Dr. Boland: Thank you for inviting us to make a presentation. We represent the Irish College of General Practitioners which is the academic body for general practice as distinct from the trade union, the Irish Medical Organisation. We look after training, post-graduate education, research, quality, etc. About 95 per cent of general practitioners in Ireland are members of the ICGP so we can speak on their behalf and take responsibility as well.

I am a general practitioner and I have worked in Skibereen, County Cork for 20 years and for the past two years I have worked full-time with the college as a director of post-graduate education and research. My colleague, Dr. Egan, is a general practitioner in south County Dublin. She is one of four tutors that have been appointed by us in conjunction with the Department of Health and Children to introduce a training programme for GPs on smoking cessation. She will take Members through the background and some basic information on smoking.

Dr. Egan: To start with I will discuss some of the facts about smoking related disease and death.

Smoking is the biggest cause of premature death in developed countries, causing 30 per cent of deaths between the ages of 35 and 69 years. Annually smoking causes 6,500 deaths in Ireland and 3 million deaths worldwide. This is more than ten times the number of road accident deaths in Ireland per year. At present, 29 per cent of Irish adults smoke, 30 per cent of males and 28 per cent of females. The prevalence of smoking is higher in Dublin, in socio-economic groups 4, 5 and 6 and in single men aged 25 to 34. Cigarette smokers also have greater morbidity than non-smokers, that is they have more acute and chronic illness, more restricted activity and disability days and more absenteeism from work. They are absent approximately 6.5 days per year more than non-smokers. They visit the health services six times as often and their dependants use the health services four times as often.

It is suggested that 50 per cent of smokers will die from their habit, half of these prematurely. The mean survival of smokers is ten years shorter than non-smokers.

With the current epidemic of tobacco use and the increased devastating health consequences numerous scientific studies have been published that document the contribution of cigarette smoking to morbidity and mortality from a variety of conditions. Since the US surgeon general's advisory committee first linked cigarette smoking with lung cancer in 1964 thousands of scientific investigations have confirmed this conclusion and provided additional evidence implicating cigarette smoking as the cause of the following conditions as well: cardiovascular disease; stroke; chronic obstructive lung disease; pregnancy complications; many cancers; peripheral vascular disease; peptic ulcer disease and accelerated rates of post-menopausal bone density loss in women.

I will now outline some specific Irish smoking related health costs. In Ireland 1,500 people die each year from lung cancer, 90 per cent of which are attributable to active smoking. Interestingly, a UK study published yesterday gives worrying statistics on the increased likelihood of women smokers developing the most malignant type of lung cancer. Also 25 per cent of heart disease deaths and 75 per cent of chronic obstructive lung disease deaths in Ireland are directly attributable to smoking. The mean total number of cancer deaths per annum between 1991 and 1995 in Ireland was over 4,000 per deaths per year, of which 30 per cent are estimated to be caused by smoking. Therefore, as smoking is clearly the biggest single risk factor for all cancers a reduced smoking prevalence would have a huge beneficial impact.

As regards public policy issues, it is interesting to note that the budget's increase in the price of cigarettes of only 5p is very disappointing to doctors as evidence from the US, UK, France, Spain and other countries show a dramatic increase in cigarette consumption rates when real cigarette prices are allowed to fall. For example, in Ireland when national incomes are rising but the price rise of cigarettes is much less. There is a definite fall in tobacco consumption when the price of cigarette is increased. This affects teenagers and smokers with lower incomes in particular. However, general practitioners are pleased with successive national and European governments plans to completely ban cigarette advertising between now and 2004. They are also pleased about health warnings on cigarette packets and the increased restriction of smoking in public places.

With regard to passive smoking, the involuntary inhalation of tobacco smoke was considered nothing more than a nuisance for centuries. However, since the 1960s hundreds of studies on the association between tobacco smoke pollution or environmental tobacco smoke have been published. These unanimously conclude that passive smoking is a cause of respiratory diseases in children and an important risk factor for lung cancer in non-smoking adults. Environmental tobacco smoke consists of side stream smoke emitted from smouldering tobacco between puffs and mainstream smoke exhaled by the smoker. It contains tar, nicotine, carbon monoxide and other chemicals and toxins and, therefore, passive smokers are likely to suffer the same health effects as smokers.

