The big ban: Bhutan’s journey towards a tobacco-free society

The Big Ban MINISTRY OF HEALTH Bhutan’s journey towards a tobacco-free society World Health Organization P.O. Box: 175 Thimphu: Bhutan Telephone: +975 2 322864 Fax: +975 2 323319 E-mail: sebhuinfo@who.int www.who.int/Bhutan https://www.facebook.com/WHOBhutan/ ©WHO, 2019 ISBN: 978-92-9022-733-5 COVER: At the entrance to the district that was the source for nationwide ban. A sign- board at Chamkhar in Bumthang put up after the ban still stands. Disclaimer Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO license (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this license, 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 orga- nization, 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 license. 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). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the license shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. The Big Ban: Bhutan’s journey towards a tobacco-free society. Thimphu: World Health Organization, Country Office for Bhutan; 2019. License: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. The Big Ban Bhutan’s journey towards a tobacco-free society

P utting the publication together required inputs from various stake- holders and agencies responsible for effective implementation of the tobacco control law. There were several correspondences over email, phone calls and face-to-face interviews through which information and data were sourced and verified. For making time, despite their busy schedules and amid deluge of work, we would like to thank officials from health ministry, revenue and customs department, Royal Bhutan Police, local government officials from Bumthang, the national referral hospital, former parliamentarians and Bhutan Narcotics Control Authority for their support and input. The publication is a testimony of their commitments towards controlling tobacco use for a healthier nation. Our appreciation also to the few youth, other individuals and shopkeepers in the three districts of Bumthang, Phuentsholing and Thimphu for consenting to share their personal anecdotes and experiences to enrich the publication. We take this opportunity to also thank monks of the central monastic body, who besides sharing materials, also helped interpret some of the spiritual be- liefs associated with tobacco and its use. Our deepest gratitude to Prime Minister Dr Lotay Tshering for his invaluable insight and clarity of vision, which is not only critical at this stage but also re- affirms Bhutan’s commitment towards tobacco control. ACKNOWLEDGMENT Contents Introduction 15 Present day 16 As of today 18 Sale ban, a national business 20 Around Asia 21 From the grassroots 22 First to ban tobacco sale 23 Q&A: “Law on its own won’t move” 24 Timeline 26 The inception 28 A spiritual tale 30 Early codified laws 32 Trade linked 34 WHO FCTC 36 The first No Tobacco Day 37 In the middle 38 Awards 40 Tobacco-biz goes underground 42 The Act in effect 44 Act of a biting kind 46 Tobacco Control Act of Bhutan 47 Trimming the c(law)s 48 Increases in permissible quantity 49 Nascent organisation, formidable responsibility 50 Routine inspection 52 Policing the black market 54 Few declares to customs 56 Change with behavior 58 For people’s wellbeing 60 Tobacco use high among youth 62 Catching them young 64 Dragged into the habit 67 Health burden 68 Cost of tobacco 70 Calling it quits 71 Impact of Secondhand smoke 72 How tobacco kills! 73 Waging on 74 A block en route to SDGs 76 Prevention is key 78 Everyone’s responsibility 80 Together for a cause? 82 In partnership 84 References 86 8 The Big Ban On the initiative to tell the world, Bhutan’s story in its bid to control tobacco use among its people, I thank and congratulate World Health Organization (WHO). It is an exciting story, of daring plots, varying interludes and unresolved ending. Which country has ever attempted a nationwide ban? It began with right intentions and everyone worked together towards realising it. Bhutan has come a long way since then. At a glance, one can notice that people do not smoke on the streets and public places. Market shelves are free of tobacco products, which would, otherwise, be screaming for attention from unassuming customers. Over the years, there has been increased understanding and discipline when it came to embracing tobacco habits. It is certain the scenario would have been different had it not been for the ban. But habits do not change overnight and we have to acknowledge that. There are issues of illicit trade in tobacco. Despite stringent law, tobacco and its products are still available and accessible. Our young people are still indulging in it and the move has not countered health consequences. Noncommunicable diseases continue to be a major cause of preventable death and disability. Tobacco, among other social vices like alcohol and substance abuse, is one of the main contributors. With health as the mainstay of the government’s priorities, we are concerned. Among others, we wish to lighten burden on treatment and healthcare cost for a sustainable system. What is also worrying is that at the centre of the expanding illegal trade in tobacco are the Bhutanese youth, the nation’s future. What happens if our children, the productive citizens we expect to serve the nation in their time, find themselves battling with health issues? Who do we have to fall back on? I call on all relevant agencies to come together, reflect on how we started, rework on coordination and explore ways to achieve what we aspired for when we took on this task on ourselves. Government, on the other hand, commits to providing necessary support to all relevant agencies for effective tobacco control measures, including working closely with counterparts FROM THE PRIME MINISTER 9 The Big Ban across the southern border to address burgeoning black market. This WHO publication comes at the right time. By way of documenting the events that unfolded so far, it makes us rethink. Where have we gone wrong and how can we do better? We are also hoping the publication will help us gain new perspectives, as we consider the way ahead. In our efforts to control tobacco and its products, WHO has been a critical partner and we remain grateful. Having said that, we also urge WHO to continue providing technical assistance, more so in areas of research. As we contemplate numerous interventions to achieve effective implementation of tobacco cessation measures, we have to base our decisions and actions on critical data and evidence. I also take this opportunity to reach out to every Bhutanese to come forward and play their parts. As much as it is the responsibility of the government, implementing agencies or law enforcers, we can make our country free of tobacco and its implications only if we work together. To those reading this message, I request you to quit the habit if you are into it. As a practicing doctor, I am passionate about creating awareness on health hazards of tobacco and its products. I have seen lives lost to cancers and tobacco infused complications. The message is earnest and comes from my heart. I thank WHO for the platform. It is time for all of us to rewrite the tobacco ban story, one that has a far more satisfactory ending. Dr Lotay Tshering Prime Minister 10 The Big Ban I t’s been 15 years since the Royal Government of Bhutan banned sale of tobacco and related products in the country. Since then, a number of achievements have been made, and a number of challenges have arisen. We no longer see people smoking in public spaces, but this does not indicate that the number of smokers have reduced. However, exposure to second-hand smoke is visibly reduced. The black market, one that emerged after the ban, is the number one challenge that Bhutan is faced with when it comes to tobacco control. The Global Youth Survey 2013 reports an increase in the number of school children between ages 13 and 15 using tobacco products. It increased from 24 percent in 2006 to 30 percent in 2013. This does not bode well for a country which is battling noncommunicable diseases (NCD)and cancer, especially when the future generation is invested in a habit that is difficult to quit. Tobacco is the main risk factor for four major NCDs – cardiovascular disease, cancer, chronic lung diseases and diabetes. The burden of tobacco on health and society should be on the decline, going by the number of years since the ban was implemented, but data collected by GYTS tells another story. Health ministry remains committed to creating awareness on the impact of tobacco on health and wellbeing, to bring about behavioral change, and will continue to support the initiatives of WHO Framework Convention on Tobacco Control (FCTC). Recently, health ministry started training school counselors in tobacco intervention strategies so students receive appropriate awareness and guidance. Awareness about cessation programmes, quitline and other interventions to aid tobacco users to quit continues to be a priority. Education, empowerment and interventions must go hand-in-hand to make the ban more effective. Dechen Wangmo Health Minister F O R E W O R D 11 The Big Ban F O R E W O R D A national ban on sale of tobacco and all its products is a bold decision, an achievement countries in other parts of the world can only hope and wish for. That Bhutan has been able to do this, its people should realise, is an accomplishment, a giant step towards becoming, not just a tobacco free society, but ensuring a healthy, productive and brighter future. In this endeavour, as has always been the case, WHO is happy to offer its assistance in terms of public advocacy and awareness, including technical support to the country. The organisation was there to observe the country’s first “No Tobacco Day” in 1989, it was there to support the legislation that drew its essence from WHO Framework Convention on Tobacco Control and it will continue to support Bhutan in its bid to stamp out this growing menace to its free healthcare. Bhutan ratified WHO FCTC in 2004 and resolved on a nationwide ban of tobacco sale that same year in its bid to control tobacco use among its people, especially the youth. Today, the country is faced with a greater challenge, that of illegal traffic in tobacco and its products. So long as the demand within the country persists, it will continue to fuel the illicit market that has expanded since the ban of its sale in early 2000. Unfortunately, as studies indicate, Bhutanese youth are at the centre of this growing illegal trade in tobacco and its products. This gives the country all the more reason to step up measures and efforts to rein in on tobacco. It owes this to its youth. WHO shares the country’s concerns and it appears timely that Bhutan embraces the Protocol to Eliminate Illicit Trade in Tobacco Products the country is yet to ratify. Dr Rui Paulo de Jesus WHO Representative

THE ORIGIN: A caution to commuters in Thimphu with structures in the backdrop that houses the nations legislature and the central monastic body.

