Tag: bhutan

  • Bhutan’s Tryst with Health Imperialism

    Bhutan’s Tryst with Health Imperialism

    The author standing with a local in front of a pharmacy stocking NRT gums adjacent to a grocery shop officially selling tobacco. (Photo courtesy of Sudhanshu Patwardhan)

    Without offering locally relevant cessation tools, prohibition is doomed to fail.

    By Sudhanshu Patwardhan

    Bhutan, a country that measures its riches in terms of “gross national happiness,” may have become an unsuspecting victim of a new form of imperialism: health imperialism. A blind copy-paste of Western tobacco control policies, worsened by local gold-plating, may have landed Bhutan in a mess. A visit to the landlocked nation gave the author a unique insight into how prohibition of tobacco without offering locally relevant and innovative tobacco cessation tools threaten this Shangri-la.

    The Forbidden Kingdom

    A series of district-wide tobacco control measures in Bhutan from the 1980s culminated in the declaration of a nationwide ban on the sale of tobacco products in 2004 through a resolution of the National Assembly. Overnight, Bhutan became a poster child of global tobacco control, an emerging David against the Goliath of transnational tobacco companies. Nanny statists got a lifeline, and the “p” word—prohibition—was resurrected after successive failures of over 150 years in alcohol and drug prohibition movements. The Tobacco Control Act of 2010 further enshrined into law restricted access, availability and appeal of tobacco products and gave sweeping powers for arresting those selling or even possessing tax-unpaid tobacco for personal consumption. Bhutan was all set to become a tobacco-free society. A happy nation was also going to become healthier. In theory.

    Market Forces Take Over

    The roller-coaster ride between 2010 and 2019 is captured in the World Health Organization’s regional office’s 2019 publication The Big Ban: Bhutan’s journey toward a tobacco-free society. A big achievement in this period was visible reduction in public place smoking. Otherwise, the optimistic title belies the details of the failed ban confessed in the publication. It is a classic tale of good intentions scuppered by poor execution. A highlight of the data reported there is the difficulty in enforcing the ban, evidenced by availability of tobacco products below the counter in most shops in Bhutan. Tobacco use among 13-year-olds to 15-year-olds went up from 24 percent in 2006 to 30 percent in 2013 based on the Global Youth Tobacco Survey findings. The severe penalties required by the initial law resulted in more than 80 people being imprisoned between 2010 and 2013. There was growing discontent about the disproportionality of the penalties among the people of a nation gradually moving from a benevolent absolute monarchy to a democratic constitutional monarchy. Public furor and rethinking among the lawmakers resulted in amendments and milder punishments, and the law’s “claws (were) trimmed,” states the WHO report. Between 2010 and 2014, permissible quantity for personal possession was steadily increased for both smoked and smokeless tobacco products. The ban and its enforcement were proving ineffective and untenable. And then Covid-19 happened.

    Reversal of a Failed Ban

    The government was obviously losing revenue due to the flourishing black market of smoked and smokeless tobacco products smuggled from India and elsewhere. The fear of tobacco smugglers bringing in the Covid-19 virus was enough excuse to act decisively. In July 2021, the government amended the 2010 Act, thus lifting a decade long ban on local tobacco sales.

    The pragmatism of the politicians who reversed the ban presents a sharp contrast to the previous prohibitionist policy. Today, sales and consumption continue, and based on the most recent (2019) WHO STEPwise approach to surveillance (STEPS) data, 24 percent of those between ages 15 and 60 currently use tobacco products. Sadly, the ban did not make Bhutan a tobacco-free society. Anecdotally, e-cigarettes are also available now in some grocery stores in the capital, Thimphu, and attracting use among smokers and never-smokers. These are not regulated nor used as smoking cessation tools, presenting another area of concern for public health. A ban may not be the answer for these products either. Regulation that balances current smokers’ needs for safer alternatives versus prevention of uptake by the youth and nonsmokers will be key.

    Peering Through an ‘Addiction’ Lens

    I first read about the ban’s overall failure in the 2019 WHO report and then heard about the reversal of the ban during the global Covid-19 pandemic. How did Bhutan land in this situation? There is, of course, economics at play: demand, supply and something to do with a genie being out of the bottle. When I put my doctor’s hat on, a key explanation stares at me: lack of quitting support for the existing 120,000 tobacco users. Reams of self-congratulatory publications and numerous WHO awards to Bhutan since the 1990s have focused on success in awareness-building and restricting access and use. The famous case of the Buddhist monk who was jailed for three years in 2011 for the possession of $2.54 worth of tax-unpaid tobacco misses the point that he was very likely addicted to tobacco and may have needed more than punishment to quit. In the absence of availability of tobacco products, it should have been a human right for him to have access to safer nicotine to manage nicotine withdrawals and achieve craving relief. This assessment should not be used to vilify tobacco users. Instead, it should be a reminder to those in tobacco control that preaching to nicotine-dependent users without offering alternatives is not enough and also unethical. A key demand-side reduction measure, to use Framework Convention on Tobacco Control (FCTC) vocabulary, is that of providing tobacco dependence treatment and services. This is covered under FCTC Article 14 but rarely implemented in low-income and middle-income countries (LMICs), Bhutan included. I saw firsthand recently the country’s struggles with rising tobacco use coupled with a lack of cessation products and services.

