Sub-Committee on Health and Smoking

The sub-committee met at 9.30 a.m.

DEPUTY BATT O'KEEFFE IN THE CHAIR.

The sub-committee met in private session at 9.30 a.m. and in public session at 9.54 a.m.

Chairman: The Sub-committee on Health and Smoking is now in public session. Today's meeting is the second of four scheduled meetings when evidence will be heard from a cross section of interested parties. While witnesses have agreed to appear voluntarily before this committee evidence is being heard under oath under the provisions of the Oireachtas Witnesses Oath Act, 1924. I'd like to welcome to our first session this morning Professor Luke Clancy, consultant respiratory physician, practising in St. James's Hospital. Professor Clancy, please rise holding the Bible while the Clerk administers the oath.

Professor Clancy was sworn in by the Clerk to the sub-committee.

Chairman: Professor Clancy will make an opening statement which will be followed by questions from members. Before we begin I'd like to advise the witness that while members of this sub-committee enjoy absolute privilege this does not apply to witnesses appearing before it. I would also like to bring to the attention of the witnesses and Members the fact that under the provisions of section 10 of the Committees of the Houses of the Oireachtas (Compellability, Privileges and Immunities of Witnesses) Act, 1997 certain rights are granted to persons who are identified in the course of the committee's proceedings. Persons being invited before the committee are made aware of these rights and any persons identified in the course of the proceedings who are not present may have to be made aware of these rights and provided with a transcript of the relevant part of the committee's proceedings if the committee considers it appropriate in the interests of justice. Notwithstanding this provision in the legislation I should remind Members of the long standing parliamentary practice to the effect that Members should not comment on, criticise or make charges against a person outside of the House or an official either by name or in such a way as to make him or her identifiable. Professor Clancy, will you make an opening statement of perhaps 10 to 15 minutes?

Professor Luke Clancy: Thank you. As you've heard, my name is Luke Clancy. I am a consultant physician at St. James's and Clinical Director there. Probably more relevant, I am the immediate past chairman of ASH and I was before the joint committee earlier. When I was before the Oireachtas Joint Committee on Health and Children I made a presentation on behalf of ASH Ireland where I addressed many of the issues that this sub-committee is considering. The headings of that document concerned (a) protecting children from tobacco use and (b) passive smoking and health of children. I outlined elements of an effective protection plan for children. I will make some further comments on this today but I believe the elements presented then are still valid.

Many aspects of this health scourge of the 21st century have also been presented by my colleague Dr. Fenton Howell, who spoke to you last week. He dealt comprehensively with the question as to whether tobacco is addictive and presented a very thorough international perspective on so-called environmental tobacco smoke or second-hand smoke, which is a more realistic term, and this is the most important indoor pollutant. I shall try to make some contribution to this question also. ASH mentioned litigation but if I am to judge from some of the questioning afterwards there seems to be some doubt as to whether this was within the remit of the sub-committee. I said instead that it was a Government matter but I would stress that it is important and I hope the sub-committee will have an opinion on it.

These matters should be of interest especially in this era of tribunals when we see an examination of the many scandals which occurred everywhere including the health sphere, particularly in blood and blood products. Is there not also a worry about tobacco and smoking products, what was known and by whom and when, what did we do as a society and what support have we given to smokers? What have we done to prevent people from smoking, to help them quit smoking, and then to take care of the diseases that smoking causes? I shall try to make some contribution under these headings as well.

Primarily, I am a practising clinician and it is in this field that my expertise lies. As Chairman of ASH, I have reported to you on the general health effects of smoking and in the joint committee's excellent "National Anti-smoking Strategy", it is clearly stated that smoking is a major cause of cancer, cardiovascular disease, stroke, respiratory illness, peptic ulcer disease, emphysema and accelerated rates of post-menopausal bone density loss in women. There are other harmful effects but I will not spend time on them this morning. Instead, as a respiratory physician, I thought it might be helpful if I concentrated more on the respiratory health effects of cigarette smoking than in reiterating the long list of smoking related diseases. I will, therefore, deal in particular with lung cancer and chronic bronchitis/emphysema, which are for practical purposes exclusively due to cigarette smoking. To dismiss it here, I realise there are other causes of these diseases but less than 10% of either of those diseases can be attributed to any other cause. They are, therefore, diseases where smoking is the overwhelming causative factor.

I do not know enough about marketing or advertising or to give you any scientific advice but I will touch on these subjects, as they are vitally important in this whole sorry plague that is smoking. The little data available on this topic have been reported to you. They tell us about the percentage of people who smoke. One of the pharmaceutical companies interested in smoking cessation also does an annual survey of smokers and estimates not only the percentage of smokers but also gives information on smokers. I thought this might be of interest to you.

Smoking is most common among single men aged 25-34, living in Dublin, and in the lower socio-economic groups. The heaviest smokers, by whom we mean people who smoke 15 or more cigarettes a day are most likely to be married people, aged between 35 and 49, living in Dublin in the lower socio-economic groups. That's really what we know about them so far.

My colleague, Dr. Howell, has welcomed the establishment of a research institute and I endorse this. Especially if you consider what we know about smoking, it is hard to find any important Irish data in this bank. Research into this important health hazard has been neglected in this country, as you will probably realise so has a lot of other research. I, therefore, commend you in having set up your sub-committee which despite all the information that exists and its acceptance by many countries and the Judiciary in the United States you still want to have a look for yourselves. I agree with this and apologise for the fact that we have so little Irish data to offer you on which to make your recommendations.

In this regard, I would like to make one small contribution. My co-workers and I at St. James's surveyed smoking habits among 3,000 13-14 year old Irish teenagers in 1995 and again in 1998. We subsequently published our results on prevalence which are in line with the SLAN survey. We also looked at respiratory symptoms that smoking causes in these young children and I enclose abstracts presented at the American Thoracic Society, which are at the back of your folder, and this shows that 20% of these children when surveyed in 1995 had cough and phlegm and in 1998 30% had cough and phlegm. The importance of this is that these are the symptoms of chronic bronchitis and we found that young Irish teenagers at that age had an incidence of cough and phlegm of 30%. It is no wonder that chronic bronchitis is so common in this country. Perhaps even more shocking, and I also enclose this abstract, we found that 13% of children who had exposure to second-hand smoke and were themselves non-smokers but had this exposure in the home also had cough and phlegm. We found the same percentage in 1995 and 1998 and in both of these abstracts we found that these symptoms were statistically significantly higher than in children not exposed. I hope that these few data from our own population will help clarify your thoughts on the damage that smoking is doing to our children even when it is second-hand smoke. I believe that without comprehensive research performed in this country on our population it will be difficult to effectively reduce cigarette smoking below the present level. Minister Martin's initiative in this regard is, therefore, heartily welcomed and we look forward to seeing Irish data which will clarify not only the health effects but also the effects of marketing, advertising, legislation, litigation, health care, usage and health economics. In my opinion, there is no shortcut to significantly reducing smoking; it has to be a comprehensive approach in which research is one of the key elements.

I turn now to my own interest in respiratory diseases. Lung cancer is the single commonest fatal malignancy of men and women in this country. We know that at least 90% of these deaths are preventable if we can eliminate smoking and at the same time we know that only one in six of these cancers is curable by any method at present. Therefore, our approach to lung cancer as a country is mystifying. We have a National Cancer Strategy, which is well thought out, and apparently transforming our cancer services. In particular, breast cancer services are rightly given very high priority and I have seen the situation being transformed. Recent all-Ireland statistics show that there is, on average, an annual breast cancer mortality of 975 women - not all women but nearly so - and 2,300 lung cancer deaths yet, as far as I can determine, there is no clear lung cancer strategy or clear allocation of money for lung cancer services in particular, for medical treatment of lung cancer. Why is this?

There is a cardiovascular health strategy and I have the privilege of being a member of the task force set up to implement that strategy. In that we pay due attention to the horrific role played by smoking in cardiovascular diseases and money has been earmarked to help fight the scourge of smoking in relation to cardiovascular diseases. We should contrast that with the services for patients with chronic bronchitis and emphysema.

You will realise that one of the main causes of the problem in our emergency departments in winter are respiratory diseases, in particular, exacerbation of smoking related chronic bronchitis and emphysema. You will have seen the heroic efforts that are being made to try to alleviate this situation and, belatedly, the realisation that the main problem in the Dublin area is a shortage of beds. Yet the money to try to help the situation is generally put into improving A & E facilities which are badly needed, surgical waiting list initiatives, money for placing of elderly sick in nursing homes when their families are no longer able to care for them. Why is it, however, that it is so difficult to get resources to tackle the cause of this overcrowding? It seems that any other plausible initiative will be tackled but plans for tackling the cause of the problem which is smoking related respiratory diseases seem easy to ignore. The Government is preparing a further necessary health strategy. It is consulting widely yet the president of the Irish Thoracic Society asked the Minister for representation but this was not considered possible.

I raise these issues to suggest that there is more that we can do in the health services for our smokers and, in particular, I am speaking here of the poor and elderly who are unfortunately the main group that suffer from chronic respiratory diseases and lung cancer. That is significant. It is of note, that, as far as I am aware, there isn't a single consultant in the hospital service whose job description or job specifically addresses care of smoking related diseases or smoking cessation or health promotion of non-smoking. There have been some recent appointments in nursing in this regard but no doctors. Even with the planned expansion of consultants where the number might double, I have not heard any proposals that would give any of these a special role in smoking related diseases or anti-smoking activities. These kinds of facts make one wonder how cigarette smoking diseases are perceived and what we think needs to be done. Perhaps your committee can help in this regard.