Some of the health effects that children can develop when they are exposed to environmental tobacco smoke are as follows: increased risk of lower respiratory tract infections; increased prevalence of fluid in the middle ear with increased ear infections and hearing loss; upper respiratory tract symptoms such as cough, phlegm and wheeze; decreased lung function; increased number and severity of asthma episodes and more new cases of asthma and more school absence. Non-smoking adults exposed to environmental tobacco smoke can have upper respiratory symptoms such as sore itchy eyes, sneezing and coughing, increased incidence of cardiovascular disease and increased incidence of lung cancer. There are also foetal effects to exposed pregnant women who do not smoke, for example, low birth weight. Cot death is more common in smoking households even if the mother did not smoke during pregnancy. We can conclude that since exposure to environmental tobacco smoke is nearly ubiquitous, passive smoking clearly has a serious impact on public health.

Dr. Boland: I want to reinforce the price issue. A US surgeon general undertook a study in relation to the price of cigarettes and found that a 10 per cent increase in the cost of cigarettes resulted in a 14 per cent decrease in the number of teenage smokers. I will now outline the attempts we have made to address the problem. Since most adult smokers acquire the habit in adolescence what we do about adolescent smokers is crucial. Price is an important factor. Otherwise adolescents are an extremely difficult group to influence. In 1993 the ESRI carried out a study which showed that 17 per cent of post-primary school children were regular smokers. Our impression is that that figure may have increased. It is very difficult to influence adolescents. For example, the Eastern Health Board undertook a programme called "Smoke Busters" which used a combination of teachers and public health nurses. Disappointingly a year after the programme 25 per cent of these 11-year olds were still smoking. Therefore, it is very hard to influence their behaviour.

General practitioners find it hard to deal with adolescents because they consult them less than any other age group. In general they are a very healthy category of people. When they do consult a doctor they are often accompanied by a parent which is not necessarily the best circumstances in which to discuss smoking. When they consult a GP it is often because they are suffering from an acute illness or a sports injury so the circumstances may again not be ideal for striking up a general discussion on health and smoking.

The final difficulty GPs face with regard adolescents is that doctors are in an older age group. We are perceived as authority figures just like parents, teachers, etc. That is not to say that there are no opportunities. There are and we are working very hard to make ourselves as effective as possible when opportunities do arise but they are a difficult group to deal with.

As far as the GP role is concerned a recent Irish survey reported that only 36 per cent of smokers reported that their GP advised them to stop smoking. That figure is a very disappointing one but it is a little better than in the UK where it is 29 per cent. Research evidence suggests that if a doctor makes no comment about the fact that someone is smoking then it is interpreted as tacit approval of the fact that they are continuing to smoke.

We must speculate on why GPs do not do more. Perhaps in the past they have not been very effective and it has not been a very rewarding task to talk to people about smoking. They may be afraid that it would upset the doctor-patient relationship if they pushed it too far. It also requires time which GPs may not always have. They may also lack in the specific skills.

As Dr. Egan has already indicated, GPs have another role to play and that is supporting public campaigns. They support the "Quit" campaign undertaken by the Department which is due to be launched within the next month. There is evidence that GPs can be effective when given the right skills and intervene with the right group of people. Research evidence suggests they can achieve a reduction of between 1 per cent and 5 per cent with brief intervention among the people who are contemplating giving up. It is clear now that many smokers do not intend to give up smoking and GPs annoy them if they keep going on about it. We can be effective with people who are beginning to contemplate giving up smoking and as a result there can be a 5 per cent reduction. If you combine that with nicotine substitution (through chewing gum, patches or other methods of nicotine substitution) that figure can increase from a 5 per cent to a 10 per cent reduction.

In many ways GPs are facing a challenge. The massive training programme we are now embarking on is as a result of this research evidence. That programme is a collaboration between the health promotion unit of the Department of Health and Children, the Irish Cancer Society, the Irish Heart Foundation and my organisation. The idea is that one day training workshops consisting of about 12 GPs will be held in all parts of the country. These GPs will be trained in a brief intervention technique for people who are contemplating giving up smoking. To deliver this programme we have appointed four GPs on a part-time basis to act as tutors in collaboration with health promotion officers from the health boards. Dr. Egan is one of those tutors and she will give Members more details about the programme.

Dr. Egan: The workshop aims to teach general practitioners skills for carrying out brief interventions with their smoking patients. This model uses stages of change training and motivational interviewing which means that GPs will learn to identify whether a smoker is ready to change his behaviour, how to help someone who feels ambivalent about smoking and finally the methods of assistance available to a smoker who wishes to quit. This approach is directive, persuasive and supportive but it is not as authoritarian, coercive or judgmental as some previous interventions may have been. There is evidence to suggest that the earlier intervention methods may have resulted in smokers becoming more entrenched and resistant.

