In the absence of Deputy R. Shortall and Senator D. Fitzpatrick, respectively.

Deputy B. O'Keeffe in the Chair

Mr. Jerry O'Dwyer, Secretary General, Department of Health and Children, in attendance.

Chairman: I welcome Jerry O'Dwyer, Secretary General, Department of Health and Children and his two officials. He has been invited here to discuss the Department's strategy statement with particular reference to health promotion. I remind the delegation that Members are covered by privilege but witnesses are not. I also remind Members that under the compellability legislation civil servants are not allowed to question or give an opinion of any Government policy. I now invite Mr. O'Dwyer to make a statement and it will be followed by a question and answer session.

Mr. O'Dwyer (Secretary-General, Department of Health and Children): My statement addresses health-promotion, but during the committee's discussion with Mr. Fitzgerald, there was a heavy emphasis on smoking. Most people will be familiar with the fact that the Department has been seriously involved at various levels of health promotion for a long time. The strategy which relates to health promotion was published in 1998. It builds on the 1994 health strategy, Shaping a Healthier Future, which started the process of change for the health services and the Department. It required us, in broad terms, to focus a great deal more in relation to bringing the overall health system together in such a way that we would seek to make very substantive changes in both morbidity and mortality and the quality of life of people that we serve.

In that context, health promotion is an important part of the overall strategy we are pursuing. It must be considered in a context where lifestyles and health behaviour have become crucial concerns for public health and health status. This is in response to the patterns of disease and illness which predominate as this millennium ends. They are very different from those which were prevalent 100 years ago. At that time sickness and ill health were largely the result of bad sanitation, poor working conditions and overcrowding in the home, workplace and urban dwelling areas and were predominantly characterised by infectious diseases. Patterns of ill health today are distinguished mainly by the high incidence of chronic degenerative disorders such as cardio-vascular diseases and cancers and, therefore, as we enter the last year of this century health promotion has emerged as a growing response to this pattern, which is influenced by lifestyle and psycho-social factors.

There are five fundamental underpinnings for health promotion - to build healthy public policy; to strengthen community action; to create environments that are supportive, where the healthy choice is the easier choice; to develop personal skills and to make sure that the health services are oriented towards health promotion. The latter is not easy given that the expectation of our health services, by and large, is to deal with illnesses and disease and to try and make sick people better quickly and get them back into the community.

There has been a health promotion unit in the Department since 1988. It arose after the Health Education Bureau had been there for 10 years. The unit has two main functions. First, it serves as a policy making unit in regard to health promotion and, then, in regard to certain national programmes and initiatives, as an executive unit. Recently, it has taken on a role in encouraging and developing the health promotion function within health boards.

There is a health promotion unit in each of the eight health boards. We also support that function with a national consultative committee on health promotion and, under its auspices, two reports were produced entitled "Health Promotion for Young People" and "Health Promotion in the Workplace". In keeping with the understanding that health promotion is most effective when considered inter-sectorally, this committee has wide ranging representation from other Departments and key bodies in the statutory and voluntary sector.

An additional support for the functions lies in the Centre for Health Promotion Studies, which is located in NUI, Galway. The centre is headed up by a professor of health promotion and it has been the main academic training area for health promotion. The Department initiated the establishment of that chair and supported it for seven years.

I wish now to turn to the policy we are trying to pursue. We brought forward a number of relevant policy documents, most notably, "Nutrition Health Promotion Framework for Action", 1991; "Recommendations for Food and Nutrition Policy", 1995; "National Alcohol Policy", 1996; "National Health Promotion Strategy", 1995; "Young People's Health Promotion", 1997 and "Health Promotion in the Workplace", 1998. We are currently working on a health promotion document to address the health needs of youth at risk as well as a review of the national health promotion strategy, which was carried out last in 1995.

The unit has been responsible for initiatives and programmes in many settings - schools, home, workplace, community and hospitals - and addressing many issues directed at key target populations. Consistently, the main issues to have been addressed are those most allied to the lifestyle risk factors associated with current patterns of morbidity and mortality. Cancers, heart diseases and accidents are how these patterns manifest themselves and, consequently, the main issues to have been addressed are smoking and nutrition. but the areas of HIV/Aids, drugs, oral health, mental health, exercise and safety have also received attention.

One of the critical requirements in this area is to understand what is happening and how effective any intervention is or might be. We have increasingly paid attention to the question of research. In recent years, we have built a monitoring and evaluation initiative into every programme and we have commissioned the first national lifestyle survey which we entitled, "Slán". It was administered to more than 13,000 during 1998. The results of the survey will be available shortly and will be of considerable benefit in targeting future actions on a range of lifestyle related issues, including smoking.

I wish now to refer to smoking. Over the past 30 years the potentially lethal hazards of tobacco as they affect the individual smoker have been scientifically proven. It is a major cause of lung cancer, chronic bronchitis, emphysema and coronary heart disease. It increases the risk of arteriosclerotic peripheral vascular disease, which can lead to gangrene and limb amputation. We reckon that 6,000 deaths annually are attributable to smoking. 90 per cent of the 1,500 deaths from lung cancer, which occur here annually, are attributable to smoking and, while men have traditionally suffered more from this type of cancer, an increasing proportion of cancer deaths among women is due to lung cancer. Smoking also increases the risk of other cancers, such as those of the mouth and throat. If we could eliminate smoking it would be the single most important means of reducing the incidence of cancer in Irish society.