I will touch on price and the CPI. Price does matter and I have heard some Members of this sub-committee, whether being devil's advocate or otherwise, cast some doubt on this. In that regard I would recommend this book, "Curbing the Epidemic", to which I have referred in my hand-out. I will not try to summarise the whole book but I will give you one interesting point. They claim that a price increase of 10% would result in 40 million fewer smokers worldwide and 10 million fewer deaths. The World Bank also considers the costs and economic consequences of tobacco control. In its opinion, only Malawi and Zimbabwe would be likely to see a net loss if all tobacco production and smoking ceased forthwith. In countries such as Ireland, there would be only a trivial economic consequence for the loss of this industry and huge gains in reduction of pain and suffering over many years and increased survival. That brings me to the CPI. We are told it is difficult to remove because of our EU membership. This may be true and if so is a matter that should be addressed and changed. However, even as it is I believe that something can be done. For instance, in many countries they run two CPIs, one with cigarettes and one without cigarettes. We were promised this here but I have not seen any evidence of it so far. I would say, however, that if the CPI was the cause of the failure to have any price ... in the last budget then this is a tragedy which I suggest will cause increased mortality in years to come and lead to many years of sickness and disability for many thousands of people and all because it affected the CPI in the year 2000. The tobacco industry paid scant attention to the Minister's worry about CPI when it imposed its recent price increase but it was, no doubt, very vocal in telling of the dire consequences of a price rise pre-budget. As a country, it is time we tried to decide what is right and what should be done in the interests of our people especially their health and welfare or whether we are more concerned with short-term embarrassment and multinational lobbying. These matters are for you as politicians. At the same time, my colleague has urged you to go a little deeper into the tobacco companies than their CEOs. This will reveal, as the tribunals show in many other settings, that many of the same people involved in our financial institutions are involved with this killing industry and some of the people even show up in the health care business.

I think its scarcely necessary any longer to ask the industry if they knew that their product was addictive or if they knew they were killing millions of people. Their relationships to people outside this industry should become centre stage. You might look for yourself why it was that the Institute of European Studies co-hosted with Philip Morris a meeting in Dublin Castle attended by the then Taoiseach and then Minister for Finance. When I was last before the joint committee, I asked you why a Government adviser smokes cigarettes on television. He stopped doing it, I am glad to say, but it can't therefore be that simply he is a smoker. Then I suppose we should not have been surprised when he became an adviser to the tobacco industry when he was no longer advising the Government. Or how is it that the Minister for Finance at the time when we were making a film about our Presidency of the European Union the Minister for Finance stopped on the stairs and went back to his office to get his cigars? Was that very important or was it an accident? If it was an accident why was it not edited?

During the early nineties, we at ASH went to the Government, year after year, and said that as our national prosperity increased cigarette smoking would increase among children because cigarettes would become more affordable if we did not substantially increase the price of cigarettes. Why were we ignored? These in my opinion are the new type of questions that it behoves you to consider.

Advertising and marketing do matter and if they did not, the industry would not feel so strongly about their curtailment. They will suggest the reason for advertising is to encourage people to change brands. This cannot be the whole truth and, as Dr. Howell suggested, perhaps discussions with their marketing and advertising agencies would clarify this matter for you. From the anti-smoking side of this activity, it is clear that we are not very good at it. We don't have an expertise, which essentially means we don't spend enough money. The amount spent by the anti-tobacco side is minuscule by comparison to the industry and the results, unfortunately, bear this out. The time when an ageing, balding doctor told children that smoking would give them cancer when they are 60 or a heart attack when they are 50 should be long gone. This image fails dismally when it is compared to a Formula One racing driving flashing by or a distraught Bridget Jones smoking another cigarette through her diary. Saying don't smoke or even do smoke is not the technique the industry uses nor can it be ours if we are to be successful. We need expertise, we need to resource it properly but, first and foremost, we need to know the best approach and that means carrying out scientifically based research. As regards smoking cessation services, these are essential if we are going to prevent the horrific mortality and morbidity attributable to cigarette smoking. In this regard, it is crucial to influence children so that they do not start smoking. Much of our effort should be in this direction but it is necessary to know that unless people who already smoke stop there will be no reduction in the mortality rate from smoking before the year 2025. This is unacceptable. Not only must we stop children from smoking but we must get current smokers to desist. We know this is possible but we know it's difficult and very few can do it on their own. We need a comprehensive programme which includes appropriate pricing mechanisms, health education, smoking cessation materials, elimination of second-hand smoke by increasing the number of no-smoking areas in the workplace, public buildings, places of entertainment and education and, very importantly, in hospitals. These need to be backed by appropriate legislation promoted by appropriate education and supported by allocation of appropriate resources. Then we can reduce smoking very considerably and we can see from the United States, particularly California, Massachusetts, Florida and increasingly New York that the rate of smoking can be lowered from its present unacceptable 30% to 20% within ten years. I believe we should set ourselves these goals and we should achieve them.

I support the implementation of the recommendations made by Dr. Howell and would ask you to consider taking on board some of the points that I made today, particularly with regard to services for smoking related respiratory diseases.

Chairman: Thank you, Dr. Clancy, for a very illuminating address. Maybe I will start the ball rolling by asking you a question. Will you go a little deeper into the tobacco companies and their COs? You are saying that it will reveal as in other settings that many of the same people involved in our financial institutions are also involved with this killing industry and some of them even in the health care business. Would you like to expand on that?

Professor Clancy: I do not think it would be surprising. It seems to me from a very unknowing situation that most of the activities in this country in business have links with everyone else. When you hear of people who are in the major banks, they have come from other companies. It is not surprising that they are in the tobacco industry. For example, if you try to invest money through one of the major banks, as a punter you will be told to look at this portfolio which will contain several tobacco stocks. You will say "but I don't want these", but you can't have this portfolio unless you have that and then say that cannot be, I don't want that stuff. So you would think why is it their policy and you would see who the directors are. You will think where is that person. He also happens to be chairman of one of the cigarette companies. He also happens to be chairperson of BUPA. You will think how can this be - the Bank of Ireland, BUPA and the cigarette industry. I don't think it is that surprising because people who are in the money business go where the money is. People have the right to be in whatever company they like, but people in the public service and people in the health care sector particularly have to be very careful about having anything to do with an industry that we know kills about 7,000 people a year. That statistical 7,000 people killed is very bad. Think of the 100,000 that are going around coughing, spitting and in pain for 20 or 30 years. Anybody in the public service or anybody who cares about people should not have anything to do with this industry.

Chairman: Are you specifically alleging that there are people in banking who are promoting tobacco companies by way of their shares? Are you alleging that there are people, for instance, who are involved in financial institutions and in other core issues who are part and parcel of the tobacco industry? You mentioned one person being chairman of BUPA. You mentioned people being directors of tobacco companies being involved with financial institutions. Is this a factual statement?

Professor Clancy: It is a factual statement in the case I referred to. It is an inevitable statement. If you think of any companies that we have seen recently, you can find a handful of people who keep showing up in everything. I am not an expert on financial institutions, I only read the papers. I am sure you know a lot more about it than I do. But if you look at the commonality of the directors and how they get to be directors, very often they represent big companies. I am not saying - because I don't know even if I suspect - that they are promoting but I think it's a great coincidence when you find these people in these positions and certain things happen. You would know better than I how influence is used. They may not be promoting in the ordinary sense of the word but things happen because people are there. That is power, as far as I am concerned, being used.

Chairman: Would you be prepared to give documentation to us on the relationship, the interchange between financial institutions, tobacco companies and in fact even people in the health care services?

Professor Clancy: I really put that to you because you have, I hope, the resource to examine this. As a private individual and as a doctor and practising physician I cannot go out there and start going through the directors of all the banks, companies and industry. I am putting it to this committee that you, hopefully, have the resource to examine this. It need not be a malicious influence. But I think when you see the same people cropping up you have to ask questions. I am hoping that you will.

Chairman: With respect, you have been very specific in one particular case where you said the chairperson of BUPA was tied into the tobacco industry. You mentioned financial institutions.

Professor Clancy: I mentioned the Bank of Ireland in that one case and I am really only talking about the one case. I am prepared to say that because I know it. But that doesn't mean that there aren't more. Perhaps you can find it when I can't.

Deputy G. Mitchell: I join you in welcoming Professor Clancy. First, in relation to the opening comment that the professor mentioned and some doubt about this committee having a role in recommending litigation, Members of the committee will be aware from our visit to New Orleans recently that the industry there settled with the individual states for an amount of $347 billion, if I recall correctly. That does not include what was paid to the Federal Government simply for the cost to the state of treating people. That may well be something we can come back to address in our recommendations. I want to ask a couple of questions. Professor, are you aware of research done - if my memory serves me correctly - by the ESRI which points out that the death rate among people aged 55 and over is something like 13 per 1,000 in higher professionals and professional people but those in lower socio-economic groups it's nearly three times that amount? I think the figure is 36 per 1,000. You mentioned specifically smoking in lower socio-economic groups and you mentioned in particular those living in Dublin are most at risk. Would you agree that smoking is probably the single biggest contributing factor to that statistic? If you do not mind I am going to ask you a few questions. Maybe you will just hold. The Chairman will be able to ask others for a contribution.

I am very surprised at what you said about there being no clear lung cancer strategy or clear allocations of money for lung cancer and yet we know that at least 90% of these deaths are preventable. Lung cancer is the single, commonest, fatal malignancy of men and women. Indeed my own father died from lung cancer when I was very young. I would just like to raise that issue. That is something we should address when we are coming to our recommendations, Chairman.

Professor Clancy mentioned that there is not a single consultant in the hospital services whose job description or job specifically addresses care of smoking. That is another issue I hope we will address. I am leading up to one question but I just want to get this point out of the way as well. We have to look at the whole question of the price increase. Since Professor Clancy mentioned two countries in particular, Malawi and Zimbabwe - maybe there are others - perhaps we should be thinking in terms of the EU giving some sort of subsidy to these countries to compensate for whatever the fall out will be in the tobacco industry. I am talking about the poorer countries. I also think if there is evidence that any person holding a public health role is also a director or an employee of a tobacco industry, that we might make a recommendation saying that this would not be consistent with holding a public health role.