We aim to teach GPs that this intervention can be used opportunistically, particularly during an ordinary ten to 15 minute consultation. This message is vital because it is important that GPs use the technique frequently as the situation arises without feeling that they must set aside extra time, something which they may not have. These skills are also beneficial for GPs because they can be used on patients with other lifestyle behaviour change issues such as alcohol abuse, obesity or lack of exercise. We have estimated that if 600 GPs attend the workshop over two years at a rate of ten to 12 GPs per group and there are four workshops around the country ten times per year we would hope to increase quit rates among patients who smoke by at least 5 per cent, yielding up to 40,000 new non-smokers.

We have run seven workshops since the end of October, and the feedback from participating GPs has been very positive.

Smoking is of great concern to all of us. General practitioners are ideally situated to take a leading role in identifying smokers who may be interested in quitting the habit and offering them information and support to do so.

Chairman: We will now have a question and answer session. Does the delegation regard smoking as addictive? Increasing the ratio of participating GPs to adolescents was mentioned. I take it that very few end up in the GP's surgery, therefore, it must be extremely difficult to influence them.

Dr. Boland: The Chairman's first point was in relation to addiction. The evidence suggests that smoking is both physically and psychologically addictive. Everyone recognises that there is a psychological element to smoking. People experience withdrawal symptoms from not having a cigarette in their hand. In addition there appears to be a physical addiction in relation to nicotine. Nicotine substitution in the period when people are attempting to give up smoking appears to improve their chances of giving up the habit. It removes some of the symptoms associated with suddenly stopping the supply of nicotine to the system. This can cause irritability and so on.

We regard the adolescent group as being very difficult to get in touch with. However, many GPs are involved in sports clubs. Medical officers are often called upon when people are injured. This is a possible route of entry. There may also be opportunities to discuss the problem with girls if they consult their doctor in relation to family planning or other adolescent health issues.

Dr. Egan: Regarding nicotine, more nicotine is absorbed from cigarettes than from nicotine replacement therapy. We can be reassured that it is more appropriate to prescribe nicotine replacement to smokers than for them to continue smoking.

On adolescent girls, certainly smoking is an issue that would be raised with them if they were considering using a contraceptive pill. Many girls look upon this as an opportunity to stop smoking.

Deputy M. Ahern: Cigarette smoking has been mentioned. How would you rate cigar smoking, tobacco smoking and snuff?

Dr. Boland: I would rate them as larger nails in the coffin. It does not make any great difference.

Senator Moylan: I welcome the presentation. Recently I heard about a study in the USA which discovered that young girls are at greater risk of developing cancer as a result of smoking. This discovery should be highlighted because there is a move afoot by many cigarette companies to try to encourage young people to smoke, particularly young girls in relation to the slimming aspect.

Dr. Egan: I am not sure if that is the study I heard about. Yesterday I heard it has been found that there seems to be an increased predisposition in women to develop the most serious types of lung cancer. It is not clear why this is so. Perhaps it may be due to a fundamental underlying tendency or to the way in which women smoke. Research is still awaited on that. However, this behoves us to press the message home even more. Even when young people have all the facts and are educated to the harmful effects of smoking, it does not influence their behaviour as much as their family and peers. Most of the smokebusters project was held in schools in disadvantaged areas where 85 per cent of children had at least one smoking parent. It was discovered that these children took on board all the information they received. Nevertheless, a year later it was found that they were still inclined to start smoking if they were influenced by their family or peers.

Senator Glynn: I was interested to hear the response to the Chairman's question in relation to addiction. The tobacco companies vehemently deny that smoking is addictive. One can only conclude that there are strong commercial reasons for this.

Is the delegation satisfied that their organisation is doing enough to press home the adverse effects of smoking on one's health? Have we as legislators done enough to ensure that tobacco companies are put out of business? Is the delegation satisfied that there is adequate legislation on the Statute Book and that the legislation is being enforced?

Dr. Boland: Irish legislators are to be commended. There is adequate legislation in relation to advertising, smoking in public places, warnings on cigarette packets and so on. We are probably ahead of many countries in this regard. However, price will ultimately be the strongest weapon. There is room for improvement in pressing ahead with relentless price increases. These increases would be justified in equity terms because people who smoke generate an enormous amount of cost on the health services. There is justification for heavy taxation in relation to this habit if people insist on smoking.

