Jigmi Wangdi

Bhutan’s initial success in tobacco control has faltered, with hard-won gains going down the drain.

The previous government’s decision to lift the ban on import and sale of tobacco products through the amendment of the Tobacco Control Act in July 2021, during the peak of the Covid-19 pandemic, has led to a dramatic spike in tobacco imports over the years.

The amendment, aimed at curbing smuggling and reducing Covid-19 transmission risks, has inadvertently spurred a steep rise in tobacco use in the country. 

Figures speak for itself. From 2020 through June 2024, Bhutan imported 531 million cigarettes, with 511 million sourced from India and 19 million from other countries.

The import value soared to Nu 1.524 billion, with the highest import recorded in 2022 at Nu 1.4 billion. That year, tobacco products even ranked among the top ten imported commodities according to Bhutan Trade Statistics.

In the first half of 2024 alone, tobacco imports amounted to Nu 337 million. The second quarter (April, May, and June) of 2024 saw the highest import of cigarettes from countries other than India, worth Nu 14 million. This was a staggering 237.75 percent increase in cigarette imports from non-Indian sources compared to the total imports in the previous three years.

Rising public health concerns

The increased availability of tobacco products in the country has become a major public health concern. And instances of public and underage smoking are on the rise.

According to section three of the Tobacco Control (Amendment) Act 2021, smoking in commercial centres, recreation centres, institutions, public spaces and public transportation are prohibited.

Officials from the erstwhile Bhutan Narcotics Control Agency, now a part of the Bhutan Food and Drug Authority (BFDA) have reported difficulties in monitoring tobacco sales and use in public spaces. 

“We are currently reviewing regulations in light of recent changes in the Act and the influx of of novel tobacco and tobacco products in recent years,” a BFDA official said.

The current tobacco regulation 2016 does not cover the scope of novel and emerging tobacco and its products.

BFDA creates awareness on the ill effects of tobacco and tobacco products while implementing strict regulations on advertising and promotion of tobacco products, including bans on tobacco advertisements in media, sponsorships, and promotions.

The authority is collaborating with the Royal Bhutan Police on enforcement of the provisions under Tobacco Act. However, it is grappling with a shortage of human resources to implement and monitor the enforcement of the tobacco control regulations.

Inadequate laboratory and technological capacity also challenge BFDA in detecting counterfeit and spurious tobacco products.

Health risks

BFDA officials said that tobacco use is a significant risk factor for various health issues, including heart disease, stroke, hypertension, chronic obstructive pulmonary disease (COPD), and several types of cancer.

“Smoking and tobacco use contribute to chronic obstructive pulmonary disease (COPD), emphysema, and chronic bronchitis. These conditions reduce lung function and quality of life and can lead to premature death,” officials said.

Tobacco is also a leading cause of various cancers, mainly lung cancer, which has a high mortality rate. It also increases the risk of cancers of the mouth, throat, oesophagus, among others.

Tobacco use among youth is particularly concerning, given its addictive nature and association with long-term health problems. “Tobacco use during adolescence can impair lung growth and function and is associated with cognitive and behavioural issues, including attention deficits and lower academic performance,” the officials added.

Similarly, tobacco use during pregnancy increases the risk of complications such as miscarriage, stillbirth, premature birth, and low birth weight. Non-smokers, particularly children, exposed to second-hand smoke are at risk of respiratory infections, asthma, sudden infant death syndrome (SIDS), and other health issues.

The National Health Survey (NHS) 2023 highlighted that tobacco use is one of the most potent behavioural risk factors for non-communicable diseases (NCDs).

The NHS 2023 revealed that 29.8 percent of Bhutanese aged 15-69 are current tobacco users, with 14.2 percent smoking and 19.8 percent using smokeless tobacco products.

Around 17.65 percent of the population aged 15-69 years reported exposure to second-hand smoke at home while 52.53 percent reported exposure in workplaces.

Efforts and challenges

Speaking to Kuensel, the World Health Organisation’s (WHO) Representative to Bhutan, Dr Bhupinder Kaur Aulakh expressed concerns over easy access to tobacco products, such as cigarettes and e-cigarettes, among youth.

“To the eye, the newer tobacco products look harmless and adolescents and the youth become the targets of this industry. Parents and teachers might not be aware that their children are indulging in these products and so we have to create awareness,” Dr Bhupinder said.

She highlighted that tobacco does not have a safety limit, stating that the main age of initiation in tobacco use is 19 years among the youth. “Research shows that those who start to smoke early develop addiction at a young age which carries on till adulthood,” Dr Bhupinder said.

She added that 70 percent of the burden of death in Bhutan is caused by NCDs, and tobacco is a major risk factor contributing to this. “Every year 400 people lose their lives to tobacco. This is 10 percent of the total deaths, and it costs Nu 1.2 billion every year.”

She emphasised that prevention is more effective than treatment and highlighted the significant financial burden that tobacco-related diseases place on the healthcare system.

“As the youth of Bhutan are the change agents for the future, we have to make sure that this form of advocacy is carried out in schools and ensure that they become aware of the harmful effects of tobacco,” Dr Bhupinder said.

The WHO is collaborating with government agencies to develop a Multi-Sectoral Action Plan aimed at curbing tobacco use through prevention and advocacy.

Health ministry stated that high treatment costs for tobacco-related diseases imposes a significant financial burden on the healthcare system. “Healthcare resources are limited, and the cost of treating chronic conditions caused by tobacco use strains public health services,” a health official said. 

Spiritual concerns

The Zhung Dratshang, the central monastic body, is concerned over tobacco use in the country. A representative of Zhung Dratshang said that consumption of tobacco products goes against Buddhist teachings and beliefs.

“It is deeply concerning, and saddening, to see many youth and young people smoking in public places. This is very regrettable,” the representative said.

The central monastic body does not advocate openly on the use of tobacco use as it is currently legal to use tobacco products, he said. “However, we are concerned about the impact of tobacco use on spiritual values and health of the people.”