Seanad debates

Thursday, 23 October 2008

Health Promotion Priorities: Statements


12:00 pm

Photo of Mary WallaceMary Wallace (Minister of State with special responsibility for Health Promotion and Food Safety, Department of Health and Children; Meath East, Fianna Fail)
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I apologise to Senators for the delay in providing copies of the script. They were outside but they appear to have gone back to the other House. They will be here in a few moments.

I welcome the opportunity to speak in Seanad Éireann on the subject of health promotion priorities. It is widely accepted that the general increase in life expectancy, particularly in the developed world, reflects both the lifestyle changes that have taken place as well as the changes and advances in medical practices. Yet, the primary focus of health care systems is on treatment rather than prevention. We all know that people are living longer. It is important for each individual, and for society in general, to ensure that this longevity is matched with good health. Health and longevity are influenced by lifestyle, and by living and working conditions. Almost 60% of the disease burden in Europe is accounted for by seven leading risk factors, which we can influence. Those are, high blood pressure, tobacco, alcohol, high blood cholesterol, overweight, low fruit and vegetable intake, and physical inactivity. People's lifestyle and behaviours can be positively influenced in regard to those risk factors. Poor lifestyle habits and practices are reversible and the benefits of such changes are great.

Individuals are responsible for lifestyle choices, which determine health in later years. However, individuals face different incentive structures with respect to those lifestyle choices. The physical environment, social and fiscal policy, housing, education, the work environment and nutrition are all directly relevant to future health. Responsibility for achieving and maintaining good health is, therefore, multi-layered, involving the individual, the health sector, other sectors and broader society. Investment in health and in addressing the so-called "determinants of health" will have positive economic and social consequences for the country. In other words, promoting and encouraging people to make better and more informed lifestyle choices is good for Ireland.

I wish to refer to two surveys, one relating to adults and the other to children. The adult survey is the national health and lifestyle survey, Slán. In order for us to make informed decisions at Government level we are assisted by research data on which to base policy. The Slán 2007 survey was the third in a series, which was commissioned by the Department of Health and Children and carried out by the Centre for Health Promotion Studies, National University of Galway. It involved face-to-face interviews with more than 10,000 adults, in addition to a sub-study on body size of 967 younger adults, 18-44 years old, and a more detailed examination of approximately 1,250 adults over the age of 45.

The Slán study provides us with invaluable data for policy development and programme planning on a range of lifestyle related health behaviours in the Irish population such as smoking, alcohol consumption, diet and physical activity. More importantly, the Slán survey allows us to identify trends and monitor changes in population behaviours, thus better informing our priority setting decisions at national and regional levels. It is only through more and better information that we can better understand the health behaviours of the population and provide the necessary services and support.

The second survey I would like to mention is the health behaviour in school-aged children, HBSC, survey. This collaborative European study measured a number of health and lifestyle factors among children in all parts of Europe between the ages of ten and 18. Information from the survey is used to inform the development and implementation of health promotion policies. A number of positive findings were contained in the 2006 HBSC survey. It found that smoking levels among young people are continuing to decrease. It also reported an increase in the number of children who have never had an alcoholic drink. However, it outlined some worrying findings regarding the use of alcohol among people between the ages of 15 and 17. The HBSC study informed us that half of all children in that age category are current drinkers. Just over a third of them reported that they had been "really drunk" in the previous 30 days. Such information is needed if we are to identify areas in which a particular focus is needed in the interests of tackling these lifestyle behaviours. I propose to speak about the three issues of alcohol, smoking and overweight and obesity separately.

The Department of Health and Children believes that the level of alcohol consumption in a population is an important determinant of health and disease levels. Therefore, alcohol policy must take into account the total drinking population when defining the scope of public health action and targeting high-risk groups and individual high-risk drinkers. Policies aimed at reducing the harmful use of alcohol reach far beyond the realm of health. They relate to matters such as fiscal policy, trade, agriculture, education and employment. Numerous governmental agencies and organisations are responsible for implementing policy in such areas. The Strategic Task Force on Alcohol, which was established in January 2002, published two reports which set out approximately 100 recommendations across a wide range of sectors. The recommendations are consistent with the measures identified by the World Health Organisation as being effective in reducing alcohol consumption in a population.

I wish to mention four statistics relating to alcohol consumption in Ireland. Irish people aged 15 and over consume an average of 13.5 litres of pure alcohol per person each year, which is 50% above the EU average. A report published by the Health Research Board, which examined the health-related consequences of problematic alcohol use, found that alcohol consumption among the Irish population has increased by 17% in the past 11 years. There was a 147% increase in alcohol-related liver disease between 1995 and 2004, resulting in 1,775 deaths. The number of people in hospital with alcohol-related problems or injuries increased by almost 90% in the same period. Such statistics demonstrate the importance of addressing the problems associated with the role of alcohol in Irish society.

The Intoxicating Liquor Act 2008 was conceived and passed by the Seanad and the Dáil within six months earlier this year. It is a demonstration of the commitment of the Government and the Oireachtas to dealing with alcohol misuse, particularly from a public order perspective. The Act reduces the hours in which off-sales of alcohol can take place and puts in place tougher public order provisions allowing the Garda to seize alcohol from minors. It provides for a court procedure whereby a wine-only off-licence can be secured and specifies new grounds for objecting to the granting of an off-licence. It attaches new conditions to the granting of a special exemption and outlines the arrangements for the structural separation of alcohol in mixed trading outlets.

The introduction on 1 July last of new codes on the advertising and marketing of alcohol was an important development. In co-operation with representatives of the Irish drinks and advertising industries, the Department of Health and Children developed the strengthened codes on advertising and sponsorship. The new codes, which came into effect on 1 July, place an upper limit of 25% on the volume of all alcohol advertising. For the first time, alcohol advertising will be limited to no more than 25% of available space or time in all Irish media — television, radio, cinema, outdoor advertising and the print media. The new controls will also deal with alcohol advertising or sponsorship during the broadcasting of sports programmes. The Government has agreed to establish a working group to examine the extent of existing sports sponsorship by alcohol companies and the terms and lengths of such contracts. The working group will seek to direct how concerns around the extent of sports sponsorship by alcohol companies might be further addressed. The group will be established by the Department of Health and Children, following consultation with other relevant Departments.

In July 2005, a working group on alcohol was established under the terms of Sustaining Progress. The group used the social partnership structure to encourage stakeholders to achieve a targeted and measurable reduction in alcohol misuse. It operated in the context of the special initiative on alcohol and drug misuse under Sustaining Progress. The group included representatives of the social partners, relevant Departments, the Garda, the national drugs strategy team and the Health Service Executive. It examined the three issues of under age drinking, drink driving and high-risk drinking. The group's report, which was published in June 2006, included recommendations on issues like community mobilisation, workplace alcohol policies, advertising, labelling and education and awareness. An implementation group was established in November 2006 to monitor and report on the progress being made with the implementation of the recommendations. The report of the implementation group is expected to be published in the next few weeks.

Almost 7,000 people die each year in Ireland as a result of tobacco use. That number of deaths is far greater than the combined death toll from car accidents, fires, drug abuse and murder. Ireland has led the way in Europe and beyond in implementing legislation to address the tobacco epidemic. There is widespread agreement that the smoke-free at work legislation that was introduced in Ireland over four and a half years ago has been hugely successful. The primary purpose of that measure was to protect the health of workers and the public from exposure to toxic environmental tobacco smoke. Compliance levels of 95%, arising from almost 29,000 inspections last year, indicate that this critical public health initiative is receiving a high level of co-operation from employers and employees. Senators will agree that the real sign of the success of the legislation is the overwhelming support it has received from the public. This positive and progressive health and safety measure has brought immediate and long-term positive benefits to workers and the general public. Its successful introduction is a reflection of the widespread public support and goodwill that exists for a clean smoke-free environment in the workplace.

Price has been identified as an effective tobacco control measure, particularly in preventing young people's initiation and subsequent addiction to tobacco. The sale of cigarettes in packs of less than 20 and the sale of confectioneries that resemble cigarettes was banned in May 2007. The minimum price below which cigarettes cannot be sold was increased to €7.14 with effect from 1 September 2008. The recent budget day increase of 50 cent in the price of a packet of cigarettes has brought the price of the most popular brands to more than €8, making cigarette prices in Ireland the highest in the 27 EU member states and the second highest in Europe. The further provisions of the Public Health (Tobacco) Acts 2002 and 2004 will be commenced from 1 July 2009. I understand that some Senators have been contacted by representatives of retail premises about this issue. It is important to remind them that the Acts contain important provisions limiting the display and advertising of tobacco products in shops. For example, the Acts provide for a ban on all in-store and point-of-sale advertising of tobacco products, a ban on the display of tobacco products in retail premises, the introduction of a closed container or dispenser provision, tighter controls on the location and operation of tobacco vending machines and the introduction of a retail register. The aim of these provisions is to further denormalise tobacco and protect children and adults alike from the dangers of tobacco consumption.