    Tobacco Cessation: The Poor, High-Maintenance Cousin

    In Bhutan, like in most LMICs, overall tobacco control is run by public health experts, and tobacco cessation specifically (and separately) falls under the remit of psychiatrists. Neither groups are excited by tobacco cessation for a variety of reasons. Public health professionals often have little or no experience in treating individual patients and have increasingly been sold a unidimensional narrative that the tobacco epidemic is singularly driven by the commercial vested interests of tobacco companies (the “vector”). For them, the tobacco user is a victim of the tobacco industry, should be labeled an addict and then preached at to quit. Psychiatrists, on the other hand, are generally geared toward treating established mental health conditions and severe mental illnesses and even within the “de-addiction” field prioritize substance abuse treatment and alcohol de-addiction over tobacco cessation. Tobacco cessation with nicotine-replacement therapy and other pharmacological interventions are costly and need a level of training and qualification to prescribe—and are therefore cost-prohibitive to be offered at scale. They are also not without their failures, give around 20 percent quit rates at one year in controlled clinical studies and much less success in real-world settings. The success of quitting cold turkey is overrated and often drives policymakers’ wrong beliefs and attitudes about the ease of quitting. Public health tobacco control awareness campaigns and advocacy, on the other hand, are highly visible, scalable, inherently worthy endeavors, and most do not require impact assessment as proof of success. The FCTC’s Article 14 thus remains a neglected tool for reducing harms from tobacco globally and receives little or no funding from international donors and national governments nor any interest from pharmaceutical companies or tobacco companies to innovate in.

    Safer Nicotine Not Widely Available in Bhutan

    Nicotine illiteracy among healthcare professionals and lack of availability of safer nicotine alternatives can translate into poor quitting among tobacco user patients. From my field visits to pharmacies and discussions with frontline healthcare professionals in Bhutan, I noted that 2 mg and 4 mg nicotine gums have only recently become available in some pharmacies in Thimphu, but patches are not stocked. Patients come and buy these over the counter, but there is little record of how long they take it for, their quit and relapse rates and whether their doctors support them in their quit journeys. Varenicline or bupropion are not available for cessation. When called, the “national quitline,” contrary to the claim of the 2019 and 2024 WHO publications, do not deal with tobacco cessation support. Most of the healthcare professionals in Bhutan receive their undergraduate and graduate training in India, Sri Lanka and other nearby Asian countries. Similar to the rest of the world, doctors in Bhutan are not confident about prescribing nicotine-replacement therapy and may harbor misperceptions about nicotine itself. They have not received any tobacco cessation-related training in the past five years, and nicotine-replacement therapy is not available for free or at subsidized prices anymore, unlike other medications in Bhutan.

    Navel-Gazing Time for All?

    The backpedaling by Bhutan on the tobacco ban has not been reported or analyzed widely enough. Bhutan’s failure to rein in tobacco sales and increased use, despite a ban, should be a wake-up call for all parties involved. What was touted as a role model for other countries for eliminating harms from tobacco has instead become a cautionary tale for poor policymaking done to pander to international funders and organizations. The undue influence of a select few Western nations in national health policymaking for LMICs is also a matter of concern as the global geopolitical order rapidly morphs. Projects such as FCTC 2030, funded by the U.K., Norway and Australia, continue to churn out reports such as the Investment Case for Tobacco Control in Bhutan (WHO/UNDP, February 2024), ignoring lessons from the ban, mostly unaware of capacity issues on the ground and not addressing the need of current tobacco users for safer nicotine alternatives. Emergent strong economies such as China and India will no longer tolerate meddling by past colonial powers and imperialist nations in their health policies, but neither should other LMICs.

    Toward Gross National Health

    For a nation of around 750,000 people, tobacco use is claimed to kill between 200 people and 400 people every year—all preventable deaths (side note: the data for the same year varies dramatically between two WHO reports). Global tobacco control has failed Bhutanese tobacco users and their families. For a nation built on principles of sustainability, risky forms of smoked and smokeless tobacco products have no place in society. The mountains, the clean air, the happy smiles and peace-loving people of Bhutan deserve to own tobacco control initiatives, not be made to adopt hand-me-down Western ideologies or policies. That will require the doctors and pharmacists in Bhutan to understand the science of tobacco cessation and harm reduction and make quitting sexy. Availability of nicotine-replacement therapy products, innovation in safer nicotine alternatives and improved cessation services will need to be ensured and incentivized by the government. That has the potential to keep their nation happier and healthier for the coming generations.

