Global Youth Tobacco Survey (GYTS), Bhutan, 2019

Title: Global Youth Tobacco Survey (GYTS), Bhutan, 2019 ISBN: 978-92-9022-772-4 © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). 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Printed in India BHUTAN, 2019 iii CONTENTS FOREWORD: Ms Dechen Wangmo, Minister, Minstry of Health, Bhutan ......................v MESSAGE from the Regional Director ........................................................................ vii ACKNOWLEDGEMENTS ..............................................................................................ix CONTRIBUTORS .......................................................................................................... x ABBREVIATIONS .........................................................................................................xi LIST OF TABLES AND FIGURES ................................................................................... xii EXECUTIVE SUMMARY ..............................................................................................xv Introduction ....................................................................................................... xv Methodology ..................................................................................................... xv Results .............................................................................................................. xvi Trend analysis and discussion ...........................................................................xviii Conclusion and recommendations ..................................................................... xx 1. INTRODUCTION ...................................................................................................... 1 1.1 Country demographics .............................................................................. 2 1.2 WHO Framework Convention on Tobacco Control and MPOWER ............. 2 1.3 Purpose and rationale ............................................................................... 3 1.4 Current policy ............................................................................................ 4 1.5 Country-specific objectives ......................................................................... 4 2. METHODOLOGY ..................................................................................................... 6 2.1 Questionnaire ............................................................................................ 6 2.2 Sampling design ........................................................................................ 6 2.3 Data collection .......................................................................................... 7 2.4 Data analysis ............................................................................................. 7 Global Youth Tobacco Survey (GYTS) iv 3. RESULTS ................................................................................................................. 9 3.1 Tobacco use .............................................................................................. 9 3.2 Areca/betel nut use................................................................................. 13 3.3 Tobacco cessation ................................................................................... 14 3.4 Exposure to SHS ...................................................................................... 15 3.5 Access and availability ............................................................................. 16 3.6 Anti-tobacco messages and information .................................................. 19 3.7 Tobacco advertising and promotion ........................................................ 21 3.8 Knowledge, attitudes, perceptions and behaviour ................................... 22 4. TREND ANALYSIS (2009–2019) AND DISCUSSION ............................................... 25 4.2 Comparison with previous rounds of GYTS (2009–2019) ........................................................................................... 28 4.3 Relevance to the FCTC............................................................................. 41 4.4 Relevance to the country ......................................................................... 44 5. CONCLUSION & RECOMMENDATIONS ................................................................. 46 BIBLIOGRAPHY ......................................................................................................... 49 ANNEXURE ONE - GYTS 2019 questionnaire ............................................................. 51 ANNEXURE TWO - GYTS 2019 indicators .................................................................. 65 ANNEXURE THREE - GYTS 2019 factSheet ................................................................ 78 BHUTAN, 2019 v Global Youth Tobacco Survey (GYTS) vi BHUTAN, 2019 vii Global Youth Tobacco Survey (GYTS) viii BHUTAN, 2019 ix ACKNOWLEDGEMENTS The Ministry of Health of the Royal Government of Bhutan acknowledges the technical and financial support of the World Health Organization’s (WHO) Regional Office for South-East Asia, and the United States Centers for Disease Control and Prevention (CDC), Atlanta, for conducting the Global Youth Tobacco Survey (GYTS) 2019 and developing this report. The Bhutan GYTS 2019 would not have been successful without the unwavering support of the Department of School Education, Ministry of Education, and the Dzongkhag Education Officers of select dzongkhags. Special credit goes to all the principals and school health coordinators of the selected schools for their sustained support and efforts during the process of the survey. The Comprehensive School Health Programme under the Heath Promotion Division of the Ministry of Health merits special mention for its active involvement throughout the implementation of this survey. The data collection was completed within a record time of five days (June 3–7, 2019), covering 50 schools spread across the country by a team of dedicated health-care providers who served as the field workers. We would like to put on record our appreciation for and gratitude to all field workers. Our appreciation also goes to all the respondents for their participation in the Bhutan GYTS 2019. Global Youth Tobacco Survey (GYTS) x CONTRIBUTORS Research coordinators Mr Mongal Singh Gurung, Sr Research Officer, Policy and Planning Division, Ministry of Health, Bhutan Mr Ugyen Norbu, Programme Officer, Department of Public Health, Ministry of Health, Bhutan Authors Dr Jagdish Kaur, Regional Adviser (Tobacco Free Initiative), WHO Regional Office, New Delhi Dr Arvind Vashishtha Rinkoo, Regional Data Coordinator, WHO Regional Office, New Delhi Advisers and Reviewers Mr Tashi Penjor, Chief Planning Officer, Policy and Planning Division, Ministry of Health, Bhutan Mr Sonam Wangdi, Sr Planning Officer, Policy and Planning Division, Ministry of Health, Bhutan Mr Kinley Dorjee, Assistant Research Officer, Policy and Planning Division, Ministry of Health, Bhutan Mr Kencho Wangdi, National Professional Officer, WHO Country Office for Bhutan Dr Karma Lhazeen, Director, Department of Public Health, Ministry of Health, Bhutan Dr Rui Paulo de Jesus, WHO Representative to Bhutan BHUTAN, 2019 xi ABBREVIATIONS CDC Centers for Disease Control and Prevention CI Confidence interval FCTC Framework Convention on Tobacco Control GYTS Global Youth Tobacco Survey IARC International Agency for Cancer Research LMIC Low and middle-income countries MPOWER Monitor tobacco use and prevention policies; protect people from tobacco smoke; offer help to quit tobacco use; warn about the dangers of tobacco; and raise taxes on tobacco SEARO Regional Office for South-East Asia SHS Secondhand smoke TAPS Tobacco advertising, promotion and sponsorship TFI Tobacco-free Initiative WHO World Health Organization Global Youth Tobacco Survey (GYTS) xii LIST OF TABLES AND FIGURES Tables Table 1. Sample sizes and response rates by level (unweighted) – GYTS 2019 Table 2. Prevalence of tobacco use among students of the age of 13–15 years, by sex (GYTS 2019) Table 3. Cigarettes smoked per day by current cigarette smokers of the age of 13–15 years, by sex (GYTS 2019) Table 4. Percentage of ever tobacco users by age at which they first tried a tobacco product (GYTS 2019) Table 5. Indicators of tobacco cessation among current tobacco users of the age of 13–15 years, by sex (GYTS 2019) Table 6. Exposure to tobacco smoke among students of the age of 13–15 years, by sex (GYTS 2019) Table 7. Access to cigarettes among current cigarette smokers of the age of 13–15 years, by sex (GYTS 2019) Table 8. Access to tobacco products among current smokeless tobacco users of the age of 13–15 years, by sex (GYTS 2019) Table 9. Unit of purchase of cigarettes among current cigarette smokers of the age of 13–15 years, by sex (GYTS 2019) Table 10. Exposure to anti-tobacco information among students of the age of 13–15 years, by sex (GYTS 2019) Table 11. Exposure to health warnings on cigarette packages among current and never smokers of the age of 13–15 years, by sex (GYTS 2019) Table 12. Exposure to tobacco marketing and promotion among students of the age of 13–15 years, by sex (GYTS 2019) Table 13. Attitudes to tobacco addiction, social smoking and SHS among students of the age of 13–15 years, by sex (GYTS 2019) Table 14. Percentage of current cigarette smokers of the age of 13–15 years by place where they usually smoke (GYTS 2019) BHUTAN, 2019 xiii Figureres Figure 1. Prevalence (%) of current tobacco use among students of the age of 13–15 years, by sex (GYTS 2009, 2013 and 2019) Figure 2. Trend in prevalence (%) of current tobacco use among students of the age of 13–15 years, by sex (GYTS 2009–2019) Figure 3. Prevalence (%) of current cigarette smoking among students of the age of 13–15 years, by sex (GYTS 2009, 2013 and 2019) Figure 4. Trend in prevalence (%) of current cigarette smoking among students of the age of 13–15 years, by sex (GYTS 2009–2019) Figure 5. Prevalence (%) of current smokeless tobacco use among students of the age of 13–15 years, by sex (GYTS 2009, 2013 and 2019) Figure 6. Trend in prevalence (%) of current smokeless tobacco use among students of the age of 13–15 years, by sex (GYTS 2009–2019) Figure 7. Percentage of tobacco smokers among students of the age of 13–15 years who tried to stop smoking in the preceding 12 months, by sex (GYTS 2009, 2013 and 2019) Figure 8. Trend in prevalence (%) of tobacco smoking among students of the age of 13–15 years who tried to stop smoking in the preceding 12 months, by sex (GYTS 2009–2019) Figure 9. Prevalence (%) of tobacco smoking among students of the age of 13–15 years who want to stop smoking now, by sex (GYTS 2009, 2013 and 2019) Figure 10. Prevalence (%) of tobacco smoking among students of the age of 13–15 years who thought they would be able to quit if they wanted to, by sex (GYTS 2009, 2013 and 2019) Figure 11. Prevalence (%) of exposure to tobacco smoke at home during the preceding 7 days among students of the age of 13–15 years, by sex (GYTS 2009, 2013 and 2019) Figure 12. Prevalence (%) of exposure to tobacco smoke in any enclosed public place during the preceding 7 days among students of the age of 13–15 years, by sex (GYTS 2009, 2013 and 2019) Figure 13. Prevalence (%) of current cigarette smoking among students of the age of 13–15 years who bought from a shop or street vendor, by sex (GYTS 2009, 2013 and 2019) Figure 14. Trend in prevalence (%) of buying from a shop or street vendor among students of the age of 13–15 years who currently smoke, by sex (GYTS 2009–2019) Global Youth Tobacco Survey (GYTS) xiv Figure 15. Percentage of current cigarette smokers* of the age of 13–15 years who were not prevented from buying cigarettes despite their age, by sex (GYTS 2009, 2013 and 2019) (*among those who tried to buy cigarettes during the preceding 30 days) Figure 16. Percentage of students of the age of 13–15 years who noticed someone using tobacco on television, videos or movies in the preceding 30 days, by sex (GYTS 2009, 2013 and 2019) Figure 17. Percentage of students of the age of 13–15 years who owned something with a tobacco brand logo on it, by sex (GYTS 2009, 2013 and 2019) Figure 18. Trend in prevalence of students of the age of 13–15 years owning something with a tobacco brand logo on it, by sex (GYTS 2009—2019) Figure 19. Percentage of students of the age of 13–15 years who had noticed anti-tobacco messages in the media in the preceding 30 days, by sex (GYTS 2009, 2013 and 2019) Figure 20. Percentage of students of the age of 13–15 years who noticed anti- tobacco messages at sporting or community events in the preceding 30 days, by sex (GYTS 2009, 2013 and 2019) Figure 21. Percentage of students of the age of 13–15 years who were taught in school about the dangers of tobacco use in the preceding 12 months, by sex (GYTS 2009, 2013 and 2019) Figure 22. Trend in prevalence of being taught in school about the dangers of tobacco use in the preceding 12 months among students of the age of 13–15 years, by sex (GYTS 2009–2019) Figure 23. Percentage of students of the age of 13–15 years who definitely thought that tobacco smoking by others is harmful to them, by sex (GYTS 2009, 2013 and 2019) Figure 24. Trend in prevalence of definite opinion that tobacco smoking by others harms one among students of the age of 13–15 years, by sex (GYTS 2009–2019) Figure 25. Percentage of students of the age of 13–15 years who favoured a ban on smoking inside enclosed public places, by sex (GYTS 2009, 2013 and 2019) BHUTAN, 2019 xv EXECUTIVE SUMMARY Introduction The Global Youth Tobacco Survey (GYTS) was developed by the Tobacco-Free Initiative (TFI), World Health Organization (WHO) and the Office on Smoking and Health of the United States Centers for Disease Control and Prevention (CDC), in collaboration with other countries representing the six WHO regions. Its aim was to generate comprehensive information on the prevention and control of tobacco use among young people. It enables countries to systematically monitor tobacco use among the youth and track the key indicators of tobacco control, using globally standardized tools. The GYTS is a nationally representative school-based survey of students of 13–15 years of age, and uses consistent and standard protocols across countries. It is intended to generate comparable data within and across countries. Methodology The survey used a standard core questionnaire, with a set of optional questions, which countries can adapt to measure and track key tobacco control indicators. The standard questionnaire covers the following topics: tobacco use (smoking and smokeless), cessation, secondhand smoke (SHS), pro- and anti-tobacco media and advertising, access to and availability of tobacco products, and knowledge and attitudes regarding tobacco use. Apart from the standard GYTS questions, several country-specific questions were included in the questionnaire, especially on the ease of availability of tobacco products within the country, use of doma or betel (areca) nut or its products, and consumption of smokeless tobacco. The GYTS used a global standardized methodology that included a two-stage sample design. It was conducted by the Ministry of Health, Royal Government of Bhutan. The overall response rate was 94.9%. A total of 4712 eligible students in grades 7 to 11 completed the survey. Of these, 2344 were 13–15 years of age. This report presents the data on the students who were 13–15 years of age. Global Youth Tobacco Survey (GYTS) xvi Results Tobacco use Tobacco