Committee Reports > List of Committees > Joint > 2001 > Committee on Health and Children > Report No. 02 - Interim Report of Sub-Committee on Health and Smoking to The Joint Committee on Health and Children

HOUSES OF THE OIREACHTAS

Joint Committee on Health and Children

Second Interim Report of the Sub-Committee on Health and Smoking

(Rapporteur: Gay Mitchell T.D.)

July 2001

Oireachtas Joint-Committee on Health and Children

Second Interim Report of the Sub-Committee on Health and Smoking

Introduction by Gay Mitchell T.D.

The Oireachtas Joint-Committee on Health and Children Report on Health and Smoking was published in November 1999 (referred to hereafter as the “1999 Report”). The recommendations of the 1999 Report are contained in Appendix 1. In January 2001, the Committee decided to establish a Sub-Committee on Health and Smoking (to be referred to hereafter as “the Sub-Committee”) with the terms of reference as set out in Appendix 4 of this report.

The members of the Sub-Committee are:

The Sub Committee met on:

1.In Private Session on 7 March 2001

2.In Private Session on 12 April 2001

3.In Private Session on 22 May 2001

4.30 May 2001

5.6 June 2001

6.7 June 2001

7.In Private Session on 14 June 2001

8.In Private Session on 11 July 2001

9.In Private session on 24 July 2001

The Sub-Committee heard evidence from:

1.Dr. Fenton Howell, Chairman of ASH Ireland.

2.Professor Luke Clancy, Professor of Respiratory Medicine at Trinity College, Dublin (TCD) and the Peamount Chest Hospital.

3.A delegation from the National Youth Council of Ireland (NYCI)

•Ms. Elaine Glynn and Ms. Anna Gunning

4.A delegation of senior civil servants from the Department of Health.

•Mr. Tom Mooney, Mr. Noel Usher, Mr. Chris Fitzgerald and Mr. Gearoid Ó Dufaigh

5.Mr. Tom Power, Chief Executive Officer, Office of Tobacco Control.

The following representatives of the tobacco industry have been invited to attend but so far have declined to do so (See Appendix 2):

1.John Player & Sons.

2.P.J. Carroll & Company Limited.

3.Gallaher (Dublin) Limited.

On 14 June 2001, Deputy Gay Mitchell was appointed Rapporteur to the Sub-Committee.

The full text of evidence given by witnesses is appended (Appendix 8)

Evidence was taken under oath.

Acknowledgements

The Sub- Committee would like to acknowledge the efforts of all those who made written and oral presentations to the Sub-Committee. The Clerk to the Oireachtas Joint-Committee on Health and Children, John Hamilton and his colleague, Jackie Leavy are deserving of particular mention. The Sub-Committee also wishes to express its appreciation to Brian Nolan and Michael Scanlon, researchers to the Sub-Committee.

Gay Mitchell T.D.

Rapporteur to the Sub-Committee

July 2001

Background

At a meeting on April 12, 2001 the Sub-Committee agreed that the nature and purpose of its proceedings were as follows:

To inquire into the general health effects of smoking, including consideration of

□The level of knowledge within the Irish tobacco industry, through research or otherwise, of the safety or otherwise of tobacco products and the health dangers posed by them to consumers or third parties;

□The issue of nicotine addiction, and an assessment of the level of knowledge within the Irish tobacco industry, through research or otherwise, of the addictive qualities of nicotine;

□The steps being taken by the Department of Health and Children and the Irish tobacco industry to advise consumers and third parties of the dangers of smoking;

□The prevalence of smoking and smoking-related illnesses amongst children and adults and

□The cost to the State and private health insurers of the treatment of smoking related illnesses.

To inquire into the problem of underage smoking, including consideration of

□The influence on underage smoking of the marketing and promotion activities of the Irish tobacco industry;

□The positive steps being taken by the Department of Health and Children and the Irish tobacco industry to eliminate underage smoking;

□To review oral evidence given by the Irish tobacco industry to the Joint Committee on previous occasions, in light of subsequent revelations in the course of litigation in the United States;

□To examine future health policy legislation, initiatives and programmes which could be implemented by the Oireachtas and the Department of Health and Children in order to eliminate underage smoking, substantially reduce adult smoking and protect the public from environmental tobacco smoke.

Overview

The relationship between smoking and health was back under the international media spotlight recently with the decision on June 6, 2001 of a jury in the Los Angeles County Superior Court to order America’s largest tobacco firm to pay US$5.5m in compensation to Richard Boeken. The jury also ordered Philip Morris to pay $3 billion in punitive damages to Mr Boeken, a smoker who developed cancer.

Unsurprisingly, Philip Morris U.S.A. swiftly announced that it will vigorously appeal the jury’s verdict and expressed the belief that it should be overturned because it is inconsistent with the evidence and the applicable law. “This verdict is outrageous and holds our legal system up to ridicule. It is the result of legal errors we believe will require reversal of this verdict,” said William S Ohlemeyer, Philip Morris vice president and associate general counsel. “This punitive award is wildly out of line with the amount of actual damages - it is roughly 600 times that amount, and no California court has sustained a ratio of more than three times the actual damages when compensatory damages exceed $500,000.”

The appeal notwithstanding, the fine currently remains by far the largest ever imposed on the tobacco industry in a lawsuit brought by an individual and dwarves the $79.5m in punitive damages imposed in a case in Portland, Oregon in 1999, a figure later reduced by the judge.

There is though nothing new about health concerns associated with tobacco consumption. Indeed, it was almost 400 years ago in 1604 that King James I of England (also King James VI of Scotland) published his Counterblast to Tobacco in which he described smoking as a ‘filthy novelty’. The monarch went on to describe the habit as “a custom loathsome to the eye, hateful to the nose, harmful to the brain, dangerous to the lungs, and in the black stinking fume thereof nearest resembling the horrible stygian smoke of the pit that is bottomless.”

Indeed, the 17^th Century was a time of much global comment on tobacco use. The Chinese banned the production or consumption of tobacco in 1612. In 1624, Pope Urban VIII pronounced on tobacco by banning snuff, a product derived from tobacco which, he claimed, took users too close to sexual ecstasy. In Persia, four years later, two merchants were punished for selling tobacco and had hot lead poured down their throats.

Notwithstanding the trenchant comment from King James et al, it was not until the middle of the 20^th Century that statistical data begun to emerge that appeared to show a correlation between cancer and smoking tobacco products. Other studies began to show that smokers do not live as long as non-smokers while public awareness and concern grew over possible health damage associated with the use of tobacco products. The US Surgeon General released a report in 1964 entitled “Smoking and Health” that concluded cigarette smoking is causally related to lung cancer in men and, to a lesser extent, women.

Since then, evidence has mounted year on year of the enormous worldwide threat to human health from the consumption of tobacco products. Indeed, it is now estimated by the World Health Organisation that 500 million people who are alive today will be killed by tobacco. Approximately four million people will die in the current year from tobacco-related illnesses and, if current trends are not arrested, this figure will rise to 10 million deaths per annum by 2030.

Health Risks Associated with Tobacco Use

While concerns had long been expressed about the health impacts of smoking, the publication of the seminal reports by the then Dr Richard Doll and Professor Austin Bradford Hill in 1950 and 1952 prompted a much greater level of debate about smoking and health in the UK and worldwide. The Doll and Hill reports were the first to scientifically link lung cancer with cigarette smoking.

Some fifty years on tobacco use, and more particularly cigarette smoking, remains the leading cause of preventable illness and death in Ireland. If we are to make serious inroads on the important task of improving the health of the nation, it’s clear that reducing levels of tobacco use is critical. Only by making progress among young people and preventing them from starting to smoke can we hope to move towards the goal of a tobacco free society.

Passive Smoking (Environmental Tobacco Smoke)

It has emerged in recent years that there is a significant risk to the health of non-smokers who inhale environmental tobacco smoke (ETS) through so-called passive smoking. The Department of Health & Children told the Sub-Committee that ETS contains almost 4,000 chemicals of which some 60 are known carcinogens.

Fresh evidence emerged from New Zealand (a country with a similar population base to Ireland’s) during the course of the Sub-Committee’s hearings in June of this year that indicates the range of health problems associated with passive smoking is very substantial. The research involved was commissioned by New Zealand’s Ministry of Heath and written by Professor Alistair Woodward from the Wellington School of Medicine who was supported by tobacco researcher Dr Murray Laugesen. The very credible findings suggest that not only does second-hand smoke have a major impact on childhood illnesses such as asthma, meningococcal disease; glue ear and respiratory infections, there are also significant effects on adults with the risk increasing in proportion to exposure levels.

Financially, the direct hospital costs attributable to second-hand smoke in New Zealand are estimated to be NZ$8.7 million each year. This figure, combined with the estimated 388 deaths each year attributable to second-hand smoke, on top of the 4,700 smokers who die in New Zealand each year from smoking related illness, all add strength to calls for enhanced protection from second-hand smoke.

The study also shows that passive or second-hand smoking was responsible for more than 500 hospital admissions of children less than two years old suffering from chest infections. It is also blamed for almost 15,000 episodes of childhood asthma as well as more than 27,000 GP consultations for asthma and other respiratory problems in childhood. In addition, 1,500 hospital operations to treat glue ear and approximately 50 cases of meningococcal disease were linked to second-hand smoking by the New Zealand research team.

The National Health and Medical Research Council of Australia published a research report in November 1997 entitled ‘The health effects of passive smoking’. This indicated that heart disease and lung cancer along with nasal sinus cancer and non-malignant respiratory disease could all be caused among adults by second-hand smoke. In children the main medical problems known to be caused by second-hand smoke are Sudden Infant Death Syndrome, foetal growth impairment (low birth-weight and small for gestational age), lower respiratory tract infections including bronchitis and pneumonia, asthma exacerbation and middle ear disease.

Other medical problems thought – rather than definitively proven – to be caused by second-hand smoke include stroke, breast cancer, cervical cancer and miscarriages. In children, it is thought that ETS can impact adversely on cognition and behaviour. It has also been linked causally to a decrease in lung function, asthma induction and exacerbation of cystic fibrosis.

Young people who live with smokers feel the impacts of ETS most keenly as they suffer largely in silence. The assertion from the tobacco industry that smoking is a matter of free choice rings hollow when one considers that these young people are being harmed by the apparent ‘choice’ of others. Indeed, this is most graphically illustrated when you consider the harm that can be caused to unborn children by their parents or others smoking.

On June 16, 1999, the World Health Organization (WHO) released a report estimating that 700 million children around the world were exposed to second hand smoke. As has already been mentioned, WHO also confirmed that second-hand smoke is associated with lower respiratory tract infections, middle ear disease, chronic respiratory symptoms, asthma, decreased lung function and SIDS.