The final main topic I propose to address is overweight and obesity. This issue can be linked to recent developments in tackling cardiovascular illnesses. Of all chronic diseases, obesity is the most preventable, however it is a complex condition. The prevalence of overweight and obesity has been described by the World Health Organisation as an epidemic. Ireland is no different from other countries in terms of obesity trends. Obesity is becoming one of the fastest growing health problems in Ireland. It is a complex condition that affects and threatens to overwhelm virtually all age and socio-economic groups. The statistics are frightening. One in eight Irish people is obese and every second person is overweight. As a result, half of the population is at an increased risk of developing a chronic health condition. Overweight and obesity contribute to a significant number of illnesses including high blood pressure, type two diabetes, excess cholesterol and, of course, cardiovascular disease, including stroke. It is estimated that obesity is responsible for around 2,000 premature deaths in Ireland each year. The indirect cost of obesity in Ireland is estimated at €400 million per annum.

With a co-ordinated multi-sectoral approach to tackling obesity, diabetes and cardiovascular disease, as identified by the task force on obesity, prevention is not only possible but essential. The task force report, entitled Obesity — the Policy Challenges, was launched in May 2005. Its recommendations relate to action across six broad sectors: high-level Government; education; social and community; health; food, including commodities, production and supply; and the physical environment. It highlights the need for cross-collaboration between all key stakeholders and real practical engagement by both the private and public sectors.

A key recommendation of the task force was the development of a national nutrition policy. My Department is finalising this policy, which will provide strategic direction on nutrition for the next ten years. While addressing the nutritional needs of the whole population, it will have a particular focus on young people and on food poverty. My Department has already produced a number of guidelines aimed at specific groups, including pre-schools and primary schools. Post-primary school guidelines and food and nutritional care in hospitals guidelines will be launched shortly.

Another key recommendation of the task force is that Departments, together with the private sector and consumer groups, should take multi-sectoral action on the marketing and advertising of products that contribute to weight gain, particularly those aimed at children. For this reason I very much welcome the new Broadcasting Bill going through the Oireachtas. It provides that the Broadcasting Authority of Ireland prepare codes governing the standards and practices to be observed by broadcasters. This will allow for revised codes on advertising and is a first step in a multi-sectoral approach towards addressing the problem of obesity.

We have made great inroads on the detection and treatment of cardiovascular disease in recent years. The Government has committed over €60 million since 2000 towards the implementation of the cardiovascular health strategy, building healthier hearts. This funding has supported a wide range of new services and initiatives. These have had a positive impact on the diagnosis and treatment of patients with heart disease.

An audit of progress on the implementation of the building healthier hearts strategy was published by the HSE in September 2007. The report, Ireland: Take Heart, showed a continuing decline in cardiovascular disease. However, a rise in obesity and low levels of physical activity have prevented Ireland from doing even better. Smoking is still an important issue, especially among younger women. The report also identifies where services fall short of what was recommended in building healthier hearts.

A cardiovascular health policy group was established in September 2007 to develop a new policy framework for the prevention, detection and treatment of cardiovascular disease, including stroke. The work of the group is nearing completion and it is expected to make recommendations shortly.

An integrated chronic disease policy framework was published earlier in the year. This policy focuses on the population measures to prevent chronic disease including diabetes and how inter-sectoral action can be taken to address the wider determinants of health. These actions will be taken through the Cabinet Committee on Social Inclusion with the support of the senior officials group on social inclusion. The integrated chronic disease policy framework also focuses on disease management programmes. This part of the policy focuses on how chronic disease should be managed. It includes the strengthening of primary care and the development of self-care programmes to empower people with chronic disease to take greater control in the management of their conditions.

The prevention of chronic diseases will benefit everyone, not just the individuals concerned, but society in general. We must ensure that the increases in longevity witnessed in the last few decades are matched with improvements in health. This will not happen unless there is real commitment to addressing the lifestyle factors which contribute to poor health. There is no doubt that the pace of life has increased and it is often difficult for people to live healthy lives. It is important that we help improve general awareness of lifestyle factors affecting health and also that we try to put in place the structures to make it easier for people to lead healthy lives. I will conclude with some wise words from the famous comedian George Burns, who lived to the ripe old age of 100: "If I had known I would live this long, I would have taken better care of myself".

Photo of Mary WhiteMary White (Fianna Fail)
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Very good.

Photo of Frances FitzgeraldFrances Fitzgerald (Fine Gael)
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I thank the Minister of State for joining us here to discuss this area of health promotion priorities. This is the first debate in this session on this issue and it is very important. The Minister of State has covered a wide range of areas and we should return to particular areas, such as alcohol, smoking and obesity, in the Seanad because there are many reports covering different areas. We might discuss each area in detail for a session in the Seanad and examine how the recommendations are being implemented in the various areas. That would be very worthwhile.

Health discussions in this country almost always focus on the crisis situation. Prevention is better than cure, however, unfortunately, the promotion of healthy lifestyles does not get the kind of attention it needs to reduce mortality and morbidity. The absence of the required focus is a serious problem for the country. Much can be done to prevent people from having to go to hospital or developing many of these so-called lifestyle diseases.

When we saw the removal of the medical card from the over 70s this week I was very struck by the numbers of doctors, physicians and consultants who said the one effect of the universal medical card was that it helped people to stay at home by providing access to all the other services. A relatively small input of service to an elderly person can ensure he or she stays at home. A home help or a nurse calling, for example to do some bandaging at home, can make a difference and keep a person at home. This week the Government took a decision that is not in the interest of health promotion and prevention rather than cure. Withdrawing the medical card has put many people at risk and made it less likely that community care will happen for a person rather than his or her having to go into a hospital or nursing home.

We know there is no comparison between the cost of a nursing home and remaining in the community. I would make that political point about the decision making in this year's budget from a health promotion perspective. It was very short-sighted and I was struck by the doctors who have spoken on this during the week and the studies that show the difference those small interventions can make to an elderly person.

The Minister of State has covered a wide range of areas and I will not be able to address them all. I am very keen to see the report of the group examining the implementation of the recommendations of the strategic task force on alcohol. I hope we can discuss that here. One would wonder about young people who are so at risk from binges. With the affluence we have had in this country in the last ten years there is no doubt alcohol consumption is very high and the Minister of State has quoted some startling and frightening figures. The implications are serious and it must be a key area for us to address, particularly regarding young people. Getting education and information about the effects of alcohol to young people is an uphill struggle, given the kind of society we have. If one looks at the health implications for them, it is a matter of life and death.

One example is driving and accidents. We should seriously consider introducing a zero level for alcohol for provisional drivers. There have been improvements. Young people are now often nominating a driver when they go out. However, when one looks at the levels being consumed it is a very serious issue. We may need to take more specific action regarding young people. There is a problem across all ages with alcohol, it is a cultural issue and it is well known that we have ambivalent attitudes. We need more action on the implications of this, and probably need to take more action on the advertising side.

I welcome the changes brought in by the Government in recent months. I hope they will protect communities because many of them are very concerned about groups of young people out of control. These young people can be assaulted and murdered. It is a critical issue. As a society, we need to shift from merely addressing and dealing with health problems as they arise to encouraging and fostering an environment whereby the public is educated about health matters. We need to shift the focus.

The promotion of health, and healthy life, living and eating, needs a champion. This is seen worldwide when one looks at what is happening with health promotion. Someone in Government is needed to drive an agenda promoting healthy lifestyles and good choices. The office held by the Minister of State provides the scope to become this champion. The energy within Government is what is needed.

I turn now to the areas of obesity, drugs and smoking and cancer screening. Cancer screening is not within the area of responsibility of the Minister of State but I am interested in the links her Department can make to this, and I want to make suggestions about some of the screening we need to do which would be important to prevent illness. These arguments could be applied to any range of health issues we face and we need the Government to play a leadership role in promotion and education.

We need to focus on the ticking time bomb of obesity. In 2001, 57% of Irish people were overweight or obese. This year, only seven years on, that figure has risen to 64%. The problem is growing. More and more Irish people are becoming obese and this is leading to serious health difficulties. We need to address this. It leads to diabetes, cancer and — the most recent research shows — dementia. It has life-long implications. We need to do a lot about it.

In 2005 the Government established the National Taskforce on Obesity. There were 93 recommendations. I am concerned. Ten of these recommendations have been farmed out to industry, and some action has been taken on them. The Minister of State said some Departments are working on this. The problem is there are approximately 80 recommendations across a range of Departments, and I do not think we have seen action on these. We need a detailed update on these recommendations and a timeframe for implementation.

I am concerned that there is currently no implementation group in place. The Minister of State might confirm this in her reply. Getting implementation of this report is problematic if there is no implementation group. I may be wrong — perhaps the interdepartmental action may be the implementation group — but is an interdepartmental group charged with acting on these recommendations and has it met? I would like a reply to that. I am not sure that there is one, and the Minister of State might outline whether the implementation group will be departmental or broader in scope. I understand the first recommendation in the obesity report involved stakeholders.

There are groups like the Nutrition and Health Foundation, with which the Minister of State is meeting, who have done much work in this area and produced some terrific publications which deserve to be seen by a wider audience. We must have the interdepartmental group, with a timeframe and an implementation plan for this to move ahead. We need co-ordination and the Minister of State is the person who can do this. This addresses the areas of healthy eating, exercise, nutrition and how we get the message to people about the risks they are taking if they do not begin to act. Getting the message to younger people in schools is critical.

