psychiatrist I am trying to take a lead in terms of education and training of my colleagues in general medicine and nursing. Other colleagues are in positions where they have developed liaison nursing posts which take a lead in this area and these can provide a focal point in terms of more intensive counselling within the hospital, with medical input, which is a helpful model. This is not hugely expensive, but it adds significant bang for the buck. The other side of the equation is the provision of somewhere for patients to go once they have been identified.
I thank all our witnesses for their interesting presentations. I will now call on Ms Michele Savage from Fetal Alcohol Spectrum Disorders Ireland to make her presentation.
Ms Michele Savage
I am grateful for the opportunity on behalf of Fetal Alcohol Spectrum Disorders Ireland to air the range of disorders and conditions that make up the challenges that prevail in this regard in Ireland. Unfortunately, fetal alcohol spectrum disorders do not officially exist in Ireland. Therefore, if we do not officially have the statistics around the epidemiology, we do not have the data to plan, prevent and know what services are needed.
As outlined by previous speakers, alcohol problems have mainly focused on troublesome alcohol misuse and binge drinking. However, any amount of alcohol exposure can be harmful prenatally and there is no proven safe dose of alcohol for the fetus. This may be the only situation where the consumption of alcohol may prove very harmful to a non-active user, namely, the embryo or the fetus. The fetus is three times more likely to become addicted to alcohol than a non-alcohol exposed fetus. The HSE ran a campaign a couple of years ago aimed at parents to try and delay their youngsters starting drinking and was directed at the authority parents have in trying to delay young people from starting drinking. Unfortunately, if young people have already been drinking before they are born, by the time they are 14, 15 or 16, they are already reigniting a drinking career they did not know they had.
There has been some good Irish research since 1999. Professor Peter Hepper, a psychologist in Belfast, noted the differences in fetal behaviour of fetuses who had been exposed to alcohol and those who had not. He noted significant neurobehavioural effects in those who had been exposed to alcohol. The social cost burden is not really seen here because we do not have a register showing who and where the affected people are. Alcohol troubled families have a higher risk of their children being taken into care and it is due to this cohort of children taken into care and the foster care community that Fetal Alcohol Spectrum Disorders Ireland was established.
Prevalence figures must be extrapolated from American figures, which suggest there is approximately a 12% maternal consumption rate of alcohol. This 12% maternal rate will result in a 1% prevalence of fetal alcohol spectrum disorders among children born. In 2007, a report published by the Coombe women's hospital showed an approximately 69% maternal consumption rate of alcohol and a particular subsection showed that 82% of women drank. The Department, the Minister and the Chief Medical Officer issued a position statement stating that no alcohol was proven safe in pregnancy and more recent figures are encouraging. One study conducted in the north of Dublin has reported that only 35% of pregnant women now drink in that area. Therefore, going from 69%, down to 62% and now down to 35% shows that public awareness campaigns do have an effect. Education is not really proven to have a long-term effect on people's behaviour, but whereas we had a situation where no information was available to women, the drop in maternal consumption from 62% to 35% we now see is significant and demonstrates an escalation in awareness.
The north west alcohol forum recently produced a report entitled Hidden Realities of Alcohol Harm. The most hidden reality is fetal alcohol spectrum disorders. The main focus on this in Ireland is where people see in the neonatal environment that fetal alcohol syndrome is present at birth. By its nature, fetal alcohol syndrome manifests in very dysmorphic features on an infant's face and a specific detrimental effect on the head size. However, those who have alcohol related neurodevelopmental disorder that presents later do not present with dysmorphic features and these little ones go under the radar. Unfortunately, these children with alcohol related neurodevelopmental disorder or alcohol related birth defects constitute between 85% and 90% of the children affected, but they do not receive early intervention as their issues are not being picked up at birth.
I outlined many of the secondary disabilities that result in the document I submitted in advance to the committee. A 21-year longitudinal study was carried out by Streissguth et al in 1996 in the States. Unfortunately, whereas at that time in the States they were diagnosing fetal alcohol syndrome, there were no FASD specific interventions and 21 years later, 90% of the cohort identified at birth have manifested mental health problems. Some 60% had interrupted school careers, 60% displayed inappropriate sexual behaviours, 30% went on to have addiction problems of one sort or another, 80% could not live independently on reaching maturity and 80% could not get and keep a job. These figures are worrying, considering that we do not have universally applied fetal alcohol spectrum diagnostics throughout Ireland. We have diagnostics for fetal alcohol syndrome, but not for the majority of fetal alcohol spectrum disorders. This has a huge cost not only on families, but on civil society and the burden of cost is not factored at all into the EU €265 billion, as cited by Anderson and Baumberg in their report of 2006.
Equally, Irish figures on alcohol harm do not reflect the burden of the services that are needed for children. If the children were identified and received services, we could extrapolate then what the effect of 1% of the 72,000 children born this year with fetal alcohol spectrum disorders would be. This would indicate quite a significant amount required for services. If those children do not receive services, there will be greater demand on secondary ancillary services such as the youth justice system and the child mental health system. For children with autism and ADHD or children with autism and attention deficit disorder, which can be co-morbid in these children, there is difficulty with regard to where they get their services. If a child has an autistic profile, the child may not be seen by CALMS and if children have ADHD and dysmorphic features also, they may only be seen by disability services. Whichever profile the child has determines where, if and when he or she gets services.
If we consider that 1% of our population has been exposed in the womb to alcohol, the fact that 25% of adults here are considered to have a functional literacy issue and the bad international comparison regarding the mathematical ability of our young people compared to others in Europe, this would influence the case for seeking to set up proper diagnostics universally, according to best international standards, for these children. This would not be to tag or label them. One of the barriers to seeking a diagnosis is that some social workers do not want to label the children and do not want the children affected because of what this might say about their mothers. However, it is not automatically the child of an alcoholic who will have this label. It may be the child of people who have binged on a weekend or people who have over indulged when on holidays. There is a critical avoidable cost to our economic, civic and community burden due to alcohol during pregnancy.
We will now take questions and I call on Deputy Ó Caoláin to commence.
Deputy Caoimghín Ó Caoláin
I do not have very many questions. The presentations of each of our visitors have made the case. The picture is very depressing. There is hardly any other way of describing it. From the information provided in the supporting documentation circulated before today's meeting, it is apparent that in excess of 1,000 deaths are attributable to alcohol per annum. If the full facts are known, the total may be significantly more. This rate is extremely worrying.