15 The Big Ban T he official nationwide ban of tobacco sale in 2004 came with a bang, or so the many stories about it were chosen to be told. International media coverage expressed a mix of bewilderment and awe in their tone of what was seen as a bold move. Numerous meetings, public advocacies and school programmes, geared towards spreading awareness on the ill-effects of tobacco use – on individual health, free health care and the society – seem, but like a speck in a distant memory. It has been 15 years since “The big ban”, as the title of the publication conveys, and it is an attempt at, as the subtitle spells out, “Bhutan’s journey towards a tobacco free society”. Working with the ban is the Tobacco Control Act, which is a representation of the political will that calls for collective endeavour of all law enforcement agencies, led by the nodal entity, Bhutan Narcotics Control Authority (BNCA) to help realise this national aspiration. Told under four sections - Present day, The inception, In the middle and Waging on - the publication attempts to capture how the ban came about, where Bhutan stands today in its implementation and what lessons it has drawn to carry on with renewed vigour. The first section is a snapshot of the scenario today, basically of visible transformations with regard to tobacco use since its sales ban. It delves into how the ban came about, the drive that cast the country into the global limelight. But the big leap was barely an upshot of overnight thoughts. Backed by health justifications and inspired by spiritual belief, it fed social disfavour that eventually effected political action. The second section attempts to, not just unfold but, document the many little periodic initiatives in the past that culminated into a move as significant as this. With landmark decisions, come big responsibilities to effectuate it. The third part of the publication states the initiatives that transpired, the coming together of relevant stakeholders, their roles and activities, all geared towards controlling tobacco sales and use nationwide. Bhutan has come a long way. The nationwide ban of tobacco sales was a result of ratification of WHO Framework Convention on Tobacco Control (FCTC) in 2004 by people’s representatives of the erstwhile National Assembly. Led by the health ministry with continued assistance from WHO, the country made significant strides in tobacco control since then and yet, fact remains that much remains to be done on the ground. The last section is an attempt at revitalising a national commitment that calls for relevant sectors to come together in realising a national effort. Introduction PRESENT DAY The current scenario and efforts of the government, grassroots elected repre- sentatives and health sector leading to the nationwide ban on tobacco sales.

PRESENT DAY 18 The Big Ban As of today B hutan continues to be the only country in the world today, to have implemented nationwide ban of sale of tobacco. One stark transformation since the ban, a decade and a half ago, has been the end of open smoking along streets and other public places, which were a common place before the ban. The same can be said about most other tobacco products. No longer are people seen puffing away along the streets, or out in the open. It is almost of a taboo to be seen doing so today. Workplaces and institutions decry such habits contemptable. Nationally, it is an offence punishable by law under the Tobacco Control Act. There were instances in the past, where those caught on the other side of this law faced imprisonment. Many today, continue to, every now and then, face penalties in the form of fines and verbal warnings, sanctions far mellowed from the initial prison term the law prescribed. From those endorsing the nationwide ban of tobacco sales in 2004 to those responsible for making (and subsequently passing) the law six years later, were all as a result of growing concerns for rising instances of noncommunicable diseases (NCDs). Tobacco, according to latest health studies, is among top four contributors to the rising cases of NCDs that weigh heavy on the country’s free health care. Despite efforts on the part of relevant authorities, tobacco black market, as initially feared, has emerged. Shops that thrive on illicit sale of tobacco and its products have found a way around the law. A steady stream of loyal customers continue to sustain these shops that have, over the years, grown into a network of black market. Recent studies have found Bhutanese youth, who are among the highest in the region to be using tobacco and its products, to be at the centre of this burgeoning contraband good. NO LONGER ARE PEOPLE SEEN PUFFING AWAY ALONG THE STREETS, OR OUT IN THE OPEN PRESENT DAY 19 The Big Ban ROADSIDE ADVOCACY: One of few signs along Paro- Thimphu highway cautioning vistors to the capital city of the consequences of tobacco use. PRESENT DAY 20 The Big Ban T he national tobacco sale ban was a culmination of numerous little efforts sparking off of public spaces like bus terminals, that were declared smoke-free, and communities that voiced against this social ill roused by religious sentiments. Such initiatives later rippled across the country’s 20 districts. Before the nationwide ban of tobacco sale, save for Thimphu and Chukha, 18 of Bhutan’s 20 districts had already initiated the move on their own. A concern emerging from individual households became an important agenda at the gewog yargay tshogchhung (assembly of elected grassroots representatives) that echoed with the same urgency at the dzongkhag yargay tshogdu (assembly of elected representatives at district level) before eventually making its way into the corridors of power, the earlier National Assembly. All the members then, comprising 99 chimis, (elected members from the grassroots), 35 government representatives (ministers, dzongdas/ governors and the armed forces) 10 from the clergy and six members of the Royal Advisory Council, unanimously agreed on the national ban of tobacco sale. A signatory to WHO Framework Convention on Tobacco Control (FCTC) since 2003, it was in ratifying the convention during the 82nd session of the then National Assembly of August 12, 2004, that the members saw an opportune occasion to endorse it. Along with the endorsement came the resolution on a 100 percent sales tax on all tobacco products entering the country for personal consumption of stipulated quantity. Sale ban, a national business 100% SALES TAX ON ALL TOBACCO PRODUCTS ENTERING THE COUNTRY FOR PERSONAL CONSUMPTION PRESENT DAY 21 The Big Ban BANGLADESH Smoking prohibited in the majority of indoor public places and workplaces, including children’s parks. CHINA Smoking completely prohibited in at least 28 indoor public places, including medical facilities, restaurants, bars, and most public transportation. NEPAL Smoking prohibited on public transport, most workplaces and public places. Outdoor areas include pilgrimage and religious places, stadiums and children’s parks and clubs. PAKISTAN Smoking prohibited in all places of public work or use, and on all public transport. Smoking prohibited in outdoor waiting areas for buses and trains. BHUTAN Sale of tobacco and its products banned nationwide in 2004. Smoking prohibited in public places. Limited quantity can be imported for self-consumption after paying 100 percent sales tax. SRI LANKA Smoking prohibited in many indoor public places and workplaces and on public transport. THAILAND Smoking prohibited in almost all indoor public places, indoor workplaces, and public transport. Smoking prohibited in markets, facilities for exercise, playgrounds, public, zoological and amusement parks. AROUND ASIA PRESENT DAY 22 The Big Ban 2004 Bumthang proposed nationwide ban during the 82nd National Assembly, which was unanimously endorsed Bhutan became the first country to ban sale of tobacco 1980s Health ministry with support from WHO started a vigorous advocacy campaign across the country. Tobacco control activi- ties were integrated into primary health care system 1991 During the fourth World No Tobacco Day, public places and transport were declared smoke-free 1993 New approach to anti-smoking campaign was launched and hospitals and health centres were declared smoke-free 1995 Advertising of tobacco products in all media channels was banned 1998 A national Tobacco Control Programme was instituted under the health ministry 2000 Through task forces, districts passed regulations and monitored activities concerning tobacco control 2003 18 of 20 districts banned sale of tobacco WHO awarded eight medals to Bhutan for tobacco control initiatives From the grassroots B y the time WHO developed the FCTC in 2003, responding to the globalisation of tobacco epidemic, Bhutan was a receptive community. The political will was strong and its culture, deeply rooted in Buddhism, antagonistic towards tobacco. Like in other countries, spread of tobacco epidemic was facilitated by factors like cross- border effects and trade liberalisation. PRESENT DAY 23 The Big Ban 2004 Bumthang proposed nationwide ban during the 82nd National Assembly, which was unanimously endorsed Bhutan became the first country to ban sale of tobacco 1980s Health ministry with support from WHO started a vigorous advocacy campaign across the country. Tobacco control activi- ties were integrated into primary health care system 1991 During the fourth World No Tobacco Day, public places and transport were declared smoke-free 1993 New approach to anti-smoking campaign was launched and hospitals and health centres were declared smoke-free 1995 Advertising of tobacco products in all media channels was banned 1998 A national Tobacco Control Programme was instituted under the health ministry 2000 Through task forces, districts passed regulations and monitored activities concerning tobacco control 2003 18 of 20 districts banned sale of tobacco WHO awarded eight medals to Bhutan for tobacco control initiatives GOING NATIONWIDE: Chamkhar-Ura Chimi (elected grassroots representrative) late Dorji Wangchuk proposes nationwide ban on tobacco sale at the National Assembly in 2004. Photo: Kuensel I t was in 1989, during a dzongkhag yargay tshogdu (assembly of elected village representatives) that the local government leaders proposed and unanimously endorsed a ban on tobacco sale in the district. It became the first district to do so. The local leaders were representing people from their communities, who were worried about the rising trend in use of tobacco products among its youth. Besides concerns over health implications, tobacco use among its inhabitants was sacrilegious. Bumthang is known for its spiritual heritage and is home to numerous monasteries and spiritual sites. In 2004, the same proposal was made at the National Assembly, this time for a nationwide ban on sale of tobacco. It received the same unanimous endorsement. First to ban tobacco sale PRESENT DAY 24 The Big Ban Q. Bumthang’s disfavour for tobacco products... A. Home to numerous sacred sites and monasteries, residence of Terton Pema Lingpa and blessed by Guru Rinpoche, Bumthang is the nation’s spiritual heartland. No one during the time of our parents consumed tobacco in any of its forms. A few who did were often looked down for desecrating the district’s sanctity. Q. Why did people of Bumthang want a ban on tobacco sales? A. In time, with more travellers along the northern east-west highway, including expatriate road construction workers, bidi (unprocessed tobacco wrapped in leaves) and khaini (chewing tobacco) began to appear in greater quantities in a few shops. Some of our people, including youth began using them. A concern arising from parents in many communities, at a scheduled meeting of the committee of local leaders, led by the dzongda (district administrator), the issue was discussed and we decided to ban smoking and sale of tobacco in the district. Q. What did people of the district think of the decision? A. The dzongda, who was a smoker himself showed the way. He quit “Law on its own won’t move” B umthang dzongkhag tshogdu (district committee) chairperson Chumey Gup (elected head of block) Jampel Dorji, 53, recalls the district’s decision to ban sale of tobacco and its products in 1994. He spares his thoughts on the district’s proposition for a nationwide ban of tobacco sale in 2004 and the continued efforts to realising this national endeavour. Gup Jampel Dorji served as the Bumthang chimi (elected grassroots representative) for 17 years, between 1990 and 2007 before the country ushered in parliamentary democracy in 2008. Q&A PRESENT DAY 25 The Big Ban immediately and expected the same of its residents. We did not experience any