I raised the issue of vending machines earlier in the year, and there has been some progress. There are still issues arising on the range of healthy eating options available to young people in our schools and hospitals. It is extraordinary to go into hospitals and frequently see that one cannot buy fruit. Often, the vending machine is the only thing available to young people. We have work to do in this area and Government action can be taken to look at healthy eating in schools. The schools have a lot to do, and parents are under increasing pressure to prepare healthy lunches, but there is a role for the Government in taking action that can impact on the way young people get food in school or patients, and their family and friends, access food in hospital.

The Minister of State did not mention screening issues, and this may be because it is dealt with by a different part of the Department of Health and Children. Screening is a very important tool for prevention. A meeting of the Joint Committee on Health and Children this week had a superb briefing from the National Cancer Screening Service. It produced some very worrying statistics on the levels of breast cancer, colerectal cancer and cervical cancer. We have had much discussion on breast cancer screening. We want to see it provided across the country. It is depressing that it has taken eight years and we still do not have universal coverage. We should reduce the age at which people have screening and extend it at the upper end. Other countries have brought it up to 75 and we ought to be doing the same.

The numbers of people who are dying of colerectal cancer this per year is extraordinary and very disturbing. There are 1,900 new cases every year, and 900 people are dying. Irish men have the fourth highest mortality rate among men in the world for colerectal cancer. We need this screening to be brought in. Women are tuned into prevention and they are good at undertaking screening, but Irish men are not. As can be seen from the statistics, colerectal cancer screening must come in very soon. It should not take ten years to come in, as breast cancer screening did. We must find a faster way to proceed because lives are being saved. As it is a good preventative tool and resource it can alleviate pressure on the hospital system.

The Minister of State highlighted very effectively the challenge we still face regarding smoking. There was cross-party agreement to put €2 on the price of cigarettes. That would not be popular with smokers. Many voters will say that it is a time of recession, people who smoke want to smoke, and they do not want cigarettes to become more expensive, but it is the most effective means of addressing the issue. We had cross-party support for a €2 increase. Can the Minister of State tell us why this was not done? The Fianna Fáil Chair of the Joint Committee on Health and Children supported it. It is the most effective way to proceed if we are serious about health promotion and preventing disease and illness. The recommendation was put forward by ASH. There have been some very good initiatives regarding smoking.

I welcome this debate, which I requested. We must start focusing on health promotion and the prevention of serious illness in Ireland. Culturally, we are not doing enough. We need a champion and it is a great opportunity for the Minister of State to take on that role and to try to promote greater debate. I would like to see the Seanad playing a stronger role in this area.

Photo of Mary WhiteMary White (Fianna Fail)
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I had the pleasure of meeting Dr. Muireann Cullen of the Nutrition and Health Foundation this morning and Mrs. Catherine Bent, a representative from the Nutrition and Health Foundation stakeholders. They pointed out that the national task force on obesity, chaired by the eminent Mr. John Treacy, made 93 recommendations but these are not being taken seriously or implemented. I ask the Minister of State to give an update on the position in that regard in her response to the House. It was frightening to hear that in 2001, 57% of adults in Ireland were overweight but by 2007 the figure had risen to 64%.

Finland, as Members know, has a reputation for heavy drinking and ill health. The Finnish Government led a ten year campaign to improve the health of the Finnish people and was very successful in this regard. Our own Government was successful in introducing innovative legislation banning smoking in the workplace and public places. This has led to a cultural change in attitudes to smoking. I took up smoking when I was 18 years old and I must say I enjoyed every cigarette I ever had but the national awareness campaign of the 1980s encouraged me to give up. Unfortunately, I put on four stone when I gave up smoking. However, having spoken to the representatives from the Nutrition and Health Foundation today, perhaps the penny will drop and I will become more physically active.

As the Minister of State has said, it is frightening to think that every second person one meets in Ireland is overweight. Dr. Cullen pointed out that nutrition is not on the curriculum for trainee doctors, which is alarming. When patients visit their doctors, they should be given nutritional advice. As we all know, unhealthy eating habits start early in life, with young people eating too much.

I urge the Minister of State to champion the cause of a healthier and fitter Ireland. However, it is important that we do not separate physical and mental health because they go hand in hand. More emphasis is placed on physical health than mental health at present because of the stigma attached to mental illness. In that context, Dr. Cullen also pointed out that trainee general practitioners do not study mental health as part of their course at university.

I spent from September 2007 to July of this year studying suicide. During that time, I spent three months writing a paper on suicide in Ireland. There are more suicides in Ireland every year than deaths by road accident. Approximately 500 people die by suicide every year. Four times more Irish men die by suicide than Irish women. Our national average on suicide in comparison to other EU countries is relatively good — we are in seventh place — but we have the second highest youth suicide rate in the EU. While I know there is a Minister of State with special responsibility for mental health, the Minister of State with responsibility for health promotion should focus on the promotion of mental and physical health.

Figures from the National Suicide Research Foundation in Cork indicate that approximately 60,000 Irish people self-harm every year. There are 11,500 self-harm presentations to accident and emergency departments, representing 8,500 individuals, as many are repeat presentations. Self-harming is a predictor of future suicide which shows that our heads are in the sand regarding the extent of the problem. We are afraid to face up to the fact that we have a serious suicidal problem in Ireland. That problem cannot be solved by simply placing advertisements in the media about mental health. We must educate young people at school about mental health.

A survey carried out by the EU in 39 secondary schools in Cork and Kerry found that 9.1% of teenagers said they had a constant history of self-harming, which is frightening. Such teenagers are in a lonely position. They are not talking about self-harm but are doing it privately. They are in purgatory because they cannot face up to their mental health problems. Discussions about the importance of physical health are broadcast widely but mental health is not seriously on the radar.

When people turn up at accident and emergency departments in other countries having self-harmed, they must go through a formal process of evaluation. They are asked about their own history, their family history and their current life situation. They are also given a formal follow-up, in terms of psychiatric help, once discharged. The system in Ireland is very ad hoc. Every accident and emergency department should have a uniform procedure for recording self-harm presentations and for ensuring that patients receive appropriate psychiatric treatment.

Approximately 60,000 people self-harm every year but only 8,500 present at accident and emergency departments. That means more than 50,000 people are not making contact with our health services and are suffering in silence because of the stigma attached to depression, mental illness and suicide. In 30 years' time we will look back and remark at how savage and barbaric we were, that we stuck our heads in the sand and ignored this problem.

People are afraid to say they suffer from depression because they feel they will be diminished in other people's eyes. The well-known author J. K. Rowling announced last year that she had felt suicidal because of personal circumstances. That announcement was very important and positive. It was pointed out to me by a Dáil Deputy that when politicians are canvassing they are often asked by constituents about the possibility of getting treatment for family members who have cancer or other physical illness. However, they are not asked about treatment for family members with mental illnesses. Mental illness is not becoming a political issue because people are ashamed to talk about it to politicians.

We must drive forward this issue. I make a total of 31 recommendations in my paper on suicide. These can be boiled down to three actions to effectively reduce the level of suicide. These are a reduction in alcohol consumption, training GPs to identify depression and restricting access to lethal means. People have told me their children died from suicide and their GPs had told them to pull themselves together. Not only do GPs not get training on nutrition, they do not get adequate training on identifying and treating mental illness.

I accept that we have a serious obesity problem. However, as a young female politician the Minister of State can influence the attitude to addressing suicide in schools and issues such as bullying. International research shows that 20% of those who die by suicide have been bullied. Bullying happens in schools, workplaces and in Leinster House. I was bullied by somebody yesterday. I told my colleagues in my office what was said to me and they asked whether there was somewhere I could go to report it. People have no right to intimidate or try to diminish other people. How dare they?

Irish people, society, schools and business need to know what are human rights and not only hear the words. Human rights involves not interfering with or intimidating people or diminishing others. I am not addressing fully this serious issue of young people being bullied in schools. I am discussing the physical and mental health of young people. We must begin by discussing nutrition with young people in schools. We all know it is too late afterwards. I have been a friend of the Minister of State since 1993 and wish her the best of luck in her role. She has a tremendous opportunity to place the issue of physical and mental health on the political radar.

Photo of Ivana BacikIvana Bacik (Independent)
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I welcome the Minister of State to the House and I also welcome the opportunity to speak on the important issue of health promotion priorities. I listened with great interest to what previous speakers stated. Clearly, this topic covers an enormous spectrum of health issues. Senator Mary White correctly spoke about the need to incorporate physical and mental health. Enormous work must be done on seeking to prevent suicide and decrease suicide rates. She was also correct to focus on bullying which is a major issue. A bullying research centre in Trinity College has done a great deal of work on how to prevent bullying and deal with it when it occurs, whether in schools or in the workplace.

I want to focus on two issues, one of which the Minister of State focused on in her speech and another which has not been raised. Alcohol is an important topic in the examination of health promotion. It feeds into bullying and difficulties with mental and physical health. The Minister of State cited figures which are of great concern. An increase of 147% occurred in alcohol related liver disease between 1995 and 2004. The number of people in hospital with alcohol related problems or injuries increased by 90% in the same period, which is an enormous increase.