    Disclaimer: The author’s work here or elsewhere is dedicated to using ethical and scientific evidence-based approaches to eliminate harms from all risky forms of smoked and smokeless tobacco products. The article is based on the author’s personal conversations with experts and lay people in Bhutan and from shop visits and an analysis of two of the most recent WHO reports on this topic. The intent of this article is to shine a light on a vulnerable LMIC’s experience with unchecked health imperialism to create insight and debate on the impact and implications of such practices. The author holds utmost respect for the nation, the policymakers and the people of Bhutan.

    Sudhanshu Patwardhan is a medical doctor, nicotine expert and health tech entrepreneur from India, based in the U.K. He works on projects around the world to reduce harm from tobacco, especially among the most disadvantaged tobacco user populations.
  • The Evil Twins

    The Evil Twins

    Photo: Taco Tuinstra

    Prohibition and illicit trade

    By Clive Bates

    The remote Himalayan Kingdom of Bhutan was the poster child of tobacco control for many years. It appeared that Bhutan had drawn the obvious conclusion from decades of scientific research and had finally done the right thing. In 2004, the kingdom banned the sale of all tobacco products. Tobacco control activists were delighted.

    Jump forward to 2020, and the picture is not so rosy. In a joint report by the government and the World Health Organization office in Bhutan, “The Big Ban: Bhutan’s Journey Toward a Tobacco-Free Society,” Health Minister Dechen Wangmo, sets out the situation: “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.”

    According to the WHO, Bhutan has high levels of ongoing tobacco use despite prohibition. The WHO representative to Bhutan, Rui Paulo de Jesus, provides a candid explanation: “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 center of this growing illegal trade in tobacco and its products.”

    Prohibition as a Perturbation

    Unusually for the WHO, the words above contain some essential truths about tobacco policy and prohibitions. The first and most important insight is that while demand for a product persists, a prohibition will just change how the product is supplied. A prohibition does not make a product disappear, even if that’s what politicians and policymakers would like. Instead, a prohibition is a perturbation of a dynamic market: a disruption that reconfigures the behavior of suppliers and consumers, changing who supplies the product, what products are available and under what terms. Prices can go up to reflect the costs and risk of illicit supply. Alternatively, prices can fall as no tax is paid on illicit goods. Illicit commerce is unregulated and ultimately controlled by violence rather than by consumer protection or contract law. An unregulated illegal market creates real dangers to consumers. The 2019 outbreak of severe and often fatal lung disease was caused by adding a harmful additive, vitamin E acetate, to illicit cannabis (THC) vapes as a cutting agent. Arguably, this disaster would never have happened had cannabis vaping products been widely available legally and without excessive taxation.

    Participation in Criminal Supply Chains

    The second insight is that young people may see the opportunity to make fast money as foot soldiers in an illicit irregular supply chain. It should be a significant consideration in assessing the case for prohibitions supposedly aimed at “protecting kids.” If adolescents want access to the banned products, then a prohibition policy will likely draw young people into the illicit supply chain and an early experience of criminality. Alternatively, the illegal supply of, say, cannabis could diversify to provide prohibited nicotine products as well. For example, in the United States, the Monitoring the Future survey shows that past 30-day cannabis use among 12th grade students has been around 20 percent for the last 25 years. That means there is a ready-made illicit supply chain for providing tobacco or vaping products to young people, should that prove attractive to cannabis suppliers.

    Types of Prohibition

    Not all prohibitions are as pervasive and straightforward as Bhutan’s. Let’s consider two further categories. First, many tobacco and nicotine policies have a partial prohibition element. By this, I mean the policies are intended to deter the use of the product rather than to protect the user. For example, a ban on flavored e-liquids has a prohibitionist purpose, but a ban on a toxic ingredient in e-liquids has a consumer protection purpose—an important distinction. Caps on nicotine strength or requiring a prescription to access vaping products are partial prohibitions. In On Liberty, John Stuart Mill famously equated taxes on stimulants to prohibition: “To tax stimulants for the sole purpose of making them more difficult to be obtained is a measure differing only in degree from their entire prohibition and would be justifiable only if that were justifiable.”

    The United States and New Zealand have proposals to reduce nicotine in cigarettes to a minimal “subaddictive” level. This is essentially a prohibition of cigarettes dressed up as a sophisticated regulatory intervention. Without adequate nicotine, cigarettes are worthless for most users, and they might as well be prohibited. The practical question is what would happen next: Would users quit altogether, move to illicit cigarettes or, for example, switch to vaping? The least likely outcome is any significant or sustained use of low-nicotine cigarettes.

    Second, a particular category needs to be defined for the prohibition of products that are beneficial to the user. The snus ban in the European Union has persisted since 1992 despite a mountain of evidence that snus has had a radically positive impact on public health in Sweden and Norway, where it is widely available. There may be arguments for prohibiting harmful products like cigarettes, even if there are doubts about the practicalities, perverse consequences and ethical implications for adult autonomy. But how can anyone defend the prohibition of much safer products that function as alternatives to cigarettes? Yet, there is now a lavishly funded international campaign to do exactly that. The international respiratory health organization The Union is calling for vaping and heated-tobacco products to be banned in all low-income and middle-income countries. That would cover 80 percent of the world’s smokers. This crazy logic is equivalent to campaigners against sexually transmitted diseases pressing for the prohibition of condoms in the hope that it would deter sex by making it more dangerous.