Smoking is also a major risk factor in cardio-vascular disease, the greatest cause of mortality in Ireland, and increases the risk of strokes. Women who smoke while pregnant put the welfare of their babies at risk and recent research has also shown that parental smoking appears to increase the risk of sudden infant deaths. Relatively recently, the hazards of environmental tobacco smoke have become known, affecting the passive smoker as well as the smoker. These include an increased risk of lung cancer and respiratory disease and, indeed, evidence is emerging that mothers who have been exposed to environmental tobacco smoke may have an increased risk of having a low birth weight baby. We know that in the last number of years that we have not been winning the battle in regard to the number of smokers.

There is persistent prevalence rate of 30 per cent in the total population. While the overall consumption of cigarettes has decreased, a situation now exists whereby, having decreased from 45 per cent in the 1970s, there now appears to be a hard-core of smokers comprising 30 per cent of the population. We will know more about that when the results of the lifestyle survey are assessed and published.

Obviously we attach a high priority to the issue of smoking. We have consistently delivered a range of anti-smoking campaigns since the health promotion unit was established in 1988. The latest media campaign is targeting smokers and follows on from the "I'm one less" campaign from 1993 to 1995 on which £600,000 was spent. £700,000 was spent on the "Say what you like, smoking kills" campaign which ran from 1995 and 1997. The spending on the current programme - "Break the habit for good" - is approximately £500,000.

It must be acknowledged that the most creative multi-media campaign imaginable, cannot, by itself, dissuade people from smoking or encourage smokers to quit. Nor can it provide the necessary and all-important support and help needed by the smoker when quitting. A reduction in the incidence of smoking can be achieved only through a concerted effort by health professionals and the general public. It is vitally important that the health promotion initiatives are complemented by a strong body of legislative environmental controls which are kept constantly under review.

Smoking is now prohibited in many areas frequented by children, including schools, childcare centres, pre-schools, crèches, playgroups, day nurseries and other services which cater for children. Smoking is also prohibited in public areas in banks, building societies, barber shops, hairdressing salons, bowling alleys, bingo halls, bridge centres, hospitals, doctors' and dentists' waiting rooms, taxis and hackney cabs. New restrictions on smoking have been introduced in cafes, canteens, restaurants and snack bars providing for specified non-smoking areas. Taxation on tobacco has increased in each budget. In addition the maximum allowable expenditure by tobacco companies on advertising and sponsorship was cut by 5 per cent in both 1996 and 1997. The current overall expenditure on sponsorship by tobacco companies in Ireland is less than £2 million each year.

We are currently reviewing smoking controls and we hope to bring proposals to the Minister very shortly. We are also taking action against smoking in various ways at health board level and in the voluntary sector. The health promotion unit, in association with voluntary agencies active in this area, produce a range of materials including leaflets and posters containing information on smoking and encouraging smokers to quit.

Obviously, one current issue is that of smoking control polices in the workplace. The voluntary code on smoking in the workplace was developed by the health promotion unit of the Department with the support of the Irish Congress of Trade Unions, Irish Business and Employers Confederation, Irish Cancer Society, Irish Heart Foundation and the Health and Safety Authority. The code is included in a booklet entitled Working Together for Cleaner Air which was distributed to over 5,000 companies, State and semi-State institutions in late 1994. It encourages a consensual approach to smoking control policies through a consultation process between staff and management interests. As Mr. Fitzgerald informed the committee when he was here, a recently conducted review of the code among employers suggests the voluntary approach has been "very well" or "well" received by 88 per cent of respondents to the survey.

However, the battle must go on and this issue is being re-examined. Prima facie, at this stage we have created the goodwill and conditions in which legislation will perhaps not only be well received, but will be made to work better. There is always a difficulty in striking the right balance in being supportive, helpful and enabling while not turning people off by an intolerable level of interference. In this instance we believe the voluntary initiative preceding the legislation has probably created a much better environment and climate in which legislative restrictions can be enacted and made to work.

The health promotion unit also co-ordinates two school programmes which seek to prevent young people from taking up smoking. The smoking reduction action programme -SCRAP- is a peer-led anti-smoking programme for schools. It was developed by the Department of Health and Children in conjunction with the Irish Cancer Society and the National Youth Federation with the support of the Department of Education and Science. The second programme, the smoke busters project, which is aimed at primary school children aged 7 to 11 in an urban environment, was developed by the Irish Cancer Society, the Department of Health and Children, the Department of Education and Science and the Eastern Health Board. Action against smoking also continues at health board level and in the voluntary sector.