I have a small number of questions. Dr. Bedford discussed the HSE paper. I welcome him and his colleagues to the meeting. The study conducted in December 2009 and January 2010 in respect of patients presenting at four emergency departments across the country informed the presentation of table 1 on page 4 of the paper. Waterford Regional Hospital's figure is the only one that requires a translation into percentage terms. The rest - Letterkenny, Naas and Cork University Hospital - add up to 100%. Waterford Regional Hospital declined to take part as a numeral rather than a percentage. I presume that the information not being available is indicative of the numbers that might have participated. Something jumps out from the figures.
I need to stop the Deputy for one second. Do people have telephones on? There is interference. I apologise to Deputy Ó Caoláin.
It is not a problem. I wonder about the information. Deputy McConalogue will not be discomforted by my asking why there would be such a marked difference in the responses received at Letterkenny hospital, where referrals to specialist services amount to 3.5% as against Cork University Hospital's 16%. There is a broad relationship between Waterford Regional Hospital at 11%, Naas at 12.5% and Cork University Hospital at 16%, but significantly fewer people are referred to specialist services in Letterkenny. Has any analysis of the compilation of these figures in that two-month period been done? Is any additional information available that might suggest why there is such a marked difference? I would welcome comments in this regard.
There has been a great deal of discussion of the various pressures in modern life that compel in some instances, encourage in others or, depending on the case, force people to take up particular lifestyles. What impact do popular television programmes that are either pub-centred or drink-centred in their presentation have on young people in particular? Much of the information in this documentation presents an increasingly worrying picture in respect of young people, not just young men, but perhaps women in the 18-35 age group even more so. These facts jump out from these pages. What impact do popular serialised programmes on any of the major channels have? They all tend to be centred around a drink culture to some degree, promoting the notion that this is as life is when it does not have to be. Is this impact measurable?
There is little that one can hope to elicit further from what each of our guests has stated other than what it is they believe we can do to help. This is a complex matter and, as legislators, we can only do so much. There is a broad, holistic responsibility societally to address all of these matters.
I will move to point No. 22 on fetal alcohol spectrum disorder and Ms Savage's closing contribution. Much of the other information that has been compiled in the 22 facts concerning the health-related consequences of alcohol use in Ireland can be elicited from profiles of individual patients presenting, but I suspect that the information on fetal alcohol spectrum disorder was gained from a non-pressured questionnaire. It states that almost two thirds of women report drinking alcohol during pregnancy, with 7% drinking six or more units per week. This information has been elicited in a casual, voluntary way. Will Ms Savage comment? My suspicion is that the information significantly understates the truth. We all have a responsibility to ensure a full awareness of the impact of alcohol during pregnancy. It is a joint responsibility where a partner is involved. Often, there is no point in promoting the notion that the woman suspends her drinking enjoyment while the male heads off to the pub. Having a little bit of invention, thought and imagination in promoting the best outcomes for unborn children requires a shared responsibility on the part of both partners. This issue invites a proactive media presentation to better inform and encourage.
With the permission of the committee, I will ask Deputy Fitzpatrick to ask his question, as he must leave at 4 p.m. Is that agreed? Agreed.
I thank the delegates for attending. One death every seven hours and half of Ireland's suicides are related to alcohol. I have been a member of this committee for the past nine months. The country is in a bad way and the closure of hospitals and nursing homes is under discussion. Every night, 2,000 acute beds are occupied because of alcohol and one third of patients presenting at acute hospitals do so for alcohol-related conditions. Of this number, how many have medical cards? Is there a way to deter people from abusing the system? When one attends an accident and emergency unit, a charge of €100 is applied unless one has a medical card. What are the facts and figures? This is an important issue. Alcohol-related hospital visits are self-inflicted and cost us money.
I thank members for their assistance.
I will not ask a question. I thank our guests for their attendance and contributions and I am sorry that I missed the first half. This meeting has been informative.
I welcome my assorted colleagues and other interested parties from the war on alcoholic excess. I beg the deference of my committee colleagues in that I will probably be repetitive. We have held a number of meetings recently on the subject of alcohol and I have tended to make the same points and ask the same questions. At the end of my contribution, I will ask our guests a question to which there is a "Yes" or "No" answer, namely, would we be better off if we stopped drinking entirely compared with how we drink now?
Unlike other drugs, we have a colossal national ambiguity towards alcohol. Most of us take a drink and can identify times in our lives when we drank too much. This gives us a different perspective on something that is perceived as other people's problem.
If we all stopped drinking, there is evidence to suggest that the following would occur: decreased liver disease; decreased cancers of the head, neck, oesophagus, pancreas, gastrointestinal tract and breast; fewer road traffic accidents and deaths; decreased rates of violence, including random and domestic violence, rape and murder; decreased rates of suicide; more money available for spending on food, clothing and education for children; and more time available for the parenting of children. The arguments in favour of stopping drinking are overwhelming. We have heard reference to a clear fact that we would probably end most of the waiting list problems in acute hospitals if everyone stopped drinking and, overnight, we became abstemious. The reality is that we will not, but if alcohol was discovered tomorrow, it would be banned, as it would not pass the carcinogenicity tests, never mind any others. How do we reduce the harm caused by alcohol and acknowledge that every drink is bad? There is no threshold for a good drink. We know from breast cancer figures that even trivial amounts of alcohol increase the risk of breast cancer. There is a canard that there is an inverse curve, that drinking a little alcohol is good for you and that it is better than not drinking. That may be the case in respect of individual diseases, but, globally, it is not and, as a society, we would be better off if we all stopped drinking.
We have asked many of our guests the same question, coming from a different perspective. As the delegates may guess, the answer has either been an evasive yes or no. Do they support a plan to deal with the alcohol problem, not just the excesses, foetal alcohol, binge drinking or violence? I propose that we all commit ourselves to banning advertising, sponsorship and minimum pricing. The crime of illegally providing alcohol should be punished in the same way as the crime of illegally providing heroin. Those who provide alcohol illegally for people who are under age should face the same rigour of the law as those who provide heroin.
