Jerry Buttimer (Cork South Central, Fine Gael)
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I welcome everyone to today's meeting, at which we will engage in pre-legislative scrutiny of the general scheme of the public health (alcohol) Bill 2015. I remind people that mobile phones should be switched off or left in aeroplane mode, as they interfere with the broadcasting of proceedings. This meeting marks the beginning of the joint committee's pre-legislative scrutiny hearings to examine the heads of the public health (alcohol) Bill, which the Minister for Health has published and referred in early February to the committee for its consideration. The joint committee has a consistent record in promoting a range of health measures. Members have been interested in and supportive of measures to tackle tobacco consumption as well as alcohol and substance misuse, and given the public interest in the issue raised by the Bill, the joint committee has consulted with key stakeholders and will engage with the public on these proposals. We have asked for written submissions through the joint committee's page on the Oireachtas website and have received almost 60 submissions on the Bill. The joint committee will hold meetings on the Bill, beginning today, with stakeholders, academics and experts. At the end of its deliberations, the joint committee will produce a report to the Minister noting key issues and recommendations. Our second session will be held on Thursday, 12 March at 11:15 a.m. when we will be joined by Dr. John Holmes from Sheffield University's alcohol research group, who is an international expert on minimum unit pricing of alcohol. In addition, the Minister for Health has intimated to the joint committee that he wishes to attend the conclusion of its hearings in order to engage with it before the joint committee produces its final report.

I welcome to our meeting this afternoon Professor Frank Murray, who is the president of the Royal College of Physicians of Ireland, RCPI, and chair of its policy group on alcohol. He is also a liver specialist at Beaumont Hospital. I also welcome his colleagues accompanying him: Dr. Len O'Hagan, chief executive officer of the RCPI, Professor Aiden McCormick, Dr. Stephen Stewart, and Ms Siobhán Creaton, head of public affairs and advocacy. All the witnesses are welcome and I thank them for their attendance.

Before we commence, I remind witnesses that they are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by it to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or an entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing parliamentary practice or ruling of the Chair to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable.

I must leave the meeting at 5.55 p.m. In the absence of the Vice Chairman, is it agreed that Deputy Neville will take over as Acting Chairman? Agreed. I invite Professor Murray to make his opening remarks.

Professor Frank Murray:

I thank the Chairman. I am here to speak on behalf of my fellow liver colleagues here, as well as the other people in the medical profession represented by the Royal College of Physicians of Ireland, RCPI. I thank the joint committee for the opportunity to speak about the heads of the public health (alcohol) Bill 2015. I am representing the RCPI's policy group on alcohol, which has made a submission to the joint committee. Our college represents more than 10,000 members and fellows who work as hospital consultants, registrars and senior house officers in hospitals, as well as in other health care settings at home and abroad. RCPI doctors work in 27 specialties treating all types of medical condition including cancer and liver diseases in both hospital and community settings. They work on the front line of the health services with nurses and other colleagues caring for patients, many of whom have come to us as a result of hazardous or problem drinking. That really is why we are here today.

It has been estimated that approximately 1,500 hospital beds are occupied every night in hospitals directly because of alcohol harm. This costs approximately €1.2 billion per year, and in view of the current crisis in beds, with hundreds of patients on trolleys in accident and emergency departments, it is a national shame. As liver specialists, I and the three doctors present are saddened and shocked by the increased number of deaths due to cirrhosis of the liver, which has doubled in the last 20 years. This doubling in the death rate from liver cirrhosis and liver failure reflects the doubling in alcohol consumption in Ireland that had taken place in the preceding years, because we now are drinking more than twice what we drank in the 1960s. Alcohol also is classed as one of the most important causes of cancer in Ireland, primarily breast, colon and oesophageal. Alcohol also is a factor in suicide, domestic abuse and incidents and accidents. One in ten first admissions to Irish psychiatric hospitals in Ireland are alcohol-related, and more than 25% of all injuries presenting to accident and emergency departments are alcohol-related.

We believe Ireland’s relationship with alcohol is at crisis point. The World Health Organization tells us that almost half of all Irish drinkers engage in heavy episodic drinking on a regular basis and that Ireland is close to the top of the binge drinking league worldwide. Research also has shown that approximately 80% of Irish adults consume alcohol and that more than half of those are classified as harmful drinkers by their own admission. Approximately 10% of those who consume alcohol are dependent on it, and this percentage rises to 15% in the 18 to 24 year old age group. This means we live in a country where virtually every family is affected by alcohol, and I doubt there is anyone in this room who does not have a family member or friend who is affected by problems related to alcohol.

As doctors, we are increasingly caring for more than 200,000 chronic dependent drinkers who are attending with organ damage, cancers, cirrhosis and liver failure, heart failure and problems related to the brain and nervous system.

Every weekend parents worry about their children getting involved in drinking games or being hurt or killed in road traffic accidents or fights when they go out with their friends. Everyone is affected by the social disorder in towns and cities late at night. There is also an enormous economic cost that we are all bearing. It costs €3.7 billion a year to provide health care and public order enforcement as a result of problem drinking. About a third of that, just over €1 billion, is spent annually by the Government on providing care in accident and emergency departments. This is an enormous sum that has the potential to do much good in many other areas of society if it could be otherwise deployed.

As an advocate of public health measures, the RCPI has commended the Minister for Health, Deputy Leo Varadkar, and the Government on its introduction of this legislation, which is an important and major step in tackling Ireland’s problem drinking. Legislators have listened to us and have taken action. We wish to support them fully. RCPI has come together with Alcohol Action Ireland to form the Alcohol Health Alliance Ireland to advocate for the adoption of this Bill. The Bill contains many of the evidence-based measures for which our policy group, made up of experts caring for people affected by alcohol use, including liver specialists such as myself and my colleagues, psychiatrists, paediatricians and general practitioners, has called.