I will not continue for much longer but I would like to be as comprehensive as possible. If we consider what we have achieved through the measures taken over the past 20 years, the prevalence of smoking has reduced from 45 per cent in the mid 1970s to between 28 and 30 per cent in the 1990s. There is better public awareness of the dangers of smoking. Everyone now acknowledges that tobacco seriously damages one's health. Up to recently we have been accepted by many countries, certainly those within Europe, as leading the way in the fight against tobacco. Many initiatives now being taken in Europe are to some extent modelled on what we have done in the past 20 years. Importantly, restrictions on smoking are now accepted by and popular with everyone, including smokers. Tobacco advertising is relatively low-key in Ireland and the sponsorship arrangements are dwindling each year. The tobacco industry accepts the inevitability of further restrictions.

There seems to be a correlation between the level of education and income and the willingness of people to smoke. There is now a growing gap in the level of smoking among those in the lower income groups compared to those in other groups. This issue must be focused on.

At present we are thoroughly examining the areas of concern and our position in terms of opportunities arising in relation to a major initiative which must be reflected in a variety of efforts. First, after many years there is agreement within the EU on a directive which will curb advertising and sponsorship. Second - and this is important - there is much more information available on tobacco companies and how they are targeting their markets. Third, we are about to receive the results of the Slán lifestyle survey to which I referred.

We have already launched a major initiative in improving cancer services as part of the strategy. We are about to receive a major report which will form the basis of a cardiovascular strategy. These two main areas which derive from the level of smoking will now have to be complemented by a more comprehensive, focused and stringently enforced programme in relation to smoking.

We have very distinct intervention strategies and improvement of service strategies in relation to cancer. It is proposed to introduce an inclusive strategy on cardiovascular conditions which will make very serious recommendations in relation to prevention and health promotion. Set alongside that will be an energetic and imaginative strategy for tackling the 30 per cent problem.

Given the addictive nature of tobacco we have to focus disproportionately on children. All the evidence suggests that once people start smoking it is extremely difficult to stop. There is evidence to suggest that, no matter what the tobacco companies may say, their marketing tactics and advertising are aimed at young people. One of the disturbing statistics is that about one-third of boys and one-quarter of girls are smoking at the age of 17 years old. That is not a very comfortable statistic.

We also have to look at the need to assist people on low incomes to try to come to grips with the problem of smoking. The impact which the cost of smoking makes on people on low incomes is very serious. It is extremely difficult for people to turn away from smoking given the addictive nature of tobacco.

Our meeting with the Committee comes at a very good time. We welcome the focus on this issue. Anything which encourages dialogue on this issue is helpful. I am not in a position to outline to the Committee today, because it has not been submitted to the Minister, the wider policy initiative which we are at an advanced stage in putting together. Obviously I will be as helpful and as informative as I can.

Chairman: Thank you. I would like a definitive statement from the Department of Health and Children. You mention the addictive nature of smoking. We are trying to establish if tobacco companies will admit that smoking is addictive. What is the view of the Department of Health and Children? Would you say smoking is addictive rather than using the phrase "the addictive nature" of smoking?

Mr. O'Dwyer: The Department of Health and Children have always considered smoking to be addictive. We probably consider it more addictive than heroin. One does not have to look too far to see the difficulties encountered by people wishing to give up smoking. The evidence which is emerging - particularly the material emerging in the United States - tells us it is undoubtedly addictive. What is of concern to us is that it may well be that when the full picture is known about the composition of cigarettes, particularly those sold to young people, that positive measures are taken to ensure that not only is it more tolerable to smoke from a physical point of view but it is more addictive. A great deal of information is becoming available on this issue. Each side has its own view on this matter. We are operating on the basis that it is a highly addictive substance and will continue to be so. We believe, for example, that cigarettes sold in packs of ten as distinct from 20 might even be marginally more addictive.

Chairman: Private individuals are taking cases against tobacco companies and this morning's news of a major movement in California in that direction. The Minister made an announcement to the effect that he has set up a committee to examine the possibility of taking an action against tobacco companies. At what stage is this committee relative to its report? I tabled a motion at the Southern Health Board meeting asking them to outline the costs involved for one year in treating smoking related diseases. Given that they had no information in that regard, is the committee seeking such information from the health boards? What period will they cover?

Mr. O'Dwyer: Consideration of what the policy position on this issue should be is at an advanced stage. I outlined the broad approach to be taken in relation to releasing a major policy statement on smoking during the first half of this year. The position which the Minister will take on litigation will be part and parcel of that. One can look at it as a tool in the armory. It is important to look at the European situation as well as the American one and the common law countries, in particular. We are very much in touch with the situation in Europe. We must also bear in mind that we are dealing with a global industry which, tend to be, is managed globally. National tobacco entities comply, by and large, on crucial matters, with globally determined policies.

We have been very diligent in acquiring all the relevant information on what has taken place in the United States. We keep in touch, through the Commission and our contacts with individual countries, with what is happening in Europe. Whatever decision is made, our view is it should be taken in a wider context of an overall policy which links all the possible initiatives which can be taken.

It is very difficult to identify costs because one then has to define what one is including. If we take the studies which have been conducted in California, in particular, one could actually argue a case that our expenditure is as high in relation to all aspects of smoking related diseases which would include expenditure outside the health services. This is expenditure which arises as a result of disability etc. One could reach a very high figure, perhaps as high as £1,500 million a year. I am not quoting that as the figure. Within the hospital system, the probability is that we could expect to directly attribute £500 million to smoking related diseases.