use remains high among the youth in Bhutan, with more than one out of five students (22.2%) currently using tobacco products. Current tobacco use was higher among boys (31.2%) than girls (13.5%). In all, 17.3% of the students were current tobacco smokers. The prevalence of current cigarette smoking was 14.7%. Smokeless tobacco products were being consumed by 12.5% of students. The susceptibility of the youth to the use of tobacco is worrisome. Among the students who had never consumed tobacco, 15.9% were susceptible to using tobacco in the future. Also, 7.3% never smokers thought they might enjoy smoking a cigarette and 9.3% never smokeless tobacco users thought they might enjoy using smokeless tobacco. A total of 13.2% students, who had ever smoked cigarettes, had tried their first cigarette before the age of 10 years. Of the ever smokeless tobacco users, 13.7% had first tried smokeless tobacco before the age of 10 years. Betel nut use The consumption of betel nut products is widespread among the youth in Bhutan, with 48.9% of students currently using doma khamtog (tobacco and betel nut product) or meetha paan (betel nut wrapped in betel leaf) and 56.9% using betel nut or various products containing it. Tobacco cessation More than 8 out of 10 current smokers wanted to stop smoking right away and around the same number had tried to quit smoking in the preceding 12 months. Similarly, around 9 out of 10 (87.1%) current smokeless tobacco users now wanted to stop using these products and 83% of students who currently consume smokeless tobacco had actually tried to stop using it in the preceding 12 months. Overall, 87.7% of current tobacco smokers and 84.9% of current smokeless tobacco users thought that they would be able to stop using these products if they wanted to. Among the current tobacco smokers, 51.2% showed signs of smoking dependence. BHUTAN, 2019 xvii Exposure to secondhand smoke More than 2 in 6 students (36.6%) were exposed to SHS in enclosed public places and 35.9% were exposed to it in outdoor public places. In addition, more than half of the students (55%) were exposed to SHS inside the school building or outside within the school premises. Access and availability It seems that the youth have easy access to tobacco products in Bhutan. More than half (57.6%) of those who tried to buy cigarettes at a store were not refused purchase, even though they are minors. As many as 55.0% of current smokers bought cigarettes from a shop or a street vendor. Interestingly, girls (61.7%) were less likely than boys (56.5%) to be prevented from purchasing cigarettes. In addition, more than half of the current cigarette smokers (51.8%) were able to purchase cigarettes as individual sticks. Similarly, more than half of the current smokeless tobacco users (52.4%; 57% boys and 43.4% girls) bought smokeless tobacco products from shops or street vendors. Despite being minors, 59.3% of them were not prevented from buying smokeless tobacco. As in the case of cigarettes, girls (67.4%) were less likely than boys (56.1%) to be prevented from purchasing smokeless tobacco. The percentage of students who reported that they could purchase tobacco products and/or cigarettes near their school was 16.8 (22% boys and 11.4% girls). Only 15.5% (18% boys and 12.9% girls) felt that it would be “very difficult” for them to get tobacco products and/or cigarettes if they wanted some. Notably, the percentage of current tobacco users who usually buy cigarettes or other tobacco products from within Bhutan was as high as 85.0 (83.8% boys and 88% girls). Anti-tobacco messages and information In the preceding 30 days, 67% of all the students and 56.9% of those who attended sporting or community events had noticed anti-tobacco messages and information in the media and at the event, respectively. About 7 out of 10 students (69.5%) mentioned that they had been taught about the dangers of tobacco use in the preceding 12 months in school. Among the current smokers, more than 7 out of 10 (72.7%) had noticed health warnings on cigarette packages and more than 2 out of 5 (41.8%) had thought of quitting because of the warnings. Nearly one-third of the never smokers (31.4%) thought they would not start smoking because of the health warnings on cigarette packages. Global Youth Tobacco Survey (GYTS) xviii Tobacco advertising and promotion Among those who had visited a point of sale in the preceding 30 days, 31.7% had noticed tobacco advertisements or promotions. Among those who had watched television, videos or movies in the preceding 30 days, 84.1% had noticed someone using tobacco. Around 8 out of 100 students (7.7%) had been offered free tobacco products by tobacco company representatives. Knowledge, attitudes, perceptions and behaviour The percentage of students who thought that smoking helps one feel more comfortable at celebrations, parties and social gatherings was 15.1. While 42.9% of the students definitely thought that it is difficult to quit smoking tobacco, only 32.3% of definitely thought that it is difficult to quit using smokeless tobacco products. More than 7 out of 10 students (74%) thought that smoking by other people was harmful to them and 77.2% were in favour of banning smoking at outdoor public places. Of the current cigarette smokers, 16% usually smoked at home, while 14.6% usually smoked in school. Around 3 out of 10 current cigarette smokers (29.4%) usually smoked in a public place. Trend analysis and discussion Tobacco use The prevalence of current tobacco use among the youth in Bhutan increased from 18.8% in 2009 to 30.3% in 2013; thereafter, it decreased and fell to 22.2% in 2019. However, considering the entire period of 2009–2019, the prevalence increased from 18.8% to 22.2%. During this period, the relative increase in the prevalence of current tobacco use among boys was around 13% (from 27.6% in 2009 to 31.2% in 2019) and among girls, around 16% (from 11.6% in 2009 to 13.5% in 2019). The prevalence of current cigarette smoking increased continuously from 2009 to 2019. There was a relative increase of around 13% during 2009–2013 (12.4% in 2009 to 14.0% in 2013), and a relative increase of 5% during 2013–2019 (14% in 2013 to 14.7% in 2019). The prevalence of current smokeless tobacco use increased drastically during 2009–2013, but decreased during 2013–2019. However, the overall prevalence of the use of smokeless tobacco increased from 9.4% in 2009 to 12.5% in 2019 – a staggering relative increase of around 33% in the last 10 years. BHUTAN, 2019 xix Susceptibility to tobacco use remains a serious concern in Bhutan. As compared to 6.7% never smokers in 2013, 7.3% never smokers reported in 2019 that they might enjoy smoking a cigarette – a relative increase of around 9% over the period 2013–2019. Tobacco cessation Over the years, there has been a strong and consistent need for quality services for tobacco cessation for current tobacco users/cigarette smokers. Almost 8 to 9 out of every 10 smokers – both girls and boys – would potentially benefit from such services. The need for quality tobacco cessation services, specifically targeting the youth and preferably in school settings, is further underscored by the fact that an astronomical proportion of current tobacco smokers and smokeless tobacco users wrongly think that they would be able to stop using these products if they wanted to. Exposure to SHS It is encouraging to note that exposure to SHS has decreased consistently over the last 10 years. However, as of 2019, more than 1 in 3 students (36.6%) continued to be exposed to SHS in enclosed public places. Therefore, diligent enforcement of extant smoke-free regulations may be the best way forward for the country. Access and availability The proportion of current smokers who bought cigarettes from a shop or a street vendor increased from 23.7% in 2009 to 55.0% in 2019 – a mammoth relative increase of 132%. Throughout this period, around half of those who tried to buy cigarettes during the 30 days preceding the survey were not prevented from buying cigarettes despite their age. The percentages of the current cigarette smokers who were not prevented to buy cigarettes because of their age were 53.4, 47.8 and 57.6 for 2009, 2013 and 2019, respectively. Tobacco advertising and promotion Though the depiction of tobacco products on television, videos and movies has decreased over the last decade, it still poses a substantial challenge. More than 84% of the youth in Bhutan are exposed to the depiction of tobacco in the entertainment media. The proportion of students who owned something carrying the logo of a tobacco brand decreased from 14.9% in 2009 to 10.9% in 2019, a relative decrease of around 27%. However, tobacco advertising, promotion and sponsorship (TAPS) remains a major threat to effective tobacco control in Bhutan. Global Youth Tobacco Survey (GYTS) xx Anti-tobacco messages and information The proportion of youth who noticed messages on tobacco control in the media or at sporting and community events decreased substantially from 2009 to 2019. There was a relative decrease of around 23% (from 86.9% in 2009 to 67% in 2019) in the proportion of students who had noticed such messages in the media in the 30 days before the survey. Similarly, there was a relative decrease of around 31% (from 83.1% in 2009 to 56.9% in 2019) in the proportion of students who had noticed anti-tobacco messages at sporting or community events in the preceding 30 days. These trends require serious attention. Knowledge, attitudes, perceptions and behaviour The percentage of students who were taught about the dangers of tobacco use in school in the 12 months preceding the survey increased from 61.6 in 2009 to 69.5 in 2019. However, though the percentage of students who definitely thought that smoking by other people is harmful to them increased from 72.8 in 2009 to 78.9 in 2013, it plummeted to 74.0 in 2019. The proportion of those who favoured a ban on smoking inside enclosed public places increased consistently from 44.1% in 2009 to 76.8% in 2019 – a relative increase of more than 74%. Conclusion and recommendations Nearly one-and-a-half decades since Bhutan ratified the WHO’s Framework Convention on Tobacco Control (FCTC) on 23 August 2004 and almost a decade after the country completely prohibited the cultivation, harvesting, manufacture, supply, distribution and sale of tobacco products through the Tobacco Control Act of Bhutan 2010, the prevalence of tobacco use among the youth remains high across the country. On the basis of the findings of the GYTS 2019, some of the high-impact and achievable action points for effective tobacco control among the youth are delineated below: ¤ No ground for complacency: The prevalence of current tobacco use among the youth in the country increased from 18.8% in 2009 to 22.2% in 2019. Thus, enhanced, effective and sustained implementation of the relevant provisions of the FCTC and the national tobacco control laws, encompassing the demand- as well as supply-side issues, are as relevant to Bhutan as to any other country. BHUTAN, 2019 xxi ¤ Go holistic: It is imperative to comprehend the issue of tobacco consumption in the national context and thereafter, take holistic and inclusive measures to mitigate tobacco use among the youth. Apart from tobacco smoking, the use of smokeless tobacco products by the youth should be a matter of utmost concern for the country. It is high time to consider the youth as the prime target audience and roll out customized tobacco control measures tailored to meet the specific needs of the youth and children who are susceptible to the use of tobacco and betel nut products. Also, girls, like boys, are important stakeholders in the fight against tobacco. ¤ Neglecting supply-side issues is a costly gap: Though Bhutan is not a tobacco cultivator or producer, tobacco control issues related to the supply side are of great concern. Despite the blanket ban on tobacco products, the percentage of current tobacco users who bought cigarettes or other tobacco products from within Bhutan was 85%. Bhutan must ratify the WHO FCTC Protocol to Eliminate Illicit Trade in Tobacco Products at the earliest. ¤ Target doma khamtog and betel nut use: The use of betel nut is addictive and betel nut has been independently classified as a Group 1 carcinogen by the International Agency for Cancer Research (IARC). Thus, measures need to be taken to discourage the use of betel nut, even without tobacco. Strategies must be adopted to promote behavioural change among the youth and discourage the use of betel nut. ¤ Accelerate implementation of efficient and quality tobacco cessation services: Tobacco cessation services, particularly those aimed at the youth, need to be strengthened across Bhutan. ¤ Maximize implementation of TAPS ban: Robust implementation of tobacco control laws pertaining to the TAPS ban should be prioritized. There ought to be zero tolerance to any type of tobacco promotion, direct or indirect, by tobacco industry representatives. A ban on brand-stretching would be useful in maximizing the level of implementation of the TAPS ban, leading to a better MPOWER score for the country. ¤ Renew efforts to communicate tobacco health risks to youth: It is imperative to conduct and sustain effective national campaigns on tobacco control through the mass media, primarily aimed at youth. ¤ Involve multiple stakeholders : Engage all relevant stakeholders in framing and implementing effective legislative, policy, regulatory and administrative tobacco control measures.