We know there are powerful and well resourced vested interests who will be working to dilute some aspects of this legislation to safeguard the profits they are required to deliver for their shareholders. It feels like a David versus Goliath situation in that we are not funded from the public purse, but there is a groundswell of support for this legislation. Research by the Health Research Board showed that a majority of the public are supportive of measures to tackle problem drinking, even if they are not the most vocal in this debate. It is a kind of silent majority. There is plenty of public discourse about alcohol and unease about our image as a nation of heavy drinkers. This is not something of which we are generally proud. I believe the time is right to implement radical solutions to address the awful problem of alcohol in Ireland.

There are many looking to the committee as legislators to step up and grasp this opportunity to introduce new laws that will immediately save lives. Committee members should be confident that not only is this legislation necessary but it is what the public demands. The introduction of a minimum unit price for alcohol, reducing the availability of alcohol and restrictions on advertising and labelling of alcohol products are the way forward if we are serious about changing the way people consume alcohol.

Although we are supportive of the legislation, we are concerned about the lack of timelines provided in it for the implementation of minimum unit pricing, as well as for a sports sponsorship ban and the statutory code on the display of alcohol. We call on the committee to ensure that these measures will be enforced once the legislation is enacted.

Minimum unit pricing is the single most important aspect of this legislation. It will reduce the flood of cheap alcohol that tends to be disproportionately consumed by young drinkers as well as problem drinkers. Robust evidence from Canada shows that it will immediately mean that lives are saved and that fewer people are harmed as a result of their use of alcohol. It also has the beneficial effect of reductions in crime levels.

It is worth reflecting that Ireland made history and showed great leadership in introducing the workplace smoking ban in 2004 in the face of a powerful tobacco lobby. We have the opportunity again, particularly as a small country, to take a lead role in regulating the sale of alcohol. As well as saving lives here, the adoption of minimum unit pricing would facilitate the implementation of similar legislation in the UK and further afield. We support setting a minimum unit price of at least €1, the same price as a litre of milk. It needs to be around this price to be effective. Whenever this issue gets discussed, the debate quickly seems to focus on how much a bottle of wine will cost. As there are eight to ten units in a bottle of wine, that would price it between €8 and €10.

It is important to reflect on what has happened elsewhere. Interestingly, countries such as France and Italy, which are major wine producers, have managed to dramatically reduce national consumption of alcohol in recent years at a time when the amount of alcohol being consumed in Ireland has been rising rapidly. Consumers in France and Italy tend to drink better or higher quality wine but less of it. Italians used to drink twice as much as Irish people per capitabut now they drink less than half. We are not prohibitionists and most of us take a drink. It is important, however, to state that there is no safe level at which to consume alcohol. Just in the past few weeks, research published in the British Medical Journaldebunked old myths about a drink being good for us with findings that drinking alcohol is of no benefit to anyone’s health.

One does not have to be addicted to alcohol to get cirrhosis of the liver. Forming a habit of regularly drinking pints or glasses of wine will damage one’s liver and other organs in a serious way over time. We care for many patients who have found themselves unwittingly in the tragic situation of not being addicted to alcohol but drinking heavily and habitually and developing organ failure as a result.

Tackling the price and availability of alcohol is the most effective way to change our relationship with alcohol. This is why we want to see separation of sales of alcohol so that it is not displayed beside everyday groceries. It is not an ordinary commodity. We also welcome the intention to enable better enforcement of a ban on selling to those who are underage. We can see how well environmental health officers have enforced the smoking ban. We want to see similar resources and priority given to policing sales to those who are underage as part of the new legislative package. The Bill should include provisions for strict regulation and enforcement around online drinks promotions, a reduction in the number of outlets where alcohol can be purchased, and further restrictions on opening times.

We also want to see a timeframe introduced for the phasing out of sponsorship of sports events by the alcohol industry. The tobacco industry opposed the move to ban advertising of its products in 2003, claiming it would result in damage to sport. Clearly that did not happen, but this argument is again being rolled out to protect lucrative campaigns that are enormously effective in terms of recruiting the next generation of drinkers. It is disappointing that the public health (alcohol) Bill will not contain a ban on sports sponsorship. This is a provision we will continue to advocate.

There is very strong evidence to link promotion of alcohol through sports sponsorship with early and more problematic alcohol consumption in young people. Drinks companies are investing in advertising and sponsoring these events because they achieve their purpose - namely, they boost alcohol sales. We strongly recommend that a commencement date be set for the phasing out of alcohol sponsorship of sport in the medium term and a target date for the ending of all alcohol sport sponsorship in the longer term.

In the weeks and months ahead, the committee will hear about the nanny state and will be asked why it is necessary to introduce measures that affect the entire population when hazardous drinking affects only a few. There are more than 200,000 chronically dependent drinkers, which represents a large number of people requiring care and support, whatever way one looks at it. International research, as well as doctors, nurses and those on the health care front line, can say that Irish people generally drink in excess of recommended low-risk limits.

There are also important issues of social justice in introducing the measures in this Bill.

The socially disadvantaged suffer disproportionately from the effects of alcohol. The proposed measures will help these individuals and reduce health inequality. While we have made great strides in extending life expectancy, quality of life can be infinitely improved by drinking less alcohol.

One of the leading public health advocates, Professor Geoffrey Rose, tells us that the best way to address large-scale public health problems is to manipulate the environment and context. In this case we are looking to members, as legislators, to control the price and availability of alcohol and seize the opportunity to finally help us to banish the image of the drunken Irish and save the next generation from certain health harms. Let us grasp the opportunity to turn off the tap of cheap, harmful alcohol and set a constructive path for drinking alcohol in Ireland.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Professor Murray for his interesting and challenging paper.