I want to ask Professor Clancy a question. My main concern is this. As a father of four children, young girls - I know you mentioned young men seem to be in the particularly high category of smokers in Dublin - seem to be increasingly smoking in large numbers. Sometimes I suspect it is to do with just the fad of the day but also maybe to do with keeping slim, not eating or something of that kind. How do we get this message across to children? What specifically can we do for young people? Is there any research you have seen that works? I note the decrease that there has been in California and other places that you mention. It is of great concern to me to identify something specific we can do to persuade young people because once they're addicted to nicotine the damage seems to be done. Thank you, Chairman.

Professor Clancy: Smoking is the main cause of increased mortality in Dublin in poor areas but it's not the only factor. The poor have several disadvantages, smoking being the most prominent as regards dying but the health service and access to it, education, housing, nutrition, all of these play a role but they are swamped by smoking but it shouldn't be that the other things are ignored either.

Deputy G. Mitchell: Is it not a fact that people who are under pressure because of poor housing and so on may turn to smoking because it's less costly and they don't have the same entertainment outlets as somebody who is better off?

Professor Clancy: It's hard to be sure about that. Certainly we know that the industry targets poor people and we know this now by their action in the Third World, for instance, where they go in and they tell people that it's sexy and prosperous to be a smoker. In this country what they used to imply was you can't afford to go to Spain like those rich people but you can have a bit of luxury in your own home and a bit of pleasure. These are cons to induce people into addiction. An addiction, when people are addicted they get no further pleasure, they just face their addiction. The initiation process may have something to do with that but it is complex and that's not the reason, that's a rationalisation that we all try to use. We all have to look at our situation and see how we can explain things.

As regards lung cancer mortality, it's the commonest malignancy, the commonest cause of death from cancer is lung cancer in both sexes. There's 2,300. There's 970 breast deaths, which is huge but it's less than half and the resources are nowhere comparable. This is, in my opinion, because lung cancer affects the poor, the elderly and the voiceless. It isn't a gender thing because plenty of women die from lung cancer. Clearly breast cancer is a gender issue and it has been forwarded and prospered in that way but lung cancer unfortunately is for the poor and the elderly and who cares?

Deputy G. Mitchell: What about young girls?

Professor Clancy: Young girls particularly. You are absolutely right. More young girls smoke now than boys and it is complex and that's why we need research. It includes the "slim thing" but that's often post-hoc. They can't give it up because they'll gain weight but a lot of them don't say I'm starting because I want to stay slim so I don't think that's the whole answer. It includes a lot of things. It includes rebellion. It's rebellious without being too dangerous immediately. It also has sexual connotations and where it's analysed it, in the girl, signifies availability without actual availability. So it's not going to be cured by saying you get cancer when your 60. This is a socio-economic issue, a question of lifestyle, this is image, sex, product placement is huge in this. That's why I mention Bridget Jones. You don't hear her saying you've got to smoke or it's good for you, or anything. It's just that it's part of it and the industry is very clever in product placement. It's not always the hero, it can be the anti-hero because there are people out there who side with the anti-hero. So product placement is huge and as you curb advertising then they become more subtle. If you give them, as we are giving them, years to prepare for these bans they go in with the best brains, the best ideas and they do the right thing from their perspective and any ban that you see, it must be derogation for three years, that's to give them time to spend plenty more money to see how to outwit us and they will because we don't match them in resources. These people are the best there are because they pay the highest dollar. They know how to do it and we don't. I don't know how to stop kids from smoking but these are the factors that go into it and I think that it's a society and cultural issue. If a society says this is not what we want for our kids, we want them non-smoking, smoking is bad for them, okay, but it's also addiction. They're also being manipulated and I think the message for kids is not how sick they'll get when they're old, it's what's happening to them now and what are these industries doing that are portraying it as being slimming, sexy, cool or whatever the phrase is. Expose the way they do it, show how product placement works, show them the consequences of smoking. Sure the health message is essential but it's not going to be useful to ram it down their throats every day as the sole mechanism. We need socio- economics, marketing, advertising and litigation.

How can you reduce it? Price is hugely important. I remember saying, year after year, the economy is taking off, cigarettes are going to become affordable for kids. The price affects kids more than adults and at a time when the economy takes off, if you want to keep up with that you have to go ahead of the economy. It's no good keeping up with it. In the past Ministers for Finance usually were concerned with how to maximise the tax take. That's understandable but I'm talking about using price as a health mechanism. That's a different thing altogether. You have to look at what would it take to stop some people smoking and any time price is used the tax take doesn't fall, it increases. For instance, the only significant price rise we had was 50p last year and the tax take was estimated to go up by £160 million. There's no talk of it going down so why aren't we using price? We asked for a £1 increase at that time and that wasn't out of the air, it would have taken a £1 to have a really good effect. We got 50p, that's politics I suppose, but nothing this year. Why? Because of the CPI. So who cares? Who cares about the young, the people who are dying and those who will die in years to come because we didn't have a price rise. Does anybody care about that or do the finance people look at this?

Deputy Kenneally: Thank you, Chairman. I, too, welcome Professor Clancy. I had raised the question of price with Dr. Howell when he was before us the last day. He spoke about nicotine and smoking being addictive. Heroin was also mentioned. I made the point that heroin is not price sensitive. I wondered if smoking is but as you have dealt with that area in depth I will not ask you to go over it again. It might be helpful if a copy of the publication to which you referred "Curbing the Epidemic, Governments and the Economics of Tobacco Control", could be made available to us. You mentioned smoking being an indoor pollutant. Dr. Howell referred to that as well and made the case that it's worse than, for instance, asbestos. If there was asbestos on the roof we'd all leave the room immediately. He gave us details of a case of passive smoking in Australia . What can we do to make it more socially unacceptable? If you think back to biblical times, nobody went near the lepers. Perhaps smokers have to be treated in like manner in current times. We bring in laws from time to time, for instance, banning smoking in restaurants and so on but we do not enforce them. If we made it more socially unacceptable would that go some way to telling people this is something you should not do? I do not know if that would work.

I was amazed to hear that 90% of lung cancer is preventable. I didn't realise it was so high. We all know of people who have died from lung cancer. It is the most common type of cancer. Do we know how much smoking-related illnesses cost the health service on an annual basis? You quoted a number of statistics and gave a few examples in your presentation but you said there was a lack of data. Are you applying data from other countries to an Irish situation? As regards the lack of data, who do you suggest should collate it in this country because I accept we do not have enough information and it is difficult to put questions to other people when they come before us and we do not have anything to back them up? Professor Clancy mentioned marketing and advertising agencies. Maybe we should consider bringing them in at some stage in relation to whatever brief they are given as regards the promotion of smoking.

Senator O'Meara: I thank you for coming here and making your presentation which has been very useful and valuable. When Dr. Fenton Howell, your predecessor was here last week, I put a question to him about the ultimate banning of cigarettes. His reply was that it is a worldwide industry. It is huge and it is just too large an issue to take on so we should be looking at control. I suggest that the Government's initiation on a director of tobacco control in many ways reflects our attitude to the issue. In other words, we think we can control it. But the other side of that, and you refer to this, is that we have extraordinary high level of tolerance of cigarette smoking. You refer to the fact that there is a tribunal sitting at the moment looking at how a group of people, the haemophiliac community, was exposed to a life threatening and, in many cases, fatal exposure to the HIV virus. There is a public investigation into why that is happening. The day may come when we will have a major public investigation into why the authorities, including State agencies and Governments, year in year out, did not do something about the fact that the entire community was exposed to what we know to be a lethal substance. Your figures bear that out. Some 90% of lung cancers are preventable; 90% of lung cancers are caused by cigarette smoking which is a lethal drug, but it is legal and we are doing nothing about it. You commented on the absence of a strategy on lung cancer, the fact that every winter our hospitals are full of people suffering from respiratory illnesses directly related to the fact that they are smoking and, as you have pointed out very clearly, lung cancer is a disease of the poor and the elderly. Put in those stark terms I do not think one could come to any other conclusion except that our tolerance of cigarette smoking is really extraordinary when you think about it. I put the same question to you, should we be moving towards not just looking at tobacco control but ultimately eliminating it?

Professor Clancy: I won't say much about the price except that it does work and I recommend it. There are other things but this is kind of neutral. It is well resourced and it does work. As regards the research, you're right, most of what we say is based on work elsewhere. I see 400 new lung cancer cases a year and I don't see four non-smokers in that group. So that's not 90% but that's my percentages and that's for real. But I would say that 90% is the world figure and that includes countries which are highly industrialised and which have a big lot of asbestos, uranium and all sorts. My guess is that it is much higher in Ireland because we have nothing else really and therefore we should have the research. Who should do it? I'm not going to suggest a new institute because another one has just been set up... hopefully if it is set up. We heard last week from Dr. Howell that there was a research,

Chairman: That is a premature announcement. He beat the Minister to this one.

Professor Clancy: I don't know if it has but as one of the people who made the proposal some years ago to the previous Minister, I look forward to that coming into being and I think that will have a pivotal role. I don't think a lot of your contribution contained questions. I wish I had said it in the same way myself but I would say it is interesting when you look at the tribunals and HIV but if you look at BSE where there isn't a single case that was contracted in this country and sat on several committees about BSE. You try to get a committee on lung cancer where 2,000 people die, so we do have this disproportionate response and it's a bit like what was said about asbestos. There are differences however - and I know this from work during the smog time - smog was banished from here because we showed that it caused deaths and it was controllable outside. However, when it comes to personal matters, you say: "I have the right to smoke and go away and leave me alone". Where we say you haven't the right to be polluting Dublin so let's do away with the smog, so there's personal morality involved in it. Also there are cultural things, it would be ridiculous not to realise that 30% of the population smoke, so it's not like saying there is a very small minority who smoke, we are talking about a million people.