BHUTAN, 2019 1 1. INTRODUCTION Each year, tobacco use is responsible for approximately 8 million deaths worldwide. Of these deaths, persons who use tobacco account for 7 million and non-smokers exposed to SHS account for 1.2 million. The situation is exacerbated by the marked rate of increase in the number of youth initiated to tobacco use, and the introduction of new tobacco products by the tobacco industry, which extensively markets its products with the aim of reaching the youth. With the continuing decline in tobacco use in high-income countries, low- and middle-income countries (LMIC) have become a prime market for the tobacco industry because of their economic and demographic contexts. To put things in perspective, approximately 80% of the 1.1 billion persons who smoke tobacco worldwide reside in LMICs. In the South-East Asia Region of WHO, nearly 1.6 million persons die every year because of the consumption of tobacco products. There are about 230 million tobacco smokers in the Region, amounting to more than one-fifth (around 21%) of all smokers worldwide. Besides, the Region has by far the largest number of adult smokeless tobacco users (around 248 million), representing about 82% of all users globally. Significantly, it has the largest number of tobacco users of 13–15 years of age (14.8 million, or around 34% of the global total). In absolute terms, it has the largest number of child cigarette smokers (6.4 million, or around 27% of the global total). Also, the Region accounts for nearly 62% of all smokeless tobacco users of the age of 13–15 years in the world. The GYTS was developed by the TFI, WHO and the Office on Smoking and Health of the CDC, in collaboration with other countries representing the six WHO regions, to generate comprehensive information on tobacco prevention and control with respect to the youth. It enables countries to systematically monitor tobacco use among the youth and track the key indicators of tobacco control, using globally standardized tools. The GYTS is a nationally representative school-based survey of students of 13–15 years of age, and uses consistent and standard protocols across countries. It is intended to generate comparable data within and across countries. Global Youth Tobacco Survey (GYTS) 2 1.1 Country demographics Bhutan, a developing country, is a Member State of the WHO South-East Asia Region. A small, landlocked country nestled deep in the Himalayas between India and China, Bhutan is characterized by steep mountains and deep valleys, making for scattered population settlement patterns. The country is famous for its unique philosophy, Gross National Happiness, which guides its development. Abundant water resources create ideal conditions for the development of hydropower, which has spurred economic growth. Fiscal revenues from hydropower have helped finance large investments in human capital, resulting in significant improvements in service delivery and educational and health outcomes. Access to electricity is almost universal, while access to functional piped water was 95% in 2015. The population of Bhutan was around 0.8 million in 2016. Bhutan has become an LMIC and poverty has been reduced by two-thirds in the last decade. The average annual growth of the gross domestic product has been 7.5% since the early 1980s, making Bhutan one of the fastest growing economies in the world. The gross national income per capita, which was $3080 in 2018, is now three times the threshold for LMICs and only 10% below the threshold for upper-middle-income countries. In 2016, life expectancy at birth was 71.0 years for women and 70 years for men. The total expenditure on health per capita was $281 in 2014 and that on health as a percentage of the gross domestic product was 3.6 in the same year. 1.2 WHO Framework Convention on Tobacco Control and MPOWER In response to the globalization of the tobacco epidemic, 191 Member States of WHO unanimously adopted the FCTC at the Fifty-sixth World Health Assembly in May 2003. The Convention entered into force on 27 February 2005 and, 90 days later, it had been approved by 40 Member States. The FCTC is the world’s first public health treaty on tobacco control. It is the driving force behind, and a blueprint for, the global response to the pandemic of tobacco-induced deaths and diseases. The treaty embodies a coordinated, effective and urgent action plan to curb tobacco consumption. In doing so, it lays out cost-effective tobacco control strategies for public policies, such as banning direct and indirect tobacco advertisements, increasing taxes on and prices of tobacco, promoting smoke-free public places and workplaces, displaying prominent health messages on tobacco packaging, and surveillance, research and exchange of information related to tobacco. BHUTAN, 2019 3 To assist countries in fulfilling their FCTC obligations, in 2008, WHO introduced MPOWER, a technical package of six evidence-based tobacco control measures that are proven to reduce tobacco use and save lives: ¤ monitor tobacco use and prevention policies ¤ protect people from tobacco smoke ¤ offer help to quit tobacco use ¤ warn about the dangers of tobacco ¤ enforce bans on tobacco advertising, promotion and sponsorship ¤ raise taxes on tobacco. The GYTS supports the MPOWER package by monitoring country-specific data on key tobacco indicators, including prevalence, knowledge and behaviour. 1.3 Purpose and rationale The GYTS enhances countries’ capacity to monitor tobacco consumption and initiation of tobacco use among the youth, guides national programmes on tobacco prevention and control, and facilitates comparison of tobacco-related data at the national, regional and global levels. The results of the GYTS are also useful for documenting changes in different variables of tobacco control measures to monitor the implementation of the various provisions of the tobacco control law and the relevant Articles of the FCTC. Bhutan has conducted four rounds of the GYTS – in 2004, 2006, 2009 and 2013. Over this period, the proportion of current cigarette smokers among the youth increased from 10.1% to 14%, while that of current smokeless tobacco users increased from 7.4% to 21.6%. No GYTS round has been conducted in Bhutan since 2013. Therefore, GYTS 2019 is crucial to track the progress in the key indicators of tobacco control and to come up with specific recommendations on how to effectively implement a tobacco control programme targeted at the youth. The GYTS provides an evidence base for developing policy measures and guiding suitable interventions and strategies for tobacco-free initiatives in the country. It also provides data for the monitoring and evaluation of tobacco control programmes to assess the progress made towards achieving global targets on the reduction of tobacco use. Global Youth Tobacco Survey (GYTS) 4 1.4 Current policy Bhutan is among the first few countries in the world to have put in place anti-tobacco measures in the form of a legal document, way back in the seventeenth century. Currently, tobacco control in Bhutan is guided by the FCTC, which the country ratified on 23 August 2004. In fact, in its commitment to making its society tobacco- free, Bhutan has moved beyond the FCTC provisions and has completely prohibited the cultivation, harvesting, manufacture, supply, distribution and sale of tobacco products through the Tobacco Control Act of Bhutan 2010. The Act stipulates the establishment of smoke-free places; prohibits the cultivation, manufacture, sale and distribution of tobacco products; and restricts the import of tobacco products for personal consumption only. Among other things, the law also regulates the advertisement, promotion and sponsorship of tobacco. In addition, several provisions of this Act have been amended by the Tobacco Control Amendment Act of Bhutan 2012, with a view to making clarifications on offences, penalties and enforcement authorities. The amendments also adjust the maximum permissible quantities of tobacco products to be imported for personal consumption. The Tobacco Control Rules and Regulations 2013, issued under the Tobacco Control Act, govern smoke- free places; importation and duties; and the duties and powers of the enforcement authorities. The Rules specifically prohibit minors (those below the age of 18 years) from importing tobacco or tobacco products, even for personal consumption. Public Notification No. 7345 provides additional information on the ban on smoking in public places and the duties of the persons in charge of the premises. 1.5 Country-specific objectives General ¤ To explore the current situation of tobacco use among the youth in Bhutan and strengthen national capacity for conducting tobacco surveillance among the youth Specific ¤ To assess the prevalence of tobacco use, including smoking and smokeless tobacco, among students of 13–15 years of age ¤ To assess exposure to SHS among the youth ¤ To assess the effect of the media on tobacco use among the youth BHUTAN, 2019 5 ¤ To explore attitudes to and perceptions of the youth regarding tobacco use ¤ To track the progress made from GYTS 2009 to GYTS 2019 with respect to key indicators, and to identify some of the high-impact and achievable action points for effective tobacco control among the youth Global Youth Tobacco Survey (GYTS) 6 2. METHODOLOGY 2.1 Questionnaire The survey uses a standard core questionnaire, with a set of optional questions, which countries can adapt to measure and track the key indicators of tobacco control. The standard questionnaire covers the following topics: tobacco use (smoking and smokeless), cessation, SHS, pro- and anti-tobacco media and advertising, access to and availability of tobacco products, and knowledge and attitudes regarding tobacco use. The questionnaire used for GYTS 2019 in Bhutan contained 74 questions (Annexure 1). Apart from the standard GYTS questions, the questionnaire included several country-specific questions, especially on the ease of availability of tobacco products in the country, use of doma or betel nut or its products, and specific questions on the consumption of smokeless tobacco. 2.2 Sampling design The GYTS 2019 used a global standardized methodology that included a two-stage sample design, as described below. ¤ School level: The first-stage sampling frame consisted of all schools that had 40 or more students in grades 7 to 11. Schools were selected with probability proportional to school enrolment size. ¤ Class level: The second sampling stage consisted of systematic equal probability sampling (with a random start) of classes from each school that participated in the survey. All classes in the selected schools were included in the sampling frame. All students in the selected classes were eligible to participate in the survey. The GYTS 2019 was conducted by the Ministry of Health. The overall response rate was 94.9% (see Table 1 for details). A total of 4712 eligible students in grades 7 to 11 completed the survey. Of these, 2344 were 13–15 years of age. This report shares the data pertaining to students of 13–15 years of age. BHUTAN, 2019 7 Table 1: Sample sizes and response rates by level (unweighted) – GYTS 2019 Total School level Number of sampled schools 50 Number of participating schools 50 School response rate 100% Class level Number of sampled classes 156 Number of participating classes 156 Class response rate 100% Student level Number of sampled students 4,963 Number of participating students 4,712 Student response rate 94.9% Overall response rate*: 94.9% *Overall response rate=school response rate x class response rate x student response rate 2.3 Data collection Measures were taken to protect the students’ privacy, allowing for anonymous and voluntary participation. The questionnaire was self-administered in a classroom setting. The students recorded their responses directly on scannable paper-based bubble sheets. 2.4 Data analysis A weight has been associated with each participating student to reflect the likelihood of sampling each student and to reduce bias by compensating for differing patterns of nonresponse. The weight used for estimation is given by: W = W1 W2 f1 f2 f3 f4 where, W1 = the inverse of the probability of selecting the school W2 = the inverse of the probability of selecting the class within the school f1 = a school-level nonresponse adjustment factor calculated by school size (small, medium, large) Global Youth Tobacco Survey (GYTS) 8 f2 = a class-level nonresponse adjustment factor calculated by school f3 = a student-level nonresponse adjustment factor calculated by class f4 = a post stratification adjustment factor calculated by gender and grade The weighted results can be used to make important inferences regarding the students’ risk behaviours related to tobacco use. SUDAAN, a software package for statistical analysis of complex survey data, was used to calculate weighted prevalence estimates and standard errors of the estimates (95% confidence intervals [CI] were calculated from the standard errors). Frequency tables were developed for the survey questions that were considered key tobacco control indicators in line with the FCTC and, in particular, the MPOWER technical package. Data were weighted to be nationally representative of all 13–15-year-old students enrolled in school. Percentages, as depicted in the results in this report, reflect the prevalence of each indicator in each group, and not the distribution across groups. BHUTAN, 2019 9 3. RESULTS 3.1 Tobacco use Key findings ¤ 22.2% of students (31.2% of boys and 13.5% of girls) currently used any tobacco product. ¤ 17.3% of students (25.4% of boys and 9.5% of girls) currently smoked tobacco in any form. ¤ 14.7% of students (22.2% of boys and 7.7% of girls) currently smoked cigarettes. ¤ 12.5% of students (17.0% of boys and 8.1% of girls) currently used smokeless tobacco. ¤ 13.2% of ever cigarette smokers tried their first cigarette before the age of 10 years. ¤ 13.7% of ever smokeless tobacco users first tried smokeless tobacco before the age of 10 years. Current use The prevalence of current tobacco use among the students was 22.2%. It was higher among boys (31.2%) than girls (13.5%). In all, 17.3% of the students were current tobacco smokers, with the prevalence of current cigarette smoking being 14.7%. In addition, 12.5% students currently consumed smokeless tobacco products, such as baba, khaini (tobacco leaf and lime), raja and snuff. As in the case of smoking, current smokeless tobacco use was higher among boys (17.0%) than girls (8.1%) (see Table 2). Ever use Overall, 38.4% of the students had ever used tobacco products. Boys were more likely than girls to have ever used tobacco products (51.7% and 25.4%, respectively). While 28.8% of students reported that they had ever smoked cigarettes, 16.6% Global Youth Tobacco Survey (GYTS) 10 reported having ever smoked tobacco products other than cigarettes, such as bidis, surti, cigars and pipes. In addition, 21.4% of students had ever used smokeless tobacco products (see Table 2). Susceptibility to tobacco use Overall, 15.9% students, who had never consumed tobacco, were susceptible to tobacco use in the future. Also, 7.3% never smokers (9.7% boys and 5.6% girls) thought they might enjoy smoking a cigarette, while 9.3% never smokeless tobacco users (11.9% boys and 7.0% girls) thought they might enjoy using smokeless tobacco (see Table 2). Table 2: Prevalence of tobacco use among students of the age of 13–15 years, by sex (GYTS 2019) Indicators Overall Boys Girls In % (95% CI) Smoked tobacco Current tobacco smokers1 17.3 (15.3–19.5) 25.4 (22.3–28.7) 9.5* (7.4–12.2) Current cigarette smokers2 14.7 (12.9–16.7) 22.2 (19.3–25.3) 7.7* ( 6.0–9.9) Frequent cigarette smokers3 0.8 (0.4–1.5) 1.0 (0.5–2.1) 0.6 (0.2–1.6) Current smokers of other tobacco4 9.0 (7.8–10.3) 13.6 (11.4–6.0) 4.6* ( 3.2– 6.6) Ever tobacco smokers5 32.3 (29.2–35.5) 46.1 (41.7–50.6) 18.8* (15.7–22.4) Ever cigarette smokers6 28.8 (25.6–32.2) 42.8 (37.8–47.9) 15.2* (12.4–18.5) Ever smokers of other tobacco7 16.6 (14.9–18.4) 24.4 (21.6–27.4) 9.2* (7.2–11.6) Smokeless tobacco Current smokeless tobacco users8 12.5 (11.0–14.1) 17.0 (14.8–19.5) 8.1* (6.6–9.9) Ever smokeless tobacco users9 21.4 (19.2–23.7) 29.2 (25.9–32.7) 13.9* (11.8–16.4) BHUTAN, 2019 11 Indicators Overall Boys Girls In % (95% CI) Any tobacco use Current tobacco users10 22.2 (20.1–24.4) 31.2 (28.2–34.3) 13.5* (11.0–16.5) Ever tobacco users11 38.4 (35.2–41.6) 51.7 (47.2–56.2) 25.4* (22.1–29.0) Susceptibility Never tobacco users susceptible to tobacco use in the future12 15.9 (12.5–20.1) 15.8 (11.3–21.8) 15.9 (12.2–20.5) Never smokers who thought they might enjoy smoking a cigarette13 7.3 (5.4–9.8) 9.7 (6.5–14.0) 5.6* (3.9–8.0) Never smokeless tobacco users who thought they might enjoy using smokeless tobacco14 9.3 (7.6–11.1) 11.9 (9.9–14.2) 7.0 (5.2–9.3) 1Smoked cigarettes or other type of tobacco any time in the preceding 30 days 2Smoked cigarettes any time during the preceding 30 days 3Smoked cigarettes on 20 or more days of the preceding 30 days 4Smoked tobacco other than cigarettes any time during the preceding 30 days 5Ever smoked cigarettes or other type of tobacco, even one or two puffs 6Ever smoked cigarettes, even one or two puffs 7Ever smoked tobacco other than cigarettes, even one or two puffs 8Used smokeless tobacco any time during the preceding 30 days 9Ever used smokeless tobacco 10Smoked cigarettes, smoked other type of tobacco, and/or used smokeless tobacco any time during the preceding 30 days 11Ever smoked tobacco and/or used smokeless tobacco 12Includes those who answered “definitely yes”, “probably yes” or “probably not” to using tobacco if one of their best friends offered it to them, or “definitely yes”, “probably yes” or “probably not” to using tobacco during the next 12 months. 