Billy Kelleher (Cork North Central, Fianna Fail)
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I welcome the witnesses. Professor Murray outlined in stark detail the difficulties that we as a nation have with drink and our unhealthy relationship with alcohol. For a long time, there has been a tacit acceptance that we have a little problem with drink which we are incapable of dealing with or facing up to as a mature society. While the issue has been swept under the carpet for a long time, it has come to a head in recent years, notably in our hospital emergency units at night, especially weekend nights. Alcohol leaves a trail of destruction in its wake in terms of health and societal damage. We stand at a crossroads as we decide how to address the problem. While my party welcomes the proposed Bill and hopes it will make an impact, it is only a stepping stone. Further measures will be required, including an overall ban on alcohol advertising.

I propose to elaborate on several issues that arise in this regard. If we want to bring members of the public with us, we must base our thesis and ideas on facts and frame the Bill accordingly. Many people regard the World Health Organization statistics on binge drinking as extreme and will argue that the maximum number of units per week set by WHO does not take Irish habits into account and is not based on scientific evidence. A person we would consider to be a light drinker would be categorised as a binge drinker under the WHO threshold for maximum alcohol consumption. I ask Professor Murray to elaborate on that issue. We need a firm acceptance that the World Health Organization standards are those on which we should base our efforts.

We must persuade the wider public, legislators and everyone else concerned to accept the difficulties the country has with alcohol. Has the introduction of minimum unit pricing or similar measures in other countries resulted in an immediate improvement, for example, in respect of the visibility of the alcohol problem on the streets and in emergency departments at weekends? How long does it take for such measures to filter through to health outcomes? I presume it takes some time before they feed into health outcomes, such as reductions in the incidence of cirrhosis of the liver, which can be seen in statistics? Is there any scientific evidence to show that health outcomes begin to improve dramatically and quickly following the introduction of such measures?

Professor Murray referred to younger people. Every Thursday, Friday and Saturday night when young people head into town, parents worry about whether their children will return home in one piece or end up in an emergency department. This is a genuine and ongoing concern among parents. As I stated, one only has to walk the streets of any town or city on a Saturday night to see the extent of the problem. Those who would prefer not to do so need only walk the streets on a Sunday morning to see the evidence of the problem on doorways all over our cities.

Much of the underage drinking that takes place is done in advance of going out. Parental supervision is needed and parents must at least encourage their children not to binge drink. A change in behaviour is required. While I am not viewing the past through rose-tinted glasses, there has been a societal shift in how Irish people drink. Previously, when people started drinking at an earlier age, an element of collective supervision was involved. Young people drank in a public house where bar staff, neighbours and other people were present and, as such, they drank in a public forum. Drinking habits have changed dramatically, however, as statistics on off-licence sales show. I ask Professor Murray to address that issue.

I have often made the following suggestion because I believe it merits discussion. Alcohol is frequently purchased legally but subsequently gets into the hands of underage young people. An 18 year old can legally purchase as much alcohol as he or she likes. If he or she has a friend aged 16 who has a girlfriend aged 14, illegal and dangerous drinking will quickly take place among this peer group. If we are to encourage people not to engage in this type of unsupervised drinking, perhaps we should consider increasing to 21 years the age at which alcohol can be purchased in off-licences as opposed to on-licensed premises. It may be worthwhile considering this option, as it could help address the problem of young people binge drinking in an unsupervised environment at home and the practice of "bushing", as we used to describe outdoor drinking. Is there any evidence available internationally to show that increasing the age requirement reduces binge drinking and damage to young people? I have often considered this option because I have seen 18 year olds buying alcohol in industrial quantities in off-licences. This drink is then consumed behind a shed or somewhere else by 14 or 15 year old children.

When an off-licence opens in an area, public representatives almost immediately receive calls from local residents raising the issue of anti-social behaviour and drunkenness in the vicinity of the premises. While many off-licence owners act responsibly and only sell alcohol legally, much of the alcohol sold in off-licences is consumed illegally. Is my proposal worth examining?

Even among medical professionals, one hears the view expressed that a drop of whiskey or glass of red wine every evening is good for the blood and so forth. There is an acceptance that some alcohol is okay. Professor Murray indicated that there is no safe level of alcohol consumption. People who should know this fact must explain it openly. General practitioners should not tell patients that a drop of whiskey in the evening will aid sleep or thin the blood, because such throwaway remarks embed themselves in people's thinking. We then hear that a couple of pints here and there or a drop of whiskey or half a bottle of wine every night is not that bad. Medical professionals need to be very clear on that issue.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I welcome the panel. We all want to reach a point at which alcohol is used responsibly across society. I will take a somewhat challenging approach to Professor Murray's presentation, not only to be a devil's advocate but also because I am not convinced of the merit of some of the proposed measures.

Professor Murray closed his presentation with "Let us grasp the opportunity to turn off the tap of cheap, harmful alcohol and set a constructive path for drinking alcohol in Ireland." There is a subliminal message referring to cheap, harmful alcohol. Expensive, harmful alcohol-----

Jerry Buttimer (Cork South Central, Fine Gael)
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Tá vótáil sa Dáil. Más féidir leat, cur deireadh leis an ráitéis. We will suspend in three minutes and then return to the meeting after the vote.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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My concern is the same as with minimum unit pricing. I would like to have seen a focus on below-cost selling, which we see quite an amount of on the shelves of the bigger supermarkets. Turning off the tap of cheap, harmful alcohol suggests we are looking at a particular cohort of society. It is also reflected in the Professor Murray's sentences:

The socially disadvantaged suffer disproportionately from the effects of alcohol. The proposed measures will help these individuals and reduce health inequality.

