Bhutan is a remote Himalayan nation, landlocked and bordered by two of the world’s most populous countries – China in the North and India to the South, West, and East. In 2004, Bhutan became, and still remains, the only country in the world to implement a nationwide ban in the sale of tobacco (both cigarettes and in smokeless form). Lack of organized lobbying by businesses and the absence of tobacco production industries made the passing of this legislation relatively easy. Along with bans on the sale of cigarettes, smoking in public spaces and the advertisement of tobacco products the ban included that tobacco products for self-consumption (only in limited quantity) declared at customs while entering the country would be subject to a 100% duty. 

The ban was implemented as a result of the concerning rising trend in the use of tobacco products in the country, particularly among the youth. Bhutan is also battling noncommunicable diseases (NCD), or diseases that cannot be transmitted from one person to the next. In fact, tobacco is the common risk factor in four major kinds of NCDs- cardiovascular disease, cancer, respiratory disease, and diabetes. As such, the proscription of tobacco stemmed not only from the recognition of a rising trend in the use of tobacco in the country, but was also due to the detrimental effects that tobacco usage has on health. 

Moreover, the ban stemmed from strong religious beliefs that influence the values of Bhutanese people. Bhutan is the last surviving Mahayana Buddhist Kingdom, a place where religion and therefore the Central Monastic Body of the country plays a pivotal role in directing development, institutions, social structure, lifestyle, and more. Among other beliefs, tobacco products are said to offend local deities and displease divine beings. Consequently, societies would be subject to disease, famine and disharmony with the continued use of tobacco products. 

The tobacco control efforts sparked visible changes. According to Dechen Wangmo, the current health minister, people are hardly seen smoking in public spaces now, indicating a difference in behavior since the legislation was enacted. However, the ban led to the nationwide growth of illicit markets for the sale of tobacco. The Tobacco Control Act (TCA) was enacted in 2010 to develop a more comprehensive bill that mainly aimed to address this illegal market. Among other reforms, the TCA mandated that the cultivation, manufacturing, and trade of tobacco products would result in the heavy penalty of a fourth-degree felony which would result in 3-5 years in prison. This act faced a lot of opposition due to its severity. In response, a new set of rules and regulations were formulated stating that most tobacco related offences would be dealt through monetary compensation and the felony charges would be replaced with a reduced prison term of between one month and three years.

When the ban was first imposed in 2004, only 1% of the Bhutanese population were smokers. Recent data shows that around 34% of men and around 13.6% of women aged 18-69 are users of tobacco– a stark growth in numbers. Additionally, it has been discovered that there has been a substantial increase in adolescent users: 22.2% of school-going children in the country currently use tobacco. According to the Global Youth Tobacco Survey, the prevalence of tobacco use in this age group is disproportionately high in Bhutan, especially when compared to other nations.. This is worrying as the addiction caused by nicotine ensures that it is difficult to quit smoking and can lead to serious health issues like cardiovascular diseases (which cause 28% of deaths in the country), respiratory diseases (which cause 9% of deaths) and cancer (which cause 10% of deaths). The rise in the prevalence of tobacco use has been attributed to the availability of the substance which is facilitated by the widespread illicit sale of tobacco.  Although implementation of legal consequences has resulted in some reduction in illegal sale, the underground market remains one of the biggest challenges faced by the government in its attempts to reduce the number of tobacco users

Policy proposals

There are several ways in which effective policy intervention can assist in decreasing the amount of illicit tobacco sale and consequently, its use. 

1. Effective border control: Bhutan shares a porous border with India to its South. It is through there that most of the illegal smuggling takes place. Although there are several checkpoints, more stringent border control measures would prove most effective. Police on duty along the border have to inspect imports along while also enforcing general law and control. Specialized officials responsible only for only goods inspection should be placed at the border. Further, it has been found that lack of scanning equipment makes goods examination difficult since consignments have to be manually checked, limiting the effectiveness of inspections. Advancement in such technology could also aid in the increased detection of illegal tobacco. 
2. Redefinition of the TCA: There are several ambiguities regarding the TCA. Although smoking in public has been banned, the law allows it in designated spots. This creates difficulties for officials to sanction offenders. They usually demand for a nominated space for facility as verified by the law. Further, the clause on permissible import quantity creates conflict as shopkeepers caught selling tobacco often avoid sanctions by claiming that it is for self-consumption. A review of the act with added detailed specifications would aid in increasing the efficiency of penalty imposition. 
3. Increased advocacy: Awareness and advocacy campaigns aimed specifically at shopkeepers and adolescents should be initiated and increased through the use of traditional and new media. Since the number of young users are high in the country, targeted interventions in schools and colleges should be strengthened. Complimenting this, helplines and access points for those wanting to quit should be made easily available in addition to the training of health workers that specialise in counselling.  

Interestingly, in light of the pandemic, the government has decided to reverse the ban on the sale of tobacco, allowing designated official outlets in the country to sell cigarettes. Bhutan closed its borders with India in March, permitting only essential goods to be imported due to the threat of the virus. This caused tobacco prices to soar as attaining products was extremely difficult. The current administration defends this reversal on the basis that demand by addicts may lead to cross border contamination due to smuggling. Although this act is justifiable considering the present global predicament, it is proof of the growing number of tobacco users whose addiction can be attributed to the thriving underground market for tobacco in the country. It calls for rigorous intervention by policy makers specifically targeting the illegal sale of tobacco products with the aim to simultaneously improve advocacy and awareness in schools and other institutions. 

Lhachi Kunzang Selden

Lhachi is a final year Political Economy student and is a member of the working group of the Global Health Policy Centre 

The featured image (top) is by Andres Siimon on Unsplash.

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