You can't really effectively have a law that will ban smoking completely. It wouldn't work and if it wouldn't work, it wouldn't be sensible to have it on the Statute Book, I think, although I don't always think that's true so I'll come back to what was said earlier. I do think that it's unlikely a ban would work and bans don't work, I mean we know that from prohibition in the States. So if you do something that will be discredited, you are not going to advance the matter. I mean, yes you're right, it should be banned, if this came before the Medicines Board, it would not get a licence, it would not be in this country and yet it is sold without any licence or anything else in shops. We are where we are, however, and a third of the population are at it. We must be realistic and, therefore, control is all we can hope for now, but I come from the TV background and control is what we are looking for there and elimination of the next phase, but the realistic one for now is control. Something skipped my mind there, I thought-

Deputy Kenneally: Passive smoking - to make it socially unacceptable.

Professor Clancy: Yes, absolutely, that is crucial and we know from, again not from here, we know from California that it works. In the United States, price is not used to the same extent as we want to use it here because they are much richer and because it's tobacco production and so on. Price has not been the same instrument there. What they have used is outlawing smoking in public places, entertainment, restaurants, everything. You get the feeling in California that you just shouldn't smoke. Now we don't have that feeling here. I saw the kids going to their leaving cert with their fags, a quick one before they went in because it would steady the nerves, all the rubbish that goes on about it.

Deputy Keaveney: Professor, I also welcome you back. There was a statement last week that the Government is getting too much money from revenue from tobacco, so maybe it will never be solved, that was maybe a kick-off, just to be controversial. My first point is that, that we should reduce the locations for smoking. One million people smoke and their right to smoke, I suppose is there, but the rights of others to avoid passive smoking must be equal. We all know about the 95 year old man who smoked since he was five and has no sign of lung cancer or anything else. With underage smoking and underage drinking, and the health promotions going on, we can see that there are different rules not being enforced, they seem to be unenforceable. I am trying to combat underage drinking in our own health board area on a sub-committee, I think that most people throw their hands up in the air, they think it's hopeless.

With the Bridget Jones type of battle that we are up against, is it not just hopeless, will we ever get the thing resolved? I thought that the focus on women is possibly one area that's not being targeted as much as it could be, because any woman, particularly a pregnant woman, would be looking after the interest of their child. Many smokers were able to give up for the length of their pregnancy maybe and then start again, but as Doctor Howe said last week, it's the one label that the tobacco industry will not put on their packet when there is rotation. I looked at the advertisements for the Government savings scheme which people said would not benefit the poor. I was just thinking of what a packet of cigarettes cost a day, never mind a week and what could be done with that money. I hope you have some answers because, as I say, the more you look into the situation it seem to be black and white. The medical evidence is there to say what happens if you are a smoker and the situation regarding passive smoking seems to be cut and dried as well as to what you will endure if you are in a smoky atmosphere.

Professor Clancy: I have a good long list here but I won't give you them all. I think tax revenue is addressed here and the points I think that people make is this isn't actually wealth or money. This is only a way of collecting money. The Department of Finance is pretty good collecting money and would find other ways of collecting it. Because if this money wasn't going up in smoke it would be available for clothes, for cars, for radios, or any type of luxury goods you like to think, of or maybe even something useful. But it would be available and the Government would find a way of collecting it. So there is no wealth involved in that. The only wealth item is whether the industry is of any use to us and the industry costs us money. So you can examine that for yourself. The tax revenue argument is nonsense. Now it means a big change because if they didn't take all this money from tobacco tomorrow and said we are going to take it all from something else, they'd all be down on them as well. So you must do this thing gradually and you have got to ease out of it but you must go in there punitively and collect the money any other way you like because it is not real wealth, it is only a collection system. That argument, where the industry say look at all the money you'd lose is rubbish and I hope that most of the Ministers understand that.

Now as regards rights, people have rights but it is the competition of rights and you will always get that played out. You know, I have the right to smoke and I have the right to have a smoke free atmosphere. You play that battle. That's a cultural one. Until that's one that we actually believe that we owe it to our fellow man not to pollute them, that's not going to be won by an edict or anything else but you can encourage it by legislation. And, as I said, they do it in the States, the no smoking areas are the signal and yes I would like to see all the laws on the Statute Book enforced and I think we don't try. We saw the border on the foot and mouth. We were all trying for the last 30 years to stop everything with foot and mouth. We are talking about sheep and we could do it then. It's a question of whether we want to do it. We can do it for sheep and anything else but we couldn't do it for people until this foot and mouth disease. So that again is about...

Deputy G Mitchell: What if they burned them all in a fire in the Cooley Peninsula?

Professor Clancy: Except the ones that were missing that day. So it can be done if we want to do it. The 95 year old, there seems to be an awful lot of them about all right but 50% of the people who smoke will die prematurely because of it. So you are in a 50/50 game. Of course not everybody dies because of it but 50% on average lose between ten and 15 years of life because of smoking. Those are the facts.

Underage, that's about the sheep as well. Hopeless? I wouldn't have thought so, but it is difficult and we haven't put the resource into it. Where are our priorities? You know if it was that we would succeed because we seem to be pretty good when we try. Labelling, yes get rid of the damn thing. Put the ads in there. I think what Dr. Howell is saying is they wouldn't put the pregnant one in the women's magazines, they might put them in the bars or somewhere but they wouldn't put them in the women's magazines. But all that is playing around at the edges. We want bans that work. Why should you be advertising cigarettes? Why should people not know how bad they are? You know we should get serious about that. But it goes to Europe and they get another committee and the WHO and they go for five years and they get a compromise that goes between 35-38%. They are not serious, neither is the EU.

Deputy Mitchell raised the matter of helping the poor countries, for instance I imagine, Greece and Italy and so on. It's not true. They are worse off because of the tobacco industry. They do get their subsidies, but do you know what they don't get?

Deputy G. Mitchell: You mentioned Zimbabwe and Malawi.

Professor Clancy: There are only two of them, but even within Europe - the poor farmers in Southern Europe get subsidies; they do not get setasides. There is no setaside for tobacco. Even though it's a product that is lousy tobacco, exported to the Third World because they can die, we don't care, but we give subsidies. But we won't give setasides for that, because the industry; you talk about our country; I think we're relatively clean in the tobacco business. You should know what goes on in Europe.

Senator Jackman: I'll be very brief, thank you. I'm glad Professor, that you've been so passionate about it, I mean there's absolutely no doubt that you're utterly committed to doing something positive and that's very refreshing. I was a teacher, and I had watched for years and known that while young girls were in primary school cigarette smoking was out. They did their posters, there was tremendous effort by teachers and by the community at large really, and by companies that had poster competitions, and various others, to try to get at them at that age. Then, this transition period of 12-13, which really continues right through, to the point that mothers would have said they would have been smokers themselves, and that it could be worse, she could be on drugs. It was very difficult to get through to the parents when you spoke to them as regards the smoking habits of their daughters, but one thing that hit me very much, it's the peer pressure aspect of it where we need to get the research. It has never been stated, it has been peer pressure in relation to other things, to drink perhaps, but not necessarily to smoking; a sense of identity, a sense of confidence, to be able to sit in a bar, with your friends and a cigarette. I don't really believe that the young girls at that age, 15, 16, 17 are even aware; I don't think that that area has been exploited enough. It's a mood rather than a thought process, and even the brightest youngsters will do that, it's not as if they need this crutch, but it certainly is seen very much in that light, and they don't seem at that particular stage to be able to lay it aside. That concerns me enormously because of increased affluence and third level access.

I notice in the University of Limerick, I live quite close to it there, and I walk through the campus regularly, and straight away you see the cigarettes in the hands, but when exam time comes, because of pressure, it's just chain-smoking. Then they move on and that stage they're 22 and 23 and the habit is ingrained, they're totally addicted. Research has to be in relation to the 11, 13 and 14 year olds, that age-group, and to get across to them, even if it's the educational prohibition, you know, that's the aspect I would like. I do feel very disturbed at the lack of implementation of no-smoking. You would have found, maybe five years ago in restaurants you would have been very definitely aware of the no-smoking on tables or whatever. That's gone in most of the areas. You have to ask where it is, unlike in America when you come to a restaurant and you're asked if you want smoking or non-smoking; you're not asked that here any more. The whole scene that was there, five, ten years ago is gone. There's a tolerance everywhere now, and you are pushed back somewhere out of view, and it appears that those who are the cigarette smokers need to be at the window, it seems to be an attraction for people coming in as well.

The last point, speaking to young people who work in American companies in the Limerick area, they cannot smoke on the floor, they smoke outside. Gradually they tend to give up the cigarettes because it's like the American scene, it's going to be implemented, you don't do it, and they reduce, and then they ask themselves "Do I really need those cigarettes?" They make the conscious decision. So, I suppose, really what I'm saying is that we should, collectively as a committee and you and others who are national figures, get at that particular age group and certainly at the implementation of laws in relation to a restaurant and some places of entertainment. People do not smoke in cinemas because they know it's not on, that was stopped. So if it can stop in the cinema which is a place of entertainment where your spend two and a half to three hours why can't it stop in restaurants and even in the pub, which is the worst of all?