On June 24, 1999 Physicians for a Smoke-Free Canada released an analysis showing that one in three Canadian children are regularly exposed to second-hand smoke in their home, and that almost 9 in 10 children who live with a smoker are given no protection from the smoke.

To assess the exposure of Canadian children, PSC commissioned Dr Tom Stephens (a sociologist with special expertise in this area) to prepare a special analysis of the National Population Health Survey, conducted in 1996-97 by Statistics Canada.

Dr Stephens’ analysis revealed that:

•1.6 million Canadian children under the age of 12 are regularly exposed to cigarette smoke at home.

•33% of all children live in smoky homes – but the proportion climbs to 85% of children who live with a daily smoker.

•51% of children whose parents are low-income are regularly exposed, compared with 18% of children of the highest-income parents.

•Parents who don’t believe that second-hand smoke makes children sick or who don’t believe that parents’ smoking will encourage children to start are twice as likely to allow their children to be exposed.

Smoking and Women

On May 30, 2001 the World Health Organization (WHO) urged governments to do more to stop a looming epidemic of women’s illnesses caused by increased smoking.

WHO confirmed that tobacco-related diseases are on the rise among women, particularly young women as they released a 222-page study on “Women and the Tobacco Epidemic – Challenges for the 21st Century”.

Blaming aggressive tobacco marketing and exposure to second-hand smoke, WHO said that women are using tobacco more, and millions of others are daily being exposed to second-hand smoke.

According to WHO, countries should adopt a range of controls on advertising and smoking in public places – many of which are already in place in an Irish context. “False images of good health, fitness, stress relief, beauty and being slim are used to appeal to women,” the report claims. “Tobacco products are promoted as a means of attaining maturity, gaining confidence, being attractive and in control of one’s destiny – effectively exploiting the struggle of women everywhere for equality.”

The WHO study said tobacco companies have aggressively marketed their products in poor countries to build up a new customer base. It also accused them of using “misleading” labels, with ‘mild’ and ‘light’ cigarettes making health claims that are “not true”.

Legislation and Enforcement

There is a body of domestic and EU legislation in place that governs the sale and supply of tobacco products as well as the marketing and advertising campaigns that support them. However, it is a source of concern that enforcement appears to lag considerably behind the law in this area.

For instance, we welcome the raising of the age limit in respect of tobacco sales from 16 to 18 years and the increase in the maximum fine for persons convicted of selling tobacco products to underage persons from £500 to £2,000 on foot of the Health (Miscellaneous) Amendment Bill, 2000. While this legislation should act as a further deterrent to any potentially errant retailers, it will only do so if it is rigorously enforced.

It is the Environmental Health Officer in each Health Board area that has traditionally been responsible for enforcing tobacco control legislation. However, most such Officers admit that they are only proactive on tobacco control where the issue is linked to the implementation of hygiene regulations. The Department of Health and Children told the Sub-Committee that “enforcement is the weakest link in our strategy”.

The Department of Health and Children has allocated additional resources totalling £1m in the current year to allow health boards to recruit additional staff to improve enforcement and compliance with the law in the area of tobacco control.

The Department’s 2000 report, ‘Ireland – A Smoke Free Zone (Towards a Tobacco Free Society)’ highlighted many of the deficiencies in our legislative framework but in particular the gaps that exist in how we enforce such legislation as has been enacted. Of particular concern in this regard are the efforts made to ensure compliance with environmental controls. These prohibit smoking in public access areas of all buildings used by the State; in public access areas of banks and building societies; in cinemas, theatres, concert halls, indoor sports centres, bingo and bridge halls; in pre-schools, crèches and day nurseries, schools and schoolyards, supermarkets, grocery shops and butcher’s premises; on all buses, DART and Arrow trains, taxis and hackney cabs; in hospitals, nursing homes and health facilities as well as doctor’s and dentist’s waiting rooms and retail pharmacies.

‘Ireland – A Smoke Free Zone (Towards a Tobacco Free Society)’ requires each health board to designate a named senior officer to deal with this issue and to include the tobacco free society initiative in their service plan as an identifiable strategic objective. A regional co-ordinator would also be appointed by each health board to co-ordinate all tobacco control initiatives and to liase with health promotion and clinical care initiatives.

Executive Summary

•The Sub-Committee heard that tobacco kills between 6500 and 7000 people in Ireland every year. 31% of the population smokes and between 35%-40% of children are smoking before they reach the age of 18.

•The Sub-Committee was informed that smoking causes over 90% of lung cancer and chronic bronchitis/emphysema and that the incidence of smoking is most common among young men aged between 25-34 in the lower socio-economic groups. The heaviest smoking rate is found among married people between the ages of 35-49 living in Dublin in the lower socio-economic group.

•Evidence was given that the number of lung cancer deaths in Ireland as a percentage of all deaths has risen from 9.7% in 1970 to 21.2% in 2000.

•The Sub-Committee heard that, not only do 33% of boys aged between 15-17 smoke, but that 80% of all smokers become addicted between the ages of 14 and 16, highlighting the need to combat underage smoking. These smokers will have a 50% chance of dying from a tobacco related illness.

•The Sub-Committee heard evidence of the high instance of smoking among young girls, which is at 40 % in socio-economic groups 5&6.**

•One suggestion was to combat smoking among young people by an extension of the voluntary I.D. card scheme introduced by the Minister for Justice in 1999 to encompass the sale of tobacco products to minors.

•Authoritative estimates suggest that by 2030, smoking will cause 10 million deaths worldwide per annum. This means that smoking will cause approximately one in every six deaths by this time.

•There are now 1.1 billion smokers worldwide. By 2025, it is estimated that this figure will rise to 1.6 billion.

•According to a report by the Royal College of Physicians in Britain, tobacco is one of the greatest causes of preventable and premature deaths.

•Evidence was given on an ASH (UK) report “Danger – PR in the Playground – Tobacco Industry initiatives on Youth Smoking” detailing the disingenuous position of the tobacco companies regarding youth smoking.

•The Sub-Committee heard that cigarettes could include genetically modified tobacco and reconstructed tobacco (tobacco ash) within it, which produces more ammonia that, in turn, increases the amount of nicotine that is released during smoking.

•Evidence was given, which suggests that nicotine is more addictive than heroin or cocaine.

•The Sub-Committee was told that most smokers do not continue to smoke out of choice, but because they are addicted to nicotine.

•Evidence was given that the tobacco industry was the first to know that nicotine was addictive, long before the anti-tobacco lobby had similar knowledge.

•The Sub-Committee heard that passive smoking or environmental tobacco smoke (ETS) was described as a major “health hazard” that needs to be addressed as a matter of urgency. It is the number 1 indoor pollutant in Ireland, more harmful than asbestos.

•The complete withdrawal of tobacco products from the Consumer Price Index (CPI), in order to exploit price to its maximum advantage as a mechanism to combat smoking was advocated in evidence.

•Price rises in tobacco products and a complete ban on smoking in public places were advocated.

•The Sub-Committee heard that smoking during pregnancy was like “hitting two people”. 60% of Sudden Infant Death Syndrome cases occurred in smoking households. Smoking can cause miscarriages and adversely affect fertility.

•Studies were cited which showed that children exposed to second-hand smoke had significantly higher levels of cough and phlegm than those not exposed.

•The Sub-Committee was informed that although lung cancer causes 2.4 times as many deaths as breast cancer, there is no strategy for lung cancer as there is for the latter disease.

•A Royal College of Physicians (UK) report concluded that smoking is strongly related to poverty and deprivation.

•A case was made for smoking to be addresses in the context of the National Anti-Poverty Strategy (NAPS).

•It was estimated that the cost of smoking to the Exchequer is between IR£400 million and IR£1.6 billion per annum.

•The Sub-Committee heard that the health promotion budget nationally is approximately IR£12.9 million and that, although over 2000 lung cancer deaths occur each year, not one hospital consultant exists to deal specifically with smoking or the health promotion of non-smoking.

•A UK Royal College of Physicians report states that smoking cessation interventions are extremely cost effective, costing society between Stg£212 and Stg£873 per annum per year of life saved (1996 Prices)

•The Sub-Committee makes detailed recommendations, which include the creation and implementation of a National Lung-Cancer Strategy and a National Youth Anti-Smoking Strategy as well as several other measures to tackle the problems that smoking causes.

The recommendations contained in this report can be seen in Chapter 7 of this Report (pages 70-80).

Chapter 1

A) Main points made by Dr. Fenton Howell, Chairman of ASH Ireland, in his submission to the Sub-Committee.

Dr. Howell informed the Sub-Committee that tobacco kills between 6500 and 7000 people in Ireland per annum.

31% of the Irish population smoke and 35%-40% of children are smoking by the time they celebrate their 18^th birthday.

Tobacco marketing techniques are a major contribution to youths commencing smoking before their 18^th birthday and to adults and youths continuing to smoke. Once smoking has commenced, the highly addictive nature of nicotine takes control. Dr. Howell referred to a report, “Nicotine Addiction in Britain”, published by the Royal College of Physicians in the U.K. in 2000, which clearly states the dangerous and highly addictive nature of nicotine. The main conclusions of this report are:

•Nicotine obtained from cigarettes can be defined as a drug of dependence or addiction.

•Nicotine is highly addictive, even more addictive than hard drugs such as heroin or cocaine.

•Most smokers do not continue to smoke as a choice, but do so because they are addicted to nicotine.

•Addiction to nicotine is established in most smokers during their teenage years, even before age when they can legally purchase cigarettes.

•Addiction to nicotine can occur in teenagers within one year of starting to smoke.

•Only a small percentage of smokers, approximately 5%, are not addicted to nicotine.

•Once addicted, most smokers are unable to quit smoking even if they incur smoking related diseases. Continued smoking worsens such diseases.

Dr. Howell said that it is remarkable that such harmful products have gone unregulated for so long. It was possible, he continued, that the relevant authorities could be brought before a tribunal of enquiry to account for their actions in the future. Dr. Howell criticised the tobacco industry for its comments when they appeared before the Committee in 1999 when, he said, they “sought to undermine the science on nicotine addiction by suggesting that in these days everything is addictive, such as the Internet, chocolate and coffee” which he labelled as “a most feeble attempt to justify their actions” and “an insult to our intelligence”. Smoking cannot be sustained without nicotine.

Dr. Howell detailed several instances when the behaviour of the tobacco companies was unacceptable such as their reluctance to provide the Minister for Health and Children with details of the constituent parts of tobacco products and then informing him that he should not disclose that information to anyone else.

Dr. Howell opined that the public had a right to know who sits on the Boards of Directors of the tobacco companies and about their promotional strategy campaigns.

The Chairman of ASH Ireland then alluded to the House of Commons Health Committee, which obtained documents from the U.K. tobacco industry’s advertising agencies, which illustrated that:

•Powerful and cynical campaigns are devised to encourage people to start, and continue, smoking.