Our organisation was not happy with what we were doing. To some extent we were a bit frustrated. Everyone wants to do their best in relation to this issue but what is effective is another question. It is very hard to be effective. It appears that identifying those who are contemplating giving up smoking and using a correct technique to influence them seems to be the thing that will yield the best results from our point of view. This is what we are now attempting to do in conjunction with the health promotion unit in the Department of Health and Children.

GPs believe that smoking is overwhelmingly the most important issue in relation to prevention of illness. Forget diet, exercise and many other factors. The elimination of smoking could make a very big difference in preventing illness. The other issues are much more marginal. This message has not got through to the public.

Deputy Neville: I thank the delegation for their excellent presentation and especially for the notes. There is a perception abroad that more young women than young men take up smoking. Is that a perception or is it a fact?

Dr. Egan: In developed countries that trend is levelling out. In developing countries in the past there was far more men smoking than women. As these countries become more democratic and cigarettes become more widely available, there is a frightening increase in the number of women smoking.

Deputy Neville: I note that Dr. Egan's figure shows that it is a 50/50 split. Is it true that less women over 40 smoke than men?

Dr. Egan: That is right. Previously, much more men would have been smoking in Ireland.

Deputy Neville: It would appear from the statistics that more young women take up smoking than young men. Why?

Dr. Egan: There are probably a number of factors. More women are working and they have their own income. Women are only catching up; their consumption is not exceeding that of men. It could be due to the influence of the media, advertising or subtle advertising like that in films, and the example of public figures, icons and models. There are many suggested reasons. Much of it is peer pressure. Their friends are smoking. They smoke to keep down weight. Women have realised that it speeds up metabolism. If a woman is smoking, she can be reluctant to quit for fear of weight gain. That is a real issue when they want to quit because women start smoking in their teens. It is multi-factorial.

Deputy Bradford: At many of our interviews earlier this year with various groups and, in particular, the tobacco companies, we appeared to have had great difficulty in getting a definition of addiction. Can Dr. Boland define it?

In the note from Professor Ryan of University College Dublin there appears to be a specific definition of addiction. The professor points out that nicotine meets all the criteria which defines an addictive substance producing brief pleasurable psycho-active effects. Its use of course has spread known harmful effects, tolerance to both the pleasurable and the unpleasant effects developed during early usage and higher doses overcome tolerance. I trust that is a definition with which Dr. Boland would concur. I make that point in passing because the tobacco companies argued vehemently with us that one could not get a watertight definition of addiction and, therefore, all of our questions as to whether or not smoking was addicted were rather pointless.

Dr. Boland made an interesting point in passing. He indicated that while one can make progress with many of the patients with whom he deals with on an ongoing basis, a certain number of them not only would appear to ignore his views but would strongly desist from taking any advice. Why would there be such an attitude? None of us is particularly good at taking advice. Would this be as a result of these people being severely addicted? Are there social factors involved? Why are these people vehemently refusing to listen to Dr. Boland and to take on board the dangers of cigarette smoking? Are their minds entirely blocked off because of this addiction or are there other social factors involved?

Dr. Boland: They are probably not ready at that particular time to change their behaviour. People do not like to have to change their behaviour. They certainly do not like it if their experience of previous attempts tells them that it is a particularly unpleasant change to make. They do not like being told by somebody else what to do either. All of those factors would make some of them not open to advice. It is important to distinguish between the ones who are open to change and those who are not open to change, and to concentrate efforts on those who are open to change.

Deputy Bradford: Is it that the people who are not open to change simply ignore Dr. Boland's advice or do they almost psychologically react against what he says?

Dr. Boland: If one keeps scolding people when they are in that state, the evidence is that it will antagonise and further entrench them. If one keeps banging away at it when they are in that phase of the change cycle, not only will it be ineffective but one will damage the relationship between yourself and the patient.

Deputy Bradford: Is that a particular tendency among the younger smokers which Dr. Boland might come across? Would young people, who in the normal vein hope that they know everything, react in such a negative fashion or would it be the more the mature smokers?

Dr. Egan: It can be either. As Dr. Boland stated, it is important to identify where a person is at with their smoking and whether or not they are ready to change. If one asks smokers, about 70 per cent want to stop. The vast majority who attend a GP expect to be asked about smoking and want to discuss smoking. That does not mean that they necessarily want to stop tomorrow but they are pleased to take on board a discussion about it. They are more likely to listen to a GP than they are to listen to family and friends so the GP has a big role to play.