13Those who answered “agree” or “strongly agree” to the statement: “I think I might enjoy smoking a cigarette.” 14Those who answered “agree” or “strongly agree” to the statement: “I think I might enjoy using smokeless tobacco.” *Gender comparisons are significant at p<0.05. Global Youth Tobacco Survey (GYTS) 12 Number of cigarettes smoked per day More than 40% of current cigarette smokers had more than 1 cigarette per day. The percentage of those who smoked less than 1 cigarette a day was 58.2 (see Table 3). Notably, around 47% of the girls who were current cigarette smokers had one cigarette or more daily. The corresponding figure for boys was around 40%. Table 3: Cigarettes smoked per day among current cigarette smokers of the age of 13–15 years, by sex (GYTS 2019) Number of cigarettes usually smoked Overall Boys Girls In % (95% CI) Less than 1 per day 58.2 (52.6–63.6) 60.1 (53.3–66.5) 52.8 (43.0–62.4) 1 per day 21.5 (17.4–26.2) 19.5 (15.0–24.9) 27.1 (20.6–34.8) 2 to 5 per day 17.8 (13.2–23.6) 17.8 (12.8–24.4) 18.0 (9.8–31.0) 6 to 10 per day 1.2 (0.4–3.5) 0.9 (0.2–3.9) 2.0 (0.5–8.4) 11 to 20 per day 1.3 (0.5–3.4) 1.7 (0.6–4.7) 0 More than 20 per day 0 0 0 Age at initiation of tobacco use Of the ever cigarette smokers, more than 4 out of 10 (44.3%) started smoking at the age of 12–13 years. Among those who had ever smoked cigarettes, 13.2% (13.4% boys and 12.7% girls) had tried their first cigarette before the age of 10 years. One in 20 ever cigarette smokers (5.2%) tried his/her first cigarette at the age of 7 years or younger, as shown in Table 4. Of the ever smokeless tobacco users, 45.1% first tried smokeless tobacco at the age of 12–13 years. Among the ever smokeless tobacco users, 13.7% (10.9% boys and 20.8% girls) had first tried smokeless tobacco before the age of 10 years. More than 1 in 15 ever smokeless tobacco users (7.0%) had tried smokeless tobacco at the age of 7 years or younger, as shown in Table 4. BHUTAN, 2019 13 Table 4: Percentage of ever tobacco users by age at initiation (GYTS 2019) Age at initiation of cigarette smoking Overall Boys Girls (95% CI) 7 years old or younger 5.2 (3.1–8.6) 5.6 (3.2–9.6) 4.2 (1.7–10.1) 8 or 9 years old 7.9 (5.7–1.0) 7.8 (5.3–11.3) 8.5 (4.7–14.9) 10 or 11 years old 17.4 (14.1–21.2) 20.1 (16.1–24.8) 9.8 (6.0–15.4) 12 or 13 years old 44.3 (40.1–48.6) 42.9 (37.7–48.3) 48.3 (39.2–57.4) 14 or 15 years old 25.0 (20.9–29.7) 23.6 (18.7–29.3) 28.8 (22.0–36.8) Age at initiation of smokeless tobacco use 7 years old or younger 7.0 (4.7–10.3) 4.5 (2.3–8.5) 13.3 (8.4–20.5) 8 or 9 years old 6.7 (4.8–9.4) 6.4 (3.7–11.0) 7.6 (3.7–14.8) 10 or 11 years old 16.3 (13.1–20.2) 17.7 (13.6–22.7) 13.0 (7.9–20.7) 12 or 13 years old 45.1 (39.7–50.6) 47.4 (40.5–54.5) 38.9 (30.7–47.7) 14 or 15 years old 24.6 (20.7–28.9) 23.6 (18.4–29.8) 27.3 (20.2–35.7) 3.2 Areca/betel nut use Key findings ¤ 48.9% of students currently consumed doma khamtog or meetha paan. ¤ 56.9% of students currently consumed areca nut or its products. Overall, 48.9% of students of the age of 13–15 years currently consumed doma khamtog or meetha paan. Notably, the prevalence of the consumption of doma khamtog or meetha paan was higher among boys (52.1%) than girls (45.9%) – gender comparison is significant at p<0.05. Overall, 64% of students (67.3% boys and 60.9% girls) were ever users of doma khamtog or meetha paan. As many as 56.9% of students of the age of 13–15 years currently consumed areca nut or its products, such as supari, saikila, wiz and guwa. It is to be noted that the prevalence of the consumption of areca nut or its products was higher among boys (62.5%) than girls (51.3%) – gender comparison is significant at p<0.05. As many as 67.7% students (73% boys and 62.6% girls) were ever users of arecanut or its products. Global Youth Tobacco Survey (GYTS) 14 3.3 Tobacco cessation Key findings ¤ More than 8 in 10 (80.7%) current tobacco smokers had tried to stop smoking in the preceding 12 months. ¤ More than 8 in 10 (84.1%) current tobacco smokers wanted to stop smoking now. ¤ More than 8 in 10 (83.0%) students who currently consumed smokeless tobacco had tried to stop using it in the preceding 12 months. ¤ Around 9 in 10 (87.1%) current smokeless tobacco users wanted to stop using these products now. Among the current tobacco smokers, 51.2% showed signs of smoking dependence. The figure was slightly higher in the case of girls (52.3%) than boys (51.1%). More than 8 in 10 (80.7%) students who currently smoked tobacco had tried to stop smoking in the preceding 12 months. Likewise, more than 8 in 10 (84.1%) current tobacco smokers wanted to stop smoking now. Notably, as many as 87.7% of the current tobacco smokers thought that they would be able to stop smoking if they wanted to (see Table 5). More than 8 in 10 (83.0%) students who currently consumed smokeless tobacco had tried to stop using it in the preceding 12 months. Also, around 9 in 10 (87.1%) of them wanted to stop using these products now. It is to be noted that as many as 84.9% of these students thought that they would be able to stop using smokeless tobacco if they wanted to (see Table 5). BHUTAN, 2019 15 Table 5: Indicators of tobacco cessation among current tobacco users of the age of 13–15 years, by sex (GYTS 2019) Indicators Overall Boys Girls In % (95% CI) Tried to stop smoking in the preceding 12 months 80.7 (75.6–84.9) 83.5 (75.5–89.3) 72.2 (61.3–81.0) Wanted to stop smoking now 84.1 (77.6–89.0) 84.2 (76.1–89.9) 84.0 (74.4–90.4) Thought they would be able to stop smoking if they wanted to 87.7 (81.5–92.1) 89.5 (83.0–93.7) 84.1 (74.0–90.8) Tried to stop using smokeless tobacco in the preceding 12 months 83.0 (78.3–86.8) 86.6 (80.5–91.0) 74.1 (64.5–81.9) Wanted to stop using smokeless tobacco now 87.1 (82.3–90.8) 88.3 (81.7–92.7) 84.6 (76.2–90.4) Thought they would be able to stop using smokeless tobacco if they wanted to 84.9 (78.0–89.8) 84.2 (75.6–90.2) 86.1 (78.6–91.2) 3.4 Exposure to SHS Key findings ¤ 17% of students were exposed to tobacco smoke at home. ¤ 36.6% of students were exposed to tobacco smoke inside enclosed public places. Seventeen per cent of the students were exposed to SHS at home (18.3% of boys and 15.9% of girls). More than 2 in 6 students (36.6%) were exposed to SHS in enclosed public places and 35.9% were exposed to SHS in outdoor public places. More than half of the students (55%) were exposed to SHS inside the school building or outside it, in the school premises (see Table 6). Boys were more likely to be exposed to SHS than girls at school and in indoor or outdoor public places. Global Youth Tobacco Survey (GYTS) 16 Table 6: Exposure to tobacco smoke among students of the age of 13–15 years, by sex (GYTS 2019) Indicators Overall Boys Girls In % (95% CI) Exposed to tobacco smoke at home1 17.0 (14.6–19.8) 18.3 (15.0–22.0) 15.9 (13.1–19.2) Exposed to tobacco smoke inside any enclosed public place1 36.6 (32.6–40.9) 39.8 (35.1–44.7) 33.5* (29.1–38.3) Exposed to tobacco smoke at any outdoor public place1 35.9 (31.8–40.3) 40.9 (36.1–45.8) 31.2* (26.8–35.9) Saw anyone smoking in the school building or outside in the school premises2 55.0 (50.3–59.7) 62.4 (56.5–68.0) 47.6* (43.2–52.0) 1 During the preceding 7 days 2 During the preceding 30 days *Gender comparisons are significant at p<0.05. 3.5 Access and availability Key findings ¤ 55% of students who currently smoked cigarettes bought them from a shop or a street vendor. ¤ Of those who currently smoked cigarettes and tried to buy them, 57.6% were not prevented from buying cigarettes despite their age. ¤ 52.4% of current smokeless tobacco users bought smokeless tobacco from a shop or a street vendor. ¤ Almost 6 out of 10 (59.3%) current smokeless tobacco users were not prevented from buying smokeless tobacco, despite being underage ¤ 85% of current tobacco users bought cigarettes or other tobacco products from within Bhutan. Table 7 shows the percentage distribution of current cigarette smokers by source of purchase of the last cigarette. Overall, more than half of these students BHUTAN, 2019 17 (55%; 57% boys and 49.6% girls) bought cigarettes from a store, shop or street vendor. Of the current cigarette smokers, 57.6% were not prevented from buying cigarettes, despite being underage. Girls (61.7%) were less likely to be prevented from purchasing cigarettes than boys (56.5%). Table 7: Access to cigarettes among current smokers of the age of 13–15 years, by sex (GYTS 2019) Indicators Overall Boys Girls In % (95% CI) Purchased from a store or shop1 48.9 (39.0–59.0) 51.8 (42.0–61.6) 41.0 (28.5–54.9) Purchased from a street vendor1 6.1 (4.1– 9.0) 5.1 (3.0–8.6) 8.6 (4.1–17.2) Got them from someone else1 39.2 (30.4–48.7) 36.6 (28.0–46.1) 46.1 (31.9–61.0) Got them some other way1 3.1 (1.3– 7.3) 3.9 (1.5–9.8) 1.0 (0.1–7.4) Obtained from other’s house1 2.7 (1.3–5.8) 2.5 (0.9–6.7) 3.3 (1.0–10.3) Not prevented to buy cigarettes despite their age2 57.6 (48.6–66.1) 56.5 (45.2 - 67.1) 61.7 (49.0–73.0) 1 Outlet from which current smokers last bought cigarettes in the preceding 30 days 2 Those who tried to buy cigarettes during the preceding 30 days Table 8 shows the percentage distribution of current smokeless tobacco users by source of purchase of the last smokeless tobacco product. Overall, more than half of these students (52.4%; 57% boys and 43.4% girls) bought smokeless tobacco from a shop or a street vendor. Of the current users, 59.3% were not prevented to buy smokeless tobacco, despite being underage. As in the case of cigarettes, girls (67.4%) were less likely to be prevented from purchasing smokeless tobacco products than boys (56.1%). Global Youth Tobacco Survey (GYTS) 18 Table 8: Access to smokeless tobacco products among current users of the age of 13–15 years, by sex (GYTS 2019) Indicators Overall Boys Girls In % (95% CI) Purchased from a shop or a street vendor1 52.4 (43.2–61.4) 57.0 (45.6–67.8) 43.4 (33.6–53.8) Not prevented to buy smokeless tobacco despite their age2 59.3 (50.1–67.9) 56.1 (46.5–65.3) 67.4 (51.8–80.0) 1 Outlet from which current users last bought smokeless tobacco in the preceding 30 days 2 Those who tried to buy smokeless tobacco during the preceding 30 days Table 9 shows the unit of purchase of cigarettes among current cigarette smokers. Of these, 37.5% purchased cigarettes in a pack, while more than half (51.8%) purchased individual cigarettes. Table 9: Unit of purchase of cigarettes among current smokers of the age of 13–15 years, by sex (GYTS 2019) Indicators1 Overall Boys Girls In % (95% CI) Individual sticks 51.8 (41.5–61.9) 52.0 (40.5–63.3) 50.5 (39.0–61.9) Packs 37.5 (28.2–47.8) 37.4 (26.5–49.6) 38.5 (27.8–50.3) Cartons 2.8 (1.1– 6.9) 4.1 (1.6–10.0) 0 Rolls 2.8 (1.1– 6.5) 0.9 (0.1– 6.5) 7.0 (2.5–18.1) Loose tobacco for hand-rolled cigarettes 5.1 (2.4–10.8) 5.7 (2.2–13.6) 4.1 (1.2–13.3) 1 Based on the last purchase during the preceding 30 days Alarmingly, 16.8% of the students (22% boys and 11.4% girls) were of the opinion that they could purchase tobacco products and/or cigarettes near their school. Only 15.5% (18% boys and 12.9% girls) felt that it would be “very difficult” for them to get tobacco products and/or cigarettes if they wanted some. The percentage (85.0; 83.8 boys and 88.0 girls) of current tobacco users who usually buy cigarettes BHUTAN, 2019 19 or other tobacco products from within Bhutan corroborates the general opinion expressed by the students. 3.6 Anti-tobacco messages and information Key findings ¤ Almost 7 in 10 (67.0%) students had noticed anti-tobacco messages in the media. ¤ 7 in 10 (69.5%) students were taught about the dangers of tobacco use in the preceding 12 months in school. ¤ More than 7 in 10 (72.7%) current smokers had noticed health warnings on cigarette packages. Table 10 shows the extent to which the students had noticed anti-tobacco messages in the media and at other events in the preceding 30 days. Overall, 67% had noticed such messages in the media in the preceding 30 days, while 56.9% of those who had attended sporting or community events in the preceding 30 days had noticed anti-tobacco information. About 7 in 10 students (69.5%) mentioned that they had been taught about the dangers of tobacco use in the preceding 12 months in school. Table 10: Exposure to anti-tobacco information among students of the age of 13–15 years, by sex (GYTS 2019) Indicators Overall Boys Girls In % (95% CI) Noticed anti-tobacco messages in the media in the preceding 30 days 67.0 (63.3–70.4) 66.7 (62.3–70.9) 67.3 (62.8–71.5) Noticed anti-tobacco messages at sporting or community events (among all students) 36.4 (33.5–39.4) 39.3 (35.2–43.7) 33.6 (31.1–36.1) Noticed anti-tobacco messages at sporting or community events (among those who had attended sporting or community events in the preceding 30 days) 56.9 (53.0–60.7) 58.2 (52.8–63.4) 55.7 (51.7–59.7) Global Youth Tobacco Survey (GYTS) 20 Indicators Overall Boys Girls In % (95% CI) Taught in school about the dangers of tobacco use in the preceding 12 months 69.5 (66.2–72.6) 67.7 (63.6–71.6) 71.1 (67.3–74.6) Table 11 provides details regarding students who had noticed health warnings on cigarette packages. Among the current smokers, more than 7 in 10 (72.7%) had noticed health warnings on cigarette packages and more than 2 in 5 (41.8%) had thought of quitting cigarettes because of the warnings. Nearly one-third of the never smokers (31.4%) thought they would not start smoking because of the health warnings. Table 11: Exposure to health warnings on cigarette packages among current and never smokers of the age of 13–15 years, by sex (GYTS 2019) Indicators1 Overall Boys Girls In % (95% CI) Current smokers who noticed health warnings on cigarette packages 72.7 (66.8–77.8) 73.3 (67.2–78.6) 71.8 (61.7–80.1) Current smokers who considered quitting because of health warnings on cigarette packages 41.8 (36.1–47.8) 42.8 (36.4–49.5) 39.7 (31.6–48.4) Current smokers who noticed health warnings and thought of quitting because of the warnings 57.6 (49.8–65.0) 58.4 (50.0–66.4) 55.3 (42.4–67.4) Never smokers who thought they would not start smoking because of health warnings on cigarette packages 31.4 (28.0–35.0) 34.4 (28.7–40.7) 28.8 (25.0–33.0) 1 In the preceding 30 days BHUTAN, 2019 21 3.7 Tobacco advertising and promotion Key findings ¤ More than 3 in 10 (31.7%) students noticed tobacco advertisements or promotions when visiting points of sale. ¤ More than 1 in 10 (10.9%) students owned something which bore the logo of a tobacco brand. ¤ More than 8 in 10 (84.1%) noticed someone using tobacco while watching television, videos or movies. Table 12 shows details regarding the students who had noticed tobacco marketing. Among those who had visited a point of sale in the preceding 30 days, 31.7% had noticed tobacco advertisements or promotions. Of those who had watched television, videos or movies in the preceding 30 days, 84.1% had noticed someone using tobacco on these media., Around 8 out of 100 (7.7%) students had been offered free tobacco products by representatives of tobacco companies. Table 12: Exposure to tobacco marketing and promotion among students of the age of 13–15 years, by sex (GYTS 2019) Indicators Overall Boys Girls In % (95% CI) Noticed tobacco advertisements or promotions at points of sale (among all students in the preceding 30 days) 23.1 (21.1–25.2) 24.1 (21.0–27.4) 22.2 (19.4–25.2) Noticed tobacco advertisements or promotions at points of sale (among those who visited a point of sale in the preceding 30 days) 31.7 (28.3–35.2) 32.5 (28.0–37.4) 30.7 (26.5–35.3) Global Youth Tobacco Survey (GYTS) 22 Indicators Overall Boys Girls In % (95% CI) Noticed someone using tobacco on television, videos or movies (among all students in the preceding 30 days) 72.5 (69.1–75.8) 72.6 (68.2–76.5) 72.6 (68.9–76.1) Noticed someone using tobacco on television, videos or movies (among those who watched television, videos or movies in the preceding 30 days) 84.1 (82.0–86.1) 83.3 (79.7–86.3) 85.0 (82.4–87.2) Ever offered a free tobacco product by a tobacco company representative 7.7 (6.4–9.4) 9.6 (7.4–12.2) 6.0* (4.2–8.3) Owned something with a tobacco brand logo on it 10.9 (9.5–12.6) 15.0 (12.3–18.3) 6.9* (5.4–8.6) Owned something with a tobacco brand logo on it or might in the future 27.1 (24.5–29.9) 31.3 (27.1–35.9) 24.1 (21.0–27.5) *Gender comparisons are significant at p<0.05. 