Deputy Gormley: I thank Mr. O'Dwyer for his very interesting presentation. He mentioned there is a real problem now with degenerative diseases, cardiovascular and cancers. Would he accept the WHO finding that 80 per cent of cancers are environmentally linked? I understand they have released that statistic. Can you explain how our cancer register works? I know in some States in America they have a very comprehensive cancer register so that they can identify where the cancers come from.

Some states in America have a very comprehensive cancer register to identify where cancers come from. You said you know how many lung cancers are caused by cigarette smoking. If this is so, can you identify how many lung cancers are attributable to breathing in polluted air in the city? For instance, breathing in polluted air in Mexico City is the equivalent for a child of smoking two packs of cigarettes a day. This is the latest statistic from the Lancet magazine. Similarly in Dublin, where we are breaking WHO limits, breathing in polluted air must be the equivalent for children of smoking a pack of cigarettes. I welcome the curbs in environmental controls in relation to smoking. There should be similar curbs in relation to pollution from vehicles? Statistics now show that diesel fumes from buses are very dangerous in terms of health. Should the Department of Health be pushing for curbs on car advertising if we are to be consistent?

I note that you are promoting increased use of fluoride and fluoride toothpaste. I do not want to preempt a debate on this issue, but could you comment on the fact that according to the EPA in the United States, there is increased evidence that in areas where there is fluoridation, there is an increased incidence of osteoporosis and fluorosis?

Mr. O'Dwyer: There is no reason to cast doubt on WHO figures. Our experience has been that the organisation is extremely meticulous and careful when publishing figures. When considering statistics, one must take into account how regions might vary because there can be big differences in the impact of particular conditions in different regions. I am not in a position to deal in detail with the figures quoted by the Deputy. Generally, WHO statistics stand up, but one would need to look carefully at the situation as between western and eastern European regions.

On the environmental issue, we increasingly take an inter-Departmental and inter-agency approach. When our policy document is nearing completion we will enter into intensive discussions with the relevant Departments to seek their support. Generally this is not a problem. It is a question of focusing on effective initiatives in the next five to ten years. We have already given money to ASH this year for preparatory work in setting up a major resource centre in relation to information and research in the area of tobacco. This will greatly intensify the amount of information and research available not only to the Department, but to anyone who wants to tap into this. We hope ASH will be back to us with firm proposals shortly. Under the aegis of the Department of the Environment and Local Government, the Council of Ministers have taken on board a new EU initiative on ambient air which is very important.

Finally, in the next phase, we must try to bring home to people the deadly combination of constituents contained in cigarettes. This makes for scary reading. One or two countries have devoted a lot of time and energy to doing this. We receive a lot of support in relation to improving the environment, and I believe we will receive ongoing support in relation to fiscal policies and so on. Children between the ages of 13 and 17 have one unfortunate characteristic; they believe they are immortal. It is very difficult to tell them that if they smoke they will have a big problem at the age of 45 because that is an eternity to them. There is also the problem of young girls succumbing to the habit of smoking. We have tried to find a way to counter this, but we have not been very successful. No one would have believed ten years ago that one could not smoke on a bus in Dublin, or no one would have believed one could not smoke in a cinema. Our approach is to be positive, energetic and imaginative. We must believe we can win this battle, but it will not be won easily.

Deputy Gormley: Is the Department concerned about ambient air quality?

Mr. O'Dwyer: Yes. Mr. Power, who spends a great deal of time dealing with the issue of smoking, is in regular contact with his counterparts in the Department of the Environment and Local Government. If someone else can do the work for us, so much the better, but I believe this directive will be very helpful.

The National Cancer Register is based in Cork for approximately four or five years. Prior to that there were good statistics in relation to parts of Munster. It will take a number of years to build up reliable statistics. In terms of its coverage, structure and systems, we are satisfied that the National Cancer Register is up to best practice. We would like it to have an all-Ireland dimension and there are no problems in the area of co-operation and so on. The two reports published have been extremely useful. However, findings cannot be based on what arises in one or two years. Much more cannot be done at this point in terms of the professionalism of the those involved and the systems and support for the Cancer Register. They are receiving a lot of co-operation through the systems that are in place.

Deputy Shatter: Some time ago the Department sought from individual tobacco companies details concerning the composition of their tobacco products. Can Mr. O'Dwyer say when that information was sought, whether it has been received, when the matter was referred to the Attorney General's Office and the current position in that regard?

Mr. O'Dwyer: The information was sought in June 1998. We got a partial but very unsatisfactory reply in December of 1998 and the papers have been referred to the Attorney General. We have not had a response as yet from the Attorney General.

Deputy Shatter: As I understand it, under existing legislation the industry was under a legal obligation to respond and furnish the information. Is there a timeframe in the legislation within which that response should have been received? Could you also indicate, what date in June did the Department seek the information and what follow up letters went from the Department to the industry in the six months period from June to December 1998?

Mr. O'Dwyer: May I come back to that. Have you any more questions you wish to ask?