They are not a people apart, these individuals. I am concerned about the language to some extent. Looking back, I have known people from all sectors of my community who have been challenged by alcohol. They were not confined to the socially deprived or disadvantaged. The notion is that we are going to do something wonderful for a particular cohort of people, but the real impact and effect is unproven. People who are seriously challenged by the need for alcohol are going to continue to find a means to access what their systems require.

There is no panacea for the issue. It must start with education and a range of other supports. I am concerned that the notion is we will have addressed something worthwhile if the less well-off are left in a position of greater disadvantage in accessing alcohol as a result the measures involved. That is not the starting point we should be working from. Alcohol injures people across the social strata and all incomes are impacted. It is not only harmful, cheap alcohol but harmful alcohol.

Jerry Buttimer (Cork South Central, Fine Gael)
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I will allow the Deputy resume after the vote. I apologise to witnesses but parliamentary democracy requires that we vote.

Dan Neville (Limerick, Fine Gael)
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We will resume in public session. I invite Deputy Ó Caoláin to continue.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Thank you, Acting Chairman. I will not revisit the points I made earlier, but I have a concern that the thrust of this critical measure will impact on a particular cohort of people more than it will on others. The person who currently pays €18 or €20 for a bottle of wine, for example, will not be impacted in any serious way. It will be those who buy cheaper alcohol options who will feel the effect. There is a picture many people have in their minds that the drinkers this measure seeks to target are, in the main, young people drinking six-packs behind the bike shed. The reality is different. In the case, for instance, of people who have worked all their life but have no employment today, the six-pack while watching football on the television is a weekend treat. They are not the people who are creating anti-social disturbances. We need to look at the reality in a more holistic and rounded way. People who are in some way disconnected from the reality of life for many within what are broadly described as deprived or disadvantaged communities are not seeing the full picture. There will be a more serious impact from these proposals on those who are least well off in our communities as against those who can better afford the more expensive choices when they visit the off-licence.

I am not convinced this measure will have the intended impact. What it comes down to is its effectiveness, and I am not convinced in this regard. In raising these concerns, I do not intend to be obstructive to the passage of the legislation. It is important, however, to question what is proposed and tease out the measure to ensure it will be effective. As well as the effectiveness or otherwise of the legislation, my other concern, as I have indicated, is that it should ensure equality across the board rather than targeting one sector of the community. I would be very enthusiastic about the proposals in regard to below-cost selling. In the case of minimum pricing, however, the question arises as to who will gain from it. The excise duty that applies to alcohol products is calculated on the unit measure, not on the actual price. When we introduce minimum pricing regulations, we are increasing the price but the excise duty remains the same. Where is the take from that for the Exchequer? I would have been happier, if we are to have minimum pricing or an increase in cost, to see it being done by way of an increase in excise duties. That would bring more moneys under central government control which could then be ring-fenced and employed in addressing the terrible outworkings of alcohol abuse, not only on individuals but, even more disturbingly, on those around them, including partners and children, who may suffer even more from the terrible effects of alcohol abuse. I would have liked to see any revenues accruing from an increase in the cost of alcohol being put to effective and better use. As it stands, it is the manufacturers, Diageo and other players, who will be raking in the money. I realise the intention is that they will actually have less money coming in, but I am not convinced it will play out that way.

Will Professor Murray indicate the source of the various statistics he cited? The indication that 1,500 hospital beds per night are occupied by people directly as a result of alcohol use is one figure that stands out for me as party health spokesperson. Professor Murray indicated that the incidence of cirrhosis of the liver has doubled in the past 20 years, which is reflective of the doubling of alcohol consumption in Ireland in the past 50 years. It is important to note that this doubling in consumption is reflective of certain changes in society. Fifty years ago, women in the main were not going out to public houses, and lounges as we know them today barely existed. There is now gender equality in terms of access to alcohol socialising in an open way, which is a welcome development. It is not something we need to be scared of and the doubling of alcohol consumption does not necessarily reflect a fall in standards. It is, to some extent, simply a reflection of the fact that 51% of the population have joined the other 49% over that period in enjoying a social drink. That is a very good thing.

John Crown (Independent)
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I welcome my friends and colleagues from my old medical school and congratulate my former classmate, Professor Murray, on the appropriate public stance he has taken on this critically important health issue. Most of us make our own deals with the devil when it comes to alcohol. People who understand what alcohol is all about have made decisions about certain compromises they make in return for the non-medical effects of alcohol. A reality we must all face, however, is that if everybody in the country stopped drinking - if, by some miracle, the good Lord appeared in the sky tomorrow and made us all turn away from alcohol - a number of things would inevitably happen. Liver failure would become far less common. While it would not disappear, its incidence would be much reduced. There would be a decrease in liver, pancreas, oesophagus, tongue, throat, breast and colorectal cancers. Pancreatitis would become an uncommon disease, and rates of heart disease would go down. There would be a major decrease in violence, including domestic violence, rape and other sexual offences. Teen pregnancy rates would dramatically decrease. There would be a decrease in spending on health matters and a reduction in the burden on hospital emergency departments. I am not sure whether we would still have the appalling situation I saw in St. Vincent's Hospital this morning where one of my colleagues was standing over a trolley trying to get to one of our patients who was waiting to be seen in the emergency department. Certainly, however, there would be far fewer people presenting at emergency units and hospital waiting lists would be shorter, including waiting lists for elective surgery. There would be more time available for families to spend together and improved family finances.

I understand Deputy Ó Caoláin's sensitivity on this issue but I am speaking not as a social commentator or as somebody who will be running in an election again but as somebody who wishes to speak the truth, as I see it. It is a fact that the burden of three of the greatest scourges in our society, namely, alcohol, tobacco and obesity, are disproportionately borne by poorer people. The reasons for this are complex but these are facts that cannot be avoided. If we can prove that increasing the price of alcohol will decrease its consumption, then we can be confident that doing so will bring disproportionate benefits to the people who can least afford the scourge of alcohol in terms both of their personal health and their personal finances. Moreover, it will have a net major positive effect for society as a whole.