3.8 Knowledge, attitudes, perceptions and behaviour Key findings ¤ More than 4 in 10 (42.9%) students definitely thought that it would be difficult to quit once one started smoking tobacco. ¤ More than 3 in 10 (32.3%) students definitely thought that it would be difficult to quit once one started using smokeless tobacco. ¤ 15.5% students felt that it would be “very difficult” for them to get tobacco products and/or cigarettes if they wanted some. ¤ 74% of students definitely thought tobacco smoking by others was harmful to them. BHUTAN, 2019 23 ¤ 76.8% of students favoured the prohibition of smoking inside enclosed public places. Table 13 shows the students’ level of knowledge and their attitude regarding smoking and tobacco use. Overall, 42.9% of them definitely thought that it would be difficult to quit once one started smoking tobacco, and 15.1% thought that smoking tobacco helped people feel more comfortable at celebrations, parties and social gatherings. More than 7 out of 10 students (74%) thought that tobacco smoking by other people was harmful to them and 77.2% were in favour of a ban on smoking at outdoor public places. Table 13: Attitudes to tobacco addiction, social smoking and SHS among students of the age of 13–15 years, by sex (GYTS 2019) Indicators Overall Boys Girls In % (95% CI) Definitely thought it would be difficult to quit once one started smoking tobacco 42.9 (39.9–45.9) 36.4 (33.0–40.0) 49.2* (44.2–54.3) Definitely thought it would be difficult to quit once one started using smokeless tobacco 32.3 (30.1–34.6) 29 (26.1–32.1) 35.7 (32.2–39.4) Felt they could purchase tobacco products/cigarettes near their school 16.8 (13.6–20.6) 22 (18–26.5) 11.4 (8.6–14.8) Felt it would be “very difficult” for them to get tobacco products and/or cigarettes if they wanted some 15.5 (13.7–17.5) 18 (15–21.3) 12.9 (10.9–15.2) Thought smoking tobacco helped people feel more comfortable at celebrations, parties and social gatherings 15.1 (13.3–17.1) 17.3 (14.8–20.2) 13.0* (10.8–15.5) Global Youth Tobacco Survey (GYTS) 24 Indicators Overall Boys Girls In % (95% CI) Definitely thought tobacco smoking by others was harmful to them 74.0 (71.2–76.6) 70.4 (67.0–73.7) 77.5* (73.8–80.9) Favoured a ban on smoking inside enclosed public places 76.8 (72.6–80.6) 73.7 (67.6–79.0) 79.9* (76.0–83.3) Favoured a ban on smoking in outdoor public places 77.2 (73.1–80.9) 73.1 (68.3–77.3) 81.1* (76.5–85.0) *Gender comparisons are significant at p<0.05. Of the current smokers, 16% usually smoked at home, while 14.6% usually smoked in school. Around 3 in every 10 (29.4%) usually smoked in a public place (see Table 14). Table 14: Usual place of smoking among current smokers of the age of 13–15 years, by sex (GYTS 2019) Place where they usually smoke Overall Boys Girls In % (95% CI) At home 16.0 (11.1–22.5) 14.9 (9.5–22.8) 19.0 (11.2–30.4) In school 14.6 (9–22.9) 16.1 (9.7–25.6) 10.8 (5.6–20) At work 6.0 (3.4–10.5) 6.9 (3.9–12) 3.8 (0.9–15) At a friend’s house 18.6 (14.1–24.1) 17.4 (11.9–24.6) 20.7 (13–31.2) During social events 15.4 (10.6–21.8) 16.4 (10.8–24) 13.0 (7.1–22.7) In a public place 29.4 (21.3–39) 28.3 (20.9–37.1) 32.7 (19.4–49.5) BHUTAN, 2019 25 4. TREND ANALYSIS (2009–2019) AND DISCUSSION 4.1 Discussion of survey findings Tobacco use The use of tobacco remains high among the youth in Bhutan, with more than one out of five students currently using tobacco products. The majority of tobacco users among the youth (25.4% boys and 9.5% girls) smoked tobacco, while a sizeable proportion (17% boys and 8.1% girls) consumed smokeless tobacco products. Notably, more girls were current users of smokeless tobacco (8.1%) than cigarette smokers (7.7%). The susceptibility of the youth to tobacco use is worrisome. To put things in perspective, 15.9% of students who never consumed tobacco were found to be susceptible to tobacco use in the future. Also, 7.3% never smokers (9.7% boys and 5.6% girls) thought they might enjoy smoking a cigarette and 9.3% never smokeless tobacco users (11.9% boys and 7.0% girls) thought they might enjoy using smokeless tobacco. The fact that a total of 13.2% students (13.4% boys and 12.7% girls) had tried their first cigarette before the age of 10 years should be an eye-opener for policy-makers and enforcement agencies alike. In the case of smokeless tobacco, the numbers are even more alarming – a total of 13.7% students (10.9% boys and 20.8% girls) had first tried smokeless tobacco before the age of 10 years. Areca/betel nut use This is the first time that the GYTS has captured the use of doma khamtog, meetha paan, and areca nut and related products. Unfortunately, the survey found that the consumption of these products is widespread among the youth and thus needs to be addressed on a priority basis. Nearly half (48.9%) of the students currently consume doma khamtog or meetha paan, and 57% currently consume areca nut or its various products. Global Youth Tobacco Survey (GYTS) 26 Tobacco cessation It is encouraging to note that more than 8 out of 10 current smokers wanted to stop smoking right away and around the same number had tried to quit smoking in the preceding 12 months. Similarly, around 9 in 10 (87.1%) current smokeless tobacco users wanted to stop using these products immediately and 83% had actually tried to stop using them in the preceding 12 months. Unfortunately, 87.7% of current tobacco smokers and 84.9% of current smokeless tobacco users thought that they would be able to stop using these products if they wanted to. Understandably, 51.2% of the current tobacco smokers showed signs of smoking dependence. Thus, there is a pressing need to provide quality services for tobacco cessation aimed specifically at the youth, addressing both smoking as well as smokeless tobacco addiction. Exposure to SHS The survey revealed that more than 1 in 3 students (36.6%) were exposed to SHS in enclosed public places and 35.9% were exposed to SHS in outdoor public places. In addition, more than half of the students (55%) were exposed to SHS inside the school building or outside, in the school premises. This indicates that regulations on smoke-free environment are not well implemented in Bhutan and the exposure of the youth to SHS remains a major concern. Interestingly, more than 7 out of 10 students (74%) thought that tobacco smoking by other people was harmful to them and 77.2% were in favour of a ban on smoking in outdoor public places. Access and availability The findings of the survey indicate that the youth has easy access to tobacco products. More than half of the smokers bought cigarettes from a shop or vendor. It is distressing to note that 57.6% of the current smokers were not prevented to buy cigarettes at a store, despite being underage. Interestingly, girls (61.7%) were less likely to be prevented from purchasing cigarettes than boys (56.5%). More than half of the current cigarette smokers (51.8%) were able to purchase individual cigarettes. Similarly, more than half of the current smokeless tobacco users (52.4%; 57% boys and 43.4% girls) bought smokeless tobacco from a shop or a street vendor. Of the current users, 59.3% were not prevented from buying smokeless tobacco, despite being underage. As in the case of cigarettes, girls (67.4%) were less likely to be prevented from purchasing smokeless tobacco than boys (56.1%). These findings BHUTAN, 2019 27 indicate that there are loopholes in law enforcement that make it easy for students to access tobacco products. Though the Tobacco Control Act, 2010 completely prohibits the cultivation, harvesting, manufacture, supply, distribution and sale of tobacco products and the Tobacco Control Rules and Regulations, 2013 specifically prohibits minors (those below the age of 18 years) from importing any tobacco or tobacco product, even for personal consumption, 16.8% of students (22% boys and 11.4% girls) were of the opinion that they could purchase cigarettes or other tobacco products near their school. Only 15.5% (18% boys and 12.9% girls) felt that it would be “very difficult” for them to obtain cigarettes or other tobacco products if they wanted some. The percentage of current tobacco users who usually bought cigarettes or other tobacco products from within Bhutan was as high as 85 (83.8 boys and 88 girls). These results, too, indicate that the enforcement of the extant laws on tobacco control needs to be bolstered. Anti-tobacco messages and information Bhutan has a number of effective anti-tobacco communication initiatives in place, as a result of which students have a high level of exposure to anti-tobacco messages. Moreover, most schools teach students about the harmful effects of smoking. In addition, health warnings on tobacco products appear to have had a strong impact. They have encouraged a good proportion of current smokers to think about quitting and have discouraged never smokers from starting. Tobacco advertising and promotion Aggressive tobacco advertisement and marketing are key deterrents to the control of tobacco use. The youth can easily be lured by tobacco promotion. The findings show that a sizeable proportion of students had noticed someone using tobacco in the media, and nearly 1 out of 3 students had noticed tobacco advertising or promotion at the point of sale. Moreover, a small proportion of students owned something bearing the logo of a tobacco brand. This indicates that despite legal interventions, tobacco companies manage to find mechanisms to reach out and market tobacco products to the youth. Knowledge, attitudes, perceptions and behaviour Overall, 15.1% of students were under the misconception that smoking tobacco helps people feel more comfortable at celebrations, parties and social gatherings. In all, 42.9% of students definitely thought that it would be difficult to quit once one Global Youth Tobacco Survey (GYTS) 28 started smoking tobacco and 32.3% definitely thought that it would be difficult to quit once one had started using smokeless tobacco. More than 7 out of 10 students (74%) thought that tobacco smoking by other people was harmful to them and 77.2% were in favour of a ban on smoking in outdoor public places. As many as 16% of current smokers usually smoked at home, while 14.6% usually smoked in school. Around 3 in every 10 current cigarette smokers (29.4%) usually smoked in a public place. 4.2 Comparison with previous rounds of GYTS (2009–2019) Tobacco use Figures 1 to 6 depict the trends in the prevalence of current use of various tobacco products among students of the age of 13–15 years, based on the GYTS of 2009, 2013 and 2019. Figure 1: Prevalence (%) of current tobacco use among students of the age of 13–15 years, by sex (GYTS 2009, 2013 and 2019) 18.8 27.6 11.6 30.3 39.0 23.222.2 31.2 13.5 0 5 10 15 20 25 30 35 40 45 Total Boys Girls GYTS 2009 GYTS 2013 GYTS 2019 BHUTAN, 2019 29 Figure 2: Trend in prevalence (%) of current tobacco use among students of the age of 13–15 years, by sex (GYTS 2009–2019) 18.8 30.3 22.2 27.6 39.0 31.2 11.6 23.2 13.5 0 5 10 15 20 25 30 35 40 45 GYTS 2009 GYTS 2013 GYTS 2019 Total Boys Girls The prevalence of current tobacco use among the youth has increased from 18.8% in 2009 to 22.2% in 2019. The relative increase in prevalence among boys was around 13% (from 27.6% in 2009 to 31.2% in 2019) and among girls was around 16% (from 11.6% in 2009 to 13.5% in 2019). On a positive note, the prevalence of current tobacco use decreased substantially during 2013–2019. Figure 3: Prevalence (%) of current cigarette smoking among students of the age of 13–15 years, by sex (GYTS 2009, 2013 and 2019) 12.4 18.3 7.9 14.0 23.1 6.6 14.7 22.2 7.7 0 5 10 15 20 25 Total Boys Girls GYTS 2009 GYTS 2013 GYTS 2019 Global Youth Tobacco Survey (GYTS) 30 Figure 4: Trend in prevalence (%) of current cigarette smoking among students of the age of 13–15 years, by sex (GYTS 2009–2019) 12.4 14.0 14.7 18.3 23.1 22.2 7.9 6.6 7.7 0 5 10 15 20 25 GYTS 2009 GYTS 2013 GYTS 2019 Total Boys Girls As is clear from Figures 3 and 4, the prevalence of current cigarette smoking has continuously increased from 2009 to 2019, a relative increase of around 13% during 2009–2013 (from 12.4% in 2009 to 14.0% in 2013) and a relative increase of 5% during 2013–2019 (from14.0% in 2013 to 14.7% in 2019). Figure 5: Prevalence (%) of current smokeless tobacco use among students of the age of 13–15 years, by sex (GYTS 2009, 2013 and 2019) 9.4 14.1 5.3 21.6 25.0 18.9 12.5 17.0 8.1 0 5 10 15 20 25 30 Total Boys Girls GYTS 2009 GYTS 2013 GYTS 2019 BHUTAN, 2019 31 Figure 6: Trend in prevalence (%) of current smokeless tobacco use among students of the age of 13–15 years, by sex (GYTS 2009–2019) 9.4 21.6 12.5 14.1 25.0 17.0 5.3 18.9 8.1 0 5 10 15 20 25 30 GYTS 2009 GYTS 2013 GYTS 2019 Total Boys Girls Figures 5 and 6 show that the prevalence of current smokeless tobacco use among the youth increased drastically during 2009–2013, but decreased during 2013–2019. However, the prevalence increased from 9.4% in 2009 to 12.5% in 2019 – a staggering relative increase of around 33%. Susceptibility to tobacco use remains a serious concern in Bhutan. As compared to 6.7% never smokers in 2013, 7.3% never smokers (9.7% boys and 5.6% girls) in 2019 thought they might enjoy smoking a cigarette, a relative increase of around 9% over the period. Tobacco cessation Figure 7: Percentage of current tobacco smokers among students of the age of 13–15 years who tried to stop smoking in the preceding 12 months, by sex (GYTS 2009, 2013 and 2019) 84.1 83.2 84.283.1 82.1 85.8 80.7 83.5 72.2 65 70 75 80 85 90 Total Boys Girls GYTS 2009 GYTS 2013 GYTS 2019 Global Youth Tobacco Survey (GYTS) 32 Figure 8: Trend in prevalence (%) of tobacco smoking among students of the age of 13–15 years who tried to stop smoking in the preceding 12 months, by sex (GYTS 2009–2019) 84.1 83.1 80.783.2 82.1 83.5 84.2 85.8 72.2 65 70 75 80 85 90 GYTS 2009 GYTS 2013 GYTS 2019 Total Boys Girls Figures 7 to 10 depict the trends in tobacco cessation behaviours and related determinants among students of the age of 13–15 years, based on the GYTS of 2009, 2013 and 2019. The data for 2009 and 2013 relate to current cigarette smokers, while those for 2019 relate to current tobacco smokers. Figure 9: Prevalence (%) of tobacco smoking among students of the age of 13–15 years who want to stop smoking now, by sex (GYTS 2009, 2013 and 2019) 79.1 79.5 76.9 81.8 87.4 65.9 84.1 84.2 84.0 0 10 20 30 40 50 60 70 80 90 100 Total Boys Girls GYTS 2009 GYTS 2013 GYTS 2019 BHUTAN, 2019 33 Figure 10: Prevalence (%) of tobacco smoking among students of the age of 13–15 years who thought they would be able to quit if they wanted to, by sex (GYTS 2009, 2013 and 2019) 77.1 76.4 75.8 83.8 87.3 74.0 87.7 89.5 84.1 0 10 20 30 40 50 60 70 