Senator Glynn: Doctor Clancy, having listened to you and Doctor Howell it's clear that smoking has a very adverse effect on one's health. Those who don't smoke will say "well I' m all right, Jack, I don't smoke" and the other part of the population who do smoke are hooked anyway and most of whom are into the stage of denial and delusion. They can't see the wood for the trees and given the huge resources devoted by the tobacco companies to marketing their product, they will say that smoking is a matter of choice. This is a never ending cycle because people are talking and talking and people like you and Doctor Howell are certainly doing their best and putting forward the best statistics available. When you look here at what is said about children who are in contact with the most potent indoor pollutant, environmental tobacco smoke or whatever you want to call it, taking into consideration what has been said by the tobacco companies that smoking is a matter of choice and that they don't force it down anybody's neck, what choice has a child? This area has been neglected. A child is not in a position to have a choice. So, therefore, who is protecting? You can leave aside the argument that the adult has taken a conscious decision to smoke. I've lots to say about that although I doubt if the Chairman will give me time to say it. It probably has all been said already. You see, he's my echo really. But who is protecting the interests of the child, the child who is sitting at a table where the mother or father or brother or sister is smoking? I don't believe that interest is being protected at all. What views have you got to protect those in society who are most vulnerable, those who are not in a position to take a decision for themselves, the children?

I've been very brief, not normally my forte, but how aware are the general public that if there was a price increase of 10% there would be 40 million fewer smokers in the world and 10 million fewer premature deaths? You made the point very well that we don't have the resources that the producers, or the pushers as I would call them have. How aware are members of the general public that those statistics are there, that they are real statistics and not something that you pulled out of the air or they're not something that was hanging out of a sky hook, that they are absolutely factual and that they are proven statistics? I don't believe members of the general public know about statistics and what measures do you think could be taken or more importantly should be taken to make those statistics available?

Professor Clancy: Well, just going backwards because I won't be able to remember the start of it but starting with that end point, I don't think they are known and those are estimates and they're economics talk. People I find read an interesting statement and then they pass on. What people I think react to is what is happening to themselves and to the people they know and to the people down the road. We can have the world's statistics but you know you really can just help so many people in Afghanistan in danger of death and it's terrible. However, every day when I look at people with lung cancer and chronic bronchitis pouring through the doors of St. James's that's what affects me and I think we can do a lot from within. We are small but it behoves us to know about our own problems and to go at them. I think the general point you make is whether we are getting the message in general out. I don't think we are but, you see, people find it boring. You know, you're a sub-committee and I'm on this side but we're interested, I'm grateful for your interest and I've noted it, but most people aren't. I think the Government has to care because we have a duty for 7,000 people dead but, as I said, the big thing is hundreds of thousands of people who are chronically debilitated, who are invalids. You see people with chronic bronchitis and emphysema and you say "oh he has a bit of a cough" but you don't realise that they are actually disabled. They can't walk, they can't go up the stairs, they can't have sex with their partner. They're disabled and they don't look it so we don't care. Remember they're poor and elderly and why should we care then, they probably won't go out next time and even vote? But if we don't care about these people they might think we're failing them.

Chairman: Professor Clancy, just before you go, given that 90% of people who present themselves to you have lung cancer which is caused by smoking, have you in your time as Chairman of ASH any knowledge of the actual cost to the health service of smoking-related illnesses?

Professor Clancy: I read your own statements which said you don't know and I don't either but I'll tell you my estimate, the hospital service is all I really know about. I reckon that in any one time about half the people in St. James's are there because of smoking. Now you can know what we cost, I don't want to announce it in public but 170 something million pounds are given to St. James's every year. Half the people in there are in there because of smoking. Lung cancer is not a very expensive disease. Why? Because we do nothing about it. Remember again these are poor and elderly so we just let them die. And it's very cheap then. If we did anything they'd be living longer and would cost more. So I think we should be examining why it is that if we have one disease we pull out all the stops, Hep.C, do the world and all, set up new units, new consultants, but if you have these diseases and you're poor and elderly you should be let die.

Chairman: I want to thank you on behalf of the sub-committee for an extremely incisive presentation. I think it will prove invaluable to us in coming to conclusions and making recommendations. Your suggestions will certainly be examined by the committee and |'ve no doubt that some of them will be taken on board. All in all it has been helpful to us and we thank you for coming before us.

Professor Clancy: Thank you, Chairman.

Sitting suspended at 11.5 a.m. and resumed at 11.20 a.m.

Ms Elaine Glynn and Ms Anna Gunning of the National Youth Council of Ireland, were sworn in by the Clerk to the sub-committee.

Chairman: The witnesses will now make an opening statement which will be followed by questions from the members, but before we begin I'd like to advise both witnesses that while the members of sub-committee enjoy absolute privilege, this does not apply to witnesses appearing before it. I'd also like to bring to the attention of the witnesses and the members, the fact that under the provisions of section 10 of the Committees of the House of the Oireachtas (Compellability, Privileges and Immunities of Witnesses) Act 1997, certain rights are granted to persons who are identified in the course of the sub-committee's proceeding. So, persons being invited before the committee are made aware of these rights and any persons identified in the course of proceedings who are not present may have to be made aware of these rights and provided with a transcript of the relevant part of the committee's proceedings, if the committee considers it appropriate and in the interests of justice.

Now, I will now invite you to make your presentation but can I just suggest to you there are 18 pages in your presentation and, really, what we want is an overview. We would prefer to spend more time at the questions and answers. So, if you could give us an overview of the presentation and then we will go immediately into questions and answers.

Ms Glynn: Okay, thank you very much.

Chairman: Do you want to lead off?

Ms Glynn: Yes, I will do the main sort of, summarisation of the text and myself and my colleague Anna will answer questions then after that. What I will do is I will actually just try and cut out certain sections and then read what I feel are the relevant bits because we believe that we have a certain expertise within this area that we wish to concentrate on. We believe and we've seen indeed this morning, that you have received a lot of information in certain areas, obviously around legislation and stuff like that, and we feel that our expertise lies in the area of education with young people. So we will be concentrating on that.

Good morning. We welcome this opportunity to make a presentation to the Sub-committee on Health and Smoking. The National Youth Council of Ireland is a representative body for Irish youth organisations and youth interests. We have 43 member organisations comprising youth clubs and youth service organisations, uniformed groups, special interest youth organisations and youth wings of political parties. NYCI has social partnership status, as one of the 18 designated social partner organisations. We take an active role in representing youth interests in a variety of fields, including youth work, education and training, employment, health, information, society and poverty and on North/South and international levels.

The National Youth Council of Ireland is also involved in a number of partnerships with Government Departments and/or statutory agencies in developing and promoting innovative interventions in a range of areas. One of these areas is health. The NYCI has been in partnership with the health promotion unit of the Department of Health and Children and with the youth affairs section of the Department of Education and Science for the past 12 years and together form the National Youth Health Programme. The National Youth Health Programme aims to provide a broad based, flexible health promotion/education support and training service to youth organisations and all those working with young people in the non-formal education sector. This work is achieved through the development of programmes and interventions specifically for and with youth organisations throughout the country and the training and support of workers and volunteers implementing these programmes.

The National Youth Council of Ireland produced a report in March 2000 on cigarette smoking and young people in Ireland with policy proposals for action. This report entitled, One in Three, highlighted our particular concerns with the issue as the incidence of young people who smoke is at 35% which is above the national average of 31%. Of particular concern, is the fact that 80% of all smokers become addicted between the ages of 14 and 16 years.

While our input here today will address issues such as legislation, policy enforcement and cessation, our principal concern is with the education and prevention aspect and we will concentrate many of our recommendations on that area. Within the youth work sector we feel we are well placed to address the issue as the particular setting of youth work is one which is ideal for education programmes of this nature. Youth work is based on a partnership between young people and adults, where there is a voluntary engagement of young people in the programmes and activities.

We welcome the Government's firm commitment to action to combat smoking and the National Anti-Smoking Strategy, the report of the Tobacco Free Policy Group, Ireland - a Smoke Free Zone, and in recent and upcoming legislation. The NYCI report, One in Three, called for multiple measures to address the prevention of smoking among young people in Ireland. Many of the legislative and policy recommendations made in that document are now in the process of being addressed or indeed, have already been implemented.

We welcome wholeheartedly the recent adoption of the conciliation text of the EU Tobacco Directive by the EU Council of Ministers. We call for the provisions of the directive to be recommended without delay by the Government. We welcome the drafting of the Public Health and Tobacco Bill to give effect to the proposals in the policy document, Towards A Tobacco Free Society, and would urge all due haste in introducing the Bill as a matter of priority in the Houses of Oireachtas at the earliest possible date.

We acknowledge the recruitment of more environmental health officers to improve enforcement and compliance with anti-tobacco legislation. However, these measures are dependent on a pro-active strategy of inspection, vis-à-vis environmental tobacco smoke and sales to minors. We recommend that such a programme be established at the earliest possible juncture. We repeat our recommendation that a licence system for tobacco retailers should be put in place. Repeated offending by such retailers should effect the removal of their licence.

We endorse the recommendation by Ash Ireland for a consistent increase in tax on tobacco products. The tax levied should be at a minimum rate of 5% above inflation each year. A proportion of the revenue generated, £25 million per annum as proposed by Ash Ireland in a submission to this committee, should be used to fund youth prevention and cessation programmes.

In 1999 the Minister for Justice, Equality and Law Reform introduced a voluntary ID card scheme as part of a provision in the Intoxicating Liquor Act, 1998. This scheme should be extended to include the sale of tobacco products which would, we believe, reduce the incidence of retailers unknowingly selling tobacco products to those under age. The current charge for such cards should be abolished.

We support the recommendation by Ash Ireland and the National Cardiovascular Strategy for the removal of tobacco from the consumer price index. We fully uphold the recommendation by the Tobacco Free Policy Review Group for a complete ban on any forms of tobacco display at point of sale. According to the Tobacco Free Policy Review Group there is evidence that the tobacco industry is not complying with existing arrangements regarding sponsorship, especially of local events. Existing controls need to be strengthened as a matter of urgency.