•Every channel of communication is exploited from the displays in newsagents to the Internet.

•Vulnerable groups such as the young and the poor are the favoured target markets.

•Voluntary agreements that the tobacco industry enters into and government health policy are ignored and treated contemptuously.

Dr. Howell said that given the ownership of the tobacco industry in Ireland, one would not expect much to be different here.

Dr. Howell gave details of a report on the role of the tobacco industry in youth smoking, compiled by the Cancer Research Campaign and ASH U.K., called “Danger – PR in the Playground – Tobacco Industry initiatives on Youth Smoking”. Its conclusions, based on internal industry documents, included, inter alia, that:

•Tobacco companies’ youth prevention programmes are conceived and publicised to delay serious regulation and to garner more positive PR rather than to facilitate a reduction in smoking.

•The industry’s focus on youth prevention programmes strengthens the idea of tobacco smoking as an adult activity, fostering the idea of cigarettes as forbidden fruit that attracts teenagers in the first place.

•Published literature on youth smoking prevention measures is ineffective unless this literature is part of a comprehensive strategy encompassing advertising bans, taxation, adult cessation, smoking restrictions in the workplace and in public places.

•Tobacco companies’ favoured strategies on youth prevention programmes are ineffective. They never promote youth initiatives being part of a comprehensive strategy.

•The Industry supports teachers, parents and other figures of adult authority, whom teenagers often rebel against, being involved in youth anti-smoking initiatives whereas actors, racing car drivers and music icons and others whom many teenagers aspire to emulate; are used in the promotion of tobacco.

•Effective measures in smoking reduction such as advertising bans and price control are ignored and resisted by the tobacco companies.

•The youth market is essential for the long-term viability of the industry and success with starters is invaluable to brand management.

•The industry has failed to establish any credible evidence base to support their programmes and have ignored the evidence that exists and disputed what does work.

On Passive Smoking or Environmental Tobacco Smoke (referred to hereafter as ETS), Dr. Howell said that, despite having evidence to the contrary for many years, the tobacco industry implied that ETS was not a health hazard. In fact, it is a major cause of many illnesses such as heart disease, stroke, lung cancer and asthma in children.

This is an issue that need to be addressed immediately. Dr. Howell suggested:

•The creation of smoke-free environments for everyone in order to eliminate ETS pollution. This should be achieved through a combination of legislation, education and enforcement.

•That laws and regulations are used to protect against ETS. Dr. Howell declared, “Voluntary agreements are not sufficient”.

•The provision for legislators, policy-makers, hospitality employers and employees and the public to “be educated about misinformation campaigns carried out by the tobacco industry”.

ETS is the number 1 indoor air pollutant in Ireland. Dr. Howell cited the successful action taken by a non-smoking public house employee in Australia, which found the pub owner liable for the employee’s cancer of the Larynx.

Dr. Howell addressed the issue of price in smoking reduction. Lower prices encourage people to smoke and higher prices prevent young people from smoking in the first place as they usually have less disposable income.

Dr. Howell believed that an opportunity was lost in the Last Budget was as a recommendation contained in the 1999 Report of the Joint Committee to remove tobacco from the CPI, which was accepted by all parties in the Oireachtas, was not realised. The Sub-Committee should pursue these issues.

Dr. Howell concluded on this point by saying that “given our current knowledge on the addictive nature of tobacco, it is perverse that tobacco products should be maintained within the CPI.”

Smokers who want to quit should be supported by the State. Dr. Howell said that non-prescription aids such as nicotine replacement products should be as available as tobacco products themselves.

Any anti-smoking campaign needs to be “comprehensive, well-funded and…sustained over time”. Dr. Howell estimated that IR£25 million per annum would be necessary for a successful campaign.

Dr. Howell urged the committee to insist that representatives of the tobacco industry and their marketing companies attend at the Sub-Committee to give evidence.

Recommendations made by Dr. Howell to the Sub-Committee:

1.That the much-awaited comprehensive legislation on tobacco control be brought forward as quickly as possible.

2.That the legislation encompasses recommendations of both the 1999 Report and the “Towards a Tobacco free Society” document.

3.Cigarette vending machines that cannot be supervised be banned.

4.The age at which one can buy or sell tobacco products be 18 years.

5.That tobacco products are sold below the counter and that all advertising/ sponsorship, promotion and patronage by the tobacco industry be ended.

6.That the Houses of the Oireachtas be at the forefront in pursuing the successful completion of a Treaty from the World Health Organisation Framework Convention on Tobacco Control.

Questions to Dr. Howell by members of the sub-committee

Dr. Howell was asked about allegations he made regarding the tobacco industry and its relationship with the media.

Dr. Howell said that many members of the media had been guests at tobacco sponsored Formula One (F1) trips abroad and that it is necessary to determine who paid for this. Such events would be very expensive for the media, in particular broadcasters like RTÉ, to cover almost every fortnight.

Asked whether he denied the rights of those individuals mentioned in his submission to be employed as consultants for the tobacco industry, Dr. Howell said he didn’t but he expected that the public had a right to know about this, adding that lobbying “is a very honourable activity as long as it’s up front and open”.

Dr. Howell was asked about the composition of the organisation of which he is Chairman, ASH Ireland. Dr. Howell told the Sub-Committee that ASH Ireland was a voluntary organisation established jointly in 1991 by the Irish Cancer Society and the Irish Heart Foundation. All of its funding is received from these organisations.

The success of the anti-smoking campaigns in the U.S.

Dr. Howell said that the campaign in Massachusetts worked because it was comprehensive and unified. 30% of the campaign budget was directed for media strategies. In Florida, a “truth campaign” was employed to display the industry for what it was and is. The tobacco industry was shown up “to be laughing all the way to the bank”.

The Chairman of ASH Ireland continued by remarking that in some parts of the United States, tobacco and alcohol are not sold unless proper identification (I.D.) is produced when requested.

Dr. Howell said that a reduction in adult smoking would trigger a reduction in youth smoking because many youths smoke to aspire to adulthood. He stated that such reductions, like those already witnessed in the U.S., have succeeded only as a result of serious investment in comprehensive initiatives.

On whether there were any benefits in smoking, Dr. Howell unequivocally asserted that there were not. He declared that if tobacco were only now coming onto the market, it would not get a licence to be sold.

The World Health Organisation (WHO) on tobacco

Dr. Howell was asked about the World Health Organisation and its efforts in finding a resolution to limit the damage tobacco products inflict, Dr. Howell said that the European Union would speak with one voice at the WHO Framework Convention Treaty negotiations on tobacco. There are tensions over differences within member states, but Ireland favours an absolute ban on tobacco advertising.

On Environmental Tobacco Smoke (ETS) or Passive Smoking

Dr. Howell then dealt with questions on ETS and the enforcement, or lack thereof, of non-smoking in public places. Legislation on ETS is important because it is a major cause of ill health. It is more dangerous than asbestos as an indoor air pollutant yet if “there was asbestos here, we would be out the door as quickly as you would think about it”.

Tobacco related deaths

When asked about studies to establish how many people tobacco kills every year in Ireland, Dr. Howell said that some major studies had taken place, monitoring groups of smokers and non-smokers. These studies showed that at the very least, 85% of lung cancer cases were attributable to direct smoking and smoking caused approximately 90% of chronic obsbtructive disease deaths.

Price and tobacco products

On the question of whether tobacco products were price sensitive, Dr. Howell replied that they were. A 10% price increase will see a 4% decrease in consumption. It is more pronounced for young smokers who, generally, have less disposable income. Price is the strongest tool there is which can be used as a disincentive to smoking.

Tobacco Industry’s denials

On the issue of tobacco companies denying the existence of smoking-related health problems, Dr. Howell claimed that these companies now realise that people are incredulous of this and say that they have changed and are responsible. In truth, they could see that the battle was being lost in the “First World” but that whole new markets are opening up in the “Third World”, particularly China.

Referring again to the case of the non-smoking pub employee in Australia who successfully pursued a lawsuit against her employer after developing cancer of the larynx, Dr. Howell said that the evidence about the adverse effects of ETS is now so substantial and concrete “that people can no longer use it as a defence and say they did not know that passive smoking is harmful”.

Positive action is required to protect people from the effects of environmental tobacco smoke, this should not be left to the courts. Leadership is required in this area. There is widespread and flagrant non-compliance with the law that states that 50% of all restaurant space must be smoke-free.

On the knowledge of tobacco industry of nicotine addiction

It is clear that the tobacco industry knew long before anyone else about the addictive nature of nicotine, whereas the medical profession has only in the last 10 to 15 years, fully understood the extent of nicotine addiction. The tobacco industry was “light years ahead of us in their own laboratories.”

On Smoking Cessation Products

Dr. Howell cited bupropion, which could have an effectiveness quit rate of up to 20%-25% and nicotine replacement therapy (NRT), which could record an effectiveness quit rate of about 12.5%.

On health damage of tobacco to smokers and former smokers

If a smoker quits the habit, after two years, his/ her risk of heart disease is closer to that of a non-smoker, certainly by around five years. In the case of lung cancer, once it has developed, quitting will not eliminate it but continued smoking will worsen it.

Lung cancer takes a long time to develop, and once developed, it is not always easily detected. A person can have lung cancer for two or three years before it is diagnosed.

On banning cigarettes

Dr. Howell said that banning cigarettes would not be practical but “we have to work towards that day”. Progress has been made in the reduction of those smoking in Ireland. In the 1960s and 1970s the figure was around 50% to 60% whereas now it is 31%. He believes that this percentage of smokers in the population can be reduced much further if money is invested in a unified and coherent campaign.

On the effects of a price rise

When asked whether an increase in tobacco products would result in declines in overall tax take and the economy, Dr. Howell said money would be spent on other taxable items. He stated that studies in the U.K. concluded that price rises could actually increase employment in other industries which would be greater than those lost in the tobacco industry, which is a) highly mechanised and b) has a very low workforce considering the size of the industry. Dr. Howell concluded on this point by saying “you’d get the tax in, you’d create more jobs, which brings in more tax and you wouldn’t have the health effects, so it’s win, win, win.”

On smoking bans in public places

A ban on smoking in public places works only when enforced. While conceding that some restaurants could see a loss of smoking customers, more non-smokers would come back, a group that constitutes 69% of the population. He cited California as an example where this ban is working.

On smoking during pregnancy

Dr. Howell said that this was like “hitting two people”, the mother and the unborn child. Smoking is extremely detrimental to the development of the baby in the uterus. Also, smoking results in a more common occurrence of Sudden Infant Death Syndrome (S.I.D.S.). Around 60% of incidences of S.I.D.S. occur in smoking households. Smoking can also cause miscarriages and adversely affect fertility.

Final Comments

Dr. Howell advocated more state-sponsored services for those who want to quit smoking, such as NRT products, making more smoking cessation counsellors available, and giving more support to general practitioners in dealing on a one to one basis with patients.