80 90 100 Total Boys Girls GYTS 2009 GYTS 2013 GYTS 2019 As these figures depict, there is a strong need for quality tobacco cessation services for current tobacco/cigarette smokers. Some 8 to 9 smokers out of 10 – girls and boys alike – would potentially benefit from such services. The fact that an astronomical proportion of current tobacco smokers wrongly think that they would be able to stop smoking if they wanted to further underscores the need for quality tobacco cessation services, specifically targeting the youth and preferably in school settings. Exposure to SHS Figure 11: Prevalence (%) of exposure to tobacco smoke at home during the preceding 7 days among students of the age of 13–15 years, by sex (GYTS 2009, 2013 and 2019) 29.5 29.2 29.5 15.3 16.3 14.4 17.0 18.3 15.9 0 5 10 15 20 25 30 35 Total Boys Girls GYTS 2009 GYTS 2013 GYTS 2019 Global Youth Tobacco Survey (GYTS) 34 Figure 12: Prevalence (%) of exposure to tobacco smoke in any enclosed public place during the preceding 7 days among students of the age of 13–15 years, by sex (GYTS 2009, 2013 and 2019) 59.4 58.6 59.7 42.8 43.0 42.7 36.6 39.8 33.5 0 10 20 30 40 50 60 70 Total Boys Girls GYTS 2009 GYTS 2013 GYTS 2019 Figures 11 and 12 depict the trend in the prevalence of exposure to SHS among the youth in Bhutan, on the basis of the GYTS of 2009, 2013 and 2019. It is encouraging to note that exposure to SHS has consistently decreased over the last 10 years. However, as of 2019, more than 1 in 3 students (36.6%) continue to be exposed to SHS in enclosed public places. Therefore, exposure of the youth to SHS remains a major concern and strict enforcement of the extant regulations on a smoke-free environment may be the best way forward for the country. Access and availability Figure 13: Percentage of current cigarette smokers among students of the age of 13–15 years who bought from a shop or street vendor, by sex (GYTS 2009, 2013 and 2019) 23.7 28.5 17.2 54.5 58.0 45.3 55.0 57.0 49.6 0 10 20 30 40 50 60 70 Total Boys Girls GYTS 2009 GYTS 2013 GYTS 2019 BHUTAN, 2019 35 Figures 13 and 14 depict the trend in the prevalence of buying cigarettes from shops or street vendors among current cigarette smokers on the basis of the GYTS of 2009, 2013 and 2019. It is worrisome to note that more than half of the current cigarette smokers buy cigarettes freely from shops. Figure 15 corroborates this trend, showing that around half of the current cigarette smokers who had tried to buy cigarettes during the preceding 30 days were not prevented from buying them, despite their age. Figure 14: Trend in prevalence (%) of buying from a shop or street vendor among students of the age 13–15 years who currently smoke, by sex (GYTS (2009–2019) 23.7 54.5 55.0 28.5 58.0 57.0 17.2 45.3 49.6 0 10 20 30 40 50 60 70 GYTS 2009 GYTS 2013 GYTS 2019 Total Boys Girls Figure 15: Percentage of current cigarette smokers* of the age of 13–15 years who were not prevented from buying cigarettes despite their age, by sex (GYTS 2009, 2013 and 2019) 53.4 48.3 64.3 47.8 47.4 48.7 57.6 56.5 61.7 0 10 20 30 40 50 60 70 Total Boys Girls GYTS 2009 GYTS 2013 GYTS 2019 *Among those who tried to buy cigarettes during the preceding 30 days Global Youth Tobacco Survey (GYTS) 36 Tobacco advertising and promotion Figures 16 to 18 depict the trend in indicators and determinants related to tobacco advertisement and promotion vis-à-vis students of the age of 13–15 years, on the basis of the GYTS of 2009, 2013 and 2019. Though the depiction of tobacco products on television, videos or movies has decreased over the last decade, it remains an ill that affects public health, with 84.1% of the youth being exposed to such depiction. Figure 16: Percentage of students of the age of 13–15 years who noticed someone using tobacco on television, videos or movies (among those who watched television, videos or movies in the past 30 days) in the preceding 30 days, by sex (GYTS 2009, 2013 and 2019) 98.4 98.9 98.2 79.8 79.0 80.5 84.1 83.3 85.0 0 20 40 60 80 100 120 Total Boys Girls GYTS 2009 GYTS 2013 GYTS 2019 The prevalence of the possession of something bearing the logo of a tobacco brand decreased from 14.9% in 2009 to 10.9% in 2019 – a relative decrease of around 27%. However, TAPS remains a major threat to effective tobacco control in Bhutan. BHUTAN, 2019 37 Figure 17: Percentage of students of the age of 13–15 years who owned something with a tobacco brand logo on it, by sex (GYTS 2009, 2013 and 2019) 14.9 17.7 12.5 14.0 18.6 10.210.9 15.0 6.9 0 2 4 6 8 10 12 14 16 18 20 Total Boys Girls GYTS 2009 GYTS 2013 GYTS 2019 Figure 18: Trend in prevalence of owning something with a tobacco brand logo on it among students of the age of 13–15 years, by sex (GYTS 2009–2019) 14.9 14.0 10.9 17.7 18.6 15.0 12.5 10.2 6.9 0 2 4 6 8 10 12 14 16 18 20 GYTS 2009 GYTS 2013 GYTS 2019 Total Boys Girls Anti-tobacco messages and information The trend analysis suggests that the proportion of the youth who noticed tobacco control messages in the media or at sporting and community events decreased substantially over the period 2009–2019. There was a relative decrease of around 23% (from 86.9% in 2009 to 67% in 2019) in the proportion of students who noticed anti-tobacco messages in the media in the preceding 30 days. Similarly, there was a relative decrease of around 31% (from 83.1% in 2009 to 56.9% in 2019) in the proportion of students who noticed anti-tobacco messages at sporting or community events in the preceding 30 days. This is worrisome, particularly in the light of the fact that the prevalence of current tobacco use among the youth increased from 18.8% in 2009 to 22.2% in 2019 – a relative increase of more than 18%. Global Youth Tobacco Survey (GYTS) 38 Figure 19: Percentage of students of the age of 13–15 years who had noticed anti-tobacco messages in the media in the preceding 30 days, by sex (GYTS 2009, 2013 and 2019) 86.9 85.2 88.3 74.0 72.7 75.1 67.0 66.7 67.3 0 10 20 30 40 50 60 70 80 90 100 Total Boys Girls GYTS 2009 GYTS 2013 GYTS 2019 Figure 20: Percentage of students* of the age of 13–15 years who noticed anti-tobacco messages at sporting or community events (*among those who attended sporting or community events) in the preceding 30 days, by sex (GYTS 2009, 2013 and 2019) 83.1 84.4 82.1 59.3 56.8 61.6 56.9 58.2 55.7 0 10 20 30 40 50 60 70 80 90 Total Boys Girls GYTS 2009 GYTS 2013 GYTS 2019 Knowledge, attitudes, perceptions and behaviour Figures 21 to 25 depict the trend in indicators and determinants related to knowledge, attitudes, perceptions and behaviour with respect to tobacco use among students of the age of 13–15 years, on the basis of the GYTS of 2009, 2013 and 2019. The percentage of students who had been taught in school about the dangers of tobacco use in the preceding 12 months increased from 61.6 in 2009 to 69.5 in 2019. The trend in the percentage of students who definitely thought that tobacco smoking BHUTAN, 2019 39 by others is harmful to them is inconsistent. It increased from 72.8% in 2009 to 78.9% in 2013, but plummeted to 74% in 2019. The percentage of students who favour a ban on smoking inside enclosed public places increased consistently over the decade, from 44.1 in 2009 to 76.8 in 2019 – a mammoth relative increase of more than 74%. Figure 21: Percentage of students of the age of 13–15 years who were taught in school about the dangers of tobacco use in the preceding 12 months, by sex (GYTS 2009, 2013 and 2019) 61.6 63.8 60.960.8 60.8 60.7 69.5 67.7 71.1 54 56 58 60 62 64 66 68 70 72 Total Boys Girls GYTS 2009 GYTS 2013 GYTS 2019 Figure 22: Trend in prevalence of being taught in school about the dangers of tobacco use in the preceding 12 months among students of the age of 13–15 years, by sex (GYTS 2009–2019) 61.6 60.8 69.5 63.8 60.8 67.7 60.9 60.7 71.1 54 56 58 60 62 64 66 68 70 72 GYTS 2009 GYTS 2013 GYTS 2019 Total Boys Girls Global Youth Tobacco Survey (GYTS) 40 Figure 23: Percentage of students of the age of 13–15 years who definitely thought that tobacco smoking by others is harmful to them, by sex (GYTS 2009, 2013 and 2019) 72.8 73.5 72.4 78.9 78.5 79.2 74.0 70.4 77.5 66 68 70 72 74 76 78 80 Total Boys Girls GYTS 2009 GYTS 2013 GYTS 2019 Figure 24: Trend in prevalence of definite opinion that tobacco smoking by others harms one among students of the age of 13–15 years. by sex (GYTS 2009–2019) 72.8 78.9 74.0 73.5 78.5 70.4 72.4 79.2 77.5 66 68 70 72 74 76 78 80 GYTS 2009 GYTS 2013 GYTS 2019 Total Boys Girls BHUTAN, 2019 41 Figure 25: Percentage of students of the age of 13–15 years who favoured a ban on smoking inside enclosed public places, by sex (GYTS 2009, 2013 and 2019) 44.1 45.4 42.9 49.1 50.5 48.0 76.8 73.7 79.9 0 10 20 30 40 50 60 70 80 90 Total Boys Girls GYTS 2009 GYTS 2013 GYTS 2019 4.3 Relevance to the FCTC The results of the GYTS strategically inform the implementation of the relevant provisions of the WHO FCTC and the MPOWER measures. Monitor tobacco use Bhutan has been consistently monitoring the prevalence of tobacco use and assessing the progress towards tobacco control among the youth by conducting GYTS at regular intervals (2004, 2006, 2009, 2013, and 2019). The survey conducted in 2019 examined the use of doma khamtog, meetha paan, and areca nut and its products for the first time. It also included questions on smokeless tobacco products for the first time to get a picture of the nature and drivers of the ongoing smokeless tobacco epidemic. The trend analysis depicts that, despite strong laws, the susceptibility of the youth to tobacco use continues to be a serious concern. The majority of the tobacco users smoked tobacco, though a sizeable proportion (around 17% boys and 8% girls) consumed smokeless tobacco products. The prevalence of current tobacco use among the youth increased from 18.8% in 2009 to 22.2% in 2019, though it decreased substantially from 30.3% in 2013 to 22.2% in 2019. The prevalence of current smokeless tobacco use increased drastically during 2009–2013, but decreased during 2013–2019. However, the overall prevalence of smokeless tobacco use among students increased from 9.4% in 2009 to 12.5% in 2019, a relative increase of around 33%. As of 2019, current use of smokeless tobacco was higher than that Global Youth Tobacco Survey (GYTS) 42 of smoking cigarettes among girls. The use of smokeless tobacco should be an area of immediate concern for policy-makers. According to the GYTS 2019, among ever cigarette smokers, more than 4 out of 10 (44.3%) had their first cigarette between the ages of 12 and13 years, while among ever smokeless tobacco users, 45.1% first tried smokeless tobacco at the age of 12–13 years. As compared to 6.7% never smokers in 2013, 7.3% never smokers (9.7% boys and 5.6% girls) in 2019 thought they might enjoy smoking. The consumption of areca nut products is even more widespread than the use of tobacco and thus needs to be addressed on priority. At the time of the survey, 48.9% of students were current consumers of doma khamtog or meetha paan and 56.9% used areca nut or products containing it. Protect people from tobacco smoke Owing to the sustained efforts and commitment of the Government, the exposure of the youth to SHS has consistently decreased over the last 10 years. However, as of 2019, 36.6% of students were exposed to SHS in enclosed public places and 35.9% at outdoor public places. More than half of the students (55%) saw people smoking inside the school building or in the school premises. Thus, a more rigorous enforcement of the extant regulations is necessary to protect the youth from SHS. Offer help to quit tobacco use The GYTS 2019 shows that the majority of students who currently use tobacco are interested in quitting. In fact, the trend analysis suggests that there has always been a strong and consistent need for quality services for tobacco cessation for current tobacco/cigarette smokers in Bhutan. Almost 8 to 9 smokers out of every 10, girls and boys alike, would potentially benefit from such services. The fact that an astronomical proportion of current tobacco smokers and current smokeless tobacco users wrongly think that they would be able to stop using these tobacco products if they wanted to confounds the situation. Treatment guidelines for tobacco dependence have been framed in Bhutan. A national toll-free quit line is available. However, tobacco cessation services at the population level, particularly those aimed at the youth, need to be strengthened across the country. Nicotine replacement therapy should be made available in the public health system. A national strategy for tobacco cessation ought to be put in place. The national toll-free quit line number should be included in all tobacco control campaigns. BHUTAN, 2019 43 Warn about the dangers of tobacco As per this survey, almost 7 in 10 (67.0%) students had noticed anti-tobacco messages in the media; around 7 in 10 (69.5%) had been taught in school about the dangers of tobacco use in the preceding 12 months; and more than 7 in 10 (72.7%) current smokers had noticed health warnings on cigarette packages. However, the trend analysis presents a different picture. The percentage of the youth who had noticed tobacco control messages in the media or at sporting and community events decreased substantially over the period 2009–2019. There was a relative decrease of around 23% (from 86.9% in 2009 to 67% in 2019) in the proportion of those who noticed anti-tobacco messages in the media in the preceding 30 days. Similarly, there was a relative decrease of around 31% (from 83.1% in 2009 to 56.9% in 2019) in the proportion of students who had noticed anti-tobacco messages at sporting or community events in the preceding 30 days. This is worrisome, particularly in the light of the fact that the prevalence of current tobacco use among the youth increased from 18.8% in 2009 to 22.2% in 2019 – a relative increase of more than 18%. It is imperative to conduct and sustain effective national mass media campaigns on tobacco control, primarily aimed at the youth. Enforce bans on tobacco advertising, promotion and sponsorship The GYTS data indicate that the exposure of students to TAPS is high. Of the students who had visited a point of sale in the preceding 30 days, 31.7% had noticed tobacco advertisements or promotions. Of those who had watched television, videos or movies in the preceding 30 days, 84.1% had noticed someone using tobacco on these media. Around 8 out of 100 students (7.7%) had been offered free tobacco products by representatives of tobacco companies. This problem can be alleviated through robust implementation of tobacco control laws pertaining to the ban on TAPS ban. There ought to be zero tolerance of any type of promotion – direct or indirect – by the tobacco industry. On the policy front, with respect to the WHO report on the global tobacco epidemic 2019, Bhutan is only one provision away from a complete ban on advertising and needs to ban only brand-stretching. (The latter occurs when a tobacco brand name, emblem, trademark, logo or trade insignia or any other distinctive feature [including distinctive colour combinations] is connected with a non-tobacco product or service in such a way that the tobacco product and the non-tobacco product or service are likely to be associated). Global Youth Tobacco Survey (GYTS) 44 Supply-side issues Despite the Tobacco Control Act of Bhutan 2010 and the Tobacco Control Rules and Regulations 2013, this survey shows that illicit tobacco products are easily available and accessible to the youth. To put things in perspective, the GYTS 2019 shows that 16.8% of the students who participated in the