It is at this point that strategy in the Department of Health comes into it. In the 1960s the Irish nation used to consume four litres of alcohol per year per person, now we consume 14 lor 15 litres per person. During the same period in France the level of consumption which used to about 14 litres has reduced to 13. We are now the heaviest drinkers in in western Europe and may be the heaviest drinkers in the western world. Ireland shows the steepest increase in the level of consumption of alcohol over a ten year period. There has been a little drop in the past few years for economic reasons, but the trend in this country is very worrying. There has been an alarming, extraordinary and unprecedented increase. As a society, we should pick a number and say that by 2020 we hope the average level of alcohol consumption will decrease from 14 or 15 litres to ten and about eight by 2025. We should also decide how we will measure this, as well as to have an education campaign highlighting the necessity of having many days on which one drinks nothing and slipping in a non-alcoholic drink every second round. If people are going to drink, there are strategies to drink less. The trick is to drink less. I thank the delegates for appearing and want to put to them the following question in the hope there will be no ifs, buts or maybes. Would we all be better off if we stopped drinking?
The Senator is not yet Chairman of the committee.
I am so sorry; I beg your pardon, Chairman. We staged a coup outside and the Senators have taken over the country.
Professor Joe Barry
I will, first, address the issue raised by Deputy Caoimhghín Ó Caoláin concerning emergency units. I was involved in that work which involved approximately 1,000 patients. The numbers are not huge, but they are indicative. One of the reasons Letterkenny may appear better is that one of the funded organisations is the North-West Alcohol Forum, as mentioned on page 18 of the HSE report. There has been a comprehensive strategy in the north west, particularly in counties Donegal and Derry. This is a cross-Border initiative involving community mobilisation to address the level of drinking in these counties. It has been funded since 2004 and the results may reflect the fact the strategy is having an impact. The important point in the accident and emergency unit report is that slightly less than half of the population is drinking at a level that it would be in their interests to reduce. Following the comments of Dr. Declan Bedford, it is not just alcoholics; most of the problems lie with people who drink heavily. The majority of the adult population drink-----
Taking Deputy Caoimhghín Ó Caoláin's point, the issue at Cork University Hospital is startling, with 72% seeking further advice or referral.
Professor Joe Barry
I can make the entire report available to the committee.
I have no doubt that I will not be casting aspersions on the North-West Alcohol Forum and the organisation's efforts if I suggest being responsible for a 12% difference in referrals to specialist services is huge achievement, but I do not think it explains the major difference between the two hospitals' results. I have no doubt the organisation is having an impact.
Experience in other areas of the health service indicates that where there are gross disparities in referrals to services, it reflects the availability of services.
Professor Joe Barry
I can make the entire report available to the committee. As the number used was 1,000, there may not be statistical differences, but the point is that there is a benefit to be gained in asking about alcohol use in the accident and emergency unit.
On Senator John Crown's question and an advertising ban, we have adopted a good public health strategy to tackle drink-driving. There would be no deaths on the roads if none of us drove. However, that is not realistic. Equally, I do not think it is realistic to have no alcohol use. No one on this side is advocating this. The public health strategy is about reducing alcohol consumption by 15% in the next four years. That would mean we would reduce the harm caused. Dr. Bedford has outlined the strategies that are effective. This committee is important in that most of the strategies that are effective require legislation and the only people who can legislate are Members of the Oireachtas.
The committee in the 29th Dáil recommended a complete ban advertising. It would be good if the recommendations of the committee had a better chance of making it over the bar into legislation. The vast majority of the public would really benefit if we addressed this issue in more focused way. We are trying to give our children a country in which they will not feel such pressure to start drinking at 14 years. Irish children are different from French children. Spanish and French children who come here in the summer do not go wild, but, unfortunately, ours do.
Yes, and it is a worrying trend.
Dr. Anthony McCarthy
With regard to the foetal alcohol problem and the use of alcohol during pregnancy, there are specific issues with a mother in a maternity hospital who is drinking too much, but the overall problem is the use of alcohol. Some 50% of pregnancies are unplanned in terms of timing, irrespective of whether someone wants to get pregnant. Many women, because they are drinking too much, are getting hammered. They do not know they are pregnant for four, five or six weeks and the neural crest, from which the brain and spinal cord will develop, starts to form between five and six days after conception. The heart starts to form nine days; therefore, most of the damage is done before the woman even knows she is pregnant. The best way to address the problem is to reduce the level of alcohol consumption in society.
To respond to Senator John Crown's question on whether we would all be better off if no one was drinking, that is absolutely the case. Being pragmatic, that will not happen, but it would radically change our environment. We have a sick society. As psychiatrists, we deal with individuals with a sickness, but it is society's attitude to alcohol that presents the real problem. If politicians want to take the lead, it is almost impossible to take the moral high ground and taking it never works. Those who do so come across as killjoys and appear to hold the moral high ground until it is pointed out how hypocritical they are. The only way to really tackle the issue is through price and advertising. There must be a real recognition across the board that there is a sickness in our society and that our attitude towards alcohol must change. There will always be alcohol; we must expect it to be consumed in small reasonable amounts, but we must hammer this problem.
When it comes to the individual, it is a different matter. Our society is causing the problem. If we start to punish someone in an accident and emergency department, we are getting into difficult territory. Do we punish diabetics for overeating? Do we punish those with heart disease for smoking? They can be punished through taxation policy; alcohol can be taxed, but punishing in a direct way the individual who has grown up in an alcoholic family, who has had drink poured into him or her since he or she was in the womb, when he or she comes into accident and emergency department is not the way to go. It would be very unhelpful. People who are consumed by alcohol and are alcoholics need help and support. They need firmness, but adopting a punitive attitude never works; it tends, in fact, to be totally counterproductive.
Dr. Declan Bedford
Deputy Caoimhghín Ó Caoláin asked about the study in the Coombe Women's Hospital. There would probably be under-reporting because people do not always admit to their true level of drinking or smoking. The Deputy also asked about television programmes being set in pubs. There are advertisements and in many films and television programmes there is product placement. It is not an accident that a particular brand is on the counter when someone is talking. Companies know this and pay for it. The CEO of Anheuser Busch which makes Budweiser was talking to shareholders and said every action taken by management was to increase their profits. The only way he can make profits is by selling drink; therefore, every action, be it product placement or sports sponsorship, is designed to increase shareholder profit. People can say what they like, but this is advertising. They keep at it because they know it works. It is not just to increase their share, it increases alcohol sales. Television programmes are influential.
There are studies to show adolescents are influenced by advertising and encouraged to drink or drink more. A study showed the advertisements most recognised by children were those which featured alcohol. Their heroes all wear football jerseys with drink logos on them; therefore, there are definitely questions to be answered.
The answer to Senator John Crown's question is a definite yes, no matter how impractical it might be. To reply to Deputy Peter Fitzpatrick's question, many of those who come into the hospital system do not realise alcohol is causing the problem in the first place. They are not drunk or causing a fight, they might have abdominal problems because of their drinking or cancer related to their alcohol use. When people come through the door, they are treated equally. Many are drinking at levels they do not realise are harmful.