    More Enforcement?

    Although the WHO’s representative in Bhutan concisely described the problem, he still followed the eternal prohibitionist playbook and called for more enforcement effort. “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.”

    But this idea, embracing hi-tech track-and-trace technology, seems implausible in the environment of a developing country and an informal economy in tobacco products. Further, more enforcement muscle brings problems of its own. It is expensive, violent and prone to bribery, corruption and abuse of office. Drug prohibition in the United States is notoriously associated with racism. As the Drug Policy Alliance puts it, “People of color experience discrimination at every stage of the criminal legal system.”

    Prohibition by Trial and Error

    Perhaps the big policy questions cannot be answered until a prohibition has been tried and experience gained? Beware! The danger is that temporary prohibitions may have irreversible effects. Prohibitionists should turn to the 2020 experience in South Africa in which the government banned tobacco sales with a justification based on a Covid-19 response. Research by independent economists at the University of Cape Town concluded that the legal supply had been replaced by illicit supply with a substantial loss of tax revenue. But now that tobacco users have found illegal suppliers to evade prohibition, what is to stop them from continuing to avoid tobacco taxation?

    Responsibility and Accountability

    One characteristic of prohibition advocates is a reluctance to assess the consequences of their work. The prohibition policy is their real goal, but the real-world consequences are of lesser concern. For example, the UN Office on Drugs and Crime has dogmatically resisted calls to conduct a thorough assessment of the benefits and detriments of the drug prohibition treaties it oversees. This mindset is already evident in the tobacco and nicotine field. In 2019, India’s federal government imposed a comprehensive ban on vaping products. In 2021, the WHO awarded India’s former health minister, Harsh Vardhan, its highest tobacco control medal “for spearheading the government of India’s legislation to ban e-cigarettes and heated-tobacco products”. However, this award was made without any evaluation of the impact of the prohibition on illicit trade, no consideration of the likely perverse consequences leading to more smoking or any reflection on the ethics of denying India’s 100 million smokers lawful access to much safer alternatives.

    Proposals for prohibitions, in all their forms, need a much stricter assessment of the likelihood of illicit trade, perverse but easily foreseeable consequences and the ethics of using the force of law to control individual risk behaviors. That has been a conspicuous failure with illicit drugs and alcohol. Let’s hope that policymakers learn those lessons and don’t repeat the mistakes with nicotine.

    Finally, a postscript. Following a temporary lifting of Bhutan’s tobacco ban in 2020 for Covid-19-related reasons, Bhutan’s National Assembly passed the Tobacco Control (Amendment) Bill 2021 and Tax Bill of Bhutan 2021. This lifts the ban and legalizes the selling, buying, possession, distribution and transportation of tobacco and tobacco products. The signature prohibition of tobacco control has officially failed.

    Clive Bates is the director of Counterfactual Consulting and the former director of Action on Smoking and Health (U.K.).
  • Bhutan to Foster Distribution Competition

    Bhutan to Foster Distribution Competition

    Photo: satori

    Lawmakers in Bhutan are drafting rules to promote greater competition in the distribution of tobacco products, reports Kuensel.

    Currently, the country has only one tobacco distributor—Bhutan Duty-Free Limited (BDFL)—according to Economic Affairs Minister Loknath Sharma. “We cannot allow only BDFL to be the sole distributor because the aim is to stop illegal trade and at the same time make tobacco and tobacco products available,” he said.

    The Tobacco Control Rules and Regulations (TCRR) 2021 would create “a good distributor wholesale system” in Bhutan, Sharma noted.

    The rules are expected to be ready by December, according to Ugyen Tshering, the officiating director general of the Bhutan Narcotics Control Authority (BNCA).

    He said that the revision of TCRR was completed and was awaiting the endorsement from the BNCA board to be submitted to the Cabinet.

    As interim measures, the government has allowed micro-license holders, such as paan shops and grocery shops, to import tobacco products to meet the growing demand.

    With the limited supply of tobacco and tobacco products from BDFL, the paan shops had resorted to the black market.

    Bhutan recently moved to lift a longstanding ban on the sale tobacco products. By legalizing tobacco, legislators hope to help check the spread of Covid-19, which they believe has been worsened by the continuous smuggling of tobacco products through Bhutan’s porous southern border.

    The manufacture of tobacco products remains illegal, however—as does public smoking.

    Tshering said that if someone was caught smoking in a public place—defined as any place with more than two persons—that person would be subject to a BTN500 ($6.77) fine.

    Bhutan banned tobacco sales in December 2004. Tobacco Reporter was the first to report from the world’s only officially smoke-free nation.