survey (22% boys and 11.4% girls) were of the opinion that they could purchase tobacco products, including cigarettes, near their school. Further, only 15.5% (18% boys and 12.9% girls) felt that it would be “very difficult” for them to get tobacco products, including cigarettes, if they wanted some. Notably, despite the blanket ban, the percentage of current tobacco users who usually bought cigarettes or other tobacco products from within Bhutan was as high as 85% (83.8% boys and 88% girls). More than half of those who were current cigarette smokers and current smokeless tobacco users bought these tobacco products from a shop or a street vendor. As many as 57.6% of the current cigarette smokers and 59.3% of the current smokeless tobacco users were not prevented from buying these tobacco products, despite being underage. In the case of both cigarette smokers and smokeless tobacco users, girls were less likely to be prevented from purchasing tobacco products than boys. Thus, there is a pressing need to effectively implement the relevant provisions of the national tobacco control law. 4.4 Relevance to the country The GYTS provides an excellent basis for monitoring and guiding the implementation of tobacco control interventions, specifically those aimed at the youth. At the same time, it aligns them with the relevant provisions and implementation guidelines of the FCTC. The results of this survey ought to be widely disseminated and, ideally, leveraged to adopt and implement effective legislative, policy, regulatory and administrative measures for preventing and reducing tobacco consumption, nicotine addiction and exposure to tobacco smoke among the youth. Many of the students who participated in this survey wanted to quit tobacco use. As mentioned earlier, more than 8 in 10 (84.1%) students who currently smoke tobacco wanted to quit now and around 9 in 10 (87.1%) current smokeless tobacco users wanted to stop using these products right away. However, school health coordinators and teachers in Bhutan are not adequately trained in tobacco cessation counselling and related aspects. Also, there is a dearth of quality cessation services BHUTAN, 2019 45 at the population level that are specifically targeted at the youth. The provision of comprehensive quality cessation services for smokers as well as smokeless tobacco users, preferably in school settings, should be taken up on priority. The evidence emerging from this report suggests that initiation of tobacco use begins at an early age in most cases. Among ever cigarette smokers, more than 4 out of 10 (44.3%) initiated smoking at the age of 12–13 years. The corresponding figure for ever smokeless tobacco users was 45.1%. Thus, effective measures for tobacco control need to be instituted in school settings. It is immensely encouraging that about 7 in 10 students (69.5%) had been taught in school about the dangers of tobacco use in the preceding 12 months. However, a more holistic and institutionalized approach, encompassing both supply- and demand-side issues (described in the preceding section of this chapter), may be the need of the hour. Global Youth Tobacco Survey (GYTS) 46 5. CONCLUSION & RECOMMENDATIONS Nearly one-and-a-half decades after Bhutan ratified the WHO FCTC on 23 August 2004 and almost a decade since the country completely prohibited the cultivation, harvesting, manufacture, supply, distribution and sale of tobacco products through the Tobacco Control Act of Bhutan 2010, the prevalence of tobacco use among the youth remains high across the country. Based on the findings of the GYTS 2019, some of the high-impact and achievable action points for effective tobacco control among the youth to realize the dream of a truly tobacco-free Bhutan are delineated below. ¤ No ground for complacency: The Royal Government of Bhutan demonstrated exemplary political will to control the tobacco epidemic by completely prohibiting all tobacco products under the Tobacco Control Act of Bhutan 2010. However, the prevalence of current tobacco use among youth in the country has increased from 18.8% in 2009 to 22.2% in 2019. Thus, enhanced, effective and sustained implementation of the relevant provisions of the WHO FCTC and national tobacco control laws, encompassing demand- as well as supply-side tobacco control measures, is as relevant to Bhutan as to any other country in the world. ¤ Go holistic: It is imperative for Bhutan to comprehend the issue of tobacco consumption in the national context and thereafter, take holistic and all- inclusive measures to mitigate tobacco use among the youth. Apart from tobacco smoking, the use of smokeless tobacco products by the youth should be a matter of utmost concern for the country. The overall prevalence of smokeless tobacco use among students increased from 9.4% in 2009 to 12.5% in 2019 – a staggering relative increase of around 33% in ten years. It is high time to consider the youth as the prime target audience and roll out customized tobacco control measures tailored to suit the specific needs of the tobacco-susceptible youth and children. Also, girls are as important stakeholders as boys in the fight against tobacco. In fact, the relative increase in the prevalence of current tobacco use during the period 2009–2019 was higher among girls (around 16%) than among boys (around 13%). BHUTAN, 2019 47 ¤ Do not overlook supply-side issues: Though Bhutan is not a tobacco cultivator, supply-side issues are very important. Illicit tobacco products are available and accessible to the youth. Despite the blanket ban, the percentage of current tobacco users who bought cigarettes or other tobacco products from within Bhutan was as high as 85. Bhutan should ratify the WHO FCTC Protocol to Eliminate Illicit Trade in Tobacco Products at the earliest as illicit tobacco trade is of immense significance for effective tobacco control. Also, the implementation of the relevant provisions of the national tobacco control law ought to be bolstered to deny the youth access to tobacco products. ¤ Target doma khamtog and areca nut use: The GYTS 2019 found that nearly half (48.9%) of the students currently consume doma khamtog or meetha paan and 56.9% currently consume areca nut or its products. Betel nut has been independently classified as a Group 1 carcinogen (one that induces cancer in human beings) by the IARC. Thus, measures need to be taken to discourage the use of betel nut, even without tobacco. Strategies need to be adopted to promote behavioural change among the youth to discourage the use of betel nut. Education and information campaigns regarding the dangers of betel nut (particularly the link to cancer and addictiveness) that target the youth and children could be game changers. The idea should be to “de-normalize” the use of betel nut (and its derivatives such as paan masala and meetha paan) by addressing the popular misconception that it is less harmful than tobacco products. ¤ Prioritize availability and implementation of efficient and quality tobacco cessation services: As per the survey, more than 8 out of 10 of the youth would be potentially benefited by quality tobacco cessation services for smokeless tobacco users and tobacco smokers. The fact that an astronomical proportion of current tobacco smokers (87.7%) and smokeless tobacco users (84.9%) are under the misconception that they would be able to stop using these products if they wanted to further underscores the need to address this issue. Tobacco cessation services, particularly those aimed at the youth at the population level, need to be strengthened across Bhutan. Nicotine replacement therapy should be made available in the public health system. A national tobacco cessation strategy ought to be in place. The national toll-free quit line number should be included in all tobacco control campaigns. Emerging technologies such as mTobaccoCessation should be leveraged. Quality counselling services and brief advice should be made available in school settings by training school health counsellors and integrating the services with primary health care and the implementation of the WHO PEN package. Global Youth Tobacco Survey (GYTS) 48 ¤ Maximize implementation of TAPS ban: Robust implementation of the tobacco control laws pertaining to the TAPS ban should be prioritized. There ought to be zero tolerance of any type of promotion – direct or indirect – by the tobacco industry. On the policy front, brand-stretching should be banned for the highest level of achievement in the context of the TAPS ban in the biennial WHO report on the global tobacco epidemic. ¤ Renew efforts to communicate tobacco health risks among youth: The trend analysis suggests that over the period 2009-2019, there is a relative decrease of around 23% in the proportion of students who noticed anti-tobacco messages in the media in the preceding 30 days and a relative decrease of around 31% in the proportion of students who noticed anti- tobacco messages at sporting or community events in the preceding 30 days. Thus, it is imperative to conduct and sustain effective tobacco control mass media campaigns at the national level aimed at the youth. ¤ Promote multistakeholder approach: Engage all stakeholders (all health and relevant non-health government departments, nongovernment organizations, academia, and the community including students, teachers and parents) in framing and implementing effective legislative, policy, regulatory and administrative tobacco control measures for preventing and reducing tobacco consumption, nicotine addiction and exposure to tobacco smoke among the youth. BHUTAN, 2019 49 BIBLIOGRAPHY 1. Ahluwalia IB, Arrazola RA, Zhao L, Shi J, Dean A, Rainey E et al. (2019). Tobacco Use and Tobacco-Related Behaviors-11 Countries, 2008-2017. MMWR Morb Mortal Wkly Rep. 68(41):928-933. doi: 10.15585/mmwr.mm6841a1. 2. Gurung MS, Pelzom D, Dorji T, Drukpa W, Wangdi C, Chinnakali P et al. (2016). 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Rinchen S, Taneepanichskul S, Dawa N. (2018). Prevalence and predictors of tobacco use among Bhutanese adolescents. Journal of Health Research, Vol. 32 No. 4, pp. 288–97. https://doi.org/10.1108/JHR-05-2018-031. 7. World Bank. (2019). The World Bank in Bhutan (https://www.worldbank.org/en/ country/bhutan/overview; accessed 27 November 2019). 8. World Health Organization. Regional Office for South-East Asia. (2010). Global Youth Tobacco Survey (GYTS): Bhutan Factsheet, 2009. New Delhi: WHO-SEARO, 2010 9. World Health Organization. Regional Office for South-East Asia. (2015). Global Youth Tobacco Survey (GYTS): Bhutan report, 2013. New Delhi: WHO-SEARO, 2015 10. World Health Organization. Regional Office for South-East Asia. (2018). Implementation of WHO MPOWER package in the South-East Asia Region: a progress report. World Health Organization Regional Office for South-East Asia. (https://apps.who.int/iris/handle/10665/274278, accessed 27 May 2020). 11. World Health Organization. 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BHUTAN, 2019 51 ANNEXURE ONE Global Youth Tobacco Survey (GYTS) 52 BHUTAN, 2019 53 Global Youth Tobacco Survey (GYTS) 54 BHUTAN, 2019 55 Global Youth Tobacco Survey (GYTS) 56 BHUTAN, 2019 57 Global Youth Tobacco Survey (GYTS) 58 BHUTAN, 2019 59 Global Youth Tobacco Survey (GYTS) 60 BHUTAN, 2019 61 Global Youth Tobacco Survey (GYTS) 62 BHUTAN, 2019 63 Global Youth Tobacco Survey (GYTS) 64 BHUTAN, 2019 65 ANNEXURE TWO GYTS 2019 indicators Core GYTS indicators This annexure contains a detailed description of the core GYTS indicators, including those provided in the GYTS factsheet and the GYTS country report. The GYTS factsheet is intended to provide an overview of the key findings and highlights of the survey for a broad audience. The GYTS country report assists in making a more detailed examination of the core indicators and other findings, and in describing the results in the context of each country’s unique tobacco control environment. Tobacco use Ever tobacco smokers Indicator: Percentage of youth who ever smoked any tobacco product Numerator: Number of respondents who ever smoked cigarettes or other type of tobacco, even one or two puffs Denominator: Total number of respondents Ever cigarette smokers Indicator: Percentage of youth who ever smoked cigarettes Numerator: Number of respondents who ever smoked cigarettes, even one or two puffs Denominator: Total number of respondents Global Youth Tobacco Survey (GYTS) 66 Ever smokers of other tobacco Indicator: Percentage of youth who ever smoked tobacco other than cigarettes Numerator: Number of respondents who ever smoked tobacco other than cigarettes, even one or two puffs Denominator: Total number of respondents Ever smokeless tobacco users Indicator: Percentage of youth who ever used smokeless tobacco Numerator: Number of respondents who ever used (tried or experimented with) smokeless tobacco Denominator: Total number of respondents Ever tobacco users Indicator: Percentage of youth who ever used any tobacco product Numerator: Number of respondents who ever smoked tobacco and/or used smokeless tobacco Denominator: Total number of respondents Current tobacco smokers Indicator: Percentage of youth who currently smoke any tobacco product Numerator: Number of respondents who smoked cigarettes or other type of tobacco any time during the preceding 30 days Denominator: Total number of respondents Current cigarette smokers Indicator: Percentage of youth who currently smoke cigarettes Numerator: Number of respondents who smoked cigarettes any time during the preceding 30 days Denominator: Total number of respondents BHUTAN, 2019 67 Frequent cigarette smokers Indicator: Percentage of youth who smoked cigarettes on 20 or more days in the preceding 30 days Numerator: Number of respondents who smoked cigarettes on 20 or more days in the preceding 30 days Denominator: Total number of respondents Current smokers of other tobacco Indicator: Percentage of youth who currently smoke tobacco other than cigarettes Numerator: Number of respondents who smoked tobacco other than cigarettes any time in the preceding 30 days Denominator: Total number of respondents Current smokeless tobacco users Indicator: Percentage of youth who currently use smokeless tobacco Numerator: Number of respondents who used smokeless tobacco any time in the preceding 30 days Denominator: Total number of respondents Current tobacco users Indicator: Percentage of youth who currently use any tobacco product Numerator: Number of respondents who smoked cigarettes, smoked other type of tobacco, and/or used smokeless tobacco any time in the preceding 30 days Denominator: Total number of respondents Susceptibility to future tobacco use Indicator: Percentage of never tobacco users susceptible to tobacco use in the future Numerator: Number of respondents who never used any tobacco product, and who answered: 1) ”Definitely yes”, ”Probably yes” or ”Probably not” to using tobacco if one of their best friends offered it to them, or 2) ”Definitely yes”, ”Probably yes” or ”Probably not” to using tobacco during the next 12 months Denominator: Number of never tobacco users Global Youth Tobacco Survey (GYTS) 68 Susceptibility to cigarette smoking Indicator: Percentage of never smokers who think they might enjoy smoking a cigarette Numerator: Number of respondents who have never smoked tobacco and who strongly agree or agree with the statement, “I think I might enjoy smoking a cigarette.” Denominator: Number of never smokers Susceptibility to smokeless tobacco use Indicator: Percentage of never smokeless users who think they might enjoy using