B) Main points made by Prof. Luke Clancy, Professor of Respiratory Medicine at Trinity College Dublin and Consultant Respiratory Physician at St. James’ Hospital, Dublin in his submission to the Sub-Committee.

Smoking-related respiratory illnesses

Prof. Clancy told the Committee that smoking causes more than 90% of lung cancer and chronic bronchitis/ emphysema.

Prevalence of Smoking

Smoking is most common among single men aged 25-34 in the lower socio-economic groups. The heaviest smoking rate, those who smoke around 15 or more daily, is found among married people between the ages of 35-49, living in Dublin in lower socio economic groups.

Active and Passive Smoking in Children

Prof. Clancy stressed the importance of research into all aspects of tobacco and informed the Committee that he carried out surveys in active and passive smoking in 1995 and 1998. In his evidence, he stated that, in 1995, 20% of the children surveyed had cough and phlegm and that, in 1998, the figure for the same smoking related respiratory symptoms was 30%.

He also alluded to the fact that in both years, 13% of children who had exposure to second-hand smoke had cough and phlegm. These symptoms were statistically higher than in children not so exposed.

Provision for lung cancer and smoking related respiratory illnesses

There is approximately 2.4 times as many lung cancer deaths as breast cancer deaths, but lung cancer is not given nearly as much priority as breast cancer services are now deservedly receiving. Prof. Clancy stated, “Our approach to lung cancer as a country is mystifying” and “As far as I can see, there is no clear lung cancer strategy”.

While money has been provided to help fight the “scourge of smoking” in relation to cardiovascular diseases, the situation regarding smoking related chronic bronchitis and emphysema is in stark contrast to this.

Respiratory diseases are on of the main causes of problems in hospital emergency departments in winter, in particular chronic bronchitis and emphysema. Money is found to try to alleviate the increased pressure this causes to overcrowding but Prof Clancy added, “any other plausible initiative will be tackled but plans for tackling the cause of the problem seem easy to ignore”.

Prof. Clancy suggested that there is more that can be done through the health services for smokers, particularly the poor and the elderly who are the main sufferers of respiratory diseases and lung cancer.

Not one hospital consultant exists within the health service to specifically address the care of those with smoking related diseases or for the promotion of non-smoking.

Price and the Consumer Price Index (CPI) with regard to tobacco products

Prof Clancy made reference to the World Bank Publication entitled “Curbing the Epidemic – Governments and the Economics Control” which claimed that a 10% price rise in cigarettes would result in 40 million less smokers and 10 million less premature deaths worldwide.

Any economic consequences caused by a price rise in countries such as Ireland would be “trivial” compared with the increased health benefits and life expectancy for many people.

The World Bank Report found that only Malawi and Zimbabwe would see a net loss to their economies if tobacco production and smoking were eliminated.

Prof. Clancy advocated the withdrawal of tobacco products from the CPI and stated that “If the CPI was the cause of the failure to have any price increase in the last (2000) budget, then this is a tragedy, which I suggest will cause an increase in mortality in the years to come and will lead to many years of sickness and disability in many thousands of others”

Many of the same people involved in our financial institutions are involved with this killing industry and some of the people even show up in the health care business.

Advertising and Marketing

Not enough money is spent on marketing and advertising pertaining to the dangers of smoking. Expertise and resources are required to communicate the message of these dangers successfully.

Smoking Cessation

Prof. Clancy said that it is important to understand that unless something is now done to successfully encourage people to stop smoking, there will be no reduction in the mortality rate from smoking before the year 2025.

He advocated a comprehensive programme to combat smoking including:

•Appropriate price mechanisms

•Health education

•Smoking cessation materials

•Elimination of second-hand smoke in the workplace, public buildings etc.

•A comprehensive research programme

Prof. Clancy said that all of these elements had contributed to reducing the population smoking rates in Massachusetts, California, Florida and increasingly New York from approximately 30% to 20%.

Questions to Prof. Clancy by members of the Sub Committee

Prof. Clancy was asked whether he would like to provide details of individual cases of cross-involvement in the tobacco, financial and health sectors. Prof. Clancy responded by saying that he had referred to the existence of such situations because he hoped that the Sub-Committee would be able to investigate the whole area of interchange among these industries further as part of its work.

On the high tobacco consumption levels of the lower socio-economic groups

Prof Clancy stated that the tobacco industry targets poor people. Tobacco used to be portrayed as an affordable luxury item, e.g. substitutable to a holiday abroad.

On lung cancer services

Prof Clancy considered that the resources for lung cancer services are in no way comparable to breast cancer services because lung cancer “affects the poor, the elderly and the voiceless”.

On smoking among young girls

More girls than boys smoke and research is required into why this is. Prof Clancy said that smoking among young girls involved many factors like:

•Rebellion.

•Sexual Connotations – Smoking in young girls “signifies availability without actual availability”.

•Socio-economic issues – Lifestyle, image, sex, product placement are all very important in the appeal of cigarettes to young girls.

As tobacco advertising has been streamlined, it has become subtler. Prof Clancy continued that because the EU and the Government are giving the tobacco industry a long time to prepare for an eventual ban on all tobacco advertising, the tobacco industry will refine and improve its marketing methods and consequently prevail because it can spend much more money than its opponents. Until such time as the Government and the anti-tobacco lobby matches their determination with resources and the same ambition, no great changes will occur.

Prof. Clancy stated that while the message that smoking harms the health of the individual and those who surround him/ her is crucially important, it is not sufficient on its own. Socio-economics, marketing, advertising, litigation and price must inform any serious initiative to combat smoking. He reiterated his belief that people are dying and will continue to die if cigarettes do not rise in price because of the effect such a rise would have on the CPI.

On lung cancer and smoking

“Lung cancer is the single commonest fatal malignancy of men and women in this country,” Prof Clancy told the Sub-Committee, and it causes 90% of lung cancer deaths. He encounters 400 new lung cancer cases a year and doesn’t see 40 non-smokers among them. He believes that the smoking related figure is probably higher in Ireland than elsewhere because there are not huge problems here with asbestos, uranium etc in comparison with other countries. The 90% figure is a global one; therefore, we need extensive research to determine the exact Irish figure.

On putative measures

Prof Clancy said that control is the most realistic measure that can be taken to combat smoking now, adding that if tobacco can before the Medicines’ Board now, it would not get a licence. Citing California, Prof Clancy remarked that control had worked there. Price is less effective in California as it has, on balance a rich population. The State Government has outlawed smoking in all public places. There is no social acceptability of smoking in California. In Ireland, attitudes of unacceptability do not exist.

On anti-smoking legislation

Prof Clancy maintained that legislation will encourage ant-smoking measures but only enforcement will have the desired result.

On smoking related deaths

Alluding to the likelihood of death from smoking related diseases, Prof Clancy said that it was a “50/50 game”. 50% of smokers will die prematurely from smoking. Smokers on average will lose between 10 and 15 years of life because of it.

On bans

Prof Clancy advocated, “Bans that work” on advertising and marketing. He said that the government should be more vigorous in its approach to this in the European Union and the World Health Organisation

On the cost of smoking to the Health Services

Prof Clancy responded that he did not know the cost of smoking to the Exchequer via the Health Service. He estimated that half of the annual budget of St. James’ Hospital, Dublin is spent treating diseases that are smoking related. He challenged the inequality in the Health Service. “Lung cancer is not a very expensive disease…. because we do nothing about it…these are poor and elderly so we just let them die. And it’s very cheap…. I think we should be examining why it is that if we have one disease we pull out all the stops…but if you have these diseases and you’re poor and elderly you should be let die”.

Chapter 2

Main points made by the National Youth Council of Ireland (NYCI) in its submission to the Sub-Committee

On Recommendations – Legislation, Policy and Enforcement, the NYCI:

•Suggested a licence system for tobacco retailers be established as a measure to control under-age smoking.

•Endorsed the ASH Ireland recommendation for a consistent increase in tax on tobacco products and recommended that a proportion of the revenue generated should be used to fund youth prevention and cessation programmes

•Proposed that the voluntary teenage ID scheme introduced under the Intoxicating Liquor Act 1998, be extended to include the sale of tobacco to minors.

•Recommended that comprehensive research be undertaken to ascertain how, why, when and where young people start smoking.

•Emphasised the point that any anti-smoking policy initiatives should be grounded in a wider approach of health promotion rather than just the health benefits from not smoking as well as the damage smoking inflicts.

•Believed that any initiatives to combat underage smoking and youth smoking in general would have to be formulated with young people themselves to ensure that the message is continuously reappraised to be relevant and effective.

•Considered it worthwhile that the anti-smoking message and data on youth smoking be included in an extended National Children’s Strategy.

•Suggested that the “partnership approach” be part of the approach of all the government and non-government agencies, both formal and non-formal education when formulating and implementing any youth anti-smoking initiatives.

•Found it strange that smoking cessation and prevention is not specifically addressed in the National Anti-Poverty Strategy (NAPS) since smoking is significantly higher in socio-economic groups 5 & 6 than in any other.

•Concluded, “smoking is no longer a matter of health policy but of public policy”.

Questions to the National Youth Council of Ireland (NYCI) by members of the Sub-Committee

On Funding

The NYCI would prefer that any funding would be targeted at national prevention of smoking to attack the causes that provoke people into tobacco consumption or other drug abuse. The organisation would prefer “to see a general national strategic approach to health education, particularly in the area of substance abuse”.

On NYCI involvement in national programmes

The NYCI informed the Sub-Committee that it co-operated with the Department of Health and Children in a recent alcohol awareness programme. It involved a promotional campaign administered by the Department’s health promotion unit. The NYCI believed that this programme would serve a template on which to base a youth anti-smoking campaign.

On research

The NYCI told the Sub-Committee of research, which it is currently carrying out, into participative research methods involving young people to ascertain how best to engage them in initiatives such as anti-smoking campaigns. The delegation was of the view that the answer to youth smoking lies, to a large extent, with young people themselves. If young people are involved in campaigns and have a sense of ownership, its success rate will be that much greater.

On why young people smoke

The NYCI agreed with the Sub-Committee that rebelliousness is a major component in youth smoking. It also cited the following:

•The influence of parents who smoke.

•The influence of peers and friends who smoke.

•The seeming acceptability of smoking in Ireland.

To combat this, a change in the “social norms” is necessary to create an environment that is not conducive to smoking. In particular, the involvement of peers in an anti-smoking campaign would undoubtedly progress the situation.

On a comprehensive approach

The NYCI was keen to emphasise the holistic approach was necessary in any anti-smoking campaign. It encouraged the provision of facilities to be made available to young people. The “healthy option” would include sufficient provision of sports facilities, sports clubs and youth organisations.