defiance from anyone. It was a rule the district set for the good of its residents and visitors had to respect that too. Q. How was the rule implemented? A. We took it on ourselves, local leaders in collaboration with police, the responsibility of supervising and monitoring. Shops found selling tobacco and its products were warned in the first instance, and their licences were cancelled if found repeating the offence. We burnt tobacco products that were seized. Q. Your take on the existing Tobacco Control Act? A. When we first initiated this ban on sale of tobacco in Bumthang, we had a rule. We had the head of the district and other local leaders lead by example and we had the residents of the district take ownership of this rule. We felt strongly for our district and the sanctity of it. We were concerned about the future of our youth. We are still on high vigilance today, just to be sure that complacence does not allow this social evil to take root again. The law is there, but it will not move on its own. Jamphel Dorji, Chumey Gup PRESENT DAY 26 The Big Ban TIMELINE 1729 Tobacco control laws date back to this year and it ensured religious institutions and dzongs remained tobacco free� 1980s Started tobacco control initiatives� 1989 Bumthang banned sale of tobacco� 1997 Zhemgang banned sale of tobacco 1998 Created Tobacco Control Programme under health ministry with WHO support 2003 Bhutan signed the Framework Convention on Tobacco Control (FCTC) During the 56th session of the World Health Assembly a commitment was made to declare Bhutan as the first tobacco-free nation 2001 The South East Asia Anti-Tobacco (SEAAT) Flame, a regional initiative, was launched in Bhutan leading to a nationwide anti-tobacco campaign 2005 Smoke-free zones declared 2007-09 Drafting of Tobacco bill 2010 Enactment of Tobacco Control Act 2014 Tobacco Control Act second ammendment 2011 Tobacco Rules and Regulations adopted 2012 Tobacco Control Act ammended 2000 Paro banned sale of tobacco Trashigang banned sale of tobacco Chukha banned sale of tobacco1651 Zhabdrung laid down a law prohibiting use of intoxicating substances, specifically, tobacco and alcohol within the walls of the fortresses and other important institutions 2004 18 districts declared themselves tobacco- free except Chhukha and Thimphu Ratification of FCTC and endorsement by the 82nd session of the National Assembly Thimphu banned sale of tobacco Nationwide ban on sale of any forms of tobacco products PRESENT DAY 27 The Big Ban TIMELINE 1729 Tobacco control laws date back to this year and it ensured religious institutions and dzongs remained tobacco free� 1980s Started tobacco control initiatives� 1989 Bumthang banned sale of tobacco� 1997 Zhemgang banned sale of tobacco 1998 Created Tobacco Control Programme under health ministry with WHO support 2003 Bhutan signed the Framework Convention on Tobacco Control (FCTC) During the 56th session of the World Health Assembly a commitment was made to declare Bhutan as the first tobacco-free nation 2001 The South East Asia Anti-Tobacco (SEAAT) Flame, a regional initiative, was launched in Bhutan leading to a nationwide anti-tobacco campaign 2005 Smoke-free zones declared 2007-09 Drafting of Tobacco bill 2010 Enactment of Tobacco Control Act 2014 Tobacco Control Act second ammendment 2011 Tobacco Rules and Regulations adopted 2012 Tobacco Control Act ammended 2000 Paro banned sale of tobacco Trashigang banned sale of tobacco Chukha banned sale of tobacco1651 Zhabdrung laid down a law prohibiting use of intoxicating substances, specifically, tobacco and alcohol within the walls of the fortresses and other important institutions 2004 18 districts declared themselves tobacco- free except Chhukha and Thimphu Ratification of FCTC and endorsement by the 82nd session of the National Assembly Thimphu banned sale of tobacco Nationwide ban on sale of any forms of tobacco products SOURCES: Kuensel & International tobacco control Bhutan project report, 2011, Ministry of Health THE INCEPTION The role of spirituality, leaders of the past and the timely health in- terventions that reinforced the ban on sale of tobacco in Bhutan.

THE INCEPTION 30 The Big Ban A ncient Buddhist scripts carry no proscription against the use of tobacco, for that matter, it is said there is no mention of tobacco as it was non-existent during the time of the Buddha. To not lie, kill, steal, to not engage in sensual misconduct and to abstain from intoxication were the basic values then. It is believed that tobacco was in use in the 8th century, around the time of the Buddhist saint, Guru Rinpoche, who was born in India and visited Bhutan, Nepal and Tibet. “By smoking, people will invite demons and chase away the dharma protectors,” it is believed, the Guru whom Bhutanese revere as the second emanation of the Buddha and the protector, was said to have written as a warning then. For decades this was the story monks at Bhutan’s many monastic institutions and monasteries told people to prevent them from taking to tobacco and its products. That it caused the god and other protecting deities to forsake people, that it offended spirits in the intermediate space and displeased semi-divine nāga in the underground realm were additional stories they told. The consequence of that, people would be warned of diseases, famine and disharmony in communities they lived in and the society at large. How effective it is today, monks in monastic institutes express uncertainty. “There was a generation of people who received the story well,” a central monastic body (Dratshang Lhentshog) representative said. The new generation of tobacco users, he said were more sophisticated to be convinced by such stories. “Besides, substance abuse is a more serious issue today for tobacco to receive any focused intervention.” That notwithstanding, at every religious gatherings in the country, revered monks led by the country’s chief abbot, the Je Khenpo, make it a point to educate people of the consequences of tobacco and alcohol consumption, including substance abuse. Apart from the sin of wasting this lifetime, the Dratshang Lhentshog representative said they explained to people, especially the youth engaging in such vices, that it dragged others close to them into the ordeal as well. A spiritual tale ARTISTIC EXPRESSION: Drawing essence from religious beliefs, an art depicts awaiting conse- quences of tobacco use in the afterlife. THE INCEPTION 31 The Big Ban THE INCEPTION 32 The Big Ban T o have found and later unified Bhutan, Zhabdrung Ngawang Namgyel, was said to have crafted laws to pacify the otherwise unruly land of, what was then referred to as, Monyul, or the land of the Mons (referring to people living in darkness). One of Zhabdrung’s remarkable achievements in Bhutan, the land he chose to flee to following apparent threat to his life in Tibet, his homeland, was the introduction of law and order for the people. Drawn up around 1651 before his final retirement into meditation, the first legal code of Bhutan known as “The Golden Yoke of Legal Edicts” prescribed, among others, against consumption of alcohol and tobacco, the prevalence of which he observed among Bhutanese. It specifically prohibited tobacco and alcohol within the walls of fortresses and other such important institutions for its officials and servants irrespective of their ranks or status. It was believed to be in violation of the dharma and obstruction in its practice. Almost a century after the Zhabdrung’s legal edict, the 10th Druk Desi (the secular head under Bhutan’s dual system of governance until the 19th century), Mipham Wangpo was said to have issued his own legal code in 1729 that specifically condemned use of tobacco. Early codified laws 1651 ZHABDRUNG LAID DOWN A LAW PROHIBITING USE OF INTOXICATING SUBSTANCES, SPECIFICALLY, TOBACCO AND ALCOHOL WITHIN THE WALLS OF THE FORTRESSES AND OTHER IMPORTANT INSTITUTIONS THE INCEPTION 33 The Big Ban It was said to have risen out of concerns over continuous use of tobacco, which he called tamakha, among peasants, administrative servants and bodyguards. It was that forbidden fruit, he was believed to have insisted, sprouting from the minds of the evil, devised to hobble the spread of dharma. Desi Mipham Wangpo’s legal code expands to government interventions to curtail tobacco use through containment of its import from India. Bhutanese officials of the time were commanded to take measures, in coordination with Indian counterparts, to prevent or restrict the import of tobacco and its products to Bhutan. Any indulgence in illicit trade of it within the country, the code warned government representatives and its officials of dire consequences. FROM THE JE KHENPO: The country’s chief abbot prescribes against tobacco use through a public notice in 1997. THE INCEPTION 34 The Big Ban W HO FCTC was developed in response to the globalisation of the tobacco epidemic. Trade liberalisation and foreign direct investment were known to facilitate this. With 168 nations signatory to it and 181 others its party, the convention is momentous in the sense of emphasis on the need to address this epidemic. Tobacco use was increasing at an alarming rate, contributed by global marketing, transnational tobacco advertising, promotion and sponsorship, among others. Bhutan’s major partner in trade is India, having a free trade agreement since 1972, renewed every 10 years. The last one was signed in November 2016. Except for a few farmers growing tobacco on the southern foothills, there were no tobacco farms or factories in Bhutan. After the South East Asian Anti-Tobacco (SEAAT) flame was passed to Bhutan in 2000, farmers stopped growing tobacco, heeding the government’s advice. Bhutan is a member of the South Asian Free Trade Area and the free trade agreement negotiations on the BIMSTEC (Bay of Bengal Initiative for Multi-Sectoral Technical and Economic Cooperation between Bangladesh, Bhutan, Burma, India, Nepal, Sri Lanka and Thailand) are ongoing. Bhutan established its first working party for WTO accession in 1999 but withdrew in 2017 on grounds that it contradicted the country’s development principles of Gross National Happiness (GNH). Trade linked THE INCEPTION 35 The Big Ban POINT OF ENTRY: The border town of Phuentsholing is the main thoroughfare for trade with India. THE INCEPTION 36 The Big Ban WHO FCTC T he World Health Assembly adopted the WHO Framework Convention on Tobacco Control (FCTC) on 21st May 2003 and it came into force on 27th February 2005. It is the first international treaty negotiated under the auspices of WHO and one of the most rapidly and widely embraced treaties in the United Nations history. It was developed in response to globalisation of the tobacco epidemic and represents a milestone for the promotion of public health. The WHO FCTC opened for signature from 16th to 22nd June 2003 in Geneva, and thereafter, at the United Nations Headquarters in New York, from 30th June 2003 to 29th June 2004. The treaty, which is now closed for signature, has 168 signatories, including the European Union. Currently there are 181 Parties covering more than 90 percent of the world population. Countries wishing to become a Party, but did not sign the Convention by 29th June 2004, can do so by means of accession, which is a one-step process equivalent to ratification. To accelerate action on WHO FCTC implementation, Conference of the Parties (COP) agreed on the need for a longer-term plan during its seventh session. A Global Strategy to Accelerate Tobacco Control, Advancing Sustainable Development through Implementation of the WHO FCTC 2019–2025, also known as Global Strategy 2025, has been developed. THE INCEPTION 37 The Big Ban A s the world observed the second World No Tobacco Day on May 31 1989, Bhutan joined, for the first time, the international community to mark the day. The sale of any tobacco product was disallowed between 6am and 6pm on the day. Students from Yangchenphug and Motithang Higher Secondary schools in Thimphu organised a debate on the ill effects of tobacco use. Simtokha Rigney School students performed a drama along a similar theme. Carrying the theme, Women and Tobacco, the National Women’s Association Of Bhutan in Thimphu took the lead in disseminating information among the public, especially women, on the harmful effects of tobacco. Posters, leaflets, books and stickers depicting negative consequences of tobacco use were distributed to the public. An audio-visual presentation on the harmful effects of tobacco was also screened. The first No Tobacco Day 1989 ‘NO TOBACCO DAY’ OBSERVED FOR THE FIRST TIME IN BHUTAN MAY 31 IN THE MIDDLE Developments and challenges in implementing the Tobacco Control Act.