I agree with the Minister of State that the issue of abuse of alcohol is of serious concern. However, I do not agree that the Intoxicating Liquor Act does enough to deal with it or to address the problems we have in our culture with alcohol abuse. We debated it at length in this House and at the time I raised some of the difficulties I had with the provisions of the legislation. Some measures concerning education in the Act are positive. Public health education is a vital part of any campaign to address the problems associated with alcohol abuse.

The part of the Act with more teeth contains provisions on the sale of alcohol, particularly relating to closing times. These represent a missed attempt to change our culture around alcohol. The highly restrictive licensing system we have in place at present does not work to prevent excessive consumption of alcohol. According to the figures given by the Minister of State, in Ireland our consumption of alcohol is well above the EU average. However, we have a long tradition of controlling the number of licences granted and the hours at which alcohol may be consumed in licensed premises and bought in off-licences.

This is in contrast with other European countries, particularly on the Continent where more relaxed and liberal licensing laws are in place with regard to the sale of alcohol, where people are more responsible about their personal drinking. We seem to have a culture in which the State has restricted the hours of drinking to a much greater extent and yet people are less responsible in terms of their consumption. This is a conundrum and all of us can grapple with how best to tackle it.

It would have been worth trying an approach which liberalised who could open licensed premises. I would love to have seen nightclub licences to address the issue that people like to dance as well as drink. It would have given people a place to go and would have dealt with public order issues that occur when pubs close. I would like to have seen a programme which introduced licences where food and drink would be sold together and which would have attempted to create a culture more like the European drinking culture where people consume food and drink together and are less likely to abuse alcohol or drink excessively. The problem is that for so long we have been treated like children in terms of drinking laws that people behave like children. It is time to move away from the paternalistic approach. This is one aspect of the issue of excessive alcohol consumption which covers a range of issues.

Another aspect I want to mention is alcohol and sports sponsorship, to which the Minister of State referred. As part of any campaign to address excessive drinking, it is important to examine the advertising and marketing of alcohol and the Minister of State and the legislation have done so. I am glad to see controls on the volume of alcohol advertising. I am also glad to see the Government has agreed to establish a working group to examine this issue.

Last March, I raised this matter in this House and held up a football jersey for a well-known English Premier League football club. It was sold in a shop in Dublin in a size to fit nine and ten year olds. However, it carries prominently the logo of a well-known beer company. The matter was brought to my attention by somebody who was greatly concerned about it. He wanted to buy a football kit for his young son but found they all advertised alcohol.

In January, the UK adopted a code which prohibits the sale to children of jerseys which bear alcohol logos. Alcohol companies which are permitted to sponsor football clubs are not allowed to display their logos on children's kits. When I raised this matter in the Seanad, I also wrote to the Minister for Health and Children, Deputy Mary Harney, requesting that a similar code be introduced here. I stated that if the industry is not willing to do so legislation should be introduced. The Minister responded that no legislative remedies were available to restrict or stop the sale or import of these jerseys. Irish clubs do not do this. It is a matter particular to English Premier League clubs. I would like an update on this issue. Will it be tackled by the working group mentioned by the Minister of State or is it being addressed?

Another aspect of health promotion which has not been touched on in this debate but was raised by Senator Prendergast on the Order of Business — I know she will address it with much more expertise than I — is the issue of health promotion in maternity and reproductive health services. Health promotion strategies and public education can play a major role in promoting public health generally.

The law on reproductive health has had a long and tortuous history. The current law on reproductive health is not best focused at meeting the needs of women and men. Due to constitutional restraints, the needs of the many thousands of women who travel to Britain and abroad for abortions every year are not being met. There are also difficulties in health promotion for crisis pregnancies. I commend the Crisis Pregnancy Agency in its positive work in promoting reproductive health and preventing crisis pregnancies. On Monday, it launched the Think Contraception campaign which will have immense public benefit in educating people about avoiding crisis pregnancies and sexually transmitted infections and diseases. It is most unfortunate that last week's budget announced the agency would be subsumed into the Health Service Executive.

Photo of Ivana BacikIvana Bacik (Independent)
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I hope that will not put a stop to the work it is doing in health promotion.

The Crisis Pregnancy Agency has not been able to stop rogue or bullying pregnancy counselling agencies because there is no legislation in place. These operate around the country to essentially bully and intimidate young women who present to them with crisis pregnancies, giving them misinformation. Some form of Government action or legislation is required in this area.

There are problems with the Regulation of Information (Services Outside the State For Termination of Pregnancies) Act 1995 which prohibits doctors and counsellors from referring women to termination providers in Britain. Even if a woman wishes to go to Britain, she can only be given information but not be referred. From a health promotion perspective, this is not adequate in dealing with the issues women in crisis pregnancy face.

The Association for Improvements in the Maternity Services, AIMS, established in 2007, has met with the Minister for Health and Children to press for changes and improvement in the delivery of maternity services. AIMS has requested adequate data collection from hospitals on the provision of maternity services. For example, there is a concern that adequate figures on maternal health are not available but come piecemeal from individual maternity hospitals. Data on maternal morbidity rates seem to be lacking.

AIMS has also lobbied the Minister for the setting in place of national guidelines for good practice on the delivery of maternity services. This was highlighted in Ms Justice Maureen Harding Clark's report on the provision of maternity services at Our Lady of Lourdes Hospital, Drogheda. Her recommendations need to be put in place and national guidelines for good practice adopted. AIMS has demanded adequate action where there are deviations in services as was highlighted in the Lourdes hospital, Drogheda, with the appalling consequences for so many women.

Maternal and infant health is a matter for health promotion. AIMS has raised this not only with the Minister for Health and Children but also with the Minister for Education and Science. Some education about normal birth and breast feeding should be included in the curriculum as part of the social, personal and health education syllabus. Irish breast-feeding rates and normal birth outcomes are among the lowest in Europe. AIMS has published figures on the rate of caesarean deliveries which is pushing 30% in some hospitals. The national breast-feeding rate has been far lower than the European average, a mere 14% in the first six weeks after birth, a critical time in the development of infant health, compared with the European average of 80% to 90%. We should be looking to promote normal birth and breast-feeding at an earlier level. Will the Minister of State embrace that as part of the health promotion strategy?

1:00 pm

Photo of Ann OrmondeAnn Ormonde (Fianna Fail)
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I welcome the Minister of State at the Department of Health and Children, Deputy Mary Wallace, to the House and wish her well in her brief. It is a challenging brief with which we all, as public representatives, can identify because we recognise what is happening in society. I have no doubt the Minister of State will be comfortable with these challenges.

What are the priorities in health promotion to deliver good health for the people, both adults and children? Lifestyles have changed over the past 15 years as Ireland has become a more wealthy society. Parents and young children have had much money to spend and this should have been matched with good health. Consumer spending, however, has brought along bad health with high blood pressure, binge drinking, obesity in children, cardiovascular disease, nervousness and asthma becoming more prevalent. These are illnesses I never heard of when I was growing up. Health profiles of young people highlight problems with self-esteem, bullying and suicide. If I were to talk on every one of these issues, I would be here for a long time. I will concentrate on the one issue that I know most about from my dealing with the public — binge drinking.

The Intoxicating Liquor Act 2008 alone will not tackle the problem of young people binge-drinking. It is a societal issue which must involve parents, communities and schools in tackling binge-drinking and its knock-on effect, anti-social behaviour. Why is binge-drinking prevalent? It is because of low self-esteem and too much money among our young people. Many of them had part-time work and were able to spend what they earned on drink. This may change with the downturn of the economy. In one way, the downturn might be good in that people will have to pull their lifestyles in a bit. Many young people believe they are a success story by proving how much they can drink. At 3 o'clock in the morning, they all spill on to the streets with resulting anti-social behaviour. Public transport could be used to prevent people congregating. The Minister of State should involve the Department of Transport.

The Garda cannot tackle this alone. Parents have a role too. There has to be a change in attitudes which can only come from the schools. Our social and personal education is not sufficient to deal with this problem. While teachers will do it well between 9 a.m. and 4 p.m, when young people leave the school environment, it changes. Schools, the Garda, the law cannot tackle this issue alone. All stakeholders must combine to change our lifestyles to bring about an attitude of good living, health, behaviour and a sense of being responsible. Good manners and how to behave in society were prevalent when we were growing up but now they are gone. We were taught these by our parents, not in the schools. The question must be asked whether they are being taught manners today. The schools will do their best but there must be continuity in the outside world to deal with that. As well as getting at the schools, therefore, the Minister of State, Deputy Wallace, must get at society.

Residents' associations will have a role. Perhaps we should invite people in to discuss the area of anti-social behaviour and how society can help out. It is like the national economy in that we all have a stake in this. We all want to have a good standard of living, to protect our way of life and to have the money in our pockets, but we must sacrifice somewhere.

In the light of this binge-drinking, we must change the attitude and the culture. I enjoy a drink. Anybody would enjoy alcohol in moderation, but this is about how to behave. It comes from our low self-esteem. I ask myself why there is such low self-esteem. Why do young people feel they must drink and judge the success of their night out by how much alcohol they can consume? What worries me about society is that the pattern of life is failing and I wonder how the young people will cope with life when they grow up to be adults.