The NYCI referred back to the Midland Health Board health forum as an example of what could also be achieved nationally, which harmonises the approach of non-formal and formal entities such as schools, health boards, youth and community organisations in a complementary manner to address and respond to youth and other youth health issues.

On advocating the reinstatement of the Health Promoting Schools’ Network (HPSN) programme

It is a unified school approach to smoking prevention and the promotion of other health issues. It is not only targeted at young people, but also at the staff, parents and community. It is designed to have a ripple effect.

On a compulsory ID scheme

The NYCI was discussing the merits of advocating a compulsory ID scheme for tobacco and alcohol purchase. There are different views among different organisations and individuals about this. It might solve the problem, but suggested that it should be examined to see how it works elsewhere.

On unity of purpose

The discussion concluded with general agreement that there is a need among the anti-smoking groups for more unity of purpose in its approach to the whole issue of an anti-smoking campaign. There are “several overlaps” among those groups and individuals seeking to bring some improvement to the whole question smoking and its costs. If people could “bring their strengths to the table,………we might actually have half a hope of combating this issue”.

Chapter 3

Main points made by the Department of Health delegation in its submission to the Sub-Committee

On Smoking Levels

The delegation furnished the Sub-Committee with the following information

•31% of the population smokes, up from 29% on previous statistics.

•36% of General Medical Scheme (GMS) patients smoke.

•A third of all boys aged 15-17 smokes.

•40% of all girls in the socio-economic groups 5&6 smoke.**

•80% of all smokers are addicted between ages of 14-16 years.

Any improved health status of the nation is linked with a further reduction in tobacco consumption.

On Tobacco related diseases

•Smoking is a causative factor in more than 90% of lung cancer deaths.

•Smoking increases the risk of obtaining throat and mouth cancer.

•Smoking is the primary cause of cardiovascular disease and the greatest cause of mortality in Ireland

•Smokers who start young have greater difficulty quitting and have a 50% chance of dying with a tobacco related illness.

On Passive Smoking or Environmental Tobacco Smoke (ETS)

Children exposed to ETS experience:

•Increased rates of bronchitis, pneumonia and ear infections.

•Exacerbation of chronic respiratory symptoms such as asthma.

•Reduced rate of lung growth

•Increased risk of sudden infant death syndrome (SIDS)

Non-smokers who live with smokers have an increased rate of heart disease. The more exposed the non-smoker is to smoke, the greater the risk of heart disease.

The Department accepted that “there is a need for increased environmental controls on smoking and for better enforcement of these controls.”

On the cost of smoking related diseases

A variety of costs should be considered when computing the cost of smoking, including:

•The treatment of unborn infants.

•Maintaining those too ill from smoking to work.

•Treating those suffering from ETS related diseases.

•The cost of anti-smoking health initiatives.

Costs could be between IR£400 million and IR£1.6 billion per annum. But as yet, no standard measure of costing has been identified.

Statistical data on cancer, heart and respiratory illness deaths from tobacco consumption do not state tobacco as a cause of death. Therefore no exact costing can be ascertained.

On Department of Health and Children measures

The Department had taken steps to combat smoking such as:

•Involving Health Boards and non-governmental organisations participate in more departmental programmes.

•Securing further reductions in the marketing budgets for tobacco companies.

•The prohibition of cut price offers, gifts and sales promotion devices of tobacco products.

•Banning of sponsorship of major events, e.g. the Irish Masters Snooker Championship.

On current anti-smoking campaigns

The department’s budget for anti-smoking initiatives had risen from IR£1.276 million in 2000 to IR£1.5 million in 2001. These initiatives include

•“Break the Habit for Good”, emphasising the positive effects that smoking can have on the individual.

•“NICO”, targeting young girls in particular, in socio-economic groups 5&6 especially.

•Social, Personal and Health Education (S.P.H.E.), a school-based scheme aiming to improve the self-esteem of pupils to make decisions for themselves.

On the curtailment of tobacco advertising and sponsorship

All sponsorship and most advertising by tobacco companies have been prohibited from July 2000.

On compliance with anti-smoking laws

IR£1 million extra has been made available to health boards this year to recruit additional staff and improve compliance with anti-smoking laws.

On the smoking age

The age at which one can purchase tobacco products has been raised from 16 to 18 years. Those convicted of selling tobacco products to minors can be fined up to IR£2000 (up from IR£500) on each occasion. This is a further disincentive to retailers.

On tobacco related legislation

The publication of a “Public Health Tobacco Bill” is imminent. It will include provisions to:

•Prohibit the sale of cigarettes in packets of less than twenty.

•End in-store promotions and advertising.

•Register all retailers who sell tobacco.

•Statutorily establish the Office of Tobacco Control.

Questions to the Department of Health delegation by members of the Sub-Committee

On the cost of smoking to the health service

The delegation was asked for further clarification of the exact cost of smoking to the health service. The delegation responded that an exact cost would have to have set parameters. It was eventually agreed that the Department would provide that Sub-Committee with a breakdown of the clinical costs of smoking to the health service.

On litigation

The Department informed the Sub-Committee that the Attorney General was considering the issue of bringing a lawsuit against the tobacco industry in Ireland and that the Government awaited his Opinion.

On Cigarette composition

The Department is generally satisfied that the information given the tobacco industry pertaining to the components of cigarettes is correct. It assured the Sub-Committee that it would have new powers under the impending Bill to insist on receiving such details in their entirety in the future.

On anti-passive smoking measures

The departmental delegation assured the Sub-Committee that it would “vigorously impose” the new provisions in the Bill in this regard. The Department was “very keen to try to find a way of banning smoking in pubs”. The best approach to this area is through negotiation and voluntary arrangements with publicans. The “top-down, directional approach” is not as effective.

On anti-smoking provision

The Department confirmed that there is not one consultant within the health service to deal specifically with smoking and its causes but that consultants deal with the effects of tobacco related diseases.

On marketing and advertising of tobacco

The delegation believes that the marketing of cigarettes “is a major determinant of the levels of smoking”. Referring to the new research institute, established under the auspices of the Office of Tobacco Control (OTC), more academic and focused data will be available regarding tobacco advertising.

On the health promotion budget

In 2001, the health promotion budget is approximately IR£6.9 million with a further IR£6 million available to the health boards. The health boards were putting increasingly more money into smoking cessation services, including the creation of more smoking cessation officer posts.

On the question of consultants, the Department said that smoking related disease would be dealt with in the context of heart specialists rather than cancer or smoking specialists.

On the State’s approach to anti-smoking measures

The Department accepted that the State has not been aggressive enough in relation to smoking, but maintained, “we are very much to the forefront” of anti-smoking initiatives such as public restrictions on smoking and the curtailment of advertising.

When the last EU directive was struck down after a successful challenge by the tobacco industry, Ireland “forged ahead with our legislation”.

On the law regarding selling tobacco

A licence to sell to tobacco existed until 1961, the Department told the Sub-Committee. Now the Department favours the re-introduction of such an arrangement or at the very least, a registration system of tobacco sellers.

On price and tobacco

The Department was anxious to exploit price as much as possible as a mechanism to combat smoking. Under the new legislation, cigarettes will only be sold in packets of twenty, which will deter children from attempting to buy cigarettes.

On genetically modified components

The Department thought that, when research reached them showing the presence of genetically modified product in cigarettes, it thought that people would rush to quit “but somehow or another, smokers don’t seem to have the aversion to GMO” as people have with genetically modified food.

On smoking during pregnancy

The Department reported that maternity hospitals make “serious efforts to get on a one-to-one basis” with pregnant smokers. The delegation cited research on the number of women who quit smoking during pregnancy and resume smoking after the baby has been born. He alluded to other research that showed smoking to be more addictive than heroin or cocaine.

On future endeavours

The Department identified the need to invest IR£20 million a year in an all encompassing any anti-smoking strategy in its “Towards a Tobacco Free Society” document.

The Department is pursuing the computerisation of all general practice activities to compile information about the nature of health complaints so it can improve its response.

It will continue to develop its specific strategies dealing with cancer and cardiovascular disease.

On law enforcement

Enforcement is “one of the weakest links in our strategy”. The department is particularly concerned about ensuring that the health of pub and restaurant workers is safeguarded and upheld under the law.

On research

Prior to 1998, the Department gathered its information from secondary market research sources, often those commissioned or undertaken by the tobacco companies themselves.

•In 1998, it carried out the first National Lifestyle survey, which will be held every four years.

•The key group that the Department wants to pursue in relation to tobacco consumption is young women smokers in the lower socio-economic groups, building on and measuring the success of the “NICO” campaign, which specifically targeted them.

On the Social, Personal and Health Education (SPHE) programme

This is planned to be fully operational in the junior cycle of all secondary schools by September. It is hoped that a similar programme will be introduced to primary schools.

On tobacco advertising of Formula One (F1)

The information available to the Department is that tobacco advertising in this industry “will be phased out sooner rather than later”.

On the Consumer Price Index (CPI) and tobacco

The Department favoured the removal of tobacco products from the CPI. Ireland was “tied into” the EU on this matter although the Department has written to the EU Health Commissioner, David Byrne on this question.

Chapter 4

Main points in evidence of Mr. Tom Power, Chief Executive Officer of the Office of Tobacco Control to the Sub-Committee

The main functions of the Office of Tobacco Control (OTC) will be to:

1.Promote the development and implementation of better supports for smokers who want to quit.

2.Ensure that consumers are properly informed about the dangers from smoking.

3.To protect non-smokers from passive smoking.

4.To focus on children and the prevention of youth and underage smoking.

Annual Business Plans

These will maintain a focus to the activities of the OTC to realise the objectives of the “Towards a Tobacco Free Society Document”. The first business plan was approved on 14^th February 2001. Its three major components were communication, research and inspection programmes.

On legislation

The new EU directive adopted in May 2001 will include:

•Regulation of emission levels from cigarettes.

•Further restrictions in design and advertising in labelling and packaging of tobacco products.

•Reductions in the permissible levels of nicotine and emissions of carbon monoxide and tar yields.

•Capacity to develop further technical regulation of tobacco products.

On the Framework Convention on Tobacco Control

The World Health Organisation (WHO) is sponsoring negotiations to develop an international Treaty that will legally bind all participating members to its aims and commitments. The EU will speak with one voice at the negotiations although there are currently some differences among member States to be reconciled.

On the tobacco industry’s knowledge

Mr. Power stated that he had no direct evidence to offer concerning the state of mind of the Irish Tobacco companies. However, he drew particular attention to certain key documents in the public domain, which he felt had relevance to Ireland.“Operation Whitecoat”, “Operation Satire”, the Shockerwick House files. These are files and papers, which have been released into the public domain detailing the negative PR strategies considered by the industry.

Mr. Power said that the tobacco products sold in Ireland comply with UK standards and that “reconstituted tobacco is used to generate complex chemical processes”. Reconstituted tobacco or ash is believed to have a higher level of ammonia, releasing more nicotine from the cigarette thus increasing the level of addictiveness of cigarettes.