IN THE MIDDLE 40 The Big Ban 2017 World No Tobacco Day award presented to Former health minister Tandin Wangchuk 2011 World No Tobacco Day Award presented to former health minister Dasho Zangley Dukpa 2012 World No Tobacco Day award presented to trade department and assistant legal officer, BNCA Recognition from WHO for promoting tobacco free societies World No Tobacco Day Award PEMAGATSHEL TRASHIGANG TRASHIYANGTSE LHUENTSE BUMTHANG 1996 1994 1998 1997 1993 AWARDS IN THE MIDDLE 41 The Big Ban EARLY RECOGNITION: WHO recognises Bumthang for its efforts in carrying out public awareness and advocacy on ills of tobacco use. IN THE MIDDLE 42 The Big Ban M uch before the nationwide ban of tobacco sales, instances of emerging illegal traffic in tobacco and its products was already apparent in the very districts that had initiated such a move on their own. When representatives of these districts later proposed and agreed to the national ban of tobacco sale at the highest decision-making body then, the looming issue of illegal trade that had begun to surface received little attention. If the import was banned, the question of illegal sale did not arise, was the prevailing logic among decision-makers then. The understanding was that the country did not grow tobacco and it did not have manufacturing plants that it should worry about illegal feed into the market. Today, illegal trade in tobacco and its products span as far as its nationwide sale ban. It continues to progress in hiding, quite contrary to the intent with which the law was initially designed. Of a thriving black market, many outside the National Assembly then, expressed fear through the national media besides also suggesting alternatives. One such caution came from WHO’s Tobacco-Free Initiative’s Acting Coordinator, Dr Armando Peruga, who said an all-out ban risked creating a black market for tobacco products. He had instead suggested that countries considering similar decisions to first ban smoking in public places and making it socially unacceptable. Public smoking is almost non- existent in the country and socially unacceptable too. The challenge, however, is the illicit trade in tobacco and one that is proving inconvenient to act on, despite the very law that was crafted to counter it. Tobacco-biz goes underground IN THE MIDDLE 43 The Big Ban UNDERHANDED: What the tobacco sale ban also did was fuel black market in the country. IN THE MIDDLE 44 The Big Ban S lightly over six months since enactment on 16th June 2010, the Tobacco Control Act netted its first case. On 24th January 2011, a 23-year- old Bhutanese monk travelling from the border town of Phuentsholing to the capital city of Thimphu was caught in possession of 48 packets of chewing tobacco (baba) worth Nu 120. After being detained for over a month, the Thimphu district court sentenced him to three years in prison on 3rd March 2011, guilty of violating the tobacco law. It was a non-bailable offence according to the provisions of the Act. Unchecked at the point of entry, the man, with the tobacco product, entered the country. Undeclared, he brought it without paying tax as mandated by the law. Unaware, he brought in an amount beyond permissible limit, which he claimed was for self-consumption to last a year. Following the 23-year-old monk, in the subsequent weeks, months, until early 2012, more than 80 people including farmers, expatriate workers, students, shopkeepers, public transport drivers, armed force personnel and airline staff were caught and charged for violating the country’s tobacco law. Voices of dissent, mainly of urban residents, and from among them a few who were active on social media, or were either consumers of tobacco themselves, or against the ban of tobacco sales, began appearing on Facebook. Bhutan’s tobacco consumers, authorities of the time had said made up about 10 percent of the national population of about 750,000. The Act in effect NEWS CLIPPINGS: The aftermath of the To- bacco Control Act in implementation received wide news coverage. IN THE MIDDLE 45 The Big Ban IN THE MIDDLE 46 The Big Ban T he Tobacco Control Act of 2010 that came into being during the tenure of the first Parliament of the constitutional democratic monarchy was in response to the sprouting tobacco black market. The resolution of the 82nd session of the earlier National Assembly of 2004, much before the country’s transition to a democracy, was deemed a paper tiger. In the face of growing tobacco black market and following derision from certain sections of the population of the law’s inefficacy, the newly elected government was compelled to resolve on a legislation. The 2004 resolution needed teeth. It came in the form of an Act. It would not just dissuade consumers of tobacco but curb the puffing illegal traffic in tobacco. Drawing its essence from the WHO Framework Convention on Tobacco Control, the Parliament on 16th June 2010 passed the Tobacco Control Act. Sixty-one of the 65 parliament members present on that day voted in favour of the law. It was, however, the severity of certain provisions of the Act that did not go down well with a few sections of the population, particularly, the urban- centric social media activitists. Cultivating, manufacturing and trade in tobacco and its products were banned, therefore, to be found doing so carried a heavy penalty of fourth degree felony of three to five-year prison term. The same penalty applied to those failing to declare tobacco of, law-specified, permissible quantity at the identified ports of entry – Gelephu, Phuentsholing, Samtse, Samdrupjongkhar – or failing to pay tax on the permissible amount, or in possession of tobacco without a receipt of paid tax. Act of a biting kind 2010 PARLIAMENT PASSES THE TOBACCO CONTROL ACT JUNE 16 Even without a specific Act, under the previous Assembly resolution, relevant authorities had cancelled 40 business licences across the country of those found in violation of the decision between 2004 and 2008. In fines, authorities had collected around Nu 400,000. IN THE MIDDLE 47 The Big Ban No smoking in commercial centers, recreation centers, institutions, public transportation and public gatherings No cultivating, harvesting, manufacturing, supplying, distributing, or trading tobacco and tobacco products Import tobacco and tobacco products for personal consumption as per quantity approved by the Tobacco Control Board Tobacco Control office to promote cessation of tobacco use and adequate treatment for tobacco dependence Smuggling tobacco or tobacco products punishable with petty misdemeanor and penalised as per Penal Code of Bhutan Any person with more than permissible quantity for personal consumption punishable with minimum sentence of fourth degree felony TOBACCO CONTROL ACT OF BHUTAN, 2010 Salient Features IN THE MIDDLE 48 The Big Ban T he case of the Bhutanese monk and the first to be improsoned under the Tobacco Control Act stirred some movement on Facebook among a few urban dwellers, who were against the law. With more people facing imprisonment, the Facebook group that called for amendment of the Act grew to some 3,000 members. That the law was draconian and that it was passed to gain international recognition were the grounds for opposing the law. They later argued that the penalty was more severe than other bigger crimes and that in a democracy, it neglected the rights of individuals. Although those voices were not representative of the Bhutanese majority, agreeing that the penalties the Act prescribed were harsh and considering the plight of people falling behind bars, the government instructed the drafting of a separate rules and regulations. It would render the law some clemency. The Act had been in implementation for only six months then. The Tobacco Control Rules and Regulations came about on January 1, 2013. Between the implementation of the Tobacco Control Act and the coming of the rules and regulations, more than 80 people were imprisoned. Among others, the rules and regulations spelt out responsibilities of relevant agencies identified by the Act. It also stipulated the amount of tax and duties applicable, the permissible amount for self-consumption and penalties if found in violation of the provisions of the Act. But most notably, instead of straight imprisonment, monetary compensation made up for most offences like failure to declare tobacco and its products to relevant authorities, failure to pay tax and duties and smoking in public places. Likewise, instead of fourth degree felony, which equated with an un- compoundable three to five-year prison term, the amended law replaced it with misdemeanour and petty- misdemeanour with prison terms ranging between one month and less than three years. It also allowed for payment in lieu of prison term. Trimming the c(law)s 49 The Big Ban INCREASE IN PERMISSIBLE QUANTITY 200 30 150 250 750 50 150 300 + 400 800+1,200Cigarette sticks bidis bidis Cigar pieces Chewing and other tobacco products in grams 2010 2013 2014 PER MONTH IN THE MIDDLE 50 The Big Ban Achievements We are the first country to ban sale of tobacco. We have a good law, the Tobacco Control Act, in place and we are signatory to WHO Framework Convention on Tobacco Control (FCTC). In terms of implementation of the provisions of the Act, we are more advanced. The provisions of the law are such that it discourages tobacco use. For example, one can legally import certain amount of tobacco by paying 100 percent tax. But how many tobacco users actually travel to the border or fly abroad to buy tobacco? Moreover, the Nascent organisation, formidable responsibility E xtract from an interview with Bhutan Narcotics Control Authority’s (BNCA) Supply Reduction Division Deputy Chief Programme Officer Chhimi Dorji. The recipient of south-east Asia WHO Regional Director’s appreciation award for effective enforcement of tobacco law gives an overview of the authority’s efforts in controlling tobacco sales and use in Bhutan. Chhimi Dorji, Deputy Chief Programme Officer, BNCA Supply Reduction Division IN THE MIDDLE 51 The Big Ban customs procedure to bring in tobacco is cumbersome, done deliberately to dissuade import. Despite challenges, to call tobacco control efforts in Bhutan inefective would be false. Visible achievements have been made. During joint inspections carried out with enforcement agencies, we rarely come across people smoking in public spaces. This indicates behavioral change. We have also had cases of shopkeepers discontinuing sale of tobacco, after being sensitised about the legal consequences. Challenges The porous international border stokes the black