Another area I wish to raise relates to overweight and obese children. That is also a societal issue. We must ask the teachers of social, personal and health education and the nutritionists. The parents at pre-school must understand before their children come to school.

The Minister of State, Deputy Mary Wallace, has a great time ahead of her. There are considerable challenges. I will continue to speak to her on this outside the Chamber. She will make it work because it is a societal issue and that is what she is good at.

Photo of Phil PrendergastPhil Prendergast (Labour)
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I welcome the Minister of State to the Chamber. I will touch on a few points which have not been covered and on ones to which Senator Bacik referred earlier.

I raised on the Order of Business this morning my concern about the severe shortage of midwives in all the major maternity hospitals in light of the current staffing restrictions. The leads me, on the issue of health promotion, to parent craft classes which are usually in place so that mothers to be can be educated on the benefits of breast feeding and those who choose not to — we are pro-choice in this regard — can know the correct way to make up bottles and be shown the skills they may need in having a new baby, if it is their first and, indeed, to refresh them if it is not, even though demand for antenatal classes continues among some no matter how many babies they might have.

I would be very concerned at present. Having worked as a midwife for more than 20 years, I am aware that in a crisis in a maternity unit, one always must go to where there is the greatest activity. In terms of priorities, there will always be a need, whether the action is in the labour ward or in the theatre because of caesarean sections, our rate of which is considerable. The service which goes off the radar, so to speak, is parent craft and health education. As a health care professional, if I have a choice between whether I have staff where they will be needed in the delivery of the baby as opposed to the delivery of education, my priorities will lie always with the woman who is having the baby because that is the greatest need. We all aim to send home a well baby with a well mother who is able to look after it as best she can.

In terms of the amount of time available, we in Clonmel are lucky. I am not just promoting Clonmel. As there are 1,200 deliveries a year in the hospital, the staff are able to have time to speak to the mothers to help them with breast feeding, to encourage them to do what feels right for them, to give them the confidence to know their skills and instinct are not flawed, and to let them know there are skills to be learnt. It is not quite as beautiful as the baby sucking gently at the breast and looking up at the mother. Sometimes there is a little harassment thrown in and, indeed, I was a great testament to that in my day. In any event, there is a significant issue in that regard.

As a person who has a great interest in young people, I was invited by schools to be a guest speaker during my time as mayor of Clonmel. Many of the young people in schools would speak about different options they might like to take up in the future and I was brought in as somebody who might be able to talk to them about midwifery, for which I have the highest regard, and nursing in general. I understand the problems due to scarce resources and what it is like when one is faced with the choice either to teach a woman about parent craft or to go to the labour ward to help out. The choice must be to go where one needs to be. That is a pragmatic decision and response with which we must deal.

There is a great interest in health promotion but there is also a great disconnect at times between it and the physiological process. That leads me to my next point, which is pertinent and relevant. I regularly visit schools in Clonmel and the surrounding areas, including Dungarvan, to talk about the sexual health programme. The content of my programme is informed by questions I take in advance. I collate the questions because as every student can ask up to three questions, naturally there is duplication and when I collate them, there probably is 40 overall. There is a significant amount of misinformation and much reference to teen magazines. I do not know whether the Minister of State has looked at the content of teen magazines recently, but it would make your hair fall out. In my case, I will not say "stand up" on account of——

Photo of Cecilia KeaveneyCecilia Keaveney (Fianna Fail)
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The hair-do.

Photo of Phil PrendergastPhil Prendergast (Labour)
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——the fact it would frighten the Minister of State. There is significant interest in the area of sexual health. I visit classes from second year to the leaving certificate. There is great interaction because I get many texts afterwards. Naturally, there is great interest. Some will not ask the questions in class but will follow up on something I said.

I do not put a tooth in it, as it were, in the case of sexual health and sexually transmitted infections. I do not give them statistics, the reason being simply that I would fall asleep myself at the mention of them. Instead, I talk about how many in a class of 40 might have the most common sexually transmitted infection — genital warts — or I talk about the dangers of chlamydia and how it can affect their future sexual health in being able to conceive, when that time comes. I also talk about crisis pregnancy and the morning-after pill. It is very relevant and those classes are very pertinent and important. There is a considerable focus, from my perspective, on young people getting the correct information in a non-judgmental way and being able to talk about the difficult questions. The students should be able to talk in their own language about what it is that affects them and the challenges they face.

I do not confine it all to matters sexual. We talk about issues of self-esteem, body image and how one might feel better in oneself. We also talk about issues of same-sex attractions. We talk about all that because the issues arise in the questions I receive in advance of classes.

Obviously, one is constrained by the length of time one has with these students and one cannot deal at length with suicide, which has been covered by Senator Mary White. As a member of the sub-committee, I have a great interest in that area and a great deal of empathy with people who deal with that daily. As the Minister of State can imagine, given the horrific numbers of people who take their own lives every year, we encounter much of that and many who are affected. There is a fear as well that talking about it in school will prompt somebody to do it.

I am well aware that if one can interrupt the sequence of events, it is possible to make a difference. Recently, I attended a conference in Scotland, the 12th European Symposium on Suicide and Suicidal Behaviour. There were 750 delegates from 53 countries at the conference. In addition to plenary sessions there were many parallel sessions in 20 minute slots throughout the day. I attended a particularly interesting one. It was about four people who were unsuccessful in completing their suicidal acts. There were four different events and the one that occurred in America made me think hard. It involved a very famous bridge where the outcome of attempted suicide was always a success. The person jumped and in that moment clarity and sanity returned. The person was able to take the necessary action to get into the correct position so as not to die. The rest of the four were similar; they took evasive action at the last minute when sanity and clarity returned.

I do not know if there are easy answers. I was a midwife for many years and I know from conducting those programmes in schools that there is a huge role to be played in educating people properly and perhaps doing it on an informal basis, which is what I do. There is always a great deal of relaxation because the students know I am not a teacher, and we use some different words that perhaps teachers will not use. That is the real world, and I am delighted to be part of that world.

I am delighted to have participated in this debate. I thank the Minister of State for her interest. I hope I have contributed in a positive way to formulating a policy that might best shape the future for our young people and make a difference.

Photo of Déirdre de BúrcaDéirdre de Búrca (Green Party)
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I welcome the Minister of State and the opportunity to discuss health promotion priorities. Health promotion is a central interest of the Minister of State's portfolio. What is most important in setting priorities in this area is the basic model of health care that underpins our health care system. Obviously, health promotion is about prevention and early intervention. It is about trying to promote health so people can avoid contracting disease or illness, and the expensive high technology interventions that are necessary at that stage to cure or rehabilitate them.

The Green Party's health policy has always put great emphasis on self-management and self-care, with the onus on the individual to manage his or her health in a responsible and effective way. To do that, the individual must have as much information and awareness as possible, particularly in today's society where lifestyle-related diseases occur more frequently. These are conditions such as obesity, diabetes and diet-related illnesses and ill health. There are also diseases that can arise due to lack of exercise, over-indulgence in drugs or alcohol and, as Senator Prendergast mentioned, sexual behaviour. These lifestyle-related issues can have a profound impact on an individual's health over the long term. Problems tend to present themselves when the individual is middle-aged or older. The cumulative effect of a lifetime of bad diet and poor lifestyle can culminate in serious health problems which then present in our acute hospitals and so forth and require all kinds of expensive interventions.

One of the priorities for health promotion is the development and implementation nationwide of an effective primary health care system that is accessible and affordable, something the Government has commenced and to which it is committed. This model involves the establishment of primary health care centres that are staffed by multidisciplinary teams. They would include professionals such as dieticians, occupational therapists, physiotherapists and so forth to deal with the wide range of lifestyle related health issues with which people can present. If our primary health care system is to be successful, it must be about early intervention on these matters and trying to prevent people reaching the point where their conditions become so chronic they must present to the acute care sector of the health care system.

While the primary health care system is important and the Government must obviously continue its efforts to roll out primary health care centres throughout the country, another part of the health sector has been overlooked and has been almost invisible in terms of the contribution it makes to health promotion. It comprises the community pharmacies and the health food sector. As the community pharmacists emphasised to public representatives during the pharmacists' dispute over the last year or so, the community pharmacists provide an informal service by providing information, advice, guidance and so forth to people on the management of their health. Again, this puts the onus on individuals to take responsibility for their health and to have an awareness of the correct information about their health condition.

The Green Party has always taken a strong interest in the health food sector. I thank the Minister of State for recently agreeing to meet representatives from the Irish Association of Health Stores who wished to discuss Ireland's position with regard to the transposition of the EU food supplements directive and the setting of maximum permitted limits for certain vitamins and minerals. The Minister of State's attitude was extremely open and she gave the representatives a fair hearing. Again, they made the point to the Minister of State that they are an important source of information and advice for people on managing their health. Obviously, they also stressed the role that the careful and responsible use of food supplements can play in managing one's health.

I hope the Department of Health and Children will find a way to include the community pharmacists and the health food sector in the health promotion strategy that will be developed. They currently play an extremely important role and, in co-operation with the Government, could play an even better role. Perhaps certain regulations might have to be introduced or tighter conditions might have to be imposed on the type of services they are currently providing informally and in an unregulated manner, but they provide an important service, which potentially could be even more important, to the public. I hope the Minister of State will take this into consideration in formulating the health promotion strategy.