  • Bhutan Moves to Legalize Tobacco

    Bhutan Moves to Legalize Tobacco

    Photo: s_jakkarin

    The National Assembly of Bhutan has taken a first step toward lifting the country’s ban on tobacco products, reports East Mojo.

    Passed on June 25, the Tobacco Control (Amendment) Bill 2021 and Tax Bill of Bhutan 2021 would legalize the selling, buying, possession, distribution and transportation of tobacco and tobacco products in the country. Manufacturing tobacco would remain illegal, however.

    By legalizing tobacco, legislators hope to help check the spread of Covid-19, which they believe has been worsened by the continuous smuggling of tobacco products through Bhutan’s porous southern border.

    The act also mandates that the government provide counselling and treatment to facilitate tobacco cessation. Premised on the physical health and well-being of the Bhutanese people, the legislation recognizes the harmful effects of tobacco consumption and exposure to tobacco smoke on both spiritual and social health.

    The bill will now be referred to the National Council for endorsement.

    Bhutan banned tobacco sales in December 2004. Tobacco Reporter was the first to report from the world’s only officially smoke-free nation.

  • Bhutan Suspends Tobacco Ban

    Bhutan Suspends Tobacco Ban

    Photo: Taco Tuinstra

    Bhutan has temporarily reversed a ban on the sale of tobacco, citing the coronavirus pandemic.

    The Himalayan kingdom prohibited the sale, manufacture and distribution of tobacco more than a decade ago but allowed smokers to import controlled amounts of tobacco products after paying hefty duties and taxes.

    Smoking is considered a sin in the mostly Buddhist country, where a tobacco control law was first passed in 1729 and the tobacco plant is believed to have grown from the blood of a demoness.

    The tobacco ban spawned a thriving black market for cigarettes smuggled over the border from India.

    When Bhutan closed its frontier with India earlier this year because of the coronavirus pandemic, under-the-counter tobacco prices soared fourfold as the traffickers found it harder to get into the country.

    To temper demand for the smuggled cigarettes and, in theory, lessen the risk of cross-border contagion, Bhutan decided to suspend its tobacco ban. The decision allows smokers to buy tobacco products from state-owned duty-free outlets for the duration of the pandemic.

    Bhutan banned tobacco sales in December 2004. Soon after, Tobacco Reporter visited the Himalayan kingdom to report from the world’s first officially smoke-free nation.

  • Bhutan to Tolerate Tobacco Sales

    Bhutan to Tolerate Tobacco Sales

    Photo: Taco Tuinstra

    The decision by Bhutan’s government to allow the opening of tobacco sale outlets in the country is consistent with the nation’s Tobacco Control Act and constitution, according to the Office of the Attorney General (OAG).
     
    While the Tobacco Control Act of 2010 restricts the domestic sale and purchase of tobacco products, it allows individuals to import tobacco for personal consumption.
     
    Because of the coronavirus crisis, however, Bhutan has closed official border crossings, boosting illegal imports. By allowing limited domestic sales, the government hopes to crack down on smuggling.
     
    Responding to critics who questioned the legality of the measure, the OAG said the extraordinary situation brought about by the coronavirus crisis justified the measure. However, the office insisted that the domestic sales outlets could be tolerated only for the duration of the pandemic.

    Bhutan banned tobacco sales in December 2004. Soon after, Tobacco Reporter visited the Himalayan kingdom to report from the world’s first officially smoke-free nation.

  • Bhutan Targets Tobacco Smuggling

    Bhutan Targets Tobacco Smuggling

    Photo: Taco Tuinstra

    The Bhutan government met on July 30 to discuss ways to combat tobacco product smuggling on the nation’s borders.

    Prime Minister Lotay Tshering noted that tobacco product smuggling has been one of the major illegal activities in the country as more than 30 individuals are arrested each day for this crime.

    Bhutan bans the sale of tobacco products but not their import. The government is proposing to introduce a scheme to allow people to purchase their tobacco products at the nation’s duty-free outlets but with the nation’s 100 percent excise tax included in the purchase price.

    Currently, an individual who enters Bhutan is permitted to carry 800 sticks of cigarettes or 1,200 sticks of bidis or 150 pieces of cigars or 750 grams of other tobacco or tobacco products in a month after paying the excise tax.

  • Bhutan tops smoking league

    Bhutan tops smoking league

    Bhutan has the highest share (24.6 percent) of smokers in Southeast Asia, reports Kuensel, citing a report by the World Health Organization on the mental health of adolescents in the region.

    Despite the country’s complete ban on tobacco sales, tobacco use remains high among 13 to 17-year-olds, who constitute 9.4 percent of the population.

    At 29.3 percent, Bhutan also has the highest share of adolescents using other tobacco products, followed by Timor-Leste (27.1 percent) and Thailand (14 percent).

    According to the report, while most countries in the region legally restrict supply including sale of tobacco to people under a certain age, consumption remains high among those aged 13-17 throughout Southeast Asia.