Deputy Shatter: In this instance firstly, I am concerned as to the delay that has occurred in response to the tobacco industry and secondly if you have not received a satisfactory response within a number of weeks, why it took until December to refer the matter to the Attorney General's Office? I would be interested in knowing what contact the Department has had with the Attorney General's Office since December and when it is anticipated prosecutions will be brought? Perhaps you could tell the Committee the names of the companies from which the information is being sought.

Mr. O'Dwyer: I am not in a position to give you that information now but I would be pleased to arrange to communicate with the Committee and Deputy Shatter the information which you seek in writing. I will do that very promptly. I know that there have been contacts and I just want to make sure that the information we give you is precise.

Deputy Shatter: On that topic I have two particular concerns. One concern from documentation has emerged from elsewhere which indicates that the tobacco industry, as Mr. O'Dwyer correctly says, may be engineering their products in a way to ensure that they are more rapidly addictive than might otherwise be the case and secondly that there are what are described as additives of sweeteners being added to products to make them more readily acceptable to children. I am concerned about the degree of urgency with which the Department approaches enforcement and mechanisms. I am disappointed that we do not have that information today. I would have thought that the failure of tobacco companies to furnish information sought and that failure now going back over a period of eight months would have been to the forefront of the Department's thinking in the fight against tobacco. Pursuing these issues might be immediately more beneficial than simple advertising campaigns.

Chairman I hope we would have that information for the next meeting.

Mr. O'Dwyer: Deputy, firstly, may I say this year we have actually given some additional budgets to each of the health boards to get them to carry out a detailed assessment of the present level of compliance in terms of how legislation is being enforced and, more particularly, to give us their assessment of what are the further steps that need to be taken to make sure that in relation to whatever legislation we have at any particular time that there is a very high level of structure in place to ensure compliance.

Secondly, in relation to practices of the tobacco companies we certainly are as connected as we can be to the emerging literature and discovery that is coming out internationally.

Thirdly, as I tried to explain to the Committee, what we are involved with at the moment, and it will not take too much longer to do, is producing an overall strategy and plan which will significantly lift our game as compared to what we have been doing up to now. We see what we are now having to do as, perhaps, on the one hand much more difficult and yet something that is being done in an environment that is perhaps a lot more favourable to us than it was ten years ago.

Deputy Shatter: My concern in the context of what Mr. O'Dwyer is saying is that there is no point in having laws unless you enforce them. It is obviously a value that the Department get responses from health boards but the Department has a specific function in certain aspects of legislation. The tobacco industry worldwide relies on the lethargy of civil servants and governments in enforcing legislation that is in place. It is my understanding that what we are talking about by the failure to provide the detailed information sought is that there are criminal proceedings that can be brought against individual tobacco companies. It would seem to me in the fight against tobacco the spotlight of publicity that would fall onto tobacco companies for concealing the constituent ingredients of the tobacco products from our Department of Health would be extremely beneficial in the fight against tobacco and it is something about which there should be a greater dynamic. That is my complaint in the context of the way the Department of Health is dealing with this issue.

May I ask Mr. O'Dwyer in relation to the reference he made to the Department being diligent in acquiring all the information that has become available in the United States that leads to the suggestion that the information acquired by our Department is largely dependent on the level of activity of other countries and other governments. It would seem to me that the Department of Health has a front line role in obtaining information and we should not simply be relying on other people's activity.

Arising from our previous hearing, it is now 15 months since I raised in the Dáil with the Minister for Health the need to give consideration to the bringing in of court actions against tobacco companies similar to those brought in the United States. Mr. O'Dwyer has told us that we have been diligent in acquiring information and we are looking at a European response. Different countries in Europe have different approaches in this area. In the context of our diligence in determining the degree to which we can take court action against the tobacco companies to recoup to this State the huge expenditure being incurred in the treatment of tobacco related illness Mr. O'Dwyer could you tell us on how many occasions and furnish us with the dates of those occasions on which officials of his Department or the Minister has met in discussion with any of the State's attorney generals in the United States who are involved on behalf of their states in processing court cases against tobacco companies. Could we also have an indication of the number of discussions that are taking place with individuals involved in this context as to the best strategy to adopt in bringing of such court cases and the number of occasions in which there have been meetings between officials of the Department of Health and the Attorney General's office to discuss this issue. Finally, has the Department of Health sought from the Attorney General's office in this State a detailed opinion on how it believes we should proceed, when did it seek such opinion and has one ever been received?

Mr. O'Dwyer: Neither the Minister nor officers of the Department have had meetings such as you mentioned with the Attorney Generals of the states. However, it is a matter of policy in the United States that all the information which they have is put on the net. We have accessed all of that information and kept up to date with it. We know what the situation is with regard to the global settlement and with regard to the Multi State Agreement. When the policy document is published, it will be clear that we have kept very much up to date with that. When a broad policy is emerging then the question of what happens next will be addressed.