Photo of Fidelma Healy EamesFidelma Healy Eames (Fine Gael)
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I am delighted to speak about health promotion. During the middle to late 1990s and over the turn of the millennium I was on secondments of up to five years working in health promotion and public health in two different health boards and in the education sector in the formulation of the new school subject known as social, personal and health education. I re-examined the statistics for that time in preparation for this debate. The two main causes of early death in Ireland at the time were smoking and fat in one's diet. Interestingly, that is still the case. The problem of fat in the diet or obesity has worsened but smoking still remains a major cause of death. I will focus on that today. Mental health and bullying, which were well discussed by Senator Mary White, are also huge factors in early death.

Health promotion is about the health of the population. I vividly recall that, especially when working with young people, it was about making the healthy choice the easier choice. That was my benchmark. As we get older the issue is adding years to life and life to years. In that regard, one can understand why free entitlement to the medical card for everyone over 70 was a very significant factor in adding years to life and life to years. It has begun to mean so much to them because it is a health-promoting factor in their lives.

I read the speech of the Minister of State although I was not present to hear her delivering it. It is wonderful to note the research she is drawing on, which confirms much of what I am about to say.

Smoking is the main cause of preventable ill health and premature death in Ireland. Some 6,000 people die here every year from smoking-related diseases. As the Minister of State said, 30% of all cancers are caused by smoking and 90% of lung cancers are caused by it. The evidence very strongly supports the view that these are preventible given the correct intervention. The effects of smoking on health include cancer of the lungs, mouth, larynx, throat, oesophagus, cervix, bladder and pancreas, in addition to coronary heart disease and pregnancy and birth complications.

This is a difficult area to work in because one never knows how effective one is. Success cannot be pinned down and, as Senator Ormonde stated, it is no good working solely in schools. A multi-pronged approach is required that reaches the home, school, community and even sports clubs, or anywhere that serves as a key influence in young people's lives.

Tobacco is the leading cause of cancer deaths in Ireland. In 2005, according to the National Cancer Registry, 1,092 males and 750 females died as a result of tobacco and lung cancer. The Slán survey, a survey of lifestyle attitudes and nutrition, indicates smoking is an issue across all age groups. Some 35% of smokers are between 18 and 29 and 34% are between 30 and 44. Therefore, over 70% of smokers are under 45. Smoking is more prevalent among the poorer social classes. Some 37% of smokers are in social class 5-6. The majority of smokers between 18 and 29, 30 and 34, and over 65 are men. Interestingly, more women are smokers in the 45-64 age category.

I would like to draw the attention of the Government to the importance of addressing smoking early in children's lives. The gateway age for the drug is between nine and 13 years. The Health Behaviour in Schoolchildren study summarised the main points. It states smoking is most prevalent among youths between 15 and 17, particularly girls. These girls are more likely to be middle-class girls, which is not so much the case among adult female smokers. While it was encouraging to note in the Slán survey that smoking on the part of boys and girls had decreased slightly in 2006, the rate among girls was still higher than that among boys.

Why do young people start smoking? They talk to me about the weight issue, as referred to this morning, and to peer pressure, the desire to conform when hanging out, self-esteem issues and the lack of physical involvement.

We need to determine the effective interventions. The approach is to start young and start now because of the cost of smoking in terms of ill health and the burden on the health system. This is a major issue that needs to be addressed in future budgets. We spend €15 billion on health annually. Some 10% of the current budget, €1.5 billion, is spent on treatment for tobacco-related diseases. It is well worth addressing this. One of the main steps that can be taken is increasing the price of cigarettes. It was interesting that Senator Fitzgerald stated there is cross-party support for increasing the price of a packet of cigarettes by €2. It would have been an easy method to acquire the extra revenue needed in the budget by comparison with the method the Government chose.

The United Kingdom has been more successful than Ireland in tackling death due to smoking. It has stronger media campaigns, which have been shown to be quite effective. If we follow the advice of the World Health Organisation to monitor tobacco and prevention policies, protect people from tobacco smoke, which we have done very well in our legislation, offer help to those who want to quit tobacco use, warn about the dangers, enforce the laws on tobacco advertising, promotion and sponsorship and raise the taxes on tobacco, we will go a long way towards preventing ill health and death by smoking.

Photo of Cecilia KeaveneyCecilia Keaveney (Fianna Fail)
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This is a vast subject and to embrace it in seven minutes is impossible. I wish the Minister of State well in her work. We will see the changes when she is successful.

I was the convenor of the Oireachtas Committee on Health and Children some years ago and we produced a very strong report on the tobacco industry. It is still available for Senators to read. It gave the then Minister for Health and Children, Deputy Martin, the confidence to introduce the smoking ban. I learned a lot about the tobacco industry's ability to promote its interests. A very brave decision — the right decision — was made by the Government and we should continue to monitor the industry.

While I acknowledge that the price of a packet of cigarettes was increased by 50 cent in the budget, I believe it should have been increased further. I do not accept that it is good enough to say revenue would decrease if cigarettes were taxed too much. The price should be a disincentive to smoking, if possible. However, some smokers to whom I spoke said they have stopped having lunch and dinner and instead use the money to buy cigarettes. Such is the difficulty associated with tobacco.

If I were to focus on one subject concerning smoking, I would ask the Minister of State to consider making patches and other equipment to help one stop smoking much more readily available. A nurse told me a number of years ago that she was only allowed to have one packet of such products at any given time and that this presented a difficulty if more than one person approached her with a view to quitting smoking.

We must bite the bullet; taxation on cigarettes should not be a revenue stream. We should try to assist people in quitting consuming what is an addictive drug. A lot of money must be invested to help people overcome any addiction.

Let us consider alcohol abuse, bearing in mind that I enjoy having a glass of most types of alcoholic beverage as much as anyone else. I raised the issue of the labelling of alcoholic beverages on the Adjournment on 28 November last year. Has the Minister of State an update? A number of Members of the Seanad and Dáil have recently lost weight — some of us again — and were facilitated in doing so by many food companies that write on their packaging the calorie content, saturated fat content and salt content of their products, in addition to all the other ingredients.

However, if one purchases an alcoholic beverage in a bar, nothing states what one is really drinking. One might know the percentage of alcohol, the stating of which is obligatory. I should not be mentioning specific alcoholic products but will refer to two to make a comparison. Bud Light is light in alcohol but not necessarily in calories while Bulmers Light is light in calories but not necessarily in alcohol. In this case, the word "light" has two completely different connotations. If I get a diet drink I will know what is in it, and people are not scared to say it. I have challenged the industry to come up with less calorific versions of alcohol.

The European Union regulatory framework, Directive 2000/13/EC, deals with this issue. Last year we presented our way forward on labelling competitiveness, consumer information and better regulation in the EU. The Minister of State might not have it to hand but I would be interested to get an update on that from her.

I saw people on "The Late Late Show" who had lost weight recently and the one point they all made was that they no longer drink alcohol. They no longer drink because there are many calories in alcohol. Everyone wants to lose weight. If people knew the calories in a pint of beer, would they drink ten or 20 pints a night?

Another point I must mention before I conclude is the promotion of mental health. I was late coming to the House for this debate because I had a meeting with the Minister of State, Deputy John Moloney, on the issue of music therapy. Music therapy is a clinical intervention and is linked to art and drama therapies. I have seen that therapy working throughout the country. It can benefit people who have sexual abuse issues they may not have dealt with. The Commission for Victims and Survivors in the North travelled to the South and said it was very important for people who had suffered trauma. It is also important in terms of conditions such as autism and for anybody dealing with mental health issues.

The difficulty in this area is that we do not yet have professional recognition of creative arts therapists. Every other country in the world has such recognition. We must move towards having that process finalised. It has started but prevention is always better than cure and early intervention is the next best thing. Creative arts therapy opens up people's minds in a clinical way to change their view of themselves and of others, and it can assist in many aspects of the health sector. I cannot explore the issue today but there is a very good report on the issue, Defining Music Therapy, September 2006, on the Oireachtas website under the arts committee heading. If anyone needs information or clues to why creative arts therapy is important, it is embraced in that report.

Photo of David NorrisDavid Norris (Independent)
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I welcome this debate and I welcome the Minister of State to the House. I must say, as a random observation, it is interesting that the Minister of State and the overwhelming number of speakers in the debate were women. Women have demonstrated that they are the people who care about the basic issues.

The basic issues are clear, and they have been dealt with fairly extensively. They are smoking and drinking alcohol. There is no question or doubt about that. There is a huge distortion in terms of the alcohol figures, and I believe the Minister of State put those on the record. We are 50% above the European norm. This is described as our culture. I find that insulting. It is not our culture the way people drink alcohol in this country, the way they damage themselves and the way they behave in public. This is an increasing phenomenon.

In view of the short time available I direct the Minister of State to the debate held in this House on the alcohol Bill during which many strong points were made. Some were taken up by the Government but it did not go as far as suggested from this side of the House particularly in terms of the control of advertising, among other things.