We welcome the establishment of a tobacco research centre and recommend that research be undertaken without delay into the reasons for smoking uptake among young people. Comprehensive research relating to the age of and reasons for smoking initiation, maintenance and cessation, and the sources from which children obtain cigarettes is needed to inform policy, legislation and particularly programmes for young people.

Section 2 deals with recommendations regarding health education for young people which we believe is the crux of this document. Health education is about enabling, supporting young people to set their own health agendas, agendas which they can then implement in ways decided by themselves collectively or as individuals. In our view an effective education programme should be holistic and comprehensive in nature, be applied across appropriate settings, including formal education, non-formal education, community, workplace and professional training. It should incorporate a message which is consistent across settings and levels and population groups. It should be developmentally appropriate, starting at early school or pre-school age. It should provide appropriate training for those facilitating or delivering programmes. It should be participative and empowering for participants, and this is one of the cruxes of what we will be talking about today. It should be monitored and evaluated and changed accordingly. It should take into account the need for targeting of specific groups and cultures and adapt the programme accordingly. It should be cross sectoral and inter-departmental as required and it should attempt to address gaps in health inequalities.

We should go into just a little bit more detail on some of those - particularly with regard to holistic and comprehensive health education. For many years Ireland, along with many other nations believed that the "just say no" approach, scare tactics or information alone were sufficient to elicit a desired change in behaviour in young people. The latest trap that we must avoid falling into is to believe that education efforts targeting specific topics, which we call vertical programming, such as smoking prevention will be successful by and of themselves. This is not the answer. A holistic approach to smoking prevention - that is health promoting as well as illness preventing - needs to be applied if smoking prevention efforts are to have any promise of success. Such an approach is settings based and acknowledges the need for environmental and policy measures as complementary to an educative programme. This approach also attempts to increase health resilience factors, also known as lifeskills among young people, as well as seeking to reduce risk factors such as smoking prevention. Such a comprehensive and holistic approach is more efficient because it is literally more radical. It gets to the roots of the situation. It addresses the determinance of health in young people.

The health promoting schools network and the health promoting youth service initiative which is run by the national youth health programme both encompass this comprehensive and holistic approach to health education with young people. They promote a whole school or youth organisation approach to health promotion and substance use and includes the development of supportive school climates, policy work, which is vital, curriculum models for health promotion and the active involvement of teachers and parents, which is also vital in work of this nature. Unfortunately the health promoting schools pilot network has in the past year been phased out of operation to allow for the development and mainstreaming of the social, personal and health education curriculum within primary schools. While we acknowledge that the SPHE curriculum needs to be embraced on a national level before a national network of health promoting schools can be successfully pursued we would urge that this holistic and comprehensive approach to the health of young people be reinstated and expanded as soon as possible. Given that the SPHE is currently also only mandatory in primary schools, it is unacceptable to us that there are present many post primary schools in the Republic without either a smoking policy or a life skills social personal health education curriculum. SPHE should be made mandatory at post level as soon as possible and smoking policy initiatives, such as those being implemented by the Southern Health Board, should be pursued with those schools who are willing and able to take part. In particular those schools that currently lack any provision with regard to health education should be targeted for provision of these services.

The health promotion youth service initiative is seeking to mainstream a similar holistic approach within the youth sector, addressing a whole organisational approach to health for young people. To date those organisations, their staff, volunteers and young people who have taken part have benefited immensely from this programme. To augment the success of this approach, a parallel programme of SPHE should be developed within the youth sector which will become an active curricular component of this health promoting youth service programme. This will serve to complement and reinforce the message and work of the schools based approach. But more importantly it will also provide vital access to those young people who lie outside the school system and who may require such assistance most.

The Joint Committee on Health and Children in its national anti-smoking strategy recommended that the current school programme should be extended to all schools and a teacher in every school, primary and post primary should be specifically appointed to co-ordinate within each school the proactive promotion of the anti-smoking message. The National Youth Council supports this move but recommends that a similar strategy should be implemented to the outer school sector. Embracing a holistic approach to health promotion, including smoking prevention requires changes to the ethos of each school and youth organisation and this is one of our most important points. Because in order for this to occur in a meaningful and successful way, each school and organisation must be provided with the resources, training, support and with regard to schools in particular, schedule times, to make such changes. In the current climate of points mean success, taking precedence within our education system, we cannot expect teachers and administrators to take such health initiatives seriously until the policy makers at the heart of our education system also do.

Just a very quick mention, I will briefly try to go through this, the settings approach, this is also a very important point in that it is important to acknowledge the fact that young people are an integral part of family, community and environmental settings. So we cannot just put them apart within a particular setting such as school and not address other settings within which they spend their daily life. Truly comprehensive health education involves community wide programmes and then involves school, parents, mass media, youth organisations, the workplace, community organisations and other elements of an adolescent social environment. In a net analysis of many other backup prevention programmes Tobler reported that embedding an interactive school based programme within a community based initiative doubled the impact of the programme. It is, therefore, vital that collaboration occurs within and between sectors involved in young people's health, education and well-being to ensure that synchronists and complementary strategies are undertaken which take into account and address all settings in which a young person operates. The National Youth Council advocates the establishment of regional health forums that address smoking and health with regard to young people at a local and regional level. These forums should utilise existing partnerships within the formal and non formal sector. Such a forum could be modelled on an existing and successful health forum organised by the health promotion department of the Midland Health Board. Young people should play an active, informed and formative part in such fora.

A focus on early children at risk is now advocated in several countries and in the recently produced Irish policy document for children. Developing the appropriate tobacco prevention education in pre-school and throughout the school year should, therefore, be provided. Such a programme should be tailored to students needs, interests and cultures. Programmes such as the Department of Education's Early Start and Breaking the Cycle initiatives should include a health promotion focus as a core element of their content and this should be continued upon entry to primary school.

Regarding appropriate and relevant training for those facilitating or delivering programmes, the National Youth Council fully supports research into and dissemination of the tobacco free initiative into third level curricula of all those professions most likely to have an effect on children. However, as previously stated, vertical programming that is topic based alone will have little effect without horizontal skills based programming. Therefore, health promotion as a subject in itself should be included in the curricula of all such professional qualifications. It should be non-elective and include topic based programmes such as tobacco use within its content.

Chairman: If I could stop you there. Your 15 minutes are up now and perhaps you just give us a brief overview of the rest because people have other meetings to go to today.

Ms Glynn: That's fine. I'll briefly address participation and empowerment. I'll read out our main recommendations. Obviously the centrepiece of what we consider to be successful tobacco prevention and control efforts is the positive promotion of youth development and active participation of them in programmes that concern and are for them. They should be actively involved in the planning, development, implementation and evaluation of programmes and policies that concern them. We would contend that research needs to be carried out to ascertain the most suitable methods of encouraging active participation by young people in smoking prevention policies and programmes. Most importantly, methods of peer education and peer research methods are valuable aspects of such participatory mechanisms which we are currently researching. We strongly support the formation of a national anti-smoking anti-tobacco youth organisation as recommended by the Joint Committee on Health and Children. Harnessing peer education, peer research methods and peer pressure to discourage youth smoking as in the case of Florida's SWAT programme is a practical and desirable development of youth empowerment and participation around smoking issues. The National Youth Council would be well placed to play an integral part in the facilitation of such youth groups.

The integration of media studies with informal and non-formal curricula is also a core requirement of youth empowerment. The media is the most potent communication system within our society. This is particularly the case for young people. Young people need to be made aware of the hidden operation codes of the mass and electronic media and particularly the advertising sector abuse of such media. Such education could become a potent weapon in informing and empowering young people to recognise that their so-called adult and so-called free choice to smoke has not been made so freely. This approach has been used to great effect also by SWAT in Florida to uncover the hidden agendas of smoking advertisements in the US. In a cross-section inter-departmental approach we would recommend that any kind of education programme of this nature should be cross-sectoral and all relevant Government Departments should be part of designing and implementing it. We give as an example the recent national children's strategy which proposed a national longitudinal study of children that will examine their progress and well-being at critical periods from birth to adulthood and this kind of information and access to it should be utilised in tobacco prevention and control.

In addition to an education programme being cross-sectoral any effective programme should also include a partnership approach involving the key agencies and the formal and non-formal education providers. Young people themselves should also be included in any partnership programme of education. Regarding health inequalities and smoking we acknowledge that smoking is significantly class-related. While one-third of the population are smokers this range varies across social classes. Similar class related results have been found in the HPSC survey among school children. To date there has been a dearth of information and any smoking policy or strategy arguments that proposes any practical methods for targeting, accessing and addressing such groups and issues. Many smoking prevention and cessation documents do acknowledge disadvantage and health inequalities as a key factor in differences in smoking rates. Yet a key avenue of access to disadvantaged young people, that is the youth sector, is not tapped adequately within their strategies or recommendations. We would ask that research be undertaken to ascertain appropriate, culturally specific and acceptable smoking interventions with disadvantaged and socially excluded young people. In particular, peer-led programmes should be assessed as a valid method for reaching such groups. To date, any mention of the national anti-poverty strategy and its current view are absent from the discourse surrounding smoking prevention and cessation. Yet health is one of the key target areas of the last review document. The underlying determinates of health inequalities as outlined by the last review need to be acknowledged and addressed by those seeking to decrease smoking rates in our society. Holistic and comprehensive strategies to address this will require inter-departmental and inter-sectoral collaboration if smoking behaviour among adults and children is to change. The non-formal youth sector and the NYPI in particular can play an active and co-ordinating role in reaching disadvantaged and socially excluded young people.