market and, often, enforcement agencies find themselves a step behind smugglers and sellers. The agencies, which have their own responsibilities and priorities, are limited by human resource. For example, the prime concern of the revenue and customs office is to check import of taxable items and tax-evasion cases. Lack of scanners at the border makes goods inspection, coming in by the truckloads, cumbersome. The police, on the other hand, have law and order to maintain, which is their priority. Strength in collaboration Being a small organisation and having to monitor the whole country is unfeasible. Often when officials from our agency visit other districts, we collaborate with other enforcement agencies and carry out inspections. We are in the process of decentralising to thromde (municipalities) and dzongkhags (districts). They are provided some fund for advocacy and are encouraged to conduct inspections without us. So far, we have drawn an agreement with Phuentsholing and Gelephu municipalities, and Paro, Wangduephodrang and Punakha districts. Besides the collaborative effort of the various stakeholders, tobacco control would also be effective with community support. It is one thing to agree that tobacco should be controlled and quite another to be a part of the process. It could be as simple as asking someone smoking in public to stub the cigarette, or reporting a person selling tobacco, to the authorities. About the authority As required under the Tobacco Control Act 2010, Bhutan Narcotics Control Authority (BNCA) was instituted in 2013. Custodian of two Acts, Bhutan Narcotic and Psychotropic Substance Abuse Act and the Tobacco Control Act, it is the secretariat to the Tobacco Control Board and the implementer of the provisions of the Tobacco Control Act of Bhutan. BNCA has two divisions that deal with demand reduction through rehabilitation and counselling and supply reduction through enforcement, complaint management and material development for capacity building of enforcement agencies. IN THE MIDDLE 52 The Big Ban S ince 2014, BNCA has organised an annual joint inspection of the tobacco law in implementation in all districts. In a few selected districts, where instances of violation of the tobacco law are high, a surprise inspection is also carried out. Officials from implementing agencies like the Department of Revenue and Customs, police and Ministry of Health join the narcotics control officials to search shops and inspect public areas for offenders. Officials of the joint inspection team also carry out advocacy campaigns. The last joint inspection was carried out between May and June 2019 in Bumthang, Dagana, Trongsa and Zhemgang in central Bhutan and Gelephu, Phuentsholing, Samdrupjongkhar, Samtse and Tsirang in the south. More than Nu 130,000 was collected in fines for illegal possession of tobacco and its products within permissible quantity. The team also seized over 5,400 cigarettes and more than 400 packets (4,140 grams) of chewing tobacco. Four people were fined for smoking in public places designated as smoke-free zones. Narcotics control officials said the joint inspections were effective, although an impact assessment is yet to be carried out. With decentralisation programme underway in Phuentsholing and Gelephu, it is expected that such inspections can be carried out without narcotics officials having to take a lead. In other districts, narcotics control officials have advised stakeholders to work together to carry out inspections. Routine inspection Joint inspections May-June, 2019 : Bumthang, Dagana, Gelephu, Phuentsholing, Samdrupjongkhar, Samtse, Tsirang, Trongsa and Zhemgang. Seized 5,492 Cigarettes 414 Packets of chewing tobacco Fined 4 People fined for smoking in smoke-free zones Source: BNCA IN THE MIDDLE 53 The Big Ban Fines collected July 2017 - June 2018 Nu 0.7M July 2018 - June 2019 Nu 1.2M FUEL TO FLAME: Seized tobacco products outside the inceneration facility at Gedu, Chhukha Photo: BNCA Source: BNCA IN THE MIDDLE 54 The Big Ban I n the capital city of Thimphu, comprising 20 percent of the country’s population, police apprehended 203 people for selling tobacco in the last three years. The capital has the biggest population of about 200,000 residents. In Bumthang, the first district to ban sale of tobacco, the numbers were comparatively smaller with only six people caught selling tobacco in the past three years. The figures, however, are only the tip of an iceberg that is the thriving black market. Random and scheduled inspections with other tobacco control agencies are a regular activity. However, police often find themselves powerless owing to some ambiguities in key provisions of the tobacco control law. The Tobacco Control Act allows a certain amount of tobacco to be imported. It also has provisions for smoking zones and rooms. If caught smoking in public, offenders demand an alternative, a designated space or facility the law prescribes. At other times, taking advantage of the permissible quantity, shopkeepers claim the tobacco in possession to be for self-consumption. Police also find themselves several steps behind offenders. During inspections, police realised that shopkeepers received information beforehand, giving them enough headway to conceal tobacco possession. Those caught are usually warned, save for repeat offenders, who are charged with fourth degree felony with choice of payment in lieu of imprisonment. Tipoffs are few and far between, including information on those smuggling tobacco into the country from border towns. Thimphu has over 1,200 paan shops (countertop stalls selling areca nut wrapped in betel leaf) and Bumthang has 36. It is from these shops, according to police and other implementing agencies, that tobacco products are usually sold. In the southern districts, the police maintain cordial relationship with their counterparts across the border. Border coordination meetings are carried out, where police superintendents meet annually or biannually and submit agenda to their counterparts regarding substance abuse and tobacco control. Policing the black market IN THE MIDDLE 55 The Big Ban 48 33 44 15 29 34 Female Male Monitoring and enforcing tobacco control measures in the border towns are a challenge. A designated revenue and customs checkpost at the entrance is absent. If caught with tobacco, people often claim they were yet to declare to the customs office. Like customs officials, police in border areas are constrained by lack of space and requirement to manually check import vehicles for controlled substances and tobacco. This is not only cumbersome but also causes traffic jam. Highway patrol teams occassionally check vehicles coming from border towns for illegal substances, including tobacco following tipoffs and at regular intervals. Caught selling tobacco (Figures are for Thimphu only, 2016-18) Source: Royal Bhutan Police IN THE MIDDLE 56 The Big Ban T he border town of Phuentsholing, the port of entry, has between 200- 300 trucks ferrying in consignments of imported goods via India on any given day. The consignments range from tonnes of basic food items to construction materials, but only a handful declare tobacco to the Regional Revenue and Customs officials. Trade statistics, however, indicate an increasing number of people declaring tobacco at the customs office and paying duty. In 2006, two years after the implementation of tobacco sales ban, tobacco products worth Nu 7,852 were declared. The figure increased to over Nu 1M in 2018, of which, Nu 514,391 worth of tobacco was imported from India and Nu 554,692 from other countries. In the initial years after the ban, customs officials apprehended a few consignments of tobacco being imported into the country illegally. Few declares to customs 2005 2010 2015 2017 2018 Value of imported tobbaco and manufactured tobacco substitutes (Figures in Nu/Million) 7,852 24,972 0.35M From India 0.49M others 1.0M others 0.71M From India 0.51M From India 0.55M others Source: Bhutan Trade Statistics IN THE MIDDLE 57 The Big Ban Today, officials hardly come across tobacco when carrying out random physical inspections of trucks bringing in imported goods. However, without a scanner the consignments have to be verified manually. This limits inspection to about five percent of the trucks coming in each day. Besides facilitating trade, given the limited parking space and traffic jams the caravan of trucks cause in the already crowded Phuentsholing town, customs officials are compelled to promptly clear consignments. Limited by these factors, customs officials rely on informants, although tipoffs are hardly about tobacco smuggling. When customs officials come across people in possession of tobacco products, they are made to pay tax for the permissible amount. The rest are confiscated and handed to BNCA. The agency disposes the tobacco in Gedu, a neighbouring settlement under the same district, where it burns the tobacco products in an incinerator. Customs officials believe smugglers used other routes in small vehicles to traffic in small consignments of tobacco. For better coordination among stakeholders, customs officials suggest a narcotic control regional office in Phuentsholing. PHYSICAL VERIFICATION: A customs official in Phuentsholing oversees inspection of imported goods. IN THE MIDDLE 58 The Big Ban T he health ministry with WHO’s support, has been instrumental in control of sale and use of tobacco in Bhutan. In the 1990s, former health minister Sangay Ngedup toured the country advocating against tobacco use and its impact on people’s health. This led to informed communities, who pushed the local government heads to take the issue to Parliament, following which a nationwide ban on tobacco sale was imposed. A separate tobacco control programme was instituted within the health ministry, which led relevant stakeholders to draft the Tobacco Control Act. To this day, the health minister of an elected government remains the chairperson of the Tobacco Control Board. After enactment of the Act, BNCA took over as the nodal agency with health ministry remaining a critical partner. Its two major mandates to bring about behavioral change lies in providing health services and preventing diseases through awareness creation and advocacy. Numerous advocacy and awareness campaigns have been conducted at various levels in both rural and urban areas. It has also conducted several researches on tobacco use as part of STEPwise approach to Surveillance (STEPs) survey, national health surveys, and Global Youth Tobacco Survey (GYTS) with support from WHO. All of it indicates