    Almost one in 10 adolescents in the 13–17 age-group years in the region smoked cigarettes.

    What’s more, the age of tobacco initiation is decreasing in Southeast Asia.

     

     

  • Lonely Leader

    Lonely Leader

    Photos: Taco Tuinstra

    In March of 2005, Tobacco Reporter’s editor, Taco Tuinstra, visited the Himalayan Kingdom of Bhutan. His editorial assignment was to prepare a firsthand report from the world’s only smoke-free nation. Taco’s personal goal was to prove wrong his publisher, Noel Morris, who had bet that he wouldn’t dare light a cigarette in the central square of Bhutan’s capital, Thimphu.

    Bhutan was the world’s first country to ban tobacco. Will it remain the only one?

    By Taco Tuinstra

    As Druk Air flight KB127 starts its descent into Paro airport, a passenger in the back of the cabin screams in terror. The gray clouds have abruptly given way to towering mountains left and right—the foothills of the Himalayas—and the pilot must make a series of sharp turns to avoid collision.

    I, too, am starting to lose my nerve, but not because of the stomach-turning approach. Druk Air recruits its pilots from the British and American air forces, and surely these flyers are accustomed to more hair-raising maneuvers than landing a civilian jet in a quiet mountain country.

    Besides, after nine years at Tobacco Reporter, I take the risks of international air travel in stride. I have survived a Russian airliner carrying more passengers than seats; a lightning strike at 20,000 feet; and, en route to a tobacco auction in Malawi, a chicken (or something else with feathers) flew into the engine of “my” plane, just as the pilot revved up for take-off. Set against such horrors, what is a bit of turbulence?

    Rather, the source of my anxiety resides in my carry-on bag—a pack of Krong Thip cigarettes purchased that morning prior to departure from Bangkok. In compliance with Thai law, the pack carries a disturbing picture of what my lungs might look like if I smoke too many of its contents, but that doesn’t worry me, either. I am well aware of the risks of smoking; and besides, to fulfill my personal mission, I have to smoke only one cigarette.

    I am nervous because I am about to enter the Kingdom of Bhutan, the world’s only country with a nationwide ban on tobacco sales and public smoking. The customs declaration form still shows an allowance of 200 cigarettes per traveler, but that paragraph has been crossed out with ballpoint, suggestion that the information has recently become outdated. There is no mention of any new allowance or of what might happen to people caught violating the rules.

    To ease my mind, I re-read an article in the in-flight magazine that describes Bhutan as a peaceful Buddhist country, with friendly people and a benevolent king. But my thoughts drift to the novel Lost Horizon, James Hilton’s classic about a group of air travelers who crash near Tibet and are taken to an idyllic, hidden mountain resort, Shangri-la—only to find that they may never leave. Travel experts have likened Bhutan to Shangri-la, and I am not certain whether to draw comfort from that comparison now.

    As the plane touches down, a group of relieved passengers burst into applause. I, on the other hand, start to sweat. Noel might win this bet.

    Photo: Jiali Chen | Dreamstime

    Smoke-free society

    I have come to Bhutan to see what a smoke-free society looks like. Is it the utopia the public health movement makes it out to be, or is it a make-believe paradise with an Orwellian tinge, like Hilton’s Shangri-la?

    One thing is certain: Bhutan’s experiment is unprecedented in modern history. Even as governments around the world step up their anti-smoking rhetoric, none seems prepared to take the argument to its logical conclusion.

    None except Bhutan. While ratifying the World Health Organization’s Framework Convention on Tobacco Control (FCTC) in August 2004, the country’s national assembly announced that it would go beyond the treaty’s proposed tax hikes and advertising restrictions and declared tobacco illegal.

    After a three-month transition period during which shopkeepers were allowed to exhaust their stocks, the ban became effective in December 2004, with authorities in Thimphu igniting bonfires of unsold cigarettes and stringing banners across the main thoroughfare exhorting people to kick the habit.

    Cautioning people to take its decision seriously, the government announced hefty fines for violators. Shopkeepers caught selling cigarettes risk losing their business licenses and can be fined up to $220, a hefty sum in a country with a per-capita income of $660. Two months later, and perhaps a tad redundantly, given that cigarettes were no longer legally available, Bhutan banned smoking from all public places. The only place where smokers may still light up is at home.

    Bhutan’s bold move is significant not only because it is unprecedented, but also because it renders obsolete one of the tobacco industry’s most effective defenses. For many years, cigarette companies have silenced their detractors by reminding them that tobacco is a legal product everywhere. If tobacco is truly the evil weed its critics purport, governments should ban it—which of course they never did, conscious of the impracticalities and loss of tax revenues associated with such a measure.

    Until now.

    A world apart

    One of the reasons Bhutan managed to pull off what other countries can seemingly only pay lip service to might lie in its isolation, both geographically and culturally. Wedged in the Himalayas between China and India, Bhutan remains a closed society that regards outside influences, including smoking, with suspicion.