smokeless tobacco Numerator: Number of respondents who have never used smokeless tobacco and who strongly agree with the statement, “I think I might enjoy using smokeless tobacco.” Denominator: Number of never smokeless users Number of cigarettes smoked per day Indicator: Percentage of current cigarette smokers who usually smoke less than 1, 1, 2 to 5, 6 to 10, 11 to 20, or more than 20 cigarettes a day, on the days that they smoke Numerator: Number of current cigarette smokers who reported that they usually smoked less than 1, 1, 2 to 5, 6 to 10, 11 to 20, or more than 20 cigarettes a day on the days that they had smoked in the preceding 30 days Denominator: Number of current cigarette smokers Age at initiation of cigarette smoking Indicator: Percentage of ever cigarette smokers who first tried a cigarette at the age of 7 years or younger, 8 or 9 years, 10 or 11 years, 12 or 13 years, or 14 or 15 years Numerator: Number of ever cigarette smokers who reported trying a cigarette at the age of 7 years or younger, 8 or 9 years, 10 or 11 years, 12 or 13 years, or 14 or 15 years Denominator: Number of ever cigarette smokers BHUTAN, 2019 69 Age at initiation of smokeless tobacco use Indicator: Percentage of ever smokeless tobacco users who first tried smokeless tobacco at the age of 7 years or younger, 8 or 9 years, 10 or 11 years, 12 or 13 years, or 14 or 15 years Numerator: Number of ever smokeless tobacco users who reported trying a smokeless tobacco product at the age of 7 years or younger, 8 or 9 years, 10 or 11 years, 12 or 13 years, or 14 or 15 years Denominator: Number of ever smokeless tobacco users Areca/betel nut use Current use of doma khamtog or meetha paan Indicator: Percentage of youth who currently consume doma khamtog or meetha paan Numerator: Number of respondents who consumed doma khamtog or meetha paan any time in the preceding 30 days Denominator: Total number of respondents Current use of areca nut or its products Indicator: Percentage of youth who currently consume areca nut or its products Numerator: Number of respondents who consumed areca nut or its products any time in the preceding 30 days Denominator: Total number of respondents Tobacco cessation Smoking dependence Indicator: Percentage of current smokers who showed signs of smoking dependence Numerator: Number of current smokers who sometimes or always smoked or felt like smoking first thing in the morning OR start to feel a strong desire to smoke again within 24 hours of smoking Denominator: Number of current smokers Attempt to stop using tobacco in the preceding 12 months Global Youth Tobacco Survey (GYTS) 70 Indicator: Percentage of current smokers/current smokeless tobacco users who tried to stop using tobacco products in the preceding 12 months Numerator: Number of current smokers/current smokeless tobacco users who tried to stop using tobacco products in the preceding 12 months Denominator: Number of current smokers/current smokeless tobacco users Desire to stop using tobacco Indicator: Percentage of current smokers/current smokeless tobacco users who want to stop using tobacco products Numerator: Number of current smokers/current smokeless tobacco users who want to stop using tobacco products now Denominator: Number of current smokers/current smokeless tobacco users Ability to stop using tobacco Indicator: Percentage of current smokers/current smokeless tobacco users who think they would be able to stop using tobacco products Numerator: Number of current smokers/current smokeless tobacco products who think they would be able to stop using tobacco products if they wanted to Denominator: Number of current smokers/current smokeless tobacco products Secondhand smoke Exposure to secondhand smoke at home Indicator: Percentage of youth who were exposed to tobacco smoke at home in the preceding 7 days Numerator: Number of respondents who reported that they had been exposed to tobacco smoke at home on one or more days in the preceding 7 days Denominator: Total number of respondents Exposure to secondhand smoke in enclosed public places Indicator: Percentage of youth who had been exposed to tobacco smoke in enclosed public places in the preceding 7 days BHUTAN, 2019 71 Numerator: Number of respondents who reported that they had been exposed to tobacco smoke in an enclosed public place other than their home (such as schools, shops, restaurants, shopping malls and movie theatres) in the preceding 7 days Denominator: Total number of respondents Exposure to secondhand smoke in outdoor public places Indicator: Percentage of youth who had been exposed to tobacco smoke in outdoor public places in the preceding 7 days Numerator: Number of respondents who reported that they had been exposed to cigarette smoke in an outdoor public place (such as playgrounds, sidewalks, entrances of buildings, parks and beaches) in the preceding 7 days Denominator: Total number of respondents Exposure to secondhand smoke at school Indicator: Percentage of youth who had seen someone smoking in the school building or outside, on school property, in the preceding 30 days Numerator: Number of respondents who had seen someone smoking in the school building or outside, on school property, in the preceding 30 days Denominator: Total number of respondents Access and availability Source for obtaining cigarettes Indicator: Percentage of current cigarette smokers/current smokeless tobacco users who last obtained tobacco products from various sources in the preceding 30 days Numerator: Number of current cigarette smokers/smokeless tobacco users who last obtained tobacco products by purchasing them from a store or shop, purchasing them from a street vendor, getting them from someone else, getting them some other way Denominator: Number of current cigarette smokers/current smokeless tobacco users Obtained tobacco products through a person-to-person retail purchase Indicator: Percentage of current cigarette smokers/current smokeless tobacco users who last obtained tobacco products by purchasing them from a store, shop, street vendor or kiosk in the preceding 30 days Global Youth Tobacco Survey (GYTS) 72 Numerator: Number of current cigarette smokers/current smokeless tobacco users who last obtained tobacco products by purchasing them from a store, shop or street vendor in the preceding 30 days Denominator: Number of current cigarette smokers/current smokeless tobacco users Minors’ access to tobacco products Indicator: Percentage of current cigarette smokers/current smokeless tobacco users who were not prevented from buying tobacco products in the preceding 30 days despite their age Numerator: Number of current cigarette smokers/current smokeless tobacco users who were not prevented from buying cigarettes/smokeless tobacco in the preceding 30 days despite their age Denominator: Number of current cigarette smokers/current smokeless tobacco users who had tried to buy cigarettes/smokeless tobacco in the preceding 30 days Unit of purchased cigarettes Indicator: Percentage of current cigarette smokers who had last bought individual cigarettes, packs or cartons of cigarettes, rolls, loose tobacco for hand-rolled cigarettes in the preceding 30 days Numerator: Number of current cigarette smokers who had last purchased individual cigarettes, packs or cartons of cigarettes, rolls, loose tobacco for hand-rolled cigarettes in the preceding 30 days Denominator: Number of current cigarette smokers Availability of tobacco products in Bhutan Indicator: Percentage of current tobacco users who usually buy cigarettes or other tobacco products from within Bhutan Numerator: Number of current tobacco users who usually buy cigarettes or other tobacco products from within Bhutan Denominator: Number of current tobacco users BHUTAN, 2019 73 Anti-tobacco messages and information Exposure to anti-tobacco information in the media Indicator: Percentage of youth who had seen or heard anti-tobacco messages in the media (e.g. television, radio, Internet, billboards, posters, newspapers, magazines and movies) in the preceding 30 days Numerator: Number of respondents who had seen or heard anti-tobacco messages in the media in the preceding 30 days Denominator: Total number of respondents Exposure to anti-tobacco messages at sporting or community events Indicator: Percentage of youth who had seen or heard anti-tobacco messages at sporting or other community events in the preceding 30 days Numerator: Number of respondents who had seen or heard anti-tobacco messages at sporting events, fairs, concerts, community events or social gatherings in the preceding 30 days Denominator: Number of respondents who had attended sporting or other community events in the preceding 30 days Exposure to anti-tobacco information in school Indicator: Percentage of youth who were taught in school about the dangers of tobacco use during the preceding 12 months Numerator: Number of respondents who were taught in school about the dangers of tobacco use during the preceding 12 months Denominator: Total number of respondents Noticed health warnings on cigarette packages Indicator: Percentage of current smokers who had noticed health warnings on cigarette packages in the preceding 30 days Numerator: Number of current smokers who had seen health warnings on cigarette packages in the preceding 30 days and who answered, “Yes, but I didn’t think much of them,” or, “Yes, and they led me to think about quitting or to not starting smoking.” Denominator: Number of current smokers Global Youth Tobacco Survey (GYTS) 74 Thought about quitting smoking because of health warnings on cigarette packages Indicator: Percentage of current smokers who had noticed health warnings on cigarette packages in the preceding 30 days, and who thought of quitting because of the warnings Numerator: Number of current smokers who reported that having seen health warnings on cigarette packages in the preceding 30 days had led them to think of quitting Denominator: Number of current smokers who had seen health warnings on cigarette packages in the preceding 30 days Thought of not starting smoking because of health warnings on cigarette packages Indicator: Percentage of never smokers who thought of not starting smoking in the preceding 30 days because of health warnings on cigarette packages Numerator: Number of never smokers who reported that seeing health warnings on cigarette packages in the preceding 30 days had led them to think of not starting smoking Denominator: Number of never smokers who had seen health warnings on cigarette packages in the preceding 30 days Tobacco advertising and promotion Noticed tobacco advertisements or promotions at point of sale Indicator: Percentage of youth who had visited points of sale in the preceding 30 days and noticed tobacco marketing there Numerator: Number of respondents who had seen advertisements or promotions for tobacco products at points of sale (such as stores, shops and kiosks) in the preceding 30 days Denominator: Number of respondents who had visited points of sale in the preceding 30 days BHUTAN, 2019 75 Noticed someone using tobacco on television, videos or movies Indicator: Percentage of youth who had seen someone using tobacco on television, videos or movies in the preceding 30 days Numerator: Number of respondents who had seen someone using tobacco on television, videos or movies in the preceding 30 days Denominator: Number of respondents who had watched television, videos or movies in the preceding 30 days Exposure to tobacco promotion Indicator: Percentage of youth who were ever offered a free tobacco product from a tobacco company representative Numerator: Number of respondents who were ever offered a free tobacco product from a tobacco company representative Denominator: Total number of respondents Owned something with a tobacco brand logo Indicator: Percentage of youth who owned something bearing a tobacco product brand logo Numerator: Number of respondents who owned something (e.g. T-shirt, pen, lighter, hat, sunglasses and backpack) bearing a tobacco product brand logo Denominator: Total number of respondents High receptivity to tobacco marketing Indicator: Percentage of youth who owned something bearing a tobacco product brand logo or who might use or wear something that has a tobacco company or product name or picture on it Numerator: Number of respondents who owned something bearing a tobacco product brand logo or answered “Yes” or ”Maybe” to whether they would ever use or wear something that has a tobacco company or tobacco product name or picture on it Denominator: Total number of respondents Global Youth Tobacco Survey (GYTS) 76 Knowledge, attitudes, perceptions and behaviour Knowledge of tobacco addiction Indicator: Percentage of youth who definitely think that it is difficult to quit once one starts smoking tobacco/using smokeless tobacco Numerator: Number of respondents who answered “Definitely yes” to whether it would be difficult to quit smoking tobacco/using smokeless tobacco once one started using these products Denominator: Total number of respondents Perception regarding tobacco availability (near school) Indicator: Percentage of youth who felt they can purchase tobacco products, including cigarettes, near their school Numerator: Number of respondents who felt they could purchase tobacco products, including cigarettes, near their school Denominator: Total number of respondents Perception regarding tobacco availability (in general) Indicator: Percentage of youth who felt it would be “very difficult” for them to get tobacco products, including cigarettes, if they wanted some Numerator: Number of respondents who felt it would be “very difficult” for them to get tobacco products, including cigarettes, if they wanted some Denominator: Total number of respondents Perception regarding smoking tobacco in social gatherings Indicator: Percentage of youth who thought that smoking tobacco helps people feel more comfortable at celebrations, parties and other social gatherings Numerator: Number of respondents who thought smoking tobacco helps people feel more comfortable at celebrations, parties and other social gatherings Denominator: Total number of respondents BHUTAN, 2019 77 Knowledge of dangers of secondhand smoke Indicator: Percentage of youth who thought that tobacco smoking by others was harmful to them Numerator: Number of respondents who answered “Definitely yes” when asked if smoke emanating from others’ tobacco smoking was harmful to them Denominator: Total number of respondents Attitude towards banning smoking inside enclosed public places Indicator: Percentage of youth in favour of a ban on smoking in enclosed public places Numerator: Number of respondents favouring a ban on smoking in enclosed public places (such as schools, shops, restaurants, shopping malls and movie theatres) Denominator: Total number of respondents Attitude towards banning smoking in outdoor public places Indicator: Percentage of youth in favour of a ban on smoking in outdoor public places Numerator: Number of respondents favouring a ban on smoking in outdoor public places (such as playgrounds, sidewalks, entrances to buildings, parks and beaches) Denominator: Total number of respondents Smoking behaviour (by place where they usually smoke) Indicator: Percentage of current cigarette smokers by place where they usually smoke cigarettes Numerator: Number of current cigarette smokers who usually smoke at home, in school, at work, at a friend’s house, during social events or in a public place] Denominator: Number of current cigarette smokers Global Youth Tobacco Survey (GYTS) 78 ANNEXURE THREE BHUTAN, 2019 79