On tobacco addiction

Mr. Power drew attention to the World Health Organisation’s classification of tobacco addiction as a “disease”. He agreed with the similar finding in the Joint-Committee’s 1999 Report, which concluded that, the evidence of the tobacco industry on this issue “lacked credibility”.

The tobacco companies maintain that people do succeed in quitting. Mr. Power opines that this position is a legal rather than scientific one. “The purpose of this assertion is to support the argument that a smoker…. must, in law, be deemed to assume the risk associated with each cigarette he or she smokes”.

Mr. Power stated that this is not consistent with the evidence from the United States’ Food and Drugs Administration, continues Mr. Power, “that the tobacco industry have a comprehensive understanding of nicotine… and have a very thorough understanding of the neurological impact of nicotine”.

On Smoking as a cause of fatal diseases

The tobacco industry’s position on causation tends to “vary between outright denials to the suggestion that the case was simply not proven”. This is in direct contrast with the majority of all medical science, which demonstrates conclusively that smoking is a cause of fatal diseases and that nicotine is addictive.

On the behaviour of tobacco companies

Mr. Power said that it was “difficult to see how the tobacco industry can claim to have discharged its duty to fully inform its customers about the harm tobacco causes when it simultaneously claims that tobacco use does not in fact cause any harm.” The same point was made in relation to addiction.

On cooperation with the tobacco industry

In Mr. Power’s experience, the tobacco industry regards engagement with the Government and politicians as “exercises in public relations”. The industry will not engage in the “substantive question of how and when we can expect to bring the tobacco epidemic to an end”.

On Cigarettes and children

In citing a report for the OTC received the day before his appearance at the Sub-Committee, Mr. Power informed members that:

•81% of children say they buy their cigarettes from their local shops, which shows that there exists flagrant non-compliance with the law by retailers, and that the price of cigarettes is well within the children’s budget and that the assertion often made by industry sources that older siblings, parents or adults give children cigarettes is refuted.

•91% of these children say that they know that smoking is harmful and addictive. This demonstrates that education and health promotion have been very successful in raising children’s consciousness but that this on its is not enough to change behaviour. These programmes need to be complemented with other strategies.

More clarity is also required on the legal relationship between retailers and tobacco companies.

On the composition of tobacco products

Mr. Power believed that there had been no changes recently to the components of tobacco products and that they were still being produced in the “same manner using the same dangerous chemical technologies”.

Questions to Mr. Power from members of the Sub-Committee

On the tobacco industry’s irresponsibility

Mr. Power believed that any company who sells tobacco undermines “public health”. The tobacco industry was secretive by its “unwillingness… to be forthcoming about its technologies”. Mr. Power made particular mention of the composition of reconstituted tobacco, and the industry’s reluctance to disclose this information.

On the OTC activities

Under existing legislation, Mr. Power said “there are no rights of access for our enforcement people”.

He stressed the need for:

•An effective complaints platform is provided to reassure people that breaches of anti-smoking laws are taken seriously.

•The reporting of instances of non-compliance is actively encouraged.

•Priority to be given for pro-active inspection of high-risk areas.

•Regular routine inspections of both retail outlets and public places ensuring that the law is being upheld.

Mr. Power stated that the OTC had made submissions on the proposed legislation as part of the deliberative process and would welcome being heard when its functions and capacities are being formally legislated for

On Price, licensing and controls

Mr. Power cited the economic theory of optimum efficiency whereby costs pertaining to a product are factored into the price; he believed that this was not happening with tobacco. He stated that there was a need to “build liability and responsibility on the tobacco industry” through pricing strategies. These strategies should incorporate the cost of treating smoking related diseases, the disease of nicotine addiction and the social costs of tobacco addiction, fully into the tobacco sector.

Licensing and Controls

While there are ongoing discussions about possible licensing systems at the WHO Framework Convention Treaty negotiations, Ireland was pushing for “adequate international controls” of tobacco distribution. Smuggling levels internationally were higher than any comparable product and the tobacco industry had certain questions to answer in relation to this phenomenon.

Any international controls would “have to be reflected into the internal distribution systems in each country and have to be effectively controlled to protect children against access. That’s a priority for us”.

On lung cancer

Mr. Power said that the only cancer that had significantly increased in prevalence over the last 100 years in the Western World was lung cancer. In Ireland, the number of deaths from smoking as a percentage of all deaths increased from 9.7% in 1970 to 21.2% last year and this is indicative of the world trend. Mr. Power agreed with the Sub-Committee that this rise was appalling. He added, “lung cancer is probably the one (disease) that we really have to invest effort in now for the future”.

Other diseases

Unlike cancers, lowering the levels of smoking could reduce incidences of the many other diseases caused by smoking very rapidly. He cited cardiovascular diseases and diseases of infants and children to support this.

On outside involvement with the office

Mr. Power said, “Unless young people take ownership of the positive message (of not smoking), I don’t think we are going to deliver it (a reduction of smoking).”

The Office of Tobacco Control would welcome involvement from all and any outside agencies and hoped that the functions to be vested in the OTC under legislation would enable them to facilitate this extension of ownership to civil society. “Our job will be to stimulate bodies as diverse as FÁS, ICTU and the social partners to actually prioritise this issue”.

On additives used in cigarettes

Mr. Power highlights the following points:

•Tobacco products include genetically modified tobacco, which gives higher yields of nicotine than normal tobacco.

•Tobacco can include tobacco ash where waste tobacco is burned and later used in production. (The tobacco ash has a higher level of ammonia than raw tobacco. Ammonia acts to free more nicotine to the smoker).

•“There has been very little disclosure internationally” about the additives used in tobacco products. Existing Irish legislation enables the Minister to request certain disclosures but did not require the industry to disclose information concerning the type of tobacco used, the composition of reconstituted tobacco, the water profiles as well as the composition of tobacco papers, gums and filters. The exact composition of reconstituted tobacco is “probably one of the best kept secrets within the industry”.

On the knowledge of Irish tobacco companies

From the evidence that the tobacco companies gave to the Joint-Committee on Health prior to the publication of the 1999 Report, it appeared to Mr. Power that the management of these companies “ seems to be integrated” with their larger international “parent” companies.

Mr. Power referred to the tobacco companies “inherent contradiction” regarding their knowledge of their products. Irish tobacco products comply with modern standards, which are heavily reliant on complex chemical technologies yet, in their evidence to the Oireachtas Joint-Committee, the Irish tobacco companies exhibited a clear lack of understanding of the dangers of tobacco products, or of the addictive nature of nicotine.

On tobacco advertising in Formula One

This is the “fundamental gap in our prohibition on advertising” and the tobacco industry exploits this as much as possible. This undermines the ban on tobacco advertising because the evidence is that for such prohibitions to be effective they must be complete. Partial bans do not yield proportionate public health returns. Mr. Power hoped that this will be addressed within the Framework Convention on an International Treaty and cites this situation as a “primary reason why we need the Treaty”.

He felt that there was a need to get a better understanding of the broadcasters position on this question and, in particular, to consider the terms of the contract between the broadcaster and the Formula 1 industry.

Chapter 5

“Curbing the Epidemic”

Summary of the Main Points

According to a World Bank document “Curbing the Epidemic: Governments and the Economics of Tobacco Control” (May 1999), by 2030, tobacco is expected to be the single biggest cause of death worldwide accounting for 10 million deaths per year.

This report states that smoking already kills one in ten adults worldwide. By 2030, perhaps sooner, the proportion will be one in six.

1.1 billion people smoke worldwide. By 2025, this figure is forecast to rise to 1.6 billion according to the World Bank report, which also states that half of all long term smokers will be killed by tobacco.

The World Bank report also states that tobacco is among the greatest causes of preventable and premature deaths.

The Report argues that, for governments intent on improving health within the framework of sound economic policies, action to control tobacco represents an unusually attractive choice.

It states that there is evidence that many smokers are not fully aware of the high risks of disease and premature death that smoking entails. In high-income countries, smoking related healthcare accounts for between 6% and 15% of all annual healthcare costs.

The Report suggests that if taxes are raised, adult smokers will tend to smoke less, and price is the most effective way to deter children from smoking.

Measured in terms of the cost per year of healthy life saved, tax increases would be cost effective. Depending on various assumptions, this instrument could cost between US$5 and $17 for each year of healthy life saved in low and middle-income countries, which compares favourably with other health interventions commonly financed by governments, such as child immunisation.

Chapter 6

Extracts from the Summary of the Royal College of Physicians (UK) Report “Nicotine Addiction in Britain”

In February 2000, the Royal College of Physicians in the UK published a report to address the fundamental role of nicotine addiction and other smoking related issues in Britain.

The Report asserted that passive smoking was damaging to children before and after birth and that smoking is strongly related to poverty and deprivation.

Animal studies provide strong and consistent evidence that nicotine is addictive and only about 5% of smokers are not addicted.

On the psychological effects of nicotine and smoking, the Report makes the following points:

•Smoking withdrawal symptoms are relieved by nicotine.

•Nicotine intake in smokers is stable and consistent over time.

•There is strong evidence of psychological dependence on cigarettes.

The Report draws attention to the fact that the use of additives in cigarettes has not been subject to appropriate assessments of public health impact.

Nicotine addiction is the underlying cause of the massive burden of premature death and disability caused by smoking in developed countries.

Tobacco products should be subject to safety regulations that are consistent with the controls that apply to all other drugs available, so that they are commensurate with the extent of the damage that smoking causes to individuals and society.

(See Appendix 5)

Chapter 7

Questions for the Tobacco Industry and Interim Recommendations of the Sub-Committee on Health and Smoking

Having considered the evidence to date, and given the public health implications of smoking, the Sub-Committee is appalled that the three tobacco companies invited to give evidence to the Sub-Committee have, to date, declined to do so.

All three companies declined the invitation by way of letter to the Sub-Committee within days of each. The Sub-Committee has been given powers of compellability and may resort to using these. In order that the tobacco industry be given every opportunity to make its views known, the Sub-Committee would like, inter alia, to put the following, and related, questions to the three companies concerned:

1.Do the tobacco companies claim that they possess accurate knowledge that their products comply with the proper legal standards ?

2.Do the tobacco companies have precise knowledge as to technologies that are used in the manufacture of their products?

3.In the British “New Statesman” magazine of 11^th June 2001, a Gallaher Group advertisement states, “by working with Governments in the future as it has in the past, Gallaher believes that positive changes can be made to tobacco products.” How has the Irish subsidiary of the Gallaher Group, Gallaher (Ireland), met this assurance in Ireland in the past and how does it propose to meet the assurance in the future?

4.In the public interest, will they state when they became aware that tobacco smoking is injurious to health ?

5.Did they make this information available to the general public ?