Dr. Boland: I certainly would not advocate a situation where a GP would never raise the subject. It is important that the GP establishes the stage at which a person is in this change cycle. If the GP makes that assessment and finds that the person is not open to change, to keep banging away at it is counter productive at that stage. If one just mentions it and works on a positive relationship with the patient, there may be an opportunity down the line when the person may be more receptive.

Deputy Clune: I would like to focus on smoking by pregnant women. Two weeks ago a toxicologist from UCD told the committee that there was evidence that babies in the first trimester of pregnancy can become addicted to nicotine. He mentioned that it could be linked to attention deficit disorder and serious difficulties later in the child's life. This is a serious issue. It is one thing to smoke and damage one's own health but damaging a baby during pregnancy is an other issue completely. There is not enough emphasis on that. Pregnant women do not seem to get the message. Will Dr. Egan comment on that? We should be doing much more in the health promotion area?

Dr. Egan: I agree that it is an important area. There have been studies linking smoking with neuro-physiological problems in childhood even in mothers who do not smoke. The Rotunda Hospital ran a stop smoking campaign with some of its pregnant mothers. It had a control group and a study group to whom they gave education during pregnancy to establish whether people knew about the effects, whether they would like help with stopping, etc. Disappointingly, they did not achieve higher quit rates although the study group made more attempts to quit, and reduced the number of cigarettes smoked per day. Again the problem is that education sometimes falls on deaf ears. People are happy to take on board the information but it does not necessarily change their behaviour. We are hopeful that our approach, which is less authoritarian and dictatorial, might have more success by taking on board somebody's reasons for smoking, exploring those reasons with them, incorporating the health information with them, seeing do they have the information and do they want to know more, and then trying to go the road of quitting. We do not assume that throwing information at people will make them stop even among a supposedly well motivated group such as pregnant women.

Deputy Keaveney: Do the members of the delegation smoke? Coming up to the budget people will say that they hope the price of cigarettes will not be increased as it is the only pleasure they have. One tries to lightly mention that we have spent the last few months discussing how harmful their only pleasure is. The older generation is convinced that cigarettes are the least of their evils and comfort themselves with the fact that they do not drink or run wild every night. The younger generation seems to shrug their shoulders and say that they cannot give up cigarettes and leave it at that.

Must our approach be age-related? Is it better to cajole than to frighten? We have had every extreme at the committee, from the tobacco companies to those who are unable to walk and who are in terrible physical shape. Their worry is that their children also smoke. Even the state of their parents' health is not discouraging children from smoking.

The children of parents who smoke probably have a predisposition to smoke. It seems to be a vicious circle. It has been said that health does not only relate to diet, exercise and such things and that smoking is the big issue. Should we be exploiting the role of sports people? Young people will look to their sporting icons. The more we listen the more difficult it is to reach a conclusion on how to deal with this situation.

Dr. Boland: Neither of us smoke. Smoking among GPs since 1975 has dropped dramatically. There has been a big change and that speaks for itself. Some of the information which emerged in the US under the freedom of information act indicated that the companies, far from believing that smoking was not addictive, actually worked on the addictive aspects of their product to see whether it could be enhanced in order to improve sales. There is no doubt about that.

As regards smoking being the only pleasure some people have, the Deputy spoke about those who were wheeled in unable to breathe. The picture we have painted is not one of people enjoying themselves. There are an enormous number of problems associated with smoking.

I agree with the comments made about sport. Young men in particular can sometimes be persuaded to stop smoking. That will have nothing to do with issues such as lung cancer but simply because their coach tells them that they are not going to make the team if they are seen smoking. That is a real and immediate disincentive.

Dr. Egan: As to whether it is better to cajole and scare or to persuade and take a more gentle approach, scare tactics do not seem to work, apart from a few patients. We are taking the motivational approach to positively influence people to make an intrinsic decision to change, and to change ambivalence so that they can change their own lives. Research seems to show that that is a better way to go and that is how we are going to do it.

Deputy Shatter: I wish to ask three questions, in one of which I am going to be deliberately provocative to get the delegation's reaction. Research is showing that the major problem with smoking starts with teenagers and this has been referred to in the document. Teenagers are becoming addicted to cigarettes at a time when it is illegal for them to purchase them. The law cannot solve this problem.