Politicians are too close to the drinks industry in this country in the same way as we have discovered they were too close to the construction industry. That relationship must be broken. Traditionally, politicians held their clinics in pubs and so on, and we have a representative of the Licensed Vintners Association in the Seanad. They have a very strong lobby and they do not always tell the truth. They do target young people. Sports sponsorship is an obscenity and a contradiction. Alcohol is something that has clearly damaged the health of the country yet we allow it to get in and target young people.

The same applies to smoking. I am very glad this country showed a lead in banning cigarette smoking because this is the second major element in terms of what we need for a health promotion strategy. Traditionally, the tobacco companies have been corrupt. They falsified evidence. They deliberately included additional chemical elements that had an addictive effect. They denied research. They lied in court in America, and they are now targeting the most vulnerable countries in the developed world to off-load their cigarettes.

We need to be aware that the drinks and the tobacco industries are two powerful groups who have no scruples. That is a change. In the old days in Ireland there was Uncle Arthur, John Jameson and the old Midleton distillery but that is gone. Nowadays the players are the big multinational corporations. They do not make their decisions here. They make their decisions looking at a graph in London or New York and it is a question of profit. It is not a question of the social damage that is being done. The mass of ridiculous groups that are established are nothing but a camouflage.

We need to get into the schools early and make sure that drinking is not seen as something heroic. I hear commentators on the radio and people on chat shows promote it subliminally. They refer to being plastered, having a hangover or that they had a few bevies. That is the way it is insidiously eating into what we see as our culture.

There is also the question of accident and emergency services. Part of the promotion of health should be to penalise people. We only have to look at the distortion in the way accident and emergency situations are dealt with because of the influx of people under the influence of drink and drugs at the weekends. We should look, too, at the collateral nuisance caused, the proliferation of off-licences and the way in which licences are being given out throughout the city.

I am on the Dublin central policing committee. I raised this issue and a report was commissioned. When it came back it was all done in terms of competition policy. There was no element of health or the social good involved. I insisted that the report be withdrawn and rewritten, as it was, but that was the priority. Competition is a little god. It appears to be more important than people's health and welfare. We can give disincentives to people by making it unattractive to smoke or drink alcohol, and the Government could do a good job on that.

I want to raise another element — spitting in the street. That went out when I was a child because every bus had advertisements saying "Don't spit in public". One could be fined for doing it. It was a serious offence but now the pavements are a mess with spit. We need to promote awareness in this area. It is partly our own fault and it is partly due to people who have come from other cultures where spitting is part of the daily routine but it is a dangerous way of spreading disease. To return to the question of alcohol, in the inner city where I live people use the pavements as public lavatories.

A number of other issues arise such as AIDS. When was the last time we had an AIDS prevention programme directed at young people? I can tell the Minister of State that in terms of sexual hygiene that message has got lost. AIDS is no longer seen as a death sentence. It is seen as something one can live with. It is not treated as seriously as it should be. We need a programme in place.

The issues of bullying and suicide were raised, and the figures outlined regarding young males in particular. Under that there is also a concealed figure for those people who are gay, and that must be tackled head on. A total of 80% of the bullying in schools has a homophobic element but in 80% of cases nothing is done because, among other things, the teachers are afraid. That is why it is wonderful that we have schools like Educate Together.

I was invited to Griffith Barracks Educate Together national school. When I was half way there I phoned my secretary to ask if it was a secondary school. She said it was a primary school. I was there to talk about the gay issue as a human rights issue. I was concerned but it was marvellous because of the context in which they put it. If that had been there when I was a child it would have been so positive and hopeful. Under the suicide figures there are many young men who are depressed and confused about their sexual identity.

With regard to the suicide figures, we used to regard ourselves as the best of the lot and compared ourselves favourably with Scandinavian countries in that they were either godless or Protestants. We were a good Catholic country. Suicide did not exist. Now we have information on the rates but it reveals only part of the picture. In the United Kingdom, for example, the authorities factor in undetermined deaths when computing the annual figures. We do not do that, even though a significant proportion of undetermined deaths are actually by suicide. I ask the Minister of State to give consideration to this matter.

I compliment the Minister of State upon her interest in this area. There is no doubt that further health promotion initiatives are required. Nutrition should be part of the school curriculum. People become fat because they eat too much junk food.

Photo of Ann OrmondeAnn Ormonde (Fianna Fail)
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The Senator should conclude.

Photo of David NorrisDavid Norris (Independent)
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This is one of the practical matters which should be dealt with in the context of the educational curriculum.

Photo of Liam TwomeyLiam Twomey (Fine Gael)
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I am sorry Senator Norris was cut short because he was making a fine contribution to the debate. It is a pity a few more people are not here to listen to what is being said.

Health promotion is linked to disease prevention. We have not exactly covered ourselves in glory with regard to implementing many of the health promotion initiatives referred to in this debate. The smoking ban has probably been the most effective of these initiatives but huge numbers of people continue to smoke and this has major implications for their general health.

We allowed the problem of alcohol consumption to spiral out of control, particularly in the context of legislation introduced by the Government and the relaxation of certain rules. People's alcohol consumption has been reined in to some degree but it is clear that health promotion was not an aspect of the Government's policy in this area in recent years.

The position in respect of obesity is strange. I do not believe the Government supports the report of the national task force on obesity. We are not doing enough in this area. Reports are being issued and small initiatives taken. When one considers, however, that this is a health crisis, it is clear that we are not at the races in terms of tackling it.

The Minister of State referred to the cardiovascular health policy group. In recent years there have been fantastic developments in cardiovascular health care — in other words, dealing with heart disease — in the context of outcomes for patients. This was achieved through health promotion, health prevention and health care. People were made aware of the dangers through health promotion, health prevention came in the form of the Heartwatch programme run by general practices and primary care facilities and the health care aspect was dealt with by means of upgrading bypass and heart surgery clinics throughout the country. The latter made a fantastic difference in the context of health care. If we did the same in respect of cancer care, there would be fantastic changes in the next couple of years.

A point missed by many Ministers is the fact that what I have stated was reflected in what occurred in recent days in respect of the budget. The Minister for Health and Children, Deputy Harney, has a pathological obsession with GPs and primary care in general. That is what caused the debacle involving medical cards for those over 70 in recent days.

The Minister received plenty of warnings regarding the nature of the issue relating to the over 70s. During the past seven years there has been a major disruption of primary and general practice care as a result of this matter. Due to the fact that the Minister set out to pay GPs capitation fees three to four times greater than they would normally receive in respect of people aged over 70, general practices in wealthier areas were able to utilise the additional resources that were becoming available. It was not just a case of there being a capitation issue in respect of those over 70 years of age, grants were also made available to general practices in respect of practice nurses, secretaries and managers. The money did not go into GPs' pockets. In order to obtain the funding, they were obliged to take on practice nurses and managers. This allowed general practices to do a great many things in the context of primary care provision.

I employ a practice nurse who is able to administer the flu vaccine to elderly people during the winter months and who also runs clinics for diabetics. The Minister of State referred to the increase in the incidence of diabetes. My practice is now in a position to screen patients for diabetes, high cholesterol and blood pressure problems. If the proper practice supports are not in place, there will be no possibility of our having practice nurses.

By dismantling, in an extremely simplistic way, the scheme that was in place, the Government has done more than just insult elderly people by removing their entitlements. Its action will result in the creation of a problem in primary care in the coming years. It is almost stupid for the Minister to refer to shifting services from the hospital sector to primary care when it is clear that she is going to withdraw supports for primary care. I will await with interest the results of the review being carried out on the Government's behalf by a senior civil servant, particularly in the context of whether he recommends that the practice supports to which I refer will be withdrawn.

The one good development in recent days is that the inequality which allowed general practices in wealthier areas to avail of these supports while those in less affluent areas could not will be a thing of the past. If one examines the position regarding health promotion and disease prevention, one will discover that it is in the poorer and more deprived areas of our cities that problems relating to alcohol abuse, people smoking too much and obesity arise. However, Government policy to date has been structured towards better-off areas. We will wait and see whether the review to which I refer tackles the inequalities to which I refer. I will monitor developments closely.

Disadvantages were built into the system for political reasons. I am surprised the Government walked into this mess last week, particularly as it would have received numerous representations from the very GPs who were in receipt of capitation payments warning that discrimination was occurring. There is no point in blaming Deputy O'Reilly for being a far better negotiator than Ministers. Perhaps the Government should avail of his services because it will be obliged to engage in negotiations with many different interest groups in the coming months.

Photo of Cecilia KeaveneyCecilia Keaveney (Fianna Fail)
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Will Deputy O'Reilly offer his services?

Photo of Liam TwomeyLiam Twomey (Fine Gael)
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Recent events show how badly the Government negotiated on behalf of the people. Deputy O'Reilly's job at the time when the capitation fees were agreed was to negotiate on behalf of——

Photo of Cecilia KeaveneyCecilia Keaveney (Fianna Fail)
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Deputy O'Reilly was——

Photo of Liam TwomeyLiam Twomey (Fine Gael)
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If Ministers are useless at their jobs, they are useless at their jobs. It is as simple as that.