an increasing trend in tobacco use, especially among youth. Health ministry officials, however, hope to carry out more in-depth studies on tobacco use. Besides advocacy and studies, health ministry has developed tobacco cessation guideline and trained health workers on brief intervention using screening tools. These interventions are for alcohol and tobacco users. The psychiatric department offers counselling, but only a handful have, so far, availed of this service to quit tobacco use. Moreover, drugs required for weaning tobacco addiction were unavailable in the country. They were not under the essential drugs list. The health emergency line, 112, which also caters to those wishing to quit tobacco is little known about among public. A separate quit line, specifically for the purpose and with greater awareness creation, health ministry officials believe, would be more effective. Change with behavior IN THE MIDDLE 59 The Big Ban SEAAT FLAME 2001: Former Health Minister Sangay Ngedup (right) hands over the anti-tobacco flame to Dasho Zangley Dukpa who was the Chhukha dzongda (district administrator) then. IN THE MIDDLE 60 The Big Ban Fifteen years after the ban on sale of tobacco and consumption in public places, people are still of the opinion that the draft bill was not thoroughly discussed. It is not true. The issue of tobacco came about in the 1980s and WHO recognised how manufacturers were targeting the youth and it was fast becoming a global health issue. In 1997, when I was the Chhukha dzongda (district administrator), former health minister Sangay Ngedup and former Prime Minister Tshering For people’s wellbeing Dasho Zangley Dukpa, Former Health Minister F ormer health minister Dasho Zangley Dukpa, who submitted the Tobacco Control Bill to the 82nd session of the first Parliament of the constitutional democratic monarchy, recounts how vigorous campaigns were carried out to advocate against tobacco, how it led to the nationwide ban and the enactment of the Tobacco Control Act. IN THE MIDDLE 61 The Big Ban Tobgay were visiting districts, creating awareness on noncommunicable diseases and advocating against risks associated with sedentary lifestyle and tobacco. Before the tobacco control bill was presented to the Parliament, it was extensively discussed since the early 1990s. It was taken across the country and meetings were conducted with dzongdas, local government leaders, in thromdes (municipalities) and development project sites. The first district to be declared tobacco-free was Bumthang, because of its historical and spiritual legacy. Following these advocacy talks, people submitted a letter of commitment, declaring the initiative appropriate and they supported it unanimously. It culminated in a nationwide ban, with representatives from the country’s 20 districts supporting the resolution. The nationwide ban was declared during the National Day (December 17) of that same year (2004). Led by the health ministry, related agencies took up the work of drafting the rules and regulations. To give the ban legality, a bill was drafted before the institution of parliamentary democracy in 2008. The health ministry and other stakeholders found it difficult to implement the countrywide ban on tobacco sale without an Act. The bill was thoroughly discussed. No bill would have received as through a deliberation as the tobacco control one. After about 10 years of advocacy against tobacco, reiterating what it meant for a spiritual country like ours and the impact it has on the health of its citizens, particularly our youth, I took it up as a responsibility and a contribution to the wellbeing of our people, to table it. I was an educationist before becoming an administrator, and to see tobacco companies target youth was disturbing. When I became the health minister in 2008, I presented the Tobacco Control Bill to the Parliament, which was endorsed by a majority. The intention was never to punish tobacco users but to deter them. NO BILL WOULD HAVE RECEIVED AS THOROUGH A DELIBERATION AS THE TOBACCO CONTROL ONE. IN THE MIDDLE 62 The Big Ban B hutan has the highest prevalence of tobacco users among youth, both at regional and global levels, according to the Global Youth Tobacco Survey, 2013. The GYTS looked at school students between ages 13-15 studying in classes VII-IX. Bhutan, Myanmar and Nepal were attributed with the highest number of youth using smokeless tobacco. Use of any tobacco products among students in Bhutan increased from 24 percent in 2006 to 30 percent in 2013. The rise was attributed to widespread black market, which emerged with the implementation of nationwide ban in 2004. Research also indicated a decline in anti-tobacco mass media campaigns and limited health education programmes on dangers of tobacco use. In 2005, following the ban in 2004, the government issued a notification prohibiting smoking in public places throughout the country. Advertisement of tobacco products in all media channels was banned since 1995. Crossborder advertisement through foreign television channels and movies and other print media continued in the early years after enforcement of the ban. GYTS 2006 pointed out that a majority of students were still exposed to pro-tobacco messages. Despite the ban and their age, students could still buy tobacco from shops. Half the students who smoked, according to GYTS 2006, reportedly bought tobacco from shops. The report deemed the ban ‘not effective’ and called for ‘stricter enforcement’ of law. GYTS 2013 had similar findings with half of the tobacco users buying it from shops. It also found that teaching students of the dangers of tobacco use in school had not improved over the last decade. Not limiting to smoking, the survey also recommended inclusion of smokeless tobacco control programmes in communities and schools. Although about 82 percent of students who currently smoked cigarettes reported to have quit and 83 percent had attempted to, only 25.3 percent had received help or advice to quit smoking from professionals, according to GYTS 2013. Bhutan’s efforts to control tobacco use have, however, resulted in significant decrease in exposure to tobacco smoke at homes and public places. Survey results show that, 15.3 Tobacco use high among youth IN THE MIDDLE 63 The Big Ban 13% 23% 34% 39% 2006 2013 24% 30% percent of youth surveyed were exposed to smoke in their homes and 42.8 percent were exposed to secondhand smoke in enclosed public places. Less than half the students were in favour of banning smoking in public places according to GYTS 2006. GYTS 2013 reported one in two student favouring smoking ban inside enclosed public places and four in five thought other people’s smoking was harmful to them. Tobacco users among students (13-15 years) (Sample size 2,012 in 2006 and 2,388 in 2013) Source: GYTS In the region Smoking rates among youth (boys and girls) were high in Timor- Leste, Thailand and Indonesia. Smokeless tobacco use was found to be high in Bhutan and Nepal. Bangladesh, Bhutan, India, Nepal and Sri Lanka have higher prevalence of smokeless tobacco use compared with smoking. The high prevalence of smokeless tobacco use was seen among young girls (13-15 years) in Bhutan, Nepal and Timor- Leste. Most countries have policies in place to prevent youth’s access to tobacco products. Factors such as high prevalence of tobacco use among adults, ease of availability, accessibility, sociocultural milieu, low prices of tobacco products and gaps in implementation of tobacco control policies were factors contributing to youth taking up tobacco use. Source: Tobacco Control for Sustainable Development, WHO SEA-Region The GYTS uses a standardised methodology for constructing sampling frames, selecting schools and classes, preparing questionnaires, carrying out field procedures and processing data. It includes data on prevalence of cigarette and other tobacco use, perception and attitudes about tobacco, access to and availability of tobacco products, exposure to secondhand smoke, school curricula, media and advertising and smoking cessation. IN THE MIDDLE 64 The Big Ban T he country’s school curriculum does not include, in any of its subjects, lessons on the harmful effects of tobacco. But schools often observe No Tobacco Day and health coordinators and guidance counsellors sensitise students and provide counselling to tobacco users. According to health ministry’s Career Education and Counseling Division officials, there is no overarching policy for tobacco in schools, but some schools have developed their own. Tobacco, officials said, was considered less serious than drugs or alcohol abuse, and there was no uniformity in ‘how to deal’ with students abusing substances and using tobacco. Only recently has intervention begun in schools across the country. In 2016, Bhutan Global School Based Health Survey indicated increasing trend in tobacco use. To tackle the issue, an intervention was initiated. Health ministry’s school health programme coordinator Sangay Thinley said that before the survey, teachers were sensitised on the issues of tobacco, doma (areca nut) and alcohol use among students. Without training, teachers had to deal with students based on their own initiatives and Catching them young IN THE MIDDLE 65 The Big Ban Students seeking help February to June 2018 467 54 boys girls Number of students that sought counselling on substance abuse, including psychotropic substances and tobacco. LEARNING TO SAY NO: Yangchenphug school students in Thimphu hold slogans that speak for themselves. IN THE MIDDLE 66 The Big Ban capacity. After the survey, with support from WHO, about 45 guidance counsellors were trained in brief intervention. The latest train-the-trainer workshop on brief intervention for tobacco, alcohol and beetle nut use in school settings in Bhutan was carried out from April 23- 30 2019. “If done properly, it takes about three minutes for an impact,” Sangay Thinley said. “We’ve found that teachers don’t have time to indulge or talk to students for long duration.” To understand the impact of the brief intervention programme, he said it would have to be assessed in the next three or four years. Besides brief intervention, life skills education, which looks at wholesome education also trains students to think critically and make decisions based on sound judgment. Peer helpers programmes was initiated with support from Career Education and Counselling Division, under education ministry, which is proving to be more effective. While schools maintain a record of students seeking counselling for substance use, there are no segregated