It has been said most people come in at the weekend; therefore, we are talking about bingeing. Is there a right or a wrong way to address this issue because it is costing a huge amount? Are people abusing the fact that they do not have to pay to go into hospital? Do many of them have medical cards and know admission to an accident and emergency department is free? Is there any way we can stop them abusing themselves at weekends? If they knew the hospital would charge them €100, would it stop them? I accept people have drink problems, but I am talking about those who are bingeing and abusing the system. Their behaviour at weekends is causing the problem.
Dr. Eamon Brazil
Much depends on the location of the accident and emergency department. In the north inner city about 23% of patients have medical cards, 23% are insured and about 50% have neither. If they come in without a medical card, they pay the fee of €100, for which they get everything. We could probably charge more than this across the board. It costs about €400 per patient to come through my department and we charge patients €100; therefor, we are making a loss all the time.
Drinking alcohol is no different from cigarette smoking or eating cheese. If we go down the road where a drunk person is charged more, people will try to avoid the place to which they should go. There are many serious injuries on a Saturday night that need specialist treatment and I would prefer people to come in rather than lie on the street or try to go somewhere else. That does not take away from the carnage on Thursday, Friday, Saturday and Sunday nights. It is a real problem. Is it only people with medical cards who are involved? No, it depends on where a person is living and his or her socio-economic grouping.
Dr. Declan Bedford
The evidence tells us what works at a societal level - reduced availability. We can now buy alcohol in every corner shop and petrol station. Making it less affordable through taxation also works. When the measures are implemented, they work. Drink driving is a great example. When I started driving in the late 1970s, more than 600 people were killed every year on the roads. At the time, the limit was 125 mg of alcohol and it was hardly enforced at all. During the years the level was reduced. The number of road casualties started to increase again; in 2005 the figure was 395 people killed. Random breath testing was introduced in July 2006 and there have been 150 deaths fewer a year since. The evidence is available that making something mandatory works. Before 2006 everyone thought drink driving was a bad idea, but until it was put up to us through enforced legislative measures, we did not change our behaviour. Now we have all changed our behaviour to a great extent and think it is a desperate thing to do. The evidence is available from international studies to show how we can tackle the issue at a societal level: make alcohol more expensive, less available and advertise it less.
Ms Michelle Savage
On Deputy Caoimhghín Ó Caoláin's point about under-reporting, in America the figure of 10% to 12% who self-report as alcohol consuming during pregnancy would be suspect; there is a belief the true figure might be around 40% to 45%. There are indications from across the Atlantic, where perhaps the stigma of reporting has worn off, that the level of consumption is heading for 40%.
In so far as drinking had not been stigmatised in Ireland, there was no knowledge that it was unsafe. Certain brands of stout were handed out on some hospital wards up until a number of years ago. We must move from a mindset that a certain product is good during pregnancy to realising it is harmful. Thankfully, the Coombe Women's Hospital report stated it offered no benefits during pregnancy.
On the study conducted by the outpatient clinic of a north Dublin maternity hospital, 35% of women self-reported that they were still drinking. Some of this could be because there is now some knowledge available following the statement made by the Chief Medical Officer that it was not safe to drink during pregnancy. There might be under-reporting, but it is anyone's guess what the true figure is.
Professor McCarthy has made the point about the organogenesis from the neural crest at the very beginning of the change from blastocyst to embryo. Furthermore, the last trimester of pregnancy is vital. The synaptogenesis, the formation of neural pathways, is a huge indicator of neuro-developmental behaviour and will have a massive impact on the child's life and educational experience. That burst of growth of the brain will start at the beginning of the last trimester and continue until the child is two years old. We do not give alcohol to anyone under five years and certainly would not give it to anyone under two. We do not even give paracetamol to newborns. If we consider this in terms of relative teratogenicity and effect, the organogenesis of vital organs in the first few weeks and the neural development of the last trimester are absolutely vital.
When we look at other mental health impacts about impulsivity and suicide, the executive functioning of a foetal alcohol affected brain does not allow for the control of impulsivity. Regardless of whether alcohol is connected with suicide, those with foetal alcohol affected brains do not have control of impulsivity or the same warning lights as others not so affected.
Professor Joe Barry
On Deputy Fitzpatrick's question in regard to binge drinking at weekends, the single most effective measure would be the setting of a minimum price for alcohol. The availability of cheap alcohol, such as a six pack for €6, encourages people to drink more and get drunk quicker. The two groups that find cheap alcohol attractive are youngsters with little money, in terms of pocket money, and people who have serious problems, who as a result of binge drinking can develop liver failure. The introduction of minimum pricing is being actively considered in Northern Ireland and Scotland. Culturally, the Scottish and Irish people are the same.
On availability, there were few off-licences around when most of us were growing up and all drinking took place in pubs. Now, more alcohol is purchased in off-licences. The real problem area is big trading stores - I will not name any - which advertise free drink offers on the radio every morning. This is causing a big problem. It is a false economy given the increased cost of food in these shops. They are encouraging people in by offering them cheap alcohol and this is causing a problem. A licence to sell alcohol should be hard to obtain. Much of what is said in regard to responsible alcohol consumption is nonsense. We all know we have a problem with alcohol in this country and that regulation is required. Regulation works in respect of drink driving and regulation in this area would help.
It works now.
Professor Joe Barry
Yes. It can be done. We are not trying to force people to stop drinking, rather we are trying to reduce the harms of drinking. Other countries have done it. For the sake of our citizens, the committee should make strong recommendations which it should seek to have incorporated into legislation.
Dr. William Flannery
The group that profits from this is the drinks industry. Its objective is to promote its product but there are consequences as a result of that. As stated by my colleague, for a person with private health insurance, some interventions in casualty will work. If he or she requires more extensive treatment they can get it elsewhere. Some interventions work and have been shown to be cost effective. The theory is that if there is effective treatment in place it should cost less. That is great for those with private health insurance but for a person on a medical card there is essentially nothing in place. I have great time for Alcohol Anonymous, AA, and for Sr. Consilio's service. For many these are the only services available. These services are provided through the goodwill and generosity of other members of AA. There are a number of issues involved.
Dr. Flannery has stated twice that follow up for non-private health insurance holders is a major issue.