Photo of Cecilia KeaveneyCecilia Keaveney (Fianna Fail)
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So the Senator is saying——

Photo of Ann OrmondeAnn Ormonde (Fianna Fail)
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Senator Twomey, without interruption. There can be only one speaker.

Photo of Liam TwomeyLiam Twomey (Fine Gael)
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Senator Keaveney should not be so crass and stupid.

Photo of Ann OrmondeAnn Ormonde (Fianna Fail)
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Senator Twomey's time is exhausted.

Photo of Liam TwomeyLiam Twomey (Fine Gael)
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When Ministers renegotiate the deal, they should try not to make fools of themselves a second time. They should try to ensure that points being made by many people, including me, that——

Photo of Cecilia KeaveneyCecilia Keaveney (Fianna Fail)
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I am not——

Photo of Ann OrmondeAnn Ormonde (Fianna Fail)
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There should be no interruptions.

Photo of Liam TwomeyLiam Twomey (Fine Gael)
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——a proper primary health care service is delivered to the people.

Senator Keaveney and I served in the Lower House. She may remember that I raised this issue with the Minister for Health and Children, Deputy Harney, who, like the Senator, was smug and smart about it.

Photo of Cecilia KeaveneyCecilia Keaveney (Fianna Fail)
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Is the Senator saying that I am smug and smart?

Photo of Mary WhiteMary White (Fianna Fail)
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Senator Keaveney may be smart but she is not smug.

Photo of Liam TwomeyLiam Twomey (Fine Gael)
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That is why Senator Keaveney ended up in the Seanad.

Photo of Cecilia KeaveneyCecilia Keaveney (Fianna Fail)
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Anybody that is——

Photo of Ann OrmondeAnn Ormonde (Fianna Fail)
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I call on the Minister of State to reply.

Photo of Mary WhiteMary White (Fianna Fail)
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Senator Keaveney is smart but she is not smug.

Photo of Cecilia KeaveneyCecilia Keaveney (Fianna Fail)
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Senator Twomey thinks I am stupid, which is a very dangerous assumption to make.

Photo of Mary WhiteMary White (Fianna Fail)
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Senator Keaveney is far from it.

2:00 pm

Photo of Mary WallaceMary Wallace (Minister of State with special responsibility for Health Promotion and Food Safety, Department of Health and Children; Meath East, Fianna Fail)
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I thank the Senators who contributed to this important debate relating to the drawing up of priorities in respect of health promotion. Many speakers focused on the specific issues of tobacco, alcohol and obesity.

Senator Fitzgerald and others highlighted the fact that prevention is better than cure. The Senator stated that this aspect is not afforded the same focus as others. However, this debate gave us the opportunity to focus on health promotion. The Senator referred, in particular, to the need to focus on young people. Whether it is tobacco, alcohol or issues relating to obesity such as overeating and a lack of physical activity, it is important to ensure that we get matters right in the context of the school curriculum. Every Senator referred to the need to ensure that we deal with this matter correctly from the point of view of education.

Senator Fitzgerald also welcomed the changes the Government has introduced in respect of alcohol and indicated her hope that these will continue to make a difference in our communities. Other Senators expressed concern in respect of legislation dealing with alcohol and stressed that there is a need to go further. Senators Bacik, Ormonde and Norris recalled the passage of the relevant legislation through this House. I reassure Senators in that regard. The Minister for Justice, Equality and Law Reform is bringing forward a new consolidated intoxicating liquor Bill next year which will bring all of the licensing laws together. That may address some of the wider issues referred to by Senators that were not addressed in the Intoxicating Liquor Act. I thank Senators for their warm support for the legislation that was passed before the summer. Reference was made to the difference it is making in communities.

Obesity was referred to as a ticking time-bomb. Without a doubt it is an important issue we must address. Vending machines and healthy eating in schools were referred to by several speakers. Senators Mary White and Ann Ormonde were particularly concerned about that issue. I wish to reassure them on a number of points.

One of the first things I did as a new Minister in this area was to initiate a system to examine the task force reports. Like them I was concerned about how we would know whether we were making progress and how to set clear benchmarking targets. We began by initiating bilateral discussions across Departments. We could have set up an interdepartmental group but my concern was it might take a long time for Departments to talk to one another. There is a need for wider discussions but initially to speed things up, we commenced a process of bilateral discussions between the Department of Health and Children and the Department of Education and Science on school guidelines, vending machines, greater exercise and other such issues. Another area of bilateral discussion has been with the Department of Transport on sustainable transport policies, cycling and other matters relating to how we change the built environment.

In the next few months the Department of Health and Children is due to publish the national nutrition policy, which is important. A number of things are happening in regard to that policy, school guidelines and the built environment. We will continue to have clear progress.

Senator Fitzgerald asked why we did not increase further the tax on cigarettes. Senator Keaveney supported that position from the point of view of health promotion. I agree that price is a big factor in cigarette smoking. From a public health perspective we welcome any increase in the cost of a packet of cigarettes. In fairness to the Minister for Finance, he also has to balance that in terms of the consumer price index and inflation. Many of the popular cigarette brands cost more than €8 and that is a way to address smoking from a health perspective. Future budgets will continue to address the issue.

Senator Mary White stated physical and mental health go hand in hand and referred to the importance of raising awareness among children in schools at a young age about health and nutrition. Senator Keaveney referred to the calorie content of alcohol and drinks such as Bud Light and Bulmers Light. She was especially concerned about labelling. Alcohol labelling will be addressed in the new EU labelling policy. Senator Bacik expressed concern also about the excessive consumption of alcohol and stated that the new legislation alone will not be enough. Senator Ormonde was also concerned about that matter. I reassure Senators that further legislation is due. The codes came through on 1 July this year. We are happy to continue to discuss the issues with Senators who are interested in the area. All suggestions from them are welcome.

Senator Prendergast focused on programmes in schools from her perspective of 20 years' experience in midwifery. She referred to sexual health programmes in schools, sexually transmitted infections, the benefits of breast feeding, parent craft education and the pressure on staff in maternity units. Across all of the topics she underlined the importance of early intervention and talking to children in schools.

Senator Bacik made an interesting point about jerseys. I am not familiar with the UK code to which she referred and I would welcome information from her on that area, which we intend to research. The working group we are setting up to examine the code on sponsorship will deal with that issue. Senator Norris expressed concern also about the obscenity of sports sponsorship and the contradictions involved. I assure both Senators and others concerned about the issue that the working group has been asked to examine this area.

Senator Norris referred to the big issues of smoking and drinking. He called also for a young people's programme for the prevention of AIDS. He suggested more health promotion is required. He also stated that nutrition should be part of the school curriculum. Many Senators referred to nutrition and schools. We intend to publish shortly guidelines for preschool, primary and post-primary schools. On a bilateral level we intend to focus on those issues with the Minister for Education and Science because, as many of us know, if we can get it right from the perspective of physical activity and nutrition in schools, we will get things right all round.

I agree with Senator Keaveney that prevention is always better than cure and early intervention is the next best thing. Senator Healy Eames mentioned an interesting statistic. She reminded all of us with concerns about smoking that the gateway age for children is nine to 13. She referred to peer pressure, self esteem and weight issues in connection with children taking up smoking. We need to watch the next step in terms of the removal of advertisements in the retail sector following the announcement on 1 July this year that it will come into effect on 1 July 2009. The protection of children is at stake. I am delighted to see so much cross-party support for that measure.

Senator de Búrca concentrated on lifestyle, diet and exercise, the role of the community pharmacist and the health food sector. We had an interesting meeting with her group in that regard. She also referred to health promotion and early intervention.

Senator Twomey referred to the effectiveness of the smoking ban but like all of us, he is concerned that people continue to smoke. We got much satisfaction for a while from the success of the smoking ban but Senators were of the view that more needs to be done. The ban on the sale of packets of ten cigarettes in May 2007 was aimed at reducing the sale of cigarettes to children. I welcome the support of Senators for the ban on the in-store point of sale and the display of tobacco products. We are delighted so many support the proposals that will come into effect on 1 July 2009.

Senator Twomey mentioned the fantastic improvements in the cardiovascular area. I agree with him. One has only to visit hospitals to see the major changes that have taken place in the past 20 years, the wonderful things the medical profession is achieving in the cardiovascular area and the difference it is making to the lives of so many. The new interventions are very good.

Senator Twomey's point that we are not doing enough about obesity is shared by all of us. If we are to take anything from today's debate, it is that obesity, especially among children, is one of the areas on which we need to focus. I agree with Senators that tackling this problem should be prioritised. When one considers that half of our population is overweight, it is clear we need to get it right. As Senators said, we need to make the easy choice the right choice. Schools and parents have a responsibility to transmit that message to our children. Similar action needs to be taken in respect of alcohol and smoking. If we can get it right for the children and teenagers of today, we will have got it right for future generations.

I thank Senators for contributing to the debate on this issue. Many of the views that have been expressed today will be taken on board. We will continue to examine this issue. If Members have further ideas, we would like to hear from them.

Photo of Ann OrmondeAnn Ormonde (Fianna Fail)
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When is it proposed to sit again?

Photo of Cecilia KeaveneyCecilia Keaveney (Fianna Fail)
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It is proposed to sit again at 2.30 p.m. on Wednesday, 29 October 2008.