6.How do the companies justify the use of reconstituted tobacco or “waste” ash in their cigarettes?

7.What is the medical or scientific advice available to the companies which has led them to dispute the medical classification of a) nicotine as addictive and b) tobacco addiction as a disease, as defined by the World Health Organisation?

8.Prof. Luke Clancy, Associate Professor of Respiratory Medicine at Trinity College, Dublin and Consultant Respiratory Physician at St. James’s Hospital Dublin, in his evidence to the Sub-Committee, said that only 2% of those who succeed in quitting smoking do so without any help. Is this not a damning indictment of the addictive nature of nicotine? The Department of Health, the World Health Organisation and the Philip Morris Company, manufacturers of the Marlboro brand, support this evidence. Do the tobacco companies now agree that this drug, nicotine, is an addictive substance? Would they like to change their evidence previously given to the Joint Committee that nicotine is not addictive ?

9.Would the tobacco companies be of the view that heroin and cocaine are addictive?

10.Is the industry aware of a report entitled “Nicotine Addiction in Britain – A Report of the Tobacco Advisory Group of the Royal College of Physicians” published in the year 2000 concluded that nicotine is not only highly addictive but “in some respects more addictive than heroin or cocaine”?

11.What is the scientific or medical evidence available to the Irish tobacco industry (the industry) that prompts it to dispute universal medical evidence outside of the industry that smoking causes cancer?

12.Has your company and the tobacco industry persisted in marketing products in a fashion designed to appeal to young people, although you say, at the same time, that smoking is an adult pastime and that you do not market or target your products at young people?

13.With 80% of adult smokers taking up the habit before they turn 18, is it not in fact the case that you strive to capture as much of this “youth” market as possible, notwithstanding the health implications for the children involved?

14.Have the companies, at any time in their years of operation in Ireland, paid for members of the media to attend tobacco-sponsored Formula One Grand Prix events as their guests?

15.Do any directors of the tobacco companies hold a directorship, or have an interest, in any company in the health sector? Would they think that contemporaneously holding these positions constitutes a conflict of interest? How do they reconcile the two diametrically opposed objectives of tobacco promotion and health promotion and services especially as tobacco is a causative factor in lung cancer and nicotine is an addictive drug?

16.Do the companies accept the view that cigarette smoking is one of the most dangerous activities engaged in by young people in Ireland? On the 14^th October 1999, the cigarette manufacturer Philip Morris Inc. stated that there is no “safe” cigarette. Do the companies agree? Will the companies comment on this statement? Has your industry ever attempted to develop, test and market potentially less hazardous products?

17.The Confederation of European Communities Cigarettes Manufacturers Ltd. is an organisation based in Dublin. Disclosure documents obtained by the Office of Tobacco Control (See Appendix 6) indicate that Irish tobacco companies are not fire-walled from global tobacco research and developments. Global information, propaganda and research are clearly shared. Given that the tobacco industry in the United States of America has settled with the individual States in a multi-million dollar payment to compensate for health costs borne by the States as a result of tobacco products, what are your proposals for similar payments to the Irish Government ?

18.Has your company and the tobacco industry given consideration to the health hazards now known to be associated with Environmental Tobacco Smoke (ETS)?

19.Does the mounting evidence that second-hand smoke kills destroy your argument that smoking is a matter of free choice involving consenting adults who are aware of any risks involved?

Introduction to Interim Recommendations

Bunreacht na hÉireann provides for the separation of powers and their distribution among the institutions of State. There has been a growing trend to somehow interpret this as giving the Courts superior powers to the Executive and even to the Oireachtas. It is the view of this Committee that it is imperative that the Oireachtas give urgent attention to this issue.

The Sub-Committee issues the following interim recommendations and intends to consider further recommendations when the Sub-Committee has taken evidence from the tobacco industry representatives under oath.

Interim Recommendations of the Sub-committee on Health and Smoking

The Sub-Committee makes the following recommendations:

On a National Lung Cancer Strategy(see also page 72)

1.The immediate creation and aggressive implementation of an extensive National Lung Cancer Strategy in consultation with medical experts in the area, the Department of Health and Children, and the Joint-Oireachtas Committee on Health and Children, which would:

•Be underpinned by an Act of the Oireachtas, which would also provide for a Covenant of Rights and Responsibilities for lung cancer patients, which would, inter alia, require patients not to engage in any activity additionally detrimental to their health and ensuring them of equality of provision of healthcare and treatment regardless of their socio-economic status.

•Be allocated its own identifiable and separate budget, under the existing National Cancer Strategy. This budget to be used for the promotion of lung cancer awareness, the development of services and the enhancement of treatment for those who suffer from the disease.

•Emphasise the damage caused by smoking in exacerbating chronic bronchitis and emphysema.

•Ensure that funds are directed to tackle the cause of smoking related (& respiratory) diseases such as lung cancer, chronic bronchitis and emphysema.

•Provide funding for the creation, on a regional and representative basis, of hospital consultants specifically dealing with smoking related illnesses and the health promotion of non-smoking.

•Provide for the creation of a post of Professor of Health Promotion in every medical school in the State similar to that at the National University of Ireland, Galway ensuring that future generations of medical professionals are sufficiently equipped to successfully communicate the importance of a healthy lifestyle. In this way, those concerned about smoking will be aided by the sustained contribution of well-reasoned and activist medical professionals, about the dangers of smoking, including the immense health opportunity costs.

A similar strategy should also be developed and implemented for other smoking related diseases.

On enforcement of anti-smoking laws

2.The Sub-Committee recommends that the Oireachtas provide the Office of Tobacco Control and the health boards with the necessary powers of enforcement and with a sufficient corps of inspectors, including a Director of Tobacco Control in each health board, to ensure that the law is upheld and that those in violation of it are brought to justice speedily and efficiently. It is our view that each health board should, in cooperation with the Office of Tobacco Control, develop and implement a programme of inspection involving those premises affected by tobacco control legislation. An effective inspection programme must respond to public complaints, carry out routine inspections and target low compliance, high-risk venues.

On the disclosure of information

3.Given the strength of evidence about the addictive nature of nicotine, and the consequences of smoking, the question of criminal negligence needs to be examined. The Sub-Committee recommends that it be made a criminal offence to conceal the true health implications for persons of any product, including tobacco, unless strong warnings, to be stated in legislation, are fully and adequately communicated to the adult consumer. The Director of Public Prosecutions should be given wide powers to apply this proposed legislative measure.

On no-smoking zones

4.The Sub-Committee recognises that the health hazard posed by passive smoking is a grave and pervasive one and recommends that smoking be banned in all public houses to protect the health of staff of such premises as well as the health of non-smoking adult customers.

On unsupervised points-of-sale

5.That all cigarette vending machines be banned as they are unsupervised and are used by minors to purchase cigarettes.

On official records

6.That all statistical data on deaths from cancer, heart disease and respiratory illness associated with tobacco consumption, including death certificates, state the relationship of tobacco to the cause of death.

7.That the Department of Health and Children report annually to the Joint Committee on Health and Children regarding the number and types of amputations associated with tobacco consumption.

8.That the Department of Health and Children report to the Joint-Committee on Health and Children on the number of smoking cessation counsellors and their plans to expand this service.

On litigation

9.That the Government move speedily to initiate legal proceedings against the tobacco industry in the Republic of Ireland, as successfully levelled by the US States’ governments and currently by the US Federal Government. Any damages received should then be a) invested in the Health Service, compensating it for the immense drainage of resources smoking related diseases demanded of it throughout the years and b) used to combat smoking in an aggressive campaign publicising the detrimental effects of tobacco.

On Price

10.That the Minister of Finance consider the creation of a second Consumer Price Index (CPI) exclusive of all tobacco products. The first CPI would continue to measure the rate of change in prices for EU comparison purposes. This would enable the Government to level extra tax on cigarettes without causing inflationary or pro-cyclical economic implications. According to evidence given to the Sub-Committee, such a facility is used in many countries and would allow price to be fully exploited as a mechanism to combat smoking, especially among young people who have a limited disposable income.

11.Proposes that a tax of IR£0.50 per annum be placed on cigarettes over the lifetime of a Parliament with all proceeds funding a National (Youth) Anti-Smoking Strategy and a National (Adult) Anti- Smoking Strategy. The latter strategy was proposed in the 1999 Joint-Oireachtas Committee Report on Smoking.

On Socio-economic issues

12.That the issue of smoking be addressed as part of the National Anti-Poverty Strategy (NAPS), so that measures are explicitly set within the Strategy to address the higher levels of smoking among the lower socio-economic groups.

On Conflicts of Interest

13.That promised legislation relating to tobacco and smoking include provisions to prohibit any individual from holding any executive or professional role in the Health Service while at the same time holding a prominent role, e.g. a directorship, in the tobacco industry.

14.The implementation in its entirety of the new EU Directive, as ratified by the European Parliament in May 2001, and that it be extended where possible by the Minister for Health, so that cigarette packages:

•Carry larger and more explicit health warnings.

•Clearly specify starker warnings about the health hazards involved in smoking.

•Maximise the usage of pictures and pictograms for health warnings.

•Do not carry misleading descriptions in branding such as “light”.

On a National Anti-Smoking Strategy

15.That the sum of at least IR£20 million per annum be spent on a comprehensive and enforced National Anti-Smoking Strategy as outlined in the “Towards a Tobacco Free Society” document of March 2000 and the 1999 Joint-Committee Report on Health and Smoking.

16.Urges the implementation of a far-reaching National Youth Anti-Smoking Strategy which would include:

•A comprehensive research programme to determine the reasons for smoking. Such research should also seek to determine ways and means of combating pro-smoking marketing methods, including examination of successful peer led campaigns in other jurisdictions.

•A concerted and long-term information campaign similar to the NICO campaign, directed in particular at young smokers and those likely to take up smoking, clearly highlighting issues such as the length of time it takes to become addicted and the illnesses smoking causes. Research should be carried out to determine the best methods of communicating such methods.

•A preparatory period of collaboration, discussion and co-operation should be initiated involving representatives of the Departments of Health & Children, Education & Science, the National Parents’ Council, the USS (Secondary Students Union), the National Youth Council of Ireland (NYCI) to assist with ongoing formulation of policy. A Minister of State at the Department of Health and Children would have overall responsibility for such collaboration. Once the strategy, policy and logistics are agreed, a group of 12 young people, being geographically, gender and socio-economically representative, should be selected to join a forum – such as that successfully established and by the Midland Health Board - to continuously advise the responsible Minister of State on the effectiveness of the Strategy. It is important that there is a partnership approach serving as the basis of the Strategy and that it engages all non-formal as well as formal education providers.

•An extension of the voluntary identification scheme, as introduced by the Minister for Justice, Equality and Law Reform in 1999 to combat under-age drinking, to include the prevention of the sale of tobacco products to minors. Such I.D. cards such be provided free of charge by the Department of Social, Community and Family Affairs.