figures. From February to June 2018, 467 male and 54 female students sought brief intervention on substance use, which includes, besides other narcotics and psychotropic substances, tobacco. Career Education and Counselling Division collected the data from 96 secondary schools across the country. Brief intervention The intervention is developed from WHO FCTC Article 14 guideline, developed for a clinical setting and used interchangeably as brief advice. The primary purpose of a brief tobacco intervention is to help the patient understand risk of tobacco use and the benefits of quitting and motivating them to quit. The intervention is considered feasible considering, counselling time can be minimal, taking about three to four minutes, and is proven effective. It has two models, 5As and 5Rs. The first is for tobacco users who are ready to quit and the second for those who are not. The five As stand for Ask, Advise, Assess, Assist and Arrange and the five Rs for Relevance, Risks, Rewards, Roadblocks and Repetition. The counsellors, while, delivering the intervention or counselling, are expected to be motivating and empathetic. IN THE MIDDLE 67 The Big Ban S ome called it curiosity, others peer pressure. Some thought it was cool, others saw in it, stress reliever. For whatever reason, many took to smoking as a “fad”. Before they knew it, they were dragged into the habit. Five years ago Kuenzang Namgay thought that was the only way to bond with people, make friends and maintain a circle. Today, a high school drop-out, he recalls all the retributions he faced in school for being caught smoking. Ultimately, that led to suspension from school. Life, since then, changed. The same could not be said about his smoking habit. For another drop-out, who works in a restaurant in Thimphu town, her early exposure to cigarettes was through her mother’s handbag. She could pull out a stick or two when her mother was not around. Pema Wangmo said she tried quitting but to no avail. She said her determination gave way when she was with her smoker friends. “I think it is also the availability in the market that makes it difficult for some of us to quit,” she said. Some youth in Thimphu said it was easy to locate shops that sold cigarettes. After frequent visits, they built contacts and maintained a steady supply. It was also their friends who travelled to border towns and returned with several packets as gifts. Youth who were interviewed said, despite knowing the ill effects of cigarettes and tobacco, they were unable to rise from its smoky veil. A few had resorted to online tips and quitline services only to be met with disappointments. Dragged into the habit 68 The Big Ban HEALTH BURDEN 221 25% 14% 42% Tobacco related deaths in the country (2018) Chronic respiratory diseases Cancer Cardiovascular diseases Tobacco users in the country and people exposed to second hand smoking Biggest current health expenditure attributed to NCDs 34% (FY 2016-17) 38% (FY 2017-18) Source: Fourth National Health Accounts study Tobacco is one of the four main risk factors of NCDs Tobacco use (adult) Male 34% 14% Female 120,000 69% of all deaths (4,700) NCD related (2018) Government expenditure on NCDs Expenditure incurred in referring complicated NCD cases to India for treatment Nu 1,633 million FY 2014-15 Nu 1,693 million FY 2015-16 Source: Factsheet Bhutan, 2018 (tobacco) Source: STEPS survey 2014 69 The Big Ban HEALTH BURDEN 221 25% 14% 42% Tobacco related deaths in the country (2018) Chronic respiratory diseases Cancer Cardiovascular diseases Tobacco users in the country and people exposed to second hand smoking Biggest current health expenditure attributed to NCDs 34% (FY 2016-17) 38% (FY 2017-18) Source: Fourth National Health Accounts study Tobacco is one of the four main risk factors of NCDs Tobacco use (adult) Male 34% 14% Female 120,000 69% of all deaths (4,700) NCD related (2018) Government expenditure on NCDs Expenditure incurred in referring complicated NCD cases to India for treatment Nu 1,633 million FY 2014-15 Nu 1,693 million FY 2015-16 Source: Factsheet Bhutan, 2018 (tobacco) Source: STEPS survey 2014 70 The Big Ban COST OF TOBACCO Nu 350 Nu 20 A tray of eggs 10 grams of chewing tobacco 200ml milk A pack of 20 cigarettes 71 The Big Ban Calling it quits I t was only when Sangay found out about the baby she was carrying within her, that her impetuous life beamed glaring back at her. Her morning started with a puff or two. After every meal and every drink, she lit a stick. She would end her day with one too. The 28-year-old picked up the habit from high school and carried it along into her marriage. Several attempts to quit in between were a disappointment. “But no reason can be bigger than doing it for one’s child,” she said. In the coming weeks, she was not just fighting the morning sickness but the longing to smoke too. She would convince herself that the life within deserved a better chance and it was her responsibility to ensure that. It also became evident that the cigarettes she stopped buying saved her a good amount, which earlier created a dent in her modest corporate salary. Well into her due date, to becoming a mother anytime now, Sangay said her baby comes as a saviour. “At the rate I was going, I would have ended up with a disease,” Sangay said. “It’s the baby I’m expecting who is giving me life actually, not otherwise.” 72 The Big Ban On passive smokers • Cardiovascular diseases • Lung cancer • Sudden infant death syndrome (SIDS) • Heart disease • Asthma • Stroke Impact of Secondhand During Pregnancy • Low birth weight • Poor lung function • Ear infections • Abnormal or delayed growth and development • Secondhand smoke • Congenital malformations or spontaneous abortion • Secondhand smoke has different chemicals, some associated with cancer • It has twice the amount of nicotine and tar and five times carbon monoxide 73 The Big Ban 5.7% 18.9 42% 75% 38% 6% 13% 25% 14% of all deaths caused by tobacco (221 deaths each year) Cardiovascular diseases (CVDs) Communicable, maternal, neonatal & nutritional diseases Others Cancers Years CVDs in younger people are more likely to be caused by tobacco use 14% 10% 5% 19% 30-44 45-59 60-69 70+ Age in years Chronic respiratory diseases Tobacco deaths by cause (221 annually) BHUTAN FACTSHEET 2018 Most people start early, increasing the risk of heart disease in younger people. Mean age at initiation of daily smoking: People who quit tobacco use Former daily smokers Former daily smokeless users Heart disease and stroke are the most common ways tobacco kills people USD 2,510 Gross national income per capita (lower middle-income country) 808,000 Total population 9% Youth population (13-17 years) 41% Economically productive population (30-69 years) SOURCE: Bhutan tobacco fact sheet 2018 WAGING ON Challenges and opportunities in addressing public health issues of tobacco use.

WAGING ON 76 The Big Ban I n a time of increasing instances of noncommunicable diseases (NCDs) and spike in preventable deaths, the need to strengthen tobacco control implementation under the Sustainable Development Goals (SDG), is timely. SDG 3 is about ensuring healthy lives and promoting wellbeing for all at all ages. Among other targets, the goal calls for strengthening implementation of the WHO FCTC in all countries. In Bhutan, NCDs account for about 69 percent of all deaths, making it the leading cause of preventable deaths. Deaths from NCDs in the country spiked from 53 percent in 2011 to 69 percent in 2018. Tobacco is one of the four risk factors associated with NCDs. Nutrition, sedentary lifestyle and alcohol are the other three. It is also linked to cardiovascular diseases, which causes about 28 percent of deaths in the country. Various chronic respiratory diseases and cancer cause nine and 10 percent of the deaths respectively. According to WHO SEA-Region’s Tobacco Control for Sustainable Development report, toxic chemicals present in tobacco smoke are responsible for adverse birth outcomes in pregnant women exposed to tobacco smoke, either directly or passively. This has implications on SGD 3 targets of reducing global maternal mortality ratio to less than 70 per 100,000 live births, and ending preventable deaths of newborns and children under five years. SDG 3 also looks to strengthening prevention and treatment of substance abuse. Tobacco is a gateway for other substance abuse, with nicotine contained in tobacco, being a highly addictive substance. Recognising tobacco as a threat to development, strengthening the implementation of WHO FCTC is of utmost importance and would be critical in realising the SDGs. A block en route to SDGs WAGING ON 77 The Big Ban 1 NO POVERTY 2 ZERO HUNGER 4 QUALITY EDUCATION 5 GENDER EQUALITY 6 CLEAN WATER AND SANITATION 7 AFFORDABLE AND CLEAN ENERGY 8 DECENT WORK AND ECONOMIC GROWTH 9 INDUSTRY, INNOVATION AND INFRASTRUCTURE 10 REDUCED INEQUALITIES 11 SUSTAINABLE CITIES AND COMMUNITIES RESPONSIBLE CONSUMPTION AND PRODUCTION 12 CLIMATE ACTION 13 LIFE BELOW WATER 14 LIFE ON LAND 15 PEACE AND JUSTICE 16 PARTNERSHIPS FOR THE GOALS 17 GOOD HEALTH AND WELL-BEING 3 WHO FCTC Tobacco Control for Sustainable Development Tobacco C ntr l for Sustai able Development WAGING ON 78 The Big Ban I n the long run, prevention is indispensable to improving health and lowering health care cost. Instead of investing heavily on health infrastructure and facilities, which will only incur more cost in future since that is targeted at a medical care with focus on treating illnesses, we should plan towards a better health care through preventive measures. Many of the diseases we see emerging today, are of the noncommunicable type, like diabetes, cancer, heart diseases and other chronic ailments, which are all preventable through intervention in behavioral change. Apart from poor diet, alcohol, substance abuse and doma (betel nut), tobacco consumption is one of the main contributors to the growing chronic noncommunicable diseases, the main cause of death and disability today. These risk factors are preventable and they call for measures that have to do with Prevention is key Health secretary Dr Ugen Dophu, who served the ministry in various capacities for over 30 years, talks about the need for every Bhutanese to work together in tackling the issue of tobacco use. Dr Ugen Dophu, Health Secretary WAGING ON 79 The Big Ban investing little today, before emergence of illnesses and much before medical care is necessitated. It is captured well by our own Bhutanese proverb: nye ma wom ley rimdo (prevention in the form of a ritual in the past to ward off illnesses). Advocacy