I believe there have already been considerable benefits to us in respect of what has happened in the United States. However, in relation to the question of costs to which the Deputy referred, it is important to consider the situation in the context of the different tax regimes which have been pursued federally in the United States over the years and the fact that, in Ireland, tobacco has been a highly taxed product for many years. The information we have received to date is that no state in Europe has taken an action against the tobacco companies. The question of other types of action and how the State would become involved in them is under examination. We will continue to consider this matter while having regard to the Irish situation and what is happening elsewhere.

I take the point made by the Deputy but I find it difficult to accept that we have been lethargic in respect of the fundamental issues we are tackling, namely, trying to reduce the incidence of misery and sickness - cancer, cardiovascular diseases, etc. - that arise as a result of smoking. This is a complex and difficult issue. I have acknowledged to the committee what has been achieved and the fact that there is a major problem which must be tackled. I also stated that we will have to develop not only a different policy but perhaps a different structure through which that policy can be implemented. I suggest that the extent of our efforts might be better judged when the policy paper is published.

Deputy Shatter: I suggest that in determining what are the policy options simply surfing the Internet and obtaining details of judgments and documentation that have emerged from American proceedings is a grossly inadequate approach. In making judgments as to how best proceed - I do not hold Mr. O'Dwyer at fault for this, I hold the Minister at fault - there would be a great deal of value in discussing with people working at the coalface in the United States the procedures they have adopted which have proved to be successful. No credible policy can be put together without that type of discussion taking place.

I suggest that this area of health is a national policy issue. We should be in the vanguard in the fight against the tobacco companies in this context, not dependent on some of our European partners who are currently in receipt of subsidies for growing tobacco to export to Third World countries. We should not be restrained in protecting the health of young people in this country by that type of European consideration. We have a national duty in that context.

Mr. O'Dwyer referred to our taxation policies. It seemed clear at our previous meeting that, when, in December, the Government decided to increase the tax on tobacco by 5p - this was not a real increase and only just matched the level of inflation - no discussions of significance took place in advance between the Departments of Finance and Health and Children or the respective Ministers in charge of them. Why did the Department of Health and Children not make a detailed pre-budget submission to the Department of Finance setting out the case for a substantial increase on the tax on tobacco?

Mr. O'Dwyer might acknowledge might acknowledge that international research has established that the more expensive tobacco products, particularly cigarettes, become, the smaller the quantities of those products young children have the capacity to purchase. That directly impacts on the amount of tobacco products consumed by young people and indirectly on the number of adults who will ultimately become addicted to the product.

Mr. O'Dwyer: I accept the Deputy's point in relation to the fact that we must act independently. In terms of our initiatives against smoking we have consistently acted independently and there is no reason to believe that we are going to act differently in the future. However, I believe the Deputy will acknowledge that the question of where litigation fits into a strategy and the extent to which one needs to assess not only the strategy but also the tactics relating to litigation requires detailed consideration. The only difference between us relates to whether the discussion with people working at the coalface should have taken place before now or whether it should take place in the future. I imagine that it will definitely take place. However, we are conscious of the different situation which obtains in the United States.

I take the Deputy's point with regard to some of the difficulties which have arisen in Europe, not least those involving attempts to reach agreement on the advertising directive.

For four to five years we have had a policy understanding with the Department of Finance in respect of the taxation of tobacco products. There is no argument between the two Departments. However, there is a role to be played in the pricing of tobacco products, particularly cigarettes, in the fight against smoking. As part and parcel of the ongoing discussions with regard to the annual Estimates, this matter would be mentioned. However, the important thing is that there is a settled policy position between the Department of Finance and ourselves. If you consider the position in recent years, that is reflected in the decisions which have been made.

Deputy Shatter: What is the settled policy position?

Mr. O'Dwyer: Basically, that the Department of Finance will work with us. The Department of Finance accepts that the pricing of cigarettes has a role to play in anti-smoking initiatives and that-----

Deputy Shatter: Was the 5p budget increase agreed between the Departments of Health and Children and Finance?

Mr. O'Dwyer: No.

Deputy Shatter: That is the point, there was no discussion about it. The Department of Finance only increased the price of tobacco to match the cost of inflation and imposed no greater price increase which, in the context of health policy, should not have been the case. There is a complete lack of communication and co-operation between the two Departments on this issue. Either that or one Department or Minister is not sufficiently active to press its view on the matter.

Mr. O'Dwyer: I beg to differ with the Deputy on that. First, if you look at the figures, the cost of cigarettes in this country, when compared to other European countries, is very high. Second, increases on the price of cigarettes during the past three to five years have gone well beyond the price index. There is the other factor which is not a matter for us but rather one for the Minister for Finance, namely, that he must make a judgment with regard to maximising what he can do in relation to prices and prevention while ensuring that he does not encourage a serious smuggling problem. I do not now the Minister for Finance's views in respect of the latter point but I would imagine it is a factor.

The other reality is that on budgetary matters line Departments, such as ours, hold discussions with the Department of Finance. The ultimate decision is made by that Department and we are not consulted on the precise detail.

Deputy Shatter: In the context of the issue of the price of tobacco is it not the case that this is one on which your Department should have a substantial input, indeed a decision making position, and that it should not be left to the Department of Finance to make that decision?