•A reinstatement of the Health Promoting Schools Pilot Network on a permanent basis in primary schools and the extension of the Social Personal and Health Education (SPHE) curriculum nationally. Both instances have proved successful and, if developed, would enjoy greater success and extensive popular support as an effective and holistic programme encouraging young people to pursue healthy lifestyles.

•All current school anti-youth smoking programmes being extended to those young people outside of the school sector and the post-school sector, in local young peoples groups or youth organisations, as well as to every school in the country, as recommended in the 1999 Oireachtas Joint-Committee on Health and Smoking Report.

•Changes in the ethos of our education system, wherein the “points race” rules supreme leaving little time available to be dedicated to the promotion of health initiatives within the school. Study requirements can be so rigid and demanding that they are conducive to perpetuating a sedentary lifestyle among second-level pupils.

•The incorporation of a health promotion / anti-smoking element into the Department of Education and Science “Earlystart” and “Breaking the Cycle” initiatives. This should be continued throughout primary school.

•The integration of a health promotion as a subject in its own right into all professional qualifications that deal with children, such as public health nursing, social work, nursing, midwifery and general practice. Also community based medical professionals like GPs and Public Health Nurses should have training available to them in youth smoking cessation programmes under the Strategy.

•Provisions for “Step-down” programmes to contain a Nicotine Replacement Treatment (NRT) element so that smokers are given an opportunity to ease out of their addiction.

On subsidies

17.Recommends that poor tobacco producing countries be given direct financial support by the international Community through a global organisation such as the World Health Organisation or the World Bank and that consideration be given to basing this on the EU set-aside scheme for agriculture so that poor countries do not loose income.

On Anti-Tobacco Advertising

18.The type of extremely graphic television adverts which have been used in an attempt to reduce the carnage on roads in this country should be adapted to force home the message that smoking can kill. The message must be sent out that not only smokers but also the friends and families of those who smoke are at risk.

On the sale of illegal tobacco products

19.The sale of contraband tobacco/ cigarettes is increasing. Aside from the fact that the proceeds of such sales often end up in the hands of criminals, there exists the potential that because these cigarettes are sold more cheaply, it encourages smoking among groups such as young people, who might otherwise be put off by the cost. The penalties for sale of contraband tobacco products should be reviewed and strengthened.

On point-of-sale advertising

20.There should be a ban on tobacco companies paying for shop refits. Currently, the tobacco companies can pay for the refurbishment of newsagents or grocery shops in return for prominent displays of certain cigarette brands. Such Practices should be banned, as should the prominent display of cigarette brands in shops.

Appendix 10

Members of the Joint Committee

Notes:

¹ Senator Kathleen O’Meara was appointed in place of Senator Pat Gallagher on 4 November 1999

² Deputy Liz McManus was appointed in place of Deputy Róisín Shortall on 4 November 1999

³ Deputy Gay Mitchell was appointed in place of Deputy Alan Shatter on 29 June 2000

⁴ Deputy Michael Ring was appointed in place of Deputy Deirdre Clune on 29 June 2000

⁵ Deputy Bernard Allen replaced Paul Bradford on the 29^th March 2001

⁶ Deputy Martin Brady replaced Deputy Michael Ahern on 17^th May 2001

Appendix 11

Orders of Reference of the Joint Committee

Joint Committee on Health and Children

ORDERS OF REFERENCE

Dáil Éireann

13th November, 1997, (** 28th April, 1998),

Ordered:

(1) (a)That a Select Committee, which shall be called the Select Committee on Health and Children, consisting of 14 members of Dáil Éireann (of whom 4 shall constitute a quorum), be appointed to consider such—

(i)Bills the statute law in respect of which is dealt with by the Department of Health and Children, and

(ii)Estimates for Public Services within the aegis of that Department,

as shall be referred to it by Dáil Éireann from time to time.

(b)For the purpose of its consideration of Bills under paragraph (1)(a)(i), the Select Committee shall have the powers defined in Standing Order 78A(1), (2) and (3).

(c)For the avoidance of doubt, by virtue of his or her ex officio membership of the Select Committee in accordance with Standing Order 84(1), the Minister for Health and Children (or a Minister or Minister of State nominated in his or her stead) shall be entitled to vote.

(2) (a)The Select Committee shall be joined with a Select Committee to be appointed by Seanad Éireann to form the Joint Committee on Health and Children to consider—

(i)such public affairs administered by the Department of Health and Children as it may select, including bodies under the aegis of that Department in respect of Government policy,

(ii)such matters of policy for which the Minister in charge of that Department is officially responsible as it may select,

(iii)the strategy statement laid before each House of the Oireachtas by the Minister in charge of that Department pursuant to section 5(2) of the Public Service Management Act, 1997, and shall be authorised for the purposes of section 10 of that Act, and

** (iv)such Annual Reports or Annual Reports and Accounts, required by law and laid before either or both Houses of the Oireachtas, of bodies under the aegis of the Department(s) specified in paragraph 2(a)(i), and the overall operational results, statements of strategy and corporate plans of these bodies, as it may select.

Provided that the Joint Committee shall not, at any time, consider any matter relating to such a body which is, which has been, or which is, at that time, proposed to be considered by the Committee of Public Accounts pursuant to the Orders of Reference of that Committee and/or the Comptroller and Auditor General (Amendment) Act, 1993.

Provided further that the Joint Committee shall refrain from inquiring into in public session, or publishing confidential information regarding, any such matter if so requested either by the body or by the Minister in charge of that Department; and

(v)such other matters as may be jointly referred to it from time to time by both Houses of the Oireachtas,

and shall report thereon to both Houses of the Oireachtas.

(b)The quorum of the Joint Committee shall be 5, of whom at least 1 shall be a member of Dáil Éireann and 1 a member of Seanad Éireann.

(c)The Joint Committee shall have the powers defined in Standing Order 78A(1) to (9) inclusive.*

(3)The Chairman of the Joint Committee, who shall be a member of Dáil Éireann, shall also be Chairman of the Select Committee.

Seanad Éireann

19 November 1997 (** 30th April, 1998),

Ordered

(1) (a)That a Select Committee consisting of 5 members of Seanad Éireann shall be appointed to be joined with a Select Committee of Dáil Éireann to form the Joint Committee on Health and Children to consider

(i)such public affairs administered by the Department of Health and Children as it may select, including bodies under the aegis of that Department in respect of Government policy,

(ii)such matters of policy for which the Minister in charge of that Department is officially responsible as it may select,

(iii)the strategy statement laid before each House of the Oireachtas by the Minister in charge of that Department pursuant to section 5 (2) of the Public Service Management Act, 1997, and shall be authorised for the purposes of section 10 of that Act, and

(iv)such Annual Reports or Annual Reports and Accounts, required by law and laid before either or both Houses of the Oireachtas, of bodies under the aegis of the Department(s) specified in paragraph 1(a)(i), and the overall operational results, statements of strategy and corporate plans of these bodies, as it may select.

Provided that the Joint Committee shall not, at any time, consider any matter relating to such a body which is, which has been, or which is, at that time, proposed to be considered by the Committee of Public Accounts pursuant to the Orders of Reference of that Committee and/or the Comptroller and Auditor General (Amendment) Act, 1993.

Provided further that the Joint Committee shall refrain from inquiring into in public session, or publishing confidential information regarding, any such matter if so requested either by the body or by the Minister in charge of that Department; and

(v)such other matters as may be jointly referred to it from time to time by both Houses of the Oireachtas,

and shall report thereon to both Houses of the Oireachtas.

(b)The quorum of the Joint Committee shall be 5, of whom at least 1 shall be a member of Dáil Éireann and 1 a member of Seanad Éireann.

(c)The Joint Committee shall have the powers defined in Standing Order 62A(1) to (9) inclusive.*

(2)The Chairman of the Joint Committee who shall be a member of Dáil Éireann.

Appendix 12

Proceedings of the Joint Committee

AN COMHCHOISTE UM SHLÁINTE AGUS LEANAÍ

THE JOINT COMMITTEE ON HEALTH AND CHILDREN

Imeachtaí An Chomhchoiste

Proceedings of the Joint Committee

Dé Céadaoin, 24 Iúil 2001

1.The Joint Committee met at 12 p.m. in Committee Room 4, LH2000.

2.MEMBERS PRESENT.

The following members were present:

Deputies Batt O’Keeffe (in the chair), Bernard Allen, Paul Connaughton, Beverley Cooper-Flynn, John Dennehy, Cecilia Keaveney, Brendan Kenneally, Gay Mitchell and Dan Neville.

Senators John Cregan*, Dermot Fitzpatrick and Mary Jackman.

3.DRAFT SECOND INTERIM REPORT OF THE SUB-COMMITTEE ON HEALTH AND SMOKING

The Chairman brought forward the draft Second Interim Report of the Sub-Committee on Health and Smoking. The Report was read and amended. The Report, as amended, was agreed.

Ordered:To report accordingly.

4.ADJOURNMENT

The Committee adjourned at 12.40 p.m. until 12 p.m. on Tuesday 31^st July 2001.

Appendix 13

Proceedings of the Sub-Committee

AN COMHCHOISTE UM SHLÁINTE AGUS LEANAÍ

(An Fochoiste ar Shláinte agus Caitheamh Tobac)

THE JOINT COMMITTEE ON HEALTH AND CHILDREN

(SUB-COMMITTEE ON HEALTH AND SMOKING)

Imeachtaí An Fhochoiste

Proceedings of the Sub-Committee

Dé Céadaoin, 24 Iúil 2001

1.The Sub-Committee met at 10.30 a.m. in Committee Room 4, LH2000.

2.MEMBERS PRESENT.

The following members were present:

Deputies Batt O’Keeffe (in the chair), Cecilia Keaveney, Brendan Kenneally and Gay Mitchell..

Senators John Cregan* and Mary Jackman.

3.DRAFT SECOND INTERIM REPORT OF THE SUB-COMMITTEE ON HEALTH AND SMOKING (RESUMED)

Consideration of the draft Second Interim Report of the Sub-Committee on Health and Smoking, brought forward by Deputy Mitchell, was resumed. The Report was read and amended. The Report, as amended, was agreed.

Ordered:To report accordingly.

4.ADJOURNMENT

The Committee adjourned at 10.40 a.m. sine die.

** Socio-economic groups 5&6 being semi-skilled or unskilled (Source “National Health and Lifestyles Surveys”, Centre for Health Promotion Studies, National University of Ireland, Galway, February 1999)

** Socio-economic groups 5&6 being semi-skilled or unskilled (Source: “National Health and Lifestyles Surveys”, Centre for Health Promotion Studies, national University of Ireland, Galway, February 1999)

* In substitution for Senator Glynn.

* In substitution for Senator Glynn.