Regarding monitoring and evaluation we would contend that it is vital that all smoking control strategies be evaluated, be they legislative or programmatic in nature. We must look into and learn from best practice here and elsewhere and avoid re-inventing the wheel or repeating mistakes. Unfortunately this has not always been the case to date. The National Youth Council propose the establishment of a consultative panel of young people drawn from different cultures and areas of the country to be involved in evaluation and implementation of media campaigns in particular as well as other programmes and legislative efforts.

Regarding cessation services for young people, we would bring to your attention that the World Health Organisation in the ranking of the addictiveness of psycho-active drugs nicotine was determined to be more addictive than heroin, cocaine, alcohol, caffeine and marijuana. Therefore, smoking cessation interventions need to be targeted at young people who become addicted between the ages of 14 and 16. The following recommendations should be put in place on a nation-wide basis. Nicotine-replacement therapy has been made available to medical card holders since April of this year. We recommend that NRT be made freely available to all young people and indeed to all people who need this service. The cardiovascular strategy states the interventions provided by professionals have been found to be cost effective in comparison to other youth and health-care resources. In acknowledging the importance of cessation services to young people as a distinct group, we recommend that community-based health professionals should be trained in youth appropriate cessation programmes. These professionals should be available to and act and proactively engage with the youth sector as necessary. Such youth appropriate programmes should be developed in partnership with young people to ensure maximum success. The Eastern Health Board, in its draft Regional Tobacco Control Strategy states that the area health boards will provide training and resources in brief interventions and motivational interviewing for teachers and guidance counsellors in schools. In order to access the widest number of young smokers ..

Chairman: I'll have to ask you to wrap up now.

Ms Glynn: We're just finished now. In order to access the widest number of young smokers, particularly those living in disadvantaged circumstances, such training should also be provided to youth workers. Research needs to be undertaken into what kind of cessation programmes are most effective and acceptable to young people. In conclusion, it must be recognised that approach to smoking control which concentrates on legislative or health education alone which targets only young people rather than adults as well, which implements strategies in single settings, such as schools, while ignoring key settings within which people live their lives and which does not actively involve the target group it is seeking to address will ultimately fail. It is only through utilising the key channels of health promotion, multi-sectoral collaboration, multiple approaches, multiple settings, multiple populations and evaluation at all stages of the process that our war against tobacco has a chance of success. Integral to this approach is the acknowledgement that smoking is no longer just a matter of health policy but of public policy. Thank you.

Chairman: Thank you, Elaine, for a very extensive document, maybe some of the members would now like to ask questions. Deputy Gay Mitchell?

Deputy G. Mitchell: Two brief questions. First of all, evidence given to us earlier this morning by Professor Luke Chancy included a view that, particularly among young women where there is an increasing number of smokers, rebelliousness, people rebelling against their parents in the home might be part of the reason people decide to smoke. It is not the most brazen rebellion but, so my question is this. Has the National Youth Council any view as to how and who would most effectively get the attention of young people - I mean we can have all these networks but we must get their attention for this issue. The second thing is what about the price of cigarettes? How will that affect young people and their disposable incomes? If we make cigarettes absolutely prohibitive in pricing, if we were to ban selling in tens and sell only packets of 20 at the price that they cost and more, what does the National Youth Council feel about that, have you done any research or have you any ideas in relation to how that sort of pricing might affect the consumption of cigarettes by young people? Thanks, Chairman.

Deputy Keaveney: I'm just thinking about the number of things there at the start of the presentation that were to be done in school and I can just listen to the teachers saying "ah, more work for school time, when we're trying to get music and PE and things like that" but I can see how it can be integrated in the existing subjects. I would be more focused on the out-of-school activities that you would have the arm into and the fact that you represent so many organisations. Do you get a chance at the moment to look into issues like the media, pure media like what happened in Florida because to me that seemed to be the way in, to use either children themselves talking to other children? I think a pilot project rather than a national thing would be useful, given that in counties like my own one or two radio stations cover the whole place and you could do a very, very good package easily. I wonder whether you have looked at the concept of bringing in local sports stars? I heard, I think, one of Westlife saying that alcohol is the biggest drug we had in the country and that we are worried about all the other drugs. A local star saying that has far more impact than anything parents and teachers say. You're right about the family approach that needs to be done. You say there that you're one of 18 designated social partnership organisations. I suppose all that I said before this would rely on funding. Have you made applications for funding on any of this type of thing already and maybe been turned down or currently pending? I suppose the most important question is where stands this issue on your list of priorities as the Youth Council of Ireland, it is important but where does it stand on a general basis in terms of priorities? I know Donegal County Council intends to but I'm not sure whether all county councils are talking about bringing in youth councils and youth foras that will be linked into that kind of development of the health boards and perhaps that will be another forum through which we can move a lot of that stuff. Perhaps there could be a pilot zone - maybe through local media - but it will need funding and to be led by groups that are exclusively dealing with youth. I think maybe you have a pivotal role possibly to play in that.

Ms Anna Gunning: Maybe I will start with the last two points you made there in relation to the application of funding. The National Youth Council, through the National Youth Health programme has been involved in making a number of petitions around particular areas but, as Elaine said we have also tried to move a little bit away from the vertical programme. We are just doing a one off smoking programme and we have moved very much to the health promoting youth service type approach which is the holistic approach, working with young people over an 18 month period and training them in a whole range of aspects including smoking, alcohol, etc., but really in a health promoting avenue. I suppose as well we would have applied and we would have inputted quite a lot to the drugs strategy discussions and through the young people facilitating the services fund.

One of our issues around that I suppose was that while we welcome the fund's targeting of particular areas and the areas of most need, obviously in relation to heroin etc., we have constantly said that we would like it to look at a more national level, at prevention, at where the beginnings of some of the drug problems possibly are. That may be smoking, it may be alcohol and I suppose we are a little bit disappointed with the latest strategy that has come out for 2001 to 2008 that while it has moved in that direction we want to see a general national strategic approach to health education, particularly in the area of substance abuse. NYCI did take on to do that report in March 2000 and from that a number of recommendations we're delighted to see have been followed through but really we are continuing to follow up on them now and have been involved, Elaine will say a bit more about it but maybe in a substantial way, in an alcohol education programme in partnership with the Department of Health which I think really could be a very good model for how we look at the whole area of smoking as well in that it was a promotional campaign with the health promotion unit to deliver a message to young people about alcohol education. Something like that I think would be quite successful in the area of smoking as well and something that we would be looking for.

Ms Glynn: You mentioned there about the chances to look into the issues of peers and work through the media and matters like that. We are currently undergoing research around participative research methods with young people which involve actually training young people as peer researchers to go out and interview their peers. We are also looking into developing a pilot programme as part of this research, we are using alcohol as the particular focus point at this particular one at the moment but it's about asking young people how they feel they could be involved in policy making at a local, regional and national level and what they think has been done to date, I think that is really what is the crux of what we are about. I think we can all sit here and theorise until the cows come home about what we think causes or prevents smoking, but we really have to get down to the nitty gritty, put our money where our mouth is and ask the young people themselves because that really is where the answer lies. They won't have all the answers given their lack of experience and other factors but they will have a good proportion of the answers that actually will work because they are the ones who suggested them. By giving them ownership within a project or a programme or within policy making you ensure their ownership and the fact that they will take it on board much more easily. I think that is a target.

There was a question around young people and rebelliousness and wanting to be adult and that is a huge factor but we must not negate many of the other factors, the influence of seeing parents smoke, peer smoking, of cues in wider society around the acceptability of smoking and, unfortunately, it's not the answer that everyone wants but overall we must change the social norms within society and the attitudes towards smoking before we see a decrease in young people's attitudes to smoking also. Yes, they want to be sexy. They want to appeal to the boy down the road by having that cigarette in their mouth and I think also peer approaches and peer education could come in there. I was at a conference two years ago where there were students from representative schools in the area who had an open discourse in front of the adult present and some very interesting things come up, how they said they would welcome peers giving them information on smoking and finding out that maybe the boy that someone fancies in the next room or in the next classroom doesn't actually find smoking particularly sexy. They are the small elements but we have to take into account the wider issues as well including role models and product placement in the media which is huge. We can do everything we want around advertising but unless we address product placement - that is how it is currently impacting on young people in the programmes they watch.

Senator O'Meara: Thank you very much for comprehensively setting out the issues as you see them. Your remarks about the involvement of young people are very important, but you did not speak about marketing, the clear targeting of young people by the tobacco companies, their major success and our failure, and I would use a wide collective "we" there. The fact is, as the statistics which you have quoted clearly show, the tobacco companies are successfully targeting young people with the product and we are not doing anything effective about it. We can talk until the cows come home about involvement, talking to young people and whatever, but unless we get down to the nitty gritty which is that the marketing strategies of the companies are working and we are not dealing with that -----

Chairman: Perhaps you would also deal with the SWAT programme as well when replying to Senator O'Meara.

Senator O'Meara: A much more radical approach is needed. We must stop pussy footing around on the matter. We need some hard hitting strategy and we are not getting that at any level. I accept that it is a priority of the National Youth Council, but I suggest that everyone involved needs to give it a far greater priority.

Senator Jackman: Is there a section of society that you do not reach in that while some young people join youth clubs, quite a number do not? Do you deal exclusively within your own member groups or have you a policy to extend? You mention that the health forum was very successful in the Midland Health Board. Perhaps you would say something briefly on that because you state that you would like it to be the norm for regional health boards to be established.