    This becomes apparent the minute you start planning a visit—you can’t just buy a ticket and go. One would expect an impoverished yet stunningly beautiful country like Bhutan to welcome tourists with open arms—and count the dollars. Yet Bhutan didn’t even permit tourism until 1974, and the government continues to restrict its numbers (only 9,000 people visited in 2004), willfully forgoing significant amounts of revenue. Visitors are required to purchase tours with strictly supervised itineraries and pay all expenditures in advance.

    The only way for me to experience the world’s first and only smoke-free society was to sign up for a guided tour of Dzongs and local festivals. Not that I minded, of course. Bhutanese culture is quite fascinating and its natural beauty unrivaled. But it also limited my freedom as a journalist. For example, when the agenda called for a tour of Thimphu’s textile museum or a visit to a shrine honoring Guru Rinpoche, the saint who brought Buddhism to Bhutan, I could hardly insist on visiting the health ministry instead. Blessed with a direct mandate from God, King Wangchuk would probably have felt little inclination to justify his policies to Taco Tuinstra from Tobacco Reporter, anyway.

    Nonetheless, between temple visits and scenic drives, I managed to get a good feel for life in a smokeless society by speaking with several current and former smokers, a few shopkeepers and a police captain. I also talked at length with my guide, Gopal Wanghug, an ex-smoker who says the ban forced him to kick the habit because, even though cigarettes are still available on the black market, they have become quite expensive. Despite the discomfort associated with quitting smoking, Wanghug says he and many other Bhutanese smokers support the ban. I couldn’t determine whether, as a state employee, he felt he had to defend the official line, or whether his feelings were genuine.

    Despite my waving of increasingly larger wads of cash, the shopkeepers I spoke to insisted they carried no undocumented inventory for smokers willing to pay the right price. Captain Dorji Tshering of the Thimphu police force said that, personally, he had not caught any vendors selling illegal cigarettes, but he knew of colleagues who had. A private security guard later boasted that “rules are meant to be broken,” but he didn’t light up in my presence, professing he had left his cigarettes at home.

    Shangri-La

    While each of my conversation partners had his own perspective, they all agreed that only in Bhutan could a government get away with a blanket tobacco ban. The country, they said, is different.

    They might be on to something. Through most of its history, Bhutan has marched to its own peculiar drumbeat. The country’s first paved roads date from 1961. Before 1986 it had no banks. Until 1999, there was no television or access to the Internet. Mobile phones, too, are a recent phenomenon, although transmission towers continue to be greatly outnumbered by Buddhist prayer flags. Thimphu still advertises itself as the only national capital without a traffic light.

    The government is governed by a king, who is regarded as an incarnation of God and as such is universally obeyed. While other nations fret about their gross domestic product, impoverished Bhutan emphasizes “gross national happiness.”

    And it’s not just smoking that’s banned. To preserve its pristine environment, Bhutan prohibits the use of plastic bags and sales of secondhand cars, which emit more pollution than do new vehicles. Environmental protection ranks high among government priorities and may have played a role in the decision to ban smoking. It’s interesting to note that when Thimphu authorities torched unsold cigarettes in the days before the ban took effect, their superiors quickly put an end to the practice, complaining about air pollution. 

    Wanghug, my guide, also told me that, while anti-tobacco sentiments are a recent phenomenon in most Asian countries, they have deep roots in Bhutan. Last year’s widely published announcement was merely the culmination of an anti-smoking policy that had been growing progressively stricter for years. Prior to the nationwide ban, tobacco sales had already been banished in 18 of the country’s 20 dzongkags. The new rule only extended prohibition to the last holdouts—the capital district of Thimphu and the eastern district of Samdrup Jongkar. Sales of tobacco products in duty-free shops have been banned since January 2003.

    In fact, Bhutan’s anti-tobacco tradition can be traced to the nation’s creation. The founder of modern Bhutan, the warrior monk Shabdrung Ngawang Namgyal, enacted the first ban on public smoking when he outlawed the use of tobacco in government buildings in 1629. Guru Rinpoche, Bhutan’s spiritual father, believed that the tobacco plant sprang from the menstrual blood of a female devil who wished for an intoxicant that would obstruct religious practice. Although Buddhist scholars suspect Rinpoche may have been referring to opium, the government clearly felt comfortable extending his concerns to tobacco.

    Unlike governments in other countries, Bhutan didn’t have to worry about alienating voters or special interest groups. Bhutan neither grows tobacco nor manufactures cigarettes, which means there were no tobacco farmers or cigarette factory workers to placate. Tax revenues weren’t much of a concern, either. Smokers account for less than 5 percent of a population that is estimated at less than 2 million. The use of chewing tobaccos is reportedly more widespread, but there are no reliable statistics. Many Bhutanese prefer chewing betel nut, a stimulant that turns saliva red and that, like tobacco, has been linked to health problems. Needless to say, the sale and consumption of betel nut remains legal.