In going forward with policy, we must bear in mind that as a community of legislators, physicians, health administrators and health advocates, we can have only one goal when it comes to alcohol and that is to decrease its consumption greatly in society. It is interesting to note that at a time when we had a national reputation for being drunks, we actually had a relatively modest alcohol intake by international league table standards. This intake level increased enormously through the 1960s, 1970s, 1980s and 1990s, however, and on through the time of our economic boom. While Deputy Ó Caoláin's point about changing social mores may be a factor, there is also the sad reality that when we got a few bob, we spent it on booze. That is what happened. How many of us, back in the 1970s or 1980s, heard somebody who had a minor windfall at bingo or by way of a bonus at work measuring their good fortune on the basis that a pound meant an extra eight pints that night? That was the type of calculus people tended to use. The truth is that we had the potential for an unhealthy relationship with alcohol in the past but it only reached full fruition when we got money. Professor Murray will correct me if I am wrong but my understanding is that since the contraction in the economy, there has been a decline in the use of alcohol. Although it remains at a level far in excess of what it was prior to the catastrophic rise in the 1960s, 1970s and 1980s, it is now somewhat lower than it was at the absolute peak.

Our job, as I said, is to seek to decrease alcohol consumption. The industry, on the other hand, has another job, which is to increase alcohol consumption.

All the manufacturers want to do is sell more alcohol. I am not moralising about it; it is a statement of fact. If they come to us and say they want to be our partners in some attempt to decrease alcohol consumption or ensure alcohol is consumed more responsibly, they are lying. I am sorry for the unparliamentary word, but that is the reality. The only thing they want to do is sell more alcohol and, therefore, we need to understand that they are not our partners, our colleagues or our collaborators in this undertaking. Many of us, myself included, may have tremendous social friendships with people who make their living in that way. I do not want to moralise about them, but when it comes to business, as Don Corleone would say, they are enemies. They are not on our side. They are our opponents and we should not in any sense invite them into the embrace of public policy formation.

Practically, I would share my professional colleagues' disappointment that there is not an immediate blanket ban on alcohol sponsorship of sporting events. I think it is not only desirable but also feasible, and we can work our way around it. It is critically important that we understand all the reasons why all of us should have only one goal when it comes to alcohol policy, and in our own personal lives, which is to decrease alcohol consumption.

Catherine Byrne (Dublin South Central, Fine Gael)
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I thank Professor Murray for his presentation. We met the other day in room A in Leinster House and I thought his presentation there was excellent as well.

In 1997, I visited Canada and toured there with a choir. Our main stay was in British Columbia, and we were taken aback by the fact that in most places we sang people were poor and had drinking problems. One of the biggest problems out there at the time was, and probably still is, the native Indians, who were at the worst end of the scale for alcoholism and everything else. Historically, people would say that land was bought for a bottle of whiskey back in the Wild West times. It was a real experience travelling around, but when we got deeper into parts where native Indians were still living, we found that alcohol consumption was huge and there was plenty of trouble around it.

A few things hopped off the page. Deputy Ó Caoláin mentioned the number of beds being used at night, which has doubled in 20 years. Anytime we have discussed alcoholism, most people have said this is at crisis point.

I am always surprised at airports to see that although, when boarding a flight, we are asked to use travel packs of toothpaste and deodorant, on the way back, people can bring in litres of vodka and other alcoholic drinks which sometimes go completely undetected. That needs to be looked at in airports, particularly from a security viewpoint.

I want to ask Professor Murray about foetal alcohol syndrome in young babies or children. I have dealt with many long-term foster parents and adoptive parents, and one of the issues that has arisen recently concerns children with foetal alcohol syndrome. It does not become apparent until they are three years of age or older, yet difficulties have arisen because of that. One parent told me that her 13-year-old child was never told at school how important it is not to drink when one is pregnant because it can affect the baby. Education in this regard is the key in schools, although some people disagree.

I do not have any more questions. I found Professor Murray's document very interesting. What is the most important recommendation he would make concerning this Bill?

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I thank Professor Murray and the other speakers for their presentations. I would like them to spell out why they are here. Do they have a vested interest? Are they here as doctors? I have just had an opportunity, during the vote, to speak to some of our elected representatives, who tell me they do not agree with minimum unit pricing. They have not sat on this committee and have not heard of the different hazards involved. Therefore, the witnesses need to spell it out loudly and clearly to Deputies, Senators and the general public.

I am not a killjoy or a puritan, but I am here as a mother who, years ago when my kids were teenagers, worried about whether they would come home safely at night or be beaten up. I am a concerned member of the community and a public representative. I have lots of friends and family members who have had problems with drink. I would like the witnesses to spell out for the listening public why they are here.

We are in here every second week talking about the accident and emergency departments and patients on trolleys. If, for example, we could sort out the 200,000 people who Professor Murray says are chronic dependent drinkers, how many beds would be freed up in our hospitals? How would our accident and emergency departments work then?

I will give one example. I spoke to a young doctor - not a junior doctor or consultant, but a registrar - who was in an accident and emergency department recently. He was trying to deal with a lady having a heart attack, yet beside him in the next cubicle was someone who was drunk and disorderly. That person took way more energy and observation than the poor woman having a heart attack. We need to get real. I hear different excuses, including minimum unit pricing and below-cost selling. I presume, however, the medical witnesses are here because they are on the front line dealing with people who are dying.

I heard patients speak at the Royal College of Surgeons and I felt sorry for the individual concerned, but I am sure doctors are used to that all the time. One of our committee members mentioned women drinking. I would like the witnesses to spell out the difference in the effect that the same number of units of alcohol has on men and women who consume them. Are doctors seeing more women coming through for such treatment?