Dr. William Flannery
Yes. Brief interventions can be administered in a casualty or general practitioner setting. The people who are dependant on alcohol or are alcoholic who come to my service are lucky because there is a service available in my catchment area. In other catchment areas, there is no service. For those with private health insurance, there are excellent services available, including after care and a wealth of residential and more intense community and in-patient services which can deal with a complexity of needs. For a person not in that situation there is nothing.
I thank the witnesses for attending today's meeting, for their excellent presentations and the work they are doing. I have previously stated at committee meetings that one of the big changes that has occurred in Ireland over the past five years is the move away from drinking outside the home to drinking in the home. This has been caused by the growth of the off-licence industry and the availability of alcohol for purchase in local supermarkets and garages. While we have impacted on the drink driving problem, we have, in so doing, created another problem. Other European countries, wherein there are no traditional pubs, also have problems in terms of alcoholism. This may be as a result of drinking at home. Sweden has been cited as a country with problems in this area.
If the witnesses were in the morning given a budget to put together a strategy, would they aim that strategy at particular groups, in particular young people? I represent Cork and have noticed that four bars within a one mile radius of UCC have closed during the past five years as a result of the increase in the number of people drinking at home. We need to focus on at whom we need to aim a strategy if we are to achieve the 15% reduction. Should young people or others in society be targeted?
There is clear evidence in respect of drink driving in terms of car accidents and so on. I spoke in the past few days with an employer who along with his employees recently went to a Christmas party, all of whom were drinking until 4 a.m. or 5 a.m. Following the party one of the employees was involved in a series incident - he fell in the street - resulting in his being absent from work for at least the next four months. There seems to be an acceptance that people attending Christmas parties must engage in a drinking session until the early hours of the morning. On what areas would the witnesses focus? In other words, if given €10 million tomorrow morning for an advertising campaign or for a strategy to address this problem, what would they do?
I thank the witnesses for attending today's meeting and for sharing their views with us. I have two questions for them, one of which relates to a statistic. Senator Crown stated earlier that ten years ago we were, as a nation, drinking four litres of alcohol per person per year but are now drinking 14 litres per person per year.
That was over 30 years ago, in the 1960s.
What, if anything, has caused this massive increase? On the statistics provided earlier in terms of the amount of alcohol intake by people who present with a list of incidents caused in some way by alcohol, how do today's statistics compare with statistics for ten, 20 or 30 years ago? Suicide has been mentioned. It was stated that more than half of the people who took their own lives in any given year had a related alcohol problem. Are current statistics in this regard the same as those recorded ten, 20 or 30 years ago?
The drink driving issue is a given, although in fairness - I hope this does not sound like a stupid comment - my father, who is well into his seventies, tells me that years ago people did not understand or realise that drink driving was bad and would often say the car had driven them home. However, there was not then, or did not appear to be, the same level of recorded loss of life or accidents on the road as there is now. I accept there are far more cars on the road today. However, that does not necessarily mean there are more people driving cars today who are drinking alcohol as compared to the situation when my father was young, which is obviously a long time ago. I am curious about the statistics.
I support Professor Barry's comments. I served as a county councillor for 12 years during which time I was critical of the planning laws and licensing regulations governing off-licences. A significant number of off-licences have sprung up around the country, including in my area, during the past few years. I see at first hand the devastation they have caused in the lives of families and young people, to which Professor Barry and others alluded. The devastating consequences of such off-licences also is evident in communities in which residents have been obliged to leave their homes because they were in the firing line. I have encountered a number of such cases over the years and not enough account is taken of the impact this is having on local communities.
I also have in mind a number of cases with which I am familiar in which local centres also accommodate other facilities such as youth cafes, youth clubs and so on. There is such incompatibility when for instance, on a Friday night one can see two ends of the spectrum. At one end, alcohol is being served to young people and many of those who are underage will find ways of getting access to it, while on the other end of a local centre, attempts are being made to provide facilities in a safe and happy environment for young people and for a better quality of life. I am also very unhappy with some of the licensing and planning regulations governing such off-licences over the years. This point cannot be emphasised enough and must be made forcefully today.
I ask Dr. Cooney to respond first, after which I will take whoever else wishes to come in.
Dr. John Cooney
I refer to Deputy Regina Doherty's question on why more is being drunk now and the escalation in consumption. While I am sure my public health colleagues can answer this question more expertly, it appears to me as though there is a variety of factors at a societal level. In a permissive society, there is much more acceptance about alcohol and there has been a decline over time in institutions such as temperance societies. However, the big things that are known to be important are the increase in affluence, and the consequential fall in the price of alcohol, and the increase in the availability of drink. This is what one is talking about in respect of licensing and availability. They are highly significant factors.
Consequently, while one may restrict the number of places in which alcohol is available, people could start to drink more at home. However, if the price is not also regulated one will run into problems. The point I am trying to make is one cannot simply deal with one part of this problem in isolation. If one tampers with one component, there will be a reaction with unintended consequences elsewhere. One could simply have moved the point of difficulty. Consequently, this needs a co-ordinated-----
Is part of the problem not that there are so many vested interests at one level of the table that tampering with part X will have a domino effect?
Dr. John Cooney
Yes. As a blueprint and plan for regulation, the report in 2004 from the strategic task force on alcohol is an excellent document. However, another question arises, which is relevant to Senator Crown's observations, regarding some kind of national idea as to society's future direction in this regard. Dr. Anthony McCarthy's comment on letting he who is without sin cast the first stone highlights one of the difficulties. One does not want to get up too high on one's high horse, as there is not much oxygen up there if one starts to become sanctimonious on this issue.
Senator Crown had better watch out, given his present altitude.
The Senator need not respond.
It was a remark in jest.
I do not advocate sanctimony and it is a question of "Physician, heal thyself", in my case but we should acknowledge the problem.
Dr. John Cooney
There is an idea that we need to be going somewhere with targets and a possible strategy. One interesting issue concerns the power of the advertising and marketing industries. Marketing is the creation of demand for things one does not need and what that industry is doing all the time is to increase the opportunities to drink. It is like the man from Anheuser-Busch, whereby if people drink more, profits go up. This is what they are about and that is fine, because they are explicit about that - sometimes.
They sometimes pretend they are not.
Dr. John Cooney
Sometimes, exactly.
When they appeared before the joint committee, they pretended they were simply trying to transfer or steal a market from some other product. This is what they tried to claim.
Dr. John Cooney
No, it is not.
I accept it is not true.
Dr. John Cooney
Absolutely, it is not true.
However, that is what they were trying to say.