When the dangers of AIDS became known, the more immediate impact of becoming HIV positive created a greater awareness among young people about the importance of safe sex and using condoms. Because of the ultimate consequences of AIDS, this message seemed to rapidly filter through to huge numbers of teenagers. More people will be killed in Ireland in one year from tobacco-related products than will die in 20 years from AIDS, based on current figures. The message has been that scare tactics do not work. However, as regards AIDS and HIV, scare tactics broke through the psyche of immortality that all teenagers feel. Is there anything we can learn from that experience? The difference was the time-frame - HIV may result in AIDS and kill one more quickly than will smoking cigarettes, which will slowly kill one.

My second question may be provocative but I raise it deliberately. The delegation stated that many GPs do not feel skilled enough to persuade or cajole patients to give up cigarettes and that raising the issue in a particularly persuasive way is perceived as unproductive. Is that unproductive from a GP's perspective, as they might lose a patient to a more user-friendly GP? This might reduce a GP's patient list and income. Is it unproductive because a GP might be perceived as an authority figure who is lecturing their patient?

General practitioners can play a far more active role. There are two reasons why they do not do so. I will leave the issue of remuneration for the delegation to respond to. GPs do not have the time to engage patients in discussion when people are queuing in their waiting rooms or if they are visiting patients in their homes. On occasions, communication may not be as good as it should be about whatever happens to be the reason why the patient is visiting their doctor. However, many doctors do not have the time to begin to question people about why they smoke and all the consequent problems. There is no reward from the Department of Health and Children for doctors who engage patients in this way. I am interested in the delegations observations on this issue.

My final point is an issue which we raised with the tobacco companies. I do not believe people take too much notice of Government health warnings on cigarette packets. If one buys a product one is going to smoke it and not read the label. Labels do not say that tobacco is a drug. We have campaigns about heroin, cannabis and other drugs, but this is the major killer drug in this country. Far more teenagers are smoking cigarettes than will ever resort to what we perceive as our major drug problem. This is the real killer drug.

The numbers affected by the awfulness of all other drugs pales into insignificance compared with the numbers hooked on tobacco. Could we learn anything from the way in which we approached the heroin issue and apply it to the tobacco issue? Do we need to do something to make cigarette companies look less respectable and more like the purveyors of an addictive drug, which is what they are?

Dr. Boland: On the scare tactics used in relation to AIDS, there are some key differences. At the time the scare tactics in relation to AIDS worked, everyone who contracted AIDS died. That is not true in relation to cigarette smoking. A proportion of people do not die. We all know of 90 year olds who are still puffing away and every smoker in the country points to them as evidence they can continue. There is a sense of invulnerability that it will not happen to me.

Also one could continue the key behaviour in relation to AIDS, that is sexual intercourse, as long as a condom was worn. However smoking has to stop. Those are key differences.

Deputy Shatter: Smoking might be more addictive than sexual intercourse.

Dr. Boland: On the unproductive approach of GPs, many GPs found that in using the scare approach and turning the heat on all smokers irrespective of the stage they were at in terms of readiness to change, they would do it a first, second and third time but nothing would happen. There would be no effect and they would stop doing it. Otherwise they would lose a patient as the patient would get fed up of the GP increasing the threats if they did not stop. It does not work. However the brief intervention technique and teaching people motivational interviewing which Dr. Michele Egan and other tutors will do, has been shown to work, provided one identifies where the smoker is at and gets him or her at the appropriate time.

If the Department wants to give us additional money for this, clearly we would not say no. However that is a matter for the IMO to negotiate on our behalf.

Dr. Egan: On the point about losing one's patients to a neighbour, while most patients who manage to quit with the help of their GP may not have to visit the doctor with so many chest infections, they will be pleased with their GP. It is a public relations exercise and perhaps they will recommend the GP or bring their children or spouse. We will not lose patients by making them well.

Deputy Shatter: I was talking more about losing the patients who the doctor was trying to stop smoking but was unsuccessful with.

Dr. Boland: A question related to tobacco companies as pushers of addictive drugs. We believe it is an addictive drug and therefore we would support any legislation which can curb its promotion.

Chairman: I thank Dr. Egan and Dr. Boland for their useful and informative presentation. Obviously we reserve the right to come back to them at a later stage. We are hoping to take account of what has been said in all presentations and draw up a report on this issue shortly. The presentation was very helpful.

The Joint Committee adjourned at 10.35 a.m.