Deputy McManus: Moving away from the legal and fiscal argument, I welcome the fact that the secretary general made the point that smoking cigarettes is addictive and that in ways it can be more addictive than heroin. That is correct. At the end of his presentation he made a crucial point and I am concerned it may appear almost as a footnote. It relates to an aspect not only concerned with smoking but with many aspects of health care and is concerned with the fact that there is a social dimension. Class is a factor in health status, which is a core issue in dealing with health promotion.

As long as there is a market for smoking and money to be made out of it somebody will provide it. We have seen how this industry has flourished with regard to illegal drugs. The same can be said about a legal market.

The question of social deprivation and the impact it has on health status is very important. We do not spend enough time on it, indeed if we spend time at all on debate it has escaped me. For example, a middle aged working class man who is unemployed is three times more likely to have cardio-vascular disease than a man of similar age who is employed and middle class. The fact that there has been a reduction in smoking generally has concentrated smoking among people from lower social groups to a greater extent than hitherto. We must focus clearly on that feature of health status because I do not believe we are doing so.

We need to look at what works and does not work much more carefully and rigorously. Those who need the health services least are getting the lion's share. There is much evidence to suggest that when it comes to general health promotion campaigns those that are engaged are the anxious healthy while those that need to change their habits ignore the promotion or are unaffected by it. The fact that middle class people are giving up smoking is good and to be welcomed, but it makes it harder for us to continue to ensure the decline in smoking continues if we do not address the issue of how to reach out to people for whom life often offers very little and where smoking a cigarette is a comfort and a pleasure which enables them to keep going under great stress and pressure.

The Department has outlined the standard on health promotion. That is no longer good enough. We must look at ways to ensure we are hitting the mark. If, for example, the idea of a well woman or well man clinic is promoted through general campaigns or general practices, invariably those that need them most will not present themselves, even if it does not cost anything. By contrast the clinics will be full of those who can afford to pay but may be able to deal with the changes in their lives that are required. In this regard I wonder how Dáil Éireann would qualify as a good health practice in the workplace.

The drugs initiative emerged from a very serious crisis affecting communities suffering great social deprivation and under pressure from drug dealing. They provide a model which should be looked at in terms of how communities engage in protecting themselves and ensuring that good practice prevails. I doubt if people can be brought together to combat smoking, but the dynamic and resources in these communities have not been used enough. Most communities have some kind or resource centre, largely run by women with children, who are strongly committed to them and who want to see them survive and flourish, very often in extremely harsh circumstances. We are not enabling these communities to engage in good health practices, nor are we resourcing them accordingly. They should not have to carry the load.

How much work has been done or what approach has been taken by the Department to seriously engage in this question? I get the impression that you have very little idea how to deal with this. It is very easy to state it and then run away from it.

Mr. O'Dwyer: I have no problem with the issue you describe and I acknowledged it in my presentation. The problem is now becoming more focused and will have to be the subject of not only analysis but proposed solutions in our policy. We have not been sitting on our hands because for the last four or five years every campaign we have run has included in the brief to the developers the need to take account of this reality and address it in their campaigns. The lifestyle survey carried out last year contained a significant element which addressed this issue. We should know considerably more when we get its results.

We are addressing the issue of peer approach with regard to the question of nutrition, which is much more acceptable to people and to groups. Our experience and that of boards and other groups is that when working with community groups one can talk to them about anything but smoking. Their response is that smoking is the only thing they have and they express the wish to be left alone. Similarly smoking is the great unmentionable with those who are prepared to become involved in tackling drugs and nutrition. Thousands are so involved and the great majority of them are probably women. We are going to have to find a way into that.

There is a need to link whatever we are doing here to the interdepartmental and inter-agency initiatives being undertaken with regard to the related issues mentioned by the Deputy. We face much the same kind of problems for different reasons with the young, schoolchildren and especially girls. We are going to have to try our best with initiatives. Some will work and others may not.

We will have to go back to it again and again. We must deal with young people under 17 years of age and we must ensure that progress is made on the issue of relatively low incomes. We must tackle those two issues, if we do nothing else. Nobody has a magic solution to them.

Deputy McManus: I am concerned about the extent of obesity among young people, particularly young girls. I spoke to the people in Weight Watchers recently and I was amazed at how many young girls were learning valuable information from that organisation which was helping them to manage their lives effectively. Many girls under 17 years of age have bad diets and weight problems, which often lead to smoking. I know young girls who have smoked heroin to keep their weight down. It is a strong motivation to keep their weight under control. If the message about weight and self-image is reinforced and support is given to young girls in the way Weight Watchers do, it might reduce the likelihood of them smoking for comfort or control.

Mr. O'Dwyer: We are extremely conscious of that and we suspect that the marketing tactics of tobacco companies take full account of it. It looks as if we may work our way into this through information on nutrition and good eating habits. We have got a positive response from all communities to anything we have done in terms of good eating habits and nutrition. One of the strategic issues we will face is whether we disproportionately focus our attention fairly narrowly on two or three areas while just doing enough in other areas to keep them ticking over. If we do that, will there be a counter rise somewhere else? Relative to what will now be done, we need more resources, more focus and new methodologies, some of which will fail and some of which will succeed.