Deputy Catherine Byrne referred to foetal alcohol syndrome and, as a school principal, I have also seen that condition. It is sad because it could have been avoided, yet such children carry that syndrome with them for the rest of their lives.

Those are the points I wished to raise. I really want the witnesses to spell it out for Deputies and Senators who will be voting on this matter, as well as for the general public. At the last meeting, I mentioned to Professor Murray that parents have contacted me wondering why their 17 and 18 year old children cannot buy cheap alcohol. They have asked me why I am such a killjoy. Will the medical witnesses here please spell it out?

Peter Fitzpatrick (Louth, Fine Gael)
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I would like to welcome Professor Murray and his team here today. I am a pioneer so, touch wood, drink does not really affect me as such. However, it does affect members of my family, which is causing the problem. Education is very important in getting young people involved.

I would like to ask Professor Murray's opinion on underage drinking and such issues facing many parents. I come from Dundalk, but I am sure drink is a problem in every city, town and village in Ireland. The main issues are the supply of drink to underage kids and the lack of real education, especially in secondary schools, on the dangers of binge drinking. What would Professor Murray think of highlighting the facts of binge drinking in transition year, showing not only the danger to children but also the effects on their families and friends? It is important to educate our kids at an early stage.

I am a firm believer that if children can get a proper foundation in sport, they will develop their skills a lot better. Many children go to secondary school at a young age and most of them stay back to do transition year.

As Professor Murray said earlier, alcohol is affecting nearly every family in the country. As I said, I do not drink, but alcohol has been a major influence in my life.

What are the witnesses' views on highlighting this problem in transition year?

Jillian van Turnhout (Independent)
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I thank the witnesses for their presentations. They have presented us with startling figures regarding the impact on the health service. In that regard I want to follow up on a question asked by Deputy Mitchell O'Connor about the evidence base for their figures. As someone who is active on social media, I have seen comments that the RCPI or others are scaremongering to encourage us to bring in this legislation. It would be useful, therefore, if the witnesses were to reiterate categorically that these figures are based on evidence and their experience.

In terms of my personal experience, we often think of children when we talk about underage drinking, but I am also conscious of the indirect impact of alcohol on children's lives, whether it is domestic violence or abuse. The Special Rapporteur on Child Protection, Dr. Geoffrey Shannon, has spoken to the committee about the importance of alcohol being seen as a factor by social workers when they are looking into families' lives.

Deputy Byrne mentioned the issue of foetal alcohol syndrome. We give mixed messages to pregnant women about their intake of alcohol. That is an issue the medical profession needs to examine, because as a society we do give mixed messages about alcohol, yet we have seen the serious consequences.

I support what the witnesses state in their submission about minimum pricing, placement and availability. On the question of staff training, do the witnesses have a view on limiting the places where alcohol can be sold?

I agree with the witnesses on sports sponsorship. My personal opinion is that whatever date we set, we should all agree on it. I would like the date to be sooner, but why do we continue to delay doing that? It is wrong, and it will have an effect on children. We are providing in this legislation that marketing to children will not be allowed, yet they see that many of their sporting heroes are linked with alcohol products. That is violating what we are trying to do here in terms of marketing. We are clearly linking alcohol with children's sporting heroes.

Professor Murray gave the example of Italy in his contribution. I am interested to know the key initiatives taken in Italy. My understanding is that the way to change the impact of alcohol-related harm is pricing, availability and marketing. Those are the three major issues to be addressed.

Many people, especially vested interests in the drinks industry, say that education and awareness is important, because if people are more informed they will change their behaviour. My experience is that education can inform people but it does not alter their behaviour. It is not coincidental that with the publication of this Bill there have been two major initiatives by the drinks industry, one of which is the Out of Control initiative. The other involves Drink Aware, whose representatives have talked about visiting schools. We will ask the Department of Education and Skills to give a categorical statement that the drinks industry will not be educating our children on alcohol. Do the witnesses have any views, as medical practitioners, on the drinks industry having an involvement, whether in schools or in so-called consultations with the public, and using their well known and respected brands, thereby normalising alcohol? I would be very interested to hear their views on that.

Colm Burke (Fine Gael)
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I apologise for not being here for the presentation. We had a debate in the Seanad on the ambulance service, which is used to bring people who have been drinking excessively to accident and emergency departments.

The winners of the Young Scientist exhibition this year did a project on alcohol consumption that involved interviewing parents and young people. The connection between the attitude of parents and the attitude of young people going out socialising was interesting. If we want to make any progress in this area we must start with parents, who will try to work with their children.

I am very concerned about another change I have seen take place. The area I represented on Cork City Council for a number of years was around University College Cork. When I first became a member of the city council I was aware that people went to the bars around UCC to drink, but people are now going into the supermarkets at 4 o'clock, 5 o'clock or 6 o'clock in the evening to buy alcohol to drink in their apartments. The big change is that one gets a measure of alcohol in a bar, but when one is drinking at home there is no measure, and people are drinking a lot more. I have seen people coming out of student apartment complexes at 11.30 at night intending to go into town. They are barely able to stand, yet they are going out to socialise further. How do we deal with the issue of measures, especially where college students are concerned?