    Bhutan’s remote location, combined with its small population, has made the country uninteresting to multinational cigarette makers pursuing economies of scale. As a result, the most popular cigarette brand in Bhutan was not Marlboro or Mild Seven but Wills, which is manufactured by ITC in neighboring India. Even so, the declared value of all tobacco imports from India was only 200,000 ngultrum—a mere $400—in 2003, according to Kuensel, Bhutan’s English-language newspaper. How much tobacco entered—and continues to enter—Bhutan unofficially remains anyone’s guess.

     

    Setting a precedent

    Is Bhutan as different as my sources suggest, or should the tobacco industry be concerned about other countries copying its policies? The Bhutanese government clearly wishes for the latter. During a meeting of health ministers at the WHO in Geneva, Bhutan’s secretary of health, Sangay Thinley, expressed hope that Bhutan’s example would prompt other countries to follow suit.

    So far, that hasn’t happened. Even a WHO official, while praising Bhutan’s initiative, admitted that a blanket ban might prove impractical in other countries. Indeed, Bhutan’s northern neighbor, China, is home to one-third of the world’s smokers and its government is said to derive almost 10 percent of its revenues from taxes on tobacco products. Following its ratification of the FCTC, China will likely place more restrictions on its tobacco industry. Considering the tobacco industry’s enormous economic clout in that country, however, it is safe to assume that Beijing will not slaughter the goose that lays it golden eggs.

    South of the border, the Indian government, too, has ratified the FCTC, restricted tobacco advertising and limited smoking in public places. A blanket sales ban appears unlikely, however, as bidi cigarettes continue to enjoy wide popularity among smokers and the bidi industry employs millions.

    Farther from home, countries such as Ireland and Italy have passed far-reaching public smoking restrictions, but they are not outlawing tobacco sales as such.

    Perhaps the country that is closest to following Bhutan’s example is South Korea, where a health-minded member of Parliament has been collecting signatures to prohibit domestic manufacturing of cigarettes within a decade.

    Nevertheless, while Bhutan is an unusual place and its cigarette market tiny, the industry would be unwise to dismiss its radical experiment completely. For example, nine cancer centers in Asia recently signed an agreement to work with their respective governments to ban tobacco. The group is not comprised of eccentric mountain kingdoms like Bhutan, but of leading industrial nations, including Singapore, Japan and China.

    Anticlimax

    My editorial mission was a success: I experienced life in the world’s first smoke-free society and realized that it will probably remain the only one for the foreseeable future. But what about my personal assignment; was it successful also? Here’s what happened: When a customs officer told me to open my bag, I lit a cigarette, blew smoke into his face and lectured him on smokers’ rights and the importance of mutual tolerance. Persuaded by my compelling arguments, the official called the royal palace. King Wangchuk, embarrassed about his mistake, revoked the ban that very day.

    Okay, I made that up. Instead, increasingly concerned about an involuntary extended stay in Shangri-la if someone were to search my bags, I silently conceded defeat before I even left the airplane. As the passengers shuffled toward the exit, I sneaked the cigarette pack into the seatback pocket of a first-class traveler—so authorities wouldn’t be able to trace me via my seat number if they found the pack. I met my guide and toured the country, which, as described in Druk Air magazine, was stunningly beautiful and full of friendly people.

    Then, on the last day of my stay, as I was packing my suitcase, something fell out the pocket of a shirt I hadn’t worn during the trip. It was a cigarette! Or rather, it was a pen shaped like one; a promotional gimmick that Tobacco Reporter once gave away at trade exhibitions.

    The “cigarette” looked remarkably realistic; it even had “ash,” which doubled as the pen’s cap. I told my guide I wanted to run a quick errand before driving to the airport, and rushed to Thimphu’s central square, which was only a block away from our hotel.

    Standing on in the middle of the square, I hesitated again, having to remind myself that I wasn’t breaking any laws. I stuck the pen in my mouth, cupped my hands around the end as if I were lighting a real cigarette, and then pretended to smoke.

    I looked around triumphantly, but nothing happened. The passersby just ignored me. Then, five young boys entered the square to play football. As they walked by, the tallest one whispered something to his friends and they giggled. But after the last boy had passed, he suddenly turned around and gave me the thumbs-up sign.

    What a victory. I had defied the world’s strictest anti-smoking regime and the local population worshipped me as a hero defending their rights. Well, maybe not. Perhaps the thumbs-up sign means something else in Bhutan than it does in western Europe or America. I should probably count myself lucky if Noel allows a fake cigarette to win the bet.

    Taco Tuinstra is Tobacco Reporter’s editorial director.Based in Raleigh, North Carolina, USA, he coordinates the work of staff writers and contributors.On his watch, Tobacco Reporter has won several awards for editorial excellence.Since joining the magazine in 1997, Taco has visited more than 75 countries to meet industry representatives in their markets and to report tobacco news firsthand.