Deputy McManus: Why do we not ban all marketing by cigarette companies?

Mr. O'Dwyer: The effect of the EU directive will achieve that and we hope to bring it about before the deadlines. One critical area is advertising, so we must try to ensure that the media, particularly the print and television media, are a positive force in our efforts. There have been more unsolicited public health messages from the media in recent years than there were in the past. Our experience has always been that every action provokes a reaction. Nevertheless, the EU directive is helpful. My understanding is that the Formula One people have said that if they can be convinced of a direct link between advertising and an increase in smoking, they will move away from tobacco sponsorship. That is probably one of the major sponsorships for tobacco companies.

Senator Jackman: We mentioned the 30 per cent of people who are addicted to smoking and difficult to treat, the under 17 year olds and those on low incomes. I question the logic of new advertising. Does the Department react to new advertising from Europe or America? How much help does it have in determining the impact of advertising? Advertisements, in which a young person tells their father to stop smoking, would not have an impact on me if I was a young person.

Is the Department allowed to advertise the composition of cigarettes? Many young people who do science in fifth and sixth class do environmental projects where cigarettes are analysed, so they know what is in them. Some projects are done in primary schools by pupils who are only ten and 11, so they are not smoking. However, once they reach a certain age, all the knowledge they have gained about the environment is lost. It is virtually impossible to know why these young people start to smoke. Perhaps it is peer pressure or the thing to do.

I am concerned about the addictive capacity of cigarettes. As a teacher, parents have said to me their child is only smoking cigarettes and that it would be worse if they were on drugs. The parents of smokers seem to regard them as a lost cause, so they continue smoking.

Deputy Shatter mentioned the enforcement of legislation. People will continue to do what they want if they see that the laws are not enforced. It is more difficult for us than for other EU countries. Has the Department consulted the multinational companies, particularly in Limerick, where the workplace is smoke-free and nobody objects to it? Is it a case that because people cannot smoke in a certain area, they will not smoke? Many people go outside to smoke but this is an environmental hazard. We should initiate research in this area.

Deputy McManus mentioned women on low incomes. It is interesting to note that if hardened smokers, particularly men, are told they need a bypass and they must stop smoking, they will give it up immediately and start chewing gum or sucking sweets. It is the motivation they need to give them up. One does not want to wait until they are about to die to give up cigarettes. What research is being done on the hardened smoker who is able to give them up? Are we giving in to the fact that once a person is addicted, they are a lost cause? I have seen women between the ages of 20 and 30 who are as fit as fiddles and who go to health clubs. Why are they members of health clubs when they smoke cigarettes?

They are fitter than those who do not smoke for five or ten years. The effects come later. It is more difficult for women to give up smoking, not only for those on low incomes but also for the upwardly mobile young women and youngsters who say that they are as affected by pollution from cars and that they could be killed crossing the road. There is a dismissiveness.

My two main points evolve around the multinationals who say there is no smoking, full stop and also if you were given legislative powers tomorrow morning what changes would you like to see introduced within further legislative enforcements?

Mr. O'Dwyer: I will pass on the last question. First, there are three things we do in relation to campaigns relevant to a question asked by the Senator. We try to write very tight specifications in regard to the target audience in what we are trying to achieve. Second, when we get the dry run of the campaign we run focus tests with relevant groups, including young people. Third, we evaluate it subsequently. All of that feeds into further evaluation.

In the current advice pack on smoking, information is simply put on the composition of cigarettes. One of the issues which will arise is the question of running a campaign(s) which will bring home to people the dangers of smoking which must be attractive, easily understood and done over a long period. It is one thing to visit the physics or chemistry classes of UCD but to try to get the person who is most likely to benefit from the campaign to be interested, we must think about how that can be done. There is a limit to what can be done in the school curriculum. Teachers have been very helpful to us over the years in very difficult circumstances. There are 15 or 16 ingredients in cigarettes. One can take one's pick of what is the most lethal. One wonders whether for the children who smoke, if anything they hear in school is a message they want to receive and that should also be considered.

The generally accepted statistic is that for people who are addicted to smoking the success rate in giving it up is as low as 2 or 3 per cent, although there are encouraging factors. The Senator referred to the multinationals and to the fact that the vast bulk of people accept their work environment should be smoke free. That is a huge change and is very supportive of anybody who wants to give up smoking. That it is not socially attractive to smoke and is getting less so is very helpful. That may alter the statistics on those who are addicted and want to give it up.

On the legislation, the critical thing that needs to happen is, first, it must be framed in such a way that it is likely to be supported. For example, take the sale of cigarettes to young people - the legislation is there but are we ensuring that it is adhered to? One of the areas which will be considered in the policy document, not only in relation to this area but others is the area of compliance. If the economy keeps growing and society changes, perhaps the area of compliance will become easier but, again, we cannot make that assumption.

Chairman: Thank you very much for your excellent contribution. I am sorry time ran out on us. The information listed will be very important to us in drawing up the report which, I hope, will be presented immediately after Easter. We look forward, perhaps, to further contacts and consultations with you in the near future.

The Joint Committee adjourned at 11.26 a.m.