That brings me to my final point. A member of my family was flying home from a holiday recently when a message came over the intercom asking for medical assistance for someone who appeared to be in difficulty. The person responded, to find that the person was experiencing delirium tremens, DTs. He had been drinking consistently for nine days and had drunk at least 14 units of alcohol per day or two full bottles of wine. The only reason the person was not drinking on the flight was that he had to drive home from the airport. The medical person said the only medical solution he could offer was for someone to give that person a drink to assist him temporarily, but the immediate response was that if he is given a drink he will be unable to drive home. That indicates that we have got the message across that people cannot drink and drive, yet we have not got the message across that there are health consequences to excessive drinking. We have not had full success in eliminating drink driving, but we have made a serious impact on it. Even heavy drinkers know they can no longer risk drinking and driving. It is not just about the danger of drinking and driving. We have not got the message across that if someone drinks excessively they are endangering their own lives. That is particularly the case if someone is drinking excessively for a long period. How do the witnesses believe we can work on getting across that message?

Professor Frank Murray:

I thank the members for their comments and for listening to our presentation. If they do not mind, I will respond now and then ask my colleagues to respond. We will work as a team, as we have done previously.

I will make some comments to set the scene. A common thread in all the members' contributions is that we have a substantial problem with the way we use alcohol in Ireland. That is a common theme in all of the comments made and questions framed. They have identified that problem. We would call it a crisis based on its destructive effect on individuals and families and the resources it is consuming within the various parts of our society, including health care, where we are involved.

We have no conflict of interest here. We are not selling any product. The three medics here are at the nidus of the policy group. We discussed the problems we saw in terms of the increasing number of younger people, particularly women, who are presenting with liver failure due to cirrhosis as a result of alcohol. We come to it from the point of view of medics and carers. We do not have any other conflict. We are not selling a product. We are particularly enthusiastic to be here because we believe the debate has changed. We believe there is now a recognition in this country that there is a crisis. We know from the Health Research Board survey that there is enormous support for taking radical steps to reduce the problems.

It is worth addressing the issue of minimum unit pricing. Deputy Catherine Byrne asked what was the most important recommendation we would make arising from this legislation. The single biggest item to us - we have discussed this in our policy group - is minimum unit pricing, because it has proven effectiveness. I would argue with Deputy Ó Caoláin, who I believe is well motivated.

I respect and understand what he says but the social justice argument is very much in favour of minimum unit pricing, specifically because it targets people who are at greatest risk from a health care point of view and the young. It is a very effective measure in that regard and it is evidence-based. In regard to the speed of impact, it is dramatic, particularly for those who are problem and harmful drinkers and have liver failure or incipient liver failure, because the reduction in the amount of alcohol available to them on the basis of cost reduces the risk of their disease progressing rapidly. This results in a fall in rates of hospitalisation due to alcohol-related complications within a year or 18 months. In addition, there is a fall in all types of crime related to alcohol over a more protracted period. This is not speculation. What we are saying is evidence based. No pilot programme is needed. The alcohol industry wants steps, other than the introduction of minimum unit pricing and restrictions on outlet numbers, to be taken because the industry knows those measures will impact on its sales and profits. We come here without any conflict of interest.

Again from a social justice point of view, a recent study from Glasgow showed quite convincingly that the risk of death from cirrhosis due to alcohol was directly related to the number of off-licences in an area. In areas where there are a number of off-licences and supermarkets, there is an increased risk of people dying from liver failure. I will ask my colleagues to comment further.

Dr. Stephen Stewart:

I am a consultant gastroenterologist in the Mater hospital. We each see different societal demographics. There is a poor population around the Mater hospital area whom I see at my clinic. As has been said, society has changed. It has especially changed over the past 30 years in its approach to alcohol, which some would say should be welcomed. What we have discovered, however, is that women are drinking a lot more. When I was a registrar in the Mater hospital in the late 1990s, alcohol related liver disease was in the main associated with 60 to 65 year old men. It was very rarely associated with women. I then went to the UK for 11 years and after that returned to Ireland. In the intervening period, statistics for death from cirrhosis had doubled. More people were presenting with and dying from cirrhosis. The demographic of age had also changed such that the age at which people were being diagnosed with cirrhosis had reduced from 60 years to 30 years, 50% of whom were men and 50% women. This is not something that should be welcomed. It is a matter that must be addressed now.

The argument is made that minimum unit pricing will impact more on the poorer population. We do not want to make it more difficult for poorer people to be able to enjoy themselves. I will try to put some perspective on this. A person who drinks two bottles of wine a week at a cost of €5.50 per bottle will, following the introduction of minimum unit pricing, which will result in each bottle of wine costing €8.00, be spending €5 more a week on wine. While that increase is not a substantial amount, it will result in countless lives being saved. This is because the people on whom this will have the greatest impact is those who are drinking heavily. A person who is drinking ten bottles of wine a week will be faced with a increase of €25 in that regard. These are the people we are targeting. They are the ones we want to reduce their alcohol consumption. Minimum unit pricing on its own will not tackle this problem but it is the single most important and most immediate measure that will have an impact. In other words, a person could have cirrhosis but not be aware of it, but if they cut back on alcohol consumption, they will never find out they had it. However, if that person carries on drinking, they could die within a year. There will be an immediate improvement in that regard. What is more, if it is made more difficult for people to buy alcohol, people will drink less. Minimum unit pricing affects all demographics. From a personal perspective when I go on holidays to a place where alcohol is cheap, I drink more. How much a person earns is irrelevant. If alcohol is cheap, people drink more, and if it is expensive, they drink less. As such, minimum unit pricing impacts on all demographics.

If we do not tackle alcohol promotion that is targeted at 13 to 15 year olds, we will be storing up problems for the future. We need to change the culture. Italy and France were referred to. The culture around alcohol in those two countries has changed. It is not acceptable to be seen drunk in Italy. France has updated its legislation around promotion. That has led to a dramatic reduction in cirrhosis mortality there.

Unfortunately, education does not work and has proven not to work. It is not that it might not work, rather that it has been proven not to work. It is for this reason the drinks industry focuses on it. We need to forget about education for now and focus instead on the three things that are evidence-based. These are the things that will have an impact on my clinics. Education from parents to children was also mentioned. I am sure that if it were possible to legislate in that regard, the result would be a dramatic improvement. Recent evidence from the Young Scientist Exhibition showed that parental drinking has a huge impact on children. We do not have legislation which could assist immediately in this area, but it is important.