Publicans claimed to be social workers. That was the best one.
Members should not cast aspersions on people who are not present.
Dr. John Cooney
A very interesting advertisement appeared a while ago that has been discussed by a colleague of Dr. William Flannery. It was one of the advertisements that used the slogan, Don't See a Good Night Wasted, and which features a group of young people in a bar. However, one man who is drinking away ends up being outrageously drunk and makes a holy show of himself. The following morning, he sends a text to ask what happened but basically, no one is talking to him because his behaviour has been so shocking. The point being made by that advertisement was very clever. While everyone will point to that man and tell oneself that he was dreadful, in the meantime of course all these other glamorous people were drinking away in a so-called safe way. I do not know when members were last in a pub but it is not quite as black and white as that on a Friday night. It is not the case there is one group of people who are awful, while the rest are grand. These things are on a spectrum and unfortunately, everyone is implicated on that spectrum and at various times one may find oneself at one point or another on it.
This illustrates the power of advertising, in that it tends to make one feel a little better about oneself, while demonising others, whereas actually, were one to be truthful, everyone is implicated. This is the reason, to revert to the possibility of having a budget of €10 million, I would consider the concept of having a national idea about alcohol, where this society is going with it and what we want to be.
Does Dr. Cooney believe there is specific targeting by the drinks industry of young people? As Deputy Dowds observed, when its representatives appeared before the joint committee, they professed not to use actors aged under 25 or to target young people.
I note that in the Chairman's own constituency, two new student complexes have been built within the past five years, both of which included off-licences built underneath them.
While my position is somewhat akin to Senator Crown in this regard, in Dr. Cooney's view should there be a bar in Leinster House?
Dr. John Cooney
As for whether there should be a bar in Leinster House, this is my first time in the place and I do not know how Members use it.
Dr. Cooney can plead the fifth amendment.
Are members in need of an education programme?
I ask the question because Dr. Cooney made a strong presentation this morning.
Dr. John Cooney
I will cite two things that happened in recent years in respect of our national image that were not great. I refer to some of the incidents about the last regime and some of the stories that were being told, whether true or otherwise. One does not wish to impugn anyone's reputation-----
No, do not.
Dr. John Cooney
-----but they did not portray a nice image of Ireland. Second, members may recall how, when the Ryder Cup was held in the K Club, it was a terrific thing for Ireland and so on. However, a Republican American man who used to be in college with me - when we used to argue all the time - came over. While he also likes a night out, he commented to me that as he watched the Ryder Cup, one of the sights was some man at the top of the K Club or whatever sculling a couple of pints. That is the image that is being put over. Although it is all hooray and well done, it is not good in terms of national image.
I have made a similar point regarding the two iconic visits this year of President Obama and the Queen. The images that were transmitted were of the Queen and Prince Philip in a certain brewery, while President Obama was seen across America lifting a pint in Moneygall.
Dr. William Flannery
The drinks industry might deny it but teenagers claim that of their top ten favourite advertisements, five are alcohol.
Do alcohol advertisements influence young people?
Dr. William Flannery
They pay money for marketing and so one might expect this response. I would be surprised were they to spend money that did not serve a direct purpose. As an anecdote, the seven year old child of one of my colleagues was dropped off at a playground, where the child's friends were all wishing one another a happy Arthur's day.
It was a good advertising campaign.
Dr. William Flannery
It works and it works very well.
Ms Michele Savage
I revert to the availability of drink and to home drinking. Affluence has increased both people's ability to buy and their mobility regarding where they get drink. One might not have been served in local communities, whereas if one looks 17 or 18 and has mobility in a car, one can go elsewhere to get it.
A phenomenon, which has not been brought to the table, as such, is that when people cannot afford to buy a lot of alcohol and tend to drink at home, when they go out socially to parties, 21st birthday parties and so on, they tend to smuggle in drink. They buy it cheap in the supermarket and bring a mixer to dilute the vodka or whatever spirit they drink. That phenomenon will not please publicans.
With regard to the inverse of marketing and advertising, in terms of the social and corporate responsibility arm of the drinks industry in Britain a certain company, which I will not name, has undertaken to provide education and training services around foetal alcohol spectrum disorders. Social and corporate responsibility at the outset must be absolutely distanced from public health and education measures. In 1989 a law was passed in the US requiring that warning labels be put on alcohol products, first, to warn of birth defects and, second, to warn that alcohol impairs a person's ability to operate machinery. Birth defects account for only 10% of the possible alcohol-related effects; there are also neurological effects. Any producer of alcohol beverages here exporting to the United States, in warning customers worldwide of the possible effects, did not see fit to warn customers at the point of origin of the product in Ireland. For the past 22 years alcohol beverage producers have been warning people abroad but they have not warned the markets. Technically, there is a case for liability. That the Government is aware of this now will provide an opportunity for it and the Oireachtas to legislative and further progress the imminent legislation covering the putting of warning labels on alcohol products.
Professor Joe Barry
In regard to the figure of €10 million, the industry spends €70 million plus on direct advertising plus much more on marketing and the way to address that is to restrict its ability to do that. The State will not be able to keep pace with the industry. The latter has the money and in many ways it determines alcohol policy throughout the world because it comes down to a few companies with global operations. If we try to play catch-up by spending money on promoting public health, we will never catch up. A more effective measure that would not cost the State anything would be to reduce the industry's capacity to market. Equally, events such as the Oxegen summer music festival are linked with drink and one could get drink-----
Would Professor Barry propose the banning of alcohol advertising completely?
Professor Joe Barry
I would ban it. A previous joint committee on health under a previous Dáil proposed the same. A demand is created for a product by advertising it and obviously advertising works. I do not know if the advertisers have appeared before the committee, but I am sure they would agree that advertising works.
On the question of where we are going with drinking levels, page 3 of our report shows that alcohol consumption here was below the OECD average until the late 1980s but the level of alcohol consumption here has shot up since then. There was only one year, 2002, where there was a reduction in the level of consumption here and that occurred because of a concern about the promotion of alcopops at the time and the Government of the day put a 20% tax on spirits, which resulted in a reduction in the level of consumption. There is a link between pricing and alcohol consumption and therefore pricing is important.
The link between sport and alcohol is also important. Young people in the main are interested in music and sport. Those are their two big items of interest. Rugby has been completely taken over by alcohol sponsorship. That is the case with all the big rugby competitions, soccer is somewhere in the middle and the GAA is trying to change that because it has a policy at club level to try to address it. Breaking the link between alcohol and sport and alcohol and music festivals would be effective because it would help to change the culture.