towards changing people’s behavior to wean them away from dependence on tobacco; cessation programmes to reduce demand for tobacco since there is nothing we can do about the supply; and providing counselling services are what we have been doing so far and will continue to. We intend to open these services throughout the country and review them so we can improve or strengthen our programmes. We will also begin cessation programmes in traditional medicine as well. It has proven effective. Advocacy and awareness programmes need to also extend to parents and families. It has, to a great degree, to do with parenting and family support when it comes to weaning and changing habits with regard to tobacco consumption and addiction. It is not our youth to be blamed if they are increasingly found to be hooked to tobacco and its products, the society is to be blamed for allowing this to perpetuate. Whatever happened to times when an elderly citizen, who came across youth smoking or chewing tobacco, advised them of its ill effects. We don’t have to change how we do things, we just have to revive some of the good old ways that have proven effective. WAGING ON 80 The Big Ban I t was a courageous step taken by the government to implement the ban on sale of tobacco. What Bhutanese should understand is that the proposal for the ban came from the people. Although there has been persisting issues and challenges, it has not been in vain, for people smoking openly in the street, cars or other public places, have significantly reduced. Bhutan has clear laws and BNCA and other law enforcement agencies are committed to implementing the laws, Everyone’s responsibility BNCA’s Director General Phuntsho Wangdi calls for a concerted effort, from not just law enforcement agencies but citizens too, for better implementation and outcome of tobacco control measures. Phuntsho Wangdi, Director General, BNCA WAGING ON 81 The Big Ban although limited by inadequate resources and challenged by the porous border. These are not defenses against what is not going right but a call to citizens to take that extra responsibility to contribute to tobacco control measures in the country and not leave everything to law enforcement agencies. It is important for the society to transform and recognise the implications of tobacco use on health, economy and society at large. Abiding by the law is every citizen’s responsibility. When people break the law, we are building a community of people who can break the law and get away with it. Following the implementation of the Act, there has been a lot of hue and cry, which brought down the penal provisions. But what we see now is people taking advantage of these changes. Shopkeepers selling tobacco keep a stock of tobacco within the permissible limit and maintain that they kept it for self-consumption. They can only be fined for illegal possession. Sympathy for offenders is, and will continue to create a society of law un- abiding citizens. When it comes to sensitisation we leave no stone unturned, taking opportunity to create awareness and educate shopkeepers, the public at gatherings, talking to local leaders, students and out of school youth. Perhaps the time calls for a little refinement in the policy. Maybe we can have limited outlets selling tobacco. However, what’s important is that we strike a balance looking at all implications. Liberalisation can sometimes make a situation worse. If the society takes responsibility and joins hands with law enforcement agencies, in a few years, we can have a country of only few tobacco users. WE ARE BUILDING A COMMUNITY OF PEOPLE WHO CAN BREAK THE LAW AND GET AWAY WITH IT. WAGING ON 82 The Big Ban T he one thing all stakeholders agree to is the lack of coordination among themselves when it comes to implementing and enforcing tobacco control measures. Each stakeholder – police, customs, health officials – are overwhelmed with their primary mandates. The police have to uphold law and order, and narcotic and psychotropic substance abuse is high on their priority list. The customs offices are burdened with manual inspections of imports into the country. Among health officials, lack of in depth studies to move decisions is an issue. The stakeholders agree that tobacco policies, rules and regulations are in place and the Tobacco Control Act gives them the legal teeth. Its implementation is, what they metaphorically allude to a mountain they have to scale and overcome. The health ministry has, even before ratifying the FCTC, carried out advocacies at various levels and throughout the country. Studies have been carried out, but not enough to provide an in-depth picture of the current scenario. There exist obvious loopholes in the Act and a relook at it could help revise strategies to control sale and use of tobacco. There are speculations and limited evidence-based findings. The GYTS indicates a rising trend in tobacco use among students calling for stakeholders to work together. The health ministry with support from WHO trains school counsellors and health coordinators. Tobacco users are often left without an alternative. Police officials feel it is necessary to have smoking facilities in places, where public gatherings usually happen. Health officials feel tobacco cessation drugs should be in the essential drugs list, because when Together for a cause? WAGING ON 83 The Big Ban Impermissible • Trade of tobacco • Sale of tobacco and its products • Smoking in public places but then... • Available across the border • Certain amount can be imported for self consumption • Available for purchase under the table • Allowed in designated smoking zones THE ACT SAYS someone wants to quit tobacco, all they can prescribe today is nicotine gum. For change in behavior, health officials feel it is not only their responsibility, or that of other stakeholders, but of every Bhutanese. The black market has made tobacco available to users, who have never been pushed to the edge of not finding it. Instead of having a flourishing black market, most stakeholders believe sale should be allowed, through limited legal outlets and jacked up tax. This would also address the issue of underage youth’s access to tobacco. The issue of porous border calls for more coordination with narcotics authorities from across the border. Today, coordination among stakeholders is limited to joint inspections. WAGING ON 84 The Big Ban A ligning more with disease prevention and health promotion, WHO will continue to advocate and provide technical support, in collaboration with the government, in its efforts towards tobacco control. It will also take up advocacy for the government to ratify the Protocol to Eliminate Illicit Trade in Tobacco Products, especially in light of the thriving illicit trade in tobacco and its products across the country. Apart from that, the support will also be in terms of surveillance, including regular survey on tobacco use, particularly among students and youth. Tobacco will be included as part of STEPS survey. WHO will extend its support in implementing the PEN protocol. In partnership WAGING ON 85 The Big Ban THE FUTURE: Every effort the country makes towards control of tobacco use , it owes it to its youth. • Alleged source caught at Chunzom, Kuensel article. March 15, 2011 • Annual Health Bulletin 2018. Ministry of Health. Available from: http://www.health. gov.bt/wp-content/uploads/ftps/annual-health-bulletins/Annual%20Health%20 Bulletin-2018 • Bhutan needs assessment report for the implementation of the WHO Framework Convention on Tobacco control. May 09, 2011, World Health Organization. • Brief Profile of Tobacco Control in Bhutan, 2010. Ministry of Health, Royal Government of Bhututan. Available from: http://www.searo.who.int/tobacco/documents/2010- pub1.pdf?ua=1 • Bhutan Tobacco Fact sheet 2018. World Health Organization. Available from: https://apps.who.int/iris/bitstream/handle/10665/272671/wntd_2018_bhutan_ fs.pdf;jsessionid=F081F0BB86722738F31465931AD912FD?sequence=1 • Do Bhutan’s Anti-Smoking Laws go to far, Kuensel article. [cited April 12, 2011] • For the want of a photocopier...,Kuensel article. March 23, 2011 • From the Ocean of Profound Essence; A Powerful Pith Instruction to Abstain from Tobacco, the Tenacious Demon Plaguing People of Degenerate Times, Zabtik Gyatso • Global Youth Tobacco Survey report. 2006, 2009, 2013. World Health Organization and Ministry of Health. Available from: http://www.health.gov.bt/wp-content/uploads/ moh-files/2016/11/GYTS-report-2015.pdf • Getting down to the nitty gritty, Kuensel article. March 24, 2011 • Getting tougher on tobacco, Kuensel article. June 1, 2010 • Implementation of tobacco control policy in Bhutan, World Health Organization. • National Health Accounts, 2019. Ministry of Health. • NCD and Cancer burden in the country, 2019. Ministry of Health. • New tobacco Act will benefit, Kuensel article. January 5, 2012 • Opposition calls for amendment, Kuensel article. March 5, 2011 • Passed by an absolute majority, Kuensel article. June 2, 2010 • PM weights in on tobacco controversy, Kuensel article. March 7, 2011 • Proposal to lighten penalties, Kuensel article. January 5, 2012 • Recapitulating an Act, Kuensel article. March 12, 2011 • STEPS survey, 2014. World Health Organization. Available from: https://www.who.int/ ncds/surveillance/steps/Bhutan_2014_STEPS_Report.pdf • Stubbing it out, Kuensel article. November 27, 2010 • The International Tobacco Control Policy Evaluation Project ITC Bhutan Project Report May 2011 (MoH, RGoB, ITC Bhutan Project Report). Available from: https://itcproject. org/files/Report_Publications/National_Report/itcbhutanreportapr27v20web.pdf References

88 The Big Ban A remote mystical Buddhist kingdom, clasped within the towering ranges of the mighty Himalayas, Bhutan made a bold, unprecedented move in 2004. As a means to deter, what the country began to witness as a menace, in the form of growing tobacco consumption among its people, especially the youth, a law, banning nationwide sale of tobacco, was put in place. Unlike most policies, this was people-led. But like most of its national policies, this too was meticulously crafted through national consultations. A decade and a half has passed since the ban. How did the decision on nationwide ban of tobacco sale come about? How has this country of slightly over 700,000 people fared with its tobacco control law? What are the issues facing its successful implementation? Come aboard and join the extraordinary journey of a magical kingdom in its campaign against tobacco, one of the greatest afflictions facing the world today.