A recent study in this area scored the tightness of legislation in all European countries around alcohol. The tighter the legislation, the lower the cirrhosis mortality rate. We can be legislatively loose and accept higher cirrhosis mortality rates or we can be legislatively tighter and reduce those rates.

I will conclude with a story about a patient who attended my clinic a few months ago. The man concerned had bled from varices from cirrhosis and was found unconscious on the floor by his daughter. He was brought into the emergency department and resuscitated. We then treated his variceal bleeding and he survived. When I saw him six weeks later at my clinic, he told me he had given up drinking and would never drink again. When I responded that I was delighted to hear that and asked why he drank so much, his response was: "I didn't know it was bad for me." He then asked: "If it's so bad for me, how come it's so cheap, available at every corner shop and promoted so heavily?" That is something we all need to think about. That is the reason we are here today.

Professor Aiden McCormick:

I echo what my colleagues have said. The issue of an increase in excise duty was raised. To be honest, that is something for which I was pushing in the college. When we discussed the issue further, however, a number of problems were identified, including that it would not prevent cross-subsidy and could result in below-cost selling. This would mean that if we were to increase excise duty, we would also have to ban below cost selling, which seems a cumbersome way of going about achieving the same thing. In my view, it would not address the social equality issue in that the same stratum of society would be affected.

On the point that 49% of the population, or females, are now drinking more, three or four years ago, along with the Health Research Board, we examined alcohol related mortality in Ireland by age and sex over the past 20 years. Rates in respect of every group have dramatically increased. The issue of on-sales and off-sales and whether it is better that young people go into bars rather than, as in the case of the students in UCC, drink behind sheds and go into town later when they are loaded up was also raised. While I agree that intuitively it seems like a bad thing to do, we do not know long-term if it is better that they do that and, one hopes, grow out of it or that they become culturalised into going to bars. There is an awful lot about alcohol that we do not know. We are doing our best with the evidence we have. Culturally, alcohol in Ireland is a different thing than it is in Canada, France or Italy. Perhaps the solutions elsewhere are not exactly the same solutions we should apply here. We believe the solutions proposed are the best and are evidence-based, but that is only the start. I am sure that in five years time we will be back here talking about what worked a little and what else we can do.

We have also called in our submission for a levy on alcohol advertising which could be used to fund proper research in this area.

It would enable us to figure out whether the measures we are taking are effective and to design new measures to deal with the problem. That is something we have not brought out but we should put it forward strongly. The levy would be a small amount. The companies spend between €50 million to €60 million a year advertising alcohol. A levy of 5% on alcohol advertising would yield €2.5 million a year to spend on high-quality research. It would mean we could produce reasonable data and reasonable plans within a few years. I strongly suggest such an initiative.

Intuitively, education is a fantastic thing but it does not work in my house with my kids. I preach to them day and night, yet my advice seems to go out the door. What seems to be important is peer pressure and example. It is difficult for parents to preach about alcohol to their children when they can open a press and see bottles of wine. When our friends come around, they sometimes drink more than they should. It is an us problem, not a them problem. We have a societal problem in that we have great tolerance for public drunkenness that I do not think we had 20 or 30 years ago. I do not know how we should address these problems. There is no policing of drunkenness any more. One can be drunk and disorderly all one wants and it does not seem to make any difference. This issue is tough for members, as legislators, as well as for doctors. No amount of talking to transition students is going to change that when they come home and see their parents doing the exact opposite.

Professor Frank Murray:

Several questions were asked about data. All of the data we used are in the public domain. The figure of 1,500 beds is from the Department of Health. I got the mortality data from the OECD database which was based on Ireland's submission. All of the data are real data which outline the extent of the problem.

On minimum unit pricing, I am delighted to hear the committee has some people from the Sheffield group coming and that Professor Tim Stockwell has been before it. The data on minimum unit pricing are hard data from the field in Canada and came through Professor Stockwell's group.

We are not talking about something that is soft and iffy but something that has been proven to work. That is why we are so passionate about these matters, particularly minimum unit pricing. We also believe there should be fewer retail outlets selling alcohol.

Deputy Ó Caoláin made an interesting point about a six-pack of bottles. I am not sure one can buy a six-pack any more because one can now buy instead a 20-pack or a 24-pack. The scale of marketing and selling has changed in a way that we think is very destructive because bigger units are being sold. We should focus on minimum unit pricing and availability. We think they are the areas of proven benefit. I would argue they are both socially just and will improve the society in which we live.

The point made by Deputy Ó Caoláin and by my colleague, Professor Aiden McCormick, about excise and how the Exchequer would benefit is important. It is something the smart people in the Department of Finance should think about. In addition to minimum unit pricing, should they increase excise in some way for all sales in particular? There is a lot to be said for such an initiative. It would be of benefit because one would have increased price and more income paid into the Exchequer rather than to off-traders. It is a great point.

Dan Neville (Limerick, Fine Gael)
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I thank Professor Murray, Dr. Len O'Hagan, Professor Aiden McCormick, Dr. Stephen Stewart and Ms Siobhán Creaton for their presence and presentations.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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As we will all be, I expect, wishing the legislation a fair wind, I hope that in 12 to 18 months we will be able to identify the difference outlined by the delegation that has been shown elsewhere. It is all about effectiveness. Any reticence is not about the goal but how we achieve it. I hope that it will be all that the delegation has argued for.

Professor Frank Murray:

I thank the Deputy. We would say that it is a very good argument.

Dan Neville (Limerick, Fine Gael)
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I thank the witnesses.