I note you allocate €6,000 to the GAA for the service of an outreach worker, yet that service is involved with an alcohol company responsible for sponsoring some of the championship.
Professor Joe Barry
Yes, but the GAA committed to getting out of that a few years ago and it has considerably reduced its level.
To be fair, it has.
Professor Joe Barry
It has reduced it.
Rugby has changed too in that respect. One of its competitions is not sponsored by the alcohol industry.
Professor Joe Barry
Is that the case?
That is the position in the case of rugby.
Professor Joe Barry
It is great that Ireland has qualified for the European Championships in soccer next summer, but the talk about it is beginning to come around to talk about alcohol as well. Ten years ago when our team had to go to Iran for a play-off, the talk on the radio was about how would the fans manage in Iran if they could not drink there. Children pick up on that type of comment by adults.
The strategic task force of 2004 laid out a balanced set of measures and if they had been implemented, we would be in a better state now. As Dr. Flannery said, a new report is imminent and if its recommendations are implemented, that would help, but they will be vigorously opposed by the industry. The issue will come back to the politicians and they will have a choice because some of what is involved is about legislation.
Mr. Declan Bedford
In the case of the Heineken Cup in rugby, the French are not allowed use the word "Heineken" to promote it. If one of the matches is being played here, the referee will have the name of the championship on the back of his shirt, but if the match is being played is France, the referee will have the words "H Cup" on the back of his shirt. The word "Heineken" cannot be used there to promote the championship. The French have significantly turned around their alcohol problems because they decided to take the hard decisions.
Deputy Doherty asked about trends in this respect. In our report we outlined some conditions in the incidence of which we have seen an increase, namely, cirrhosis, alcohol-related admissions to hospital and various alcohol-related cancers. We have seen the effect of alcohol consumption. As people consume more, there have been more alcohol-related effects. The Deputy mentioned the incidence of suicide. Alcohol is a depressant and it does not help in that respect. One of the big problems we saw was the change in the drinking culture with people drinking huge amounts of alcohol and young people drinking not only pints, as we would have done in the old days, but drinking shorts along with pints.
I was involved in a study in the north east a few years ago where I went around the offices of coroners and read the reports on all the people who died as a result of accidents and suicides. I read many reports in those offices on young men who died from suicide. I also read the witness and family reports. It is unfortunate that those young men died. When they went out on the night they died, I am sure, for many of them, suicide was the last thing on their minds. They consumed unbelievable amounts of drink and then they made a bad decision. If they had not had so much alcohol, I am sure some of them would be still alive today. It is a very sad situation.
Dr. Anthony McCarthy
Some people are shocked at the question of banning advertising. It sounds like such a radical proposal - imagine banning advertising. It seems like a ridiculously excessive idea, but we should think along the lines of alcohol being a poison. That is what it is. It is used to preserve bodies and products. Most of us will know the hammering drinking to excess does to our brains, heads and muscles. Ironically, we know that while big sports events are sponsored, all our elite sportspeople do not drink for weeks in advance of a big sports event. We know it is a poison, yet we are fearful of being on a moral high horse or being ridiculous in saying we will not allow the advertising of a poison. It will poison our muscles, brains, babies, bodies, relationships, families, culture and society. It requires courage to say there should be no advertising, but there should be none. Why should we allow the advertising of a poison?
Dr. William Flannery
I believe the figure mentioned was €100 million or €200 million.
It was €10 million.
Dr. William Flannery
In terms of banning alcohol advertising in sports sponsorship, I mentioned already about putting that money towards that end as well as minimum pricing. Deputy Keating referred to strategies or interventions that are probably in place through the mechanism of the national drugs strategy. If those structures were extended to include alcohol, some of that money could be used to reinforce what already exists. Certainly the people using those facilities would not distinguish between alcohol, cannabis or whatever. The interventions are essentially the same.
On an anecdotal note, a female patient made a comment to me which sums up this issue. She said that if she goes to an off-licence or a garage and buys a bottle of vodka, everybody would look at her and think that is terrible, how could she buy spirits, but if she were to buy a few bottles of wine every night, the comment she would get would be for her to enjoy her dinner party.
Dr. Eamon Brazil
Another way of looking at it - I take the Senator's point - is that if we can reduce our volume of alcohol consumption from 14 to ten litres that is the best conversation to start in the country. The best people to influence doing that are the advertising agencies and the marketing industry. Presumably the drinks industry just want to keep their profits up. They do not care whether they sell five bottles of beer at 5% or 20 bottles at 2%. An alternate strategy, if I was to be given the €10 million I would give €2 million to the drinks industry and specify that in five years the number should be down to ten litres per person and the most popular beers in the country should be 2% and if they achieve that I would give them the other €8 million. We may as well use what they are good at. I would love to say we should get rid of all advertising of alcohol but I am not certain how practical that would be. Irish people drink because they like being out socialising. If they are drinking only 1% beer they would have to drink an awful lot to have the effect we are worried about, particularly in my department. I would get rid of binge and drinking overnight.
But if we did not achieve an overall ban on advertising, would Dr. Brazil bring in a watershed and change the structure?
Dr. Eamon Brazil
From my point of view, if one does not achieve, I would go lower to eight litres per person, two years from now.
I preface my remarks by saying that Dr. Brazil wants an overall ban and I accept that. However, if that cannot be achieved-----
Dr. Eamon Brazil
I do not really care as long as we get down to eight litres per person. The best way to do that is to keep the advertiser advertising but advertising something else.
Okay.
Dr. William Flannery
If all of us were drinking at recommended rates, it would be about abut eight litres per person and not at the current very high rate.
The funding for any campaign would have to be collected from the sale of drinks. In Government we are moving towards making the person who is causing the problem responsible for ensuring the correct information gets out. No matter what funding we would collect that is what we would try to do.
I congratulate the witnesses. I come from a marketing background and we have had this conversation previously. I do not hold the store that most of the witnesses have displayed today and that previous guests have displayed in recent weeks that advertising has this huge impact. I do not give it the same amount of credit as others have given it. I think the suggestion they have made is magic. Obviously the reason they spend money on it is because it works but only in the confines of taking market share from one brand to another. It is not increasing the overall market. Statistics have shown that, albeit slightly, the overall consumption of alcohol has dipped in recent years. Therefore, the amount of money they are spending - if it was to increase consumption - would not be working so the answer is to rob from one brand to another. The advertisers are good at it. The witnesses are correct in what they said about the children; I have four. They love marketing and are suckers for it. They go around singing the songs one does not hear. The idea they have proposed is magic. I would never have thought of it.