Ms Gunning: To go back to your point about targeting young people and the tobacco companies, at the end of the day a lot of it does go back to money. The tobacco companies are ahead of us as was said yesterday and again today. They have money and they have no problem pouring it into programmes targeting the most vulnerable, and that's young people as far as we are concerned. And I suppose, if we had the money, it's not just about programmes and preventative work but about options for young people. You have spoke about sports stars and using sports stars. It's not just about, as I say, education programmes, it's about putting in sports facilities, looking at the primary and post primary schools, youth organisations, sports clubs and building up a good network of viable alternatives for young people, I suppose the healthy option really. And it's also putting money into research which we haven't done. Research is always the bonus, particularly in the youth sector. If we can get money for research, it's like wow, that's great. We wing it a lot of the time, with regard to statistics it's anecdotal, etc. In relation to the groups of people that we work with, the National Youth Council has 43 members but because the National Youth Health Programme is in partnership with the two Government departments, Health and Education, its remit is actually wider. So we work with Youthreach, the community training workshops, the out of school young people who wouldn't necessarily be in youth organisations. There's a huge growth in community based youth projects that would in many cases, with these organisations, be dealing with those most unattached. I think our mailing list of youth groups would be into thousands, well above the membership of the council itself.

Ms Glynn: I'll just address the question round the Youth Forum in the Midland Health Board. It has been very successful to date. It's actually still in quite its infancy in many ways, but basically it came out of the youth forum as a resource recommendation, that was one of the recommendations, that essentially what had been found was that in the different services acting upon their areas, some people fell through the cracks in between services. This was in an effort in a health promoting rather than just illness prevention way, to get all these services together, both non-formal and formal, so it would be schools, it would be the health services, the health boards, the youth organisations and the community organisations. Anybody who came into contact with a young person in that area would get together and talk about what they were doing, making sure that they were not duplicating too much, that their approaches were complementary, that the same messages were being given to the young person, so that no matter what field the young person moved from within their day-to-day life they were getting similar supports and that it was never a matter of somebody dropping off the face of the earth, that nobody quite knew where Jack went to. It was that if Jack left there, if Jack left that service, Jack was immediately onto another service who had him, it was a monitoring service also in that sense to make sure that no young person in any type of need was left alone. But it has also been about improving the health of those who are not necessarily suffering from any illness or have any health related problems or are at risk, it's about promoting the health of all the young people within that region or area.

Senator Glynn: Given our failure in relation to having made any great impact, I am a member of the Midland Health Board and I thank you for selecting my board. However, really we are whistling past the graveyard. Aren't we? Because given all that has been done, all the reports, all the forums that have been set up, we don't seem to be winning the battle. We are winning it at one end of the spectrum but losing at the other. You have 43 constituent organisations associated with the National Youth Council of Ireland. Are you aware of the incidence of smoking among the members of any of those constituent organisations? Numerically, approximately how many young people are you talking about?

Deputy Kenneally: You say very early on in your submission that the number of young people who smoke is at 35%. You say the number who become addicted are between the ages of 14 and 16 years, but what age group is this 35% taken from? You go on and mention the recruitment of more environmental health officers to improve enforcement and compliance with anti-tobacco legislation. I'm not aware in my own particular area that additional environmental health officers have been taken on, and indeed if they have, I have certainly not heard of anybody being prosecuted for selling tobacco to people who are underage. If they are there, it would appear that it is not a priority of the health boards to enforce that legislation. That sort of leads on into another area, you mentioned the ID scheme that was previously introduced as a voluntary scheme and was mostly to tackle the alcohol problem. Given the problems we have now in the number of underage people who are drinking and buying tobacco products, what is the view of the National Youth Council of Ireland on the introduction of compulsory ID? We are not doing enough to tackle the problem and the introduction of compulsory ID would be one way to remedy that. You mentioned the SPHE programme which is now running in primary schools. I forgot to ask Professor Clancy about the number of consultants who are perhaps warning people against the dangers of smoking and at the same time are smoking themselves. The same applies here, that perhaps there are teachers who are trying to educate children but are not leading by example. It is a case of do as I say rather than do as I do. I wonder how effective it can be for that reason.

Ms Glynn: I'll address the SPHE programme. I agree with you that it is problematic that we have significant role models for young people who would be doctors, teachers, or whatever within the community who are smoking and yet be giving anti-smoking messages. That's something that needs to be tackled but cannot be tackled easily. That is why we would call for a reinstatement as soon as possible of the health promoting schools network because it is a whole school approach to smoking prevention and to other health promotion issues and prevention in that it is not just young people who are targeted within the health promoting schools network it is also the staff, parents and the community. Therefore in policies being drawn up around smoking in schools these would also impact upon teachers and also hopefully if any cessation programmes are run that they would also be ones that would be run with teachers. We cannot actually deny the fact that it is an addictive problem so it's not as simple as saying to teachers do not smoke. You can say do not smoke in front of young people and they will still try but will inevitably be caught running around the back of the school yard if there's no smoking or whatever. So, it's about a whole school approach, a holistic approach to health promotion where you're actually addressing issues for the staff, volunteers in the case of youth organisations and young people, not just targeting young people themselves but all of those around them as well.

As regards the ID scheme, that is a very tough one. We've even had discussions internally, even within the National Youth Council there are people who personally believe it should be compulsory and there are those who would have reasons for it being voluntary, so I don't know.

Ms Gunning: To date we haven't really come down on one or other side because our main issue would be around the effectiveness of a compulsory ID scheme and how effective is it. We feel travel cards or other systems of ID can be copied and there can be cheap imitations. I suppose all I would say is, you know, don't put all our eggs in one basket. It's not going to get rid of the problem. There are other strategies that need to be done. Maybe we do need to go back and look at it but I don't think we can say compulsory ID is the answer and that under 18s aren't going to get cigarettes.

Deputy Kenneally: It might be part of it.

Ms Gunning: It might be part of it and maybe it does need to be looked at like that. As I say, we're continuing to look at it but maybe there should be a little more research into that, how it is used elsewhere, does it work and is it effective.

Ms Glynn: An issue to date has been the fact that they have yet to find a card that can't actually be copied on the black market, whatever you want to call it and it is not something that we can actually sit around and discuss in all openness until we can say that issue is okay - now we know that it certainly cannot be copied, now let us discuss the merits. Whereas at the moment while it can be copied, voluntary or not, it will only have a certain level of success.

Senator Glynn: Are you aware of the incidence among the membership of your constituent organisations –

Ms Glynn: We wish we had the money we need to research such issues. Obviously it would help us with more hard hitting messages if we could do that, but I'm sorry to say that we don't have it.

Senator Glynn: I asked that question because it is very important that those who are giving example give the right example.

Ms Glynn: Yes, absolutely.

Chairman: We have ASH, the Department of Health and Children, the Department of Education and Science, we have your own youth council and other groups as well all involved in the anti-smoking and it just strikes me has the time come when perhaps there should be a fusion of the service because in your own presentation there's an overlap between what ASH are saying, what the Minister is saying, what the Department is saying, what our report stated. There's a lot of commonality there and everybody tells us that, you know, we arenot in the race at all in terms of advertising with the tobacco companies but it appears to me that there is a tremendous amount of resources being wasted in the vast number of groups and organisations that are in this business and that if there is a far more co-ordinated approach to this particular issue then, perhaps, more funding could be made available to fight the very issue that we are talking about.

Secondly, can I ask you about the SWAT programme in Florida? We were particularly interested in this particular programme because what was involved was young people coming together devising advertisements and coming from their own thinking as it were rather than, you know, the older generation thinking about an ad., presenting that ad. and it not being meaningful to young people. The success rate with the SWAT programme was quite high. So, I just wondered did your federation ever think about piloting a programme, a SWAT programme in Ireland, because the great difficulty, if you look through your presentation, is that there are about five different instances where you say that they should be part of the school programme or the teachers should be involved. Cecilia is quite right, I can see teachers recoiling and saying "not more of this again". So, I just wonder what your organisation in terms of a pilot programme can do specifically in the SWAT area because this is a proven entity in Florida and it seems to be one area as a youth group that you, when you say that 80 % of people are addicted from14 to16, would ideally get involved with?

Ms Glynn: Yes, do you want me to respond to that? Absolutely, I think it has proven very successful and it's an approach we would be very keen to see adopted. It's something obviously that we would like to look into but, obviously, that is subject to resources, money, people and time and it always comes to down to that because we have so many wonderful ideas that we think could be great that we should pilot and could pilot around various interventions, activities, policies, whatever else, and we can't do any of it because at the end of the day it can be fair to say that sometimes the youth sector can draw some short straws regarding funding, that it can be hard to get the money you want to do everything. I suppose everybody would find that to some degree. Subject to having the funding and the personnel we would be interested in, certainly in acting and piloting a programme of that kind particularly because we feel that we have that specific expertise within Ireland, which very few others have, around participative methods with young people, around working with young people, in active approaches to health education and to education in general that the school sector doesn't have. It's much more chalk and talk methods and didactic methods while we move away from that deliberately and involve young people in their own programmes.

So, yes, we would be very interested, subject to funding and resources. On the previous point that you made, I think it is very important. It's coming back once again to an inter-sectoral and collaborative approach among Departments and I think the difference between us and the tobacco companies is that they have been a united front to date. We haven't been quite so united. I think it's back to the 'united we stand, divided we fall' and if we can in some way unite ... I think it's very interesting, although there were several overlaps and we could even see that while we were watching the last presentation from the waiting room, we were pleased to see that we were right in targeting on a specific area to us which was education with young people in the non-formal sector and education with young people in general. We believe that the various parties can bring their strengths to the table and by uniting all of those strengths together we might actually have half a hope of actually combating this issue.

Chairman: Well maybe this sub-committee can be helpful in that regard.

Ms. Glynn: Indeed.

Chairman: I'd like to thank you both, Elaine and Anna, for appearing before us and for answering the questions of members. Those answers have been very helpful to us and, in particular, we'll take note and cognisance of the recommendations that you have included in your presentation. Thanks very much.

The sub-committee adjourned at 12.15 p.m.

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