I wish to make a quick point. I am sorry for being repetitive. We probably cannot put a multiplier on it but there is some quantitation of the percentage harm reduction we would have for every litre less we drink nationally. It might be a good index to compile. The other representatives who have appeared before the committee in recent weeks from the industry and the other vested interest groups, none of them has any interest in seeing the total amount of alcohol consumption reduced. This has to be a goal which we put out there. We have to put it out globally and we have to inform people about strategies and how they can, as individuals, contribute to it. There is nobody in the country who should be advising to drink more than the present rate. The reality is that whatever amount one drinks now, one would be better off if one was to drink less. That is the message we have to get out there.
Before calling Professor Joe Barry, I would like to ask about young people. In his submission there is a reference to a 247% increase in the rate of alcohol-liver disease discharges. We are ahead of America and the UK for alcohol consumption in the 15-16 age group which is a worrying trend. If young people start at that age the drinking escalates into adult live
Professor Joe Barry
The 247% increase is according to hospital discharges over a period of 15 years. The bad news for women is that because wine consumption has increased so much there is a different gender balance. There is a need to be careful in phrasing any recommendations about shifting marketing from one product to another because women are drinking a lot of wine. Wine is very expensive and is marketed at women. Hospital clinicians see women in their thirties with liver failure transplants. We need to be careful. France is a wine drinking country but it acted 15 years ago. One can imagine how powerful the wine drinking fraternity is there but it said it had a problem with cirrhosis of the liver. We have a much higher level of drinking. Those are the statistics and about 10% of those people died. This causes enormous misery for families and is a huge burden on intensive care units. Various Dublin hospitals, including St. James's Hospital conducted studies about two years ago which showed that approximately half the patients in the intensive care unit at a given time were suffering from chronic liver failure. The service is under pressure. The broad public health community suggested we get back to the European average, that is, an 18% reduction.
Is that attainable given the present trend?
Professor Joe Barry
It is.
I know it has to be but it is about winning minds. However, the trend is going up.
Professor Joe Barry
No, it has plateaued but the difficulty is that some people have stored up many problems from the past. The other issue is that we have the highest percentage of teetotallers in Europe. The drinking is happening in 80% of cases.
That is worse.
Professor Joe Barry
It is worse.
I will come back to Professor Barry again but I want to all Dr. Declan Bedford.
Dr. Declan Bedford
The question is whether we can turn the trend around. It was turned around in France.
I am advocating turning it around.
Dr. Declan Bedford
Yes, we can do that. If we reduce consumption the argument will be made that are taking money out of the economy. That is not correct because if people are not spending money on alcohol they will spend it on something else. Therefore, there is no problem there.
It would also reduce the amount of money we have to spend on public services.
Dr. Declan Bedford
It is a no brainer.
Ms Michele Savage
With regard to the chairman's point about the increase in alcohol consumption among 15-16 years olds. the rate of increase among the female cohort in that age group outstrips the level of male drinking. Given that women do not metabolise alcohol as much or as well as men, that is a serious indicator.
On the issue of marketing, even within the internecine wars of sister brands within the same company, one is competing not just with marketing to a public but there are internecine issues. Considering the attitude to alcohol and behaviour around alcohol in families, it is surreptitiously marketed between the different generations in the family, therefore one should not start out on that road.
Dr. John Cooney
I will make two points. I did not say anything on the issue the chairman raised about alcohol and suicide, the exposure of suicide, particularly among young men, between the 1990s and the noughties. While we know that much suicide is associated with mental illness, it strikes me that there was no signal of a massive increase in mental illness among that young population but there was a real change in other factors. There was disconnection from society and alcohol abuse and substance escalated massively during that period. That was probably the strongest correlate. While mental illness must be addressed as a factor, other factors such as alcohol are significantly implicated.
One of the impediments in the hospitals to management of people with alcohol problems is the lack of services in the community that are organised or integrated in any way. I contrast that with the drug treatment services. Whereas a drug addict may rob one's house or car, an alcoholic will lose his or her house and car; there is not the same imperative to organise services to treat this disease and manage alcoholism. There is plenty of expertise available in the country; however, it needs an organising and integrative function and a management function, which the HSE is best placed to perform.
Dr. Anthony McCarthy
It is ironic that we believe we are in competition with the drinks industry, the representatives of which have appeared before the committee. If we were discussing cannabis addiction, cannabis suppliers would not be brought before the committee to advise it. If we were discussing any other social ill, they would not be here competing with those treating it. Why, therefore, do we have to compete with the drinks industry? If all of the problems resulting from alcohol use disappeared, we would be out of job. We could celebrate this, as we have no personal incentive to be here, but the representatives of the drinks industry are here for one reason only and that is to push their products and fight against the obvious good that could only come from reducing the level of alcohol consumption.
The difficulty is that the emerging trend, backed up by figures, is that many go out to drink to get drunk rather than to have a social drink. We have to try to change that attitude.
Professor Joe Barry
Did anybody hear the radio programme before "Morning Ireland", on which the issue of house fires was discussed? House fires result in many deaths. About half of all house fires are drink related, for example, they are caused by people putting on chip pans which catch fire. The advice was to buy chips at a chipper after a night out drinking rather than to drink less.
Dr. John Cooney
The national burns unit is based in St James's Hospital. If one talks to anybody who works in that unit, he or she will tell one that alcohol is a massive issue in many cases in which people present with burns.
Professor Joe Barry
People who did not think they were going to die overnight were found dead.
We have changed our attitude to drink driving. I hope we can also change our attitude to alcohol consumption.
Dr. Anthony McCarthy
I hear it said the real problem is that people are drinking too much. The drinks industry will state the individual drinker is drinking too much; that it is not the problem of the industry but of the individual. The same argument is made by the American gun industry. We must oppose this ridiculous argument.
I thank the representatives for appearing before the committee. We have had a very interesting and significant discussion. I thank them for the quality of their presentations and delivery. I encourage members of the committee and the media to read their in-depth and informative presentations. I acknowledge the presence of Mr. Ray Mitchell from the HSE who is in the Visitors Gallery. We will resume our deliberations on this issue tomorrow. It will be the final meeting on the subject. I know the Minister of State, Deputy Róisín Shortall, will bring a report on the matter to the Cabinet, as announced by the Minister for Finance, Deputy Michael Noonan, in the budget.