Bhutan's Journey Towards a Tobacco-Free Society

MINISTRY OF HEALTH

The Big Ban Bhutan’s journey towards a tobacco-free society 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 organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons 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.

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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. The Big Ban Bhutan’s journey towards a tobacco-free society

ACKNOWLEDGMENT

utting the publication together required inputs from various stakeholders 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 Pand 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 beliefs 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. 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 FROM THE PRIME MINISTER

n the initiative to tell the world, countered health consequences. Bhutan’s story in its bid to control Noncommunicable diseases continue to tobacco use among its people, I be a major cause of preventable death and thank and congratulate World Health disability. Tobacco, among other social vices like OrganizationO (WHO). alcohol and substance abuse, is one of the main It is an exciting story, of daring plots, varying contributors. interludes and unresolved ending. Which country With health as the mainstay of the has ever attempted a nationwide ban? It began government’s priorities, we are concerned. with right intentions and everyone worked Among others, we wish to lighten burden on together towards realising it. treatment and healthcare cost for a sustainable Bhutan has system. come a long way What is also since then. At a worrying is that glance, one can at the centre of notice that people the expanding do not smoke on illegal trade in the streets and tobacco are the public places. Bhutanese youth, Market shelves the nation’s future. are free of tobacco What happens products, which if our children, would, otherwise, the productive be screaming for citizens we expect attention from to serve the nation unassuming in their time, customers. find themselves Over the battling with years, there has health issues? Who been increased do we have to fall understanding and back on? discipline when it I call on all came to embracing relevant agencies tobacco habits. to come together, It is certain the reflect on how we scenario would started, rework on have been different coordination and had it not been for explore ways to the ban. achieve what we But habits aspired for when do not change we took on this overnight and we have to acknowledge that. task on ourselves. There are issues of illicit trade in tobacco. Despite Government, on the other hand, commits stringent law, tobacco and its products are still to providing necessary support to all relevant available and accessible. Our young people agencies for effective tobacco control measures, are still indulging in it and the move has not including working closely with counterparts

8 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

9 The Big Ban FOREWORD

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 t’s been 15 years since the Royal school counselors in tobacco intervention Government of Bhutan banned sale strategies so students receive appropriate of tobacco and related products in awareness and guidance. the country. Since then, a number of Awareness about cessation programmes, achievementsI have been made, and a number quitline and other interventions to aid tobacco of challenges have arisen. users to quit continues to be a priority. We no longer see people smoking in public Education, empowerment and interventions spaces, but this does not indicate that the must go hand-in-hand to make the ban more number of smokers have reduced. However, effective. 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. Dechen Wangmo The Global Youth Survey 2013 reports an Health Minister

10 The Big Ban FOREWORD

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. national ban on sale of tobacco and This gives the country all the more reason all its products is a bold decision, to step up measures and efforts to rein in on an achievement countries in other tobacco. It owes this to its youth. parts of the world can only hope WHO shares the country’s concerns and andA wish for. it appears timely that Bhutan embraces the That Bhutan has been able to do this, its Protocol to Eliminate Illicit Trade in Tobacco people should realise, is an accomplishment, a Products the country is yet to ratify. 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 Dr Rui Paulo de Jesus in terms of public advocacy and awareness, WHO Representative

11 The Big Ban

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

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

15 The Big Ban PRESENT DAY The current scenario and efforts of the government, grassroots elected representatives and health sector leading to the nationwide ban on tobacco sales.

PRESENT DAY

As of today

hutan continues to be the the law prescribed. only country in the world From those endorsing the today, to have implemented nationwide ban of tobacco sales in nationwide ban of sale of 2004 to those responsible for making tobacco.B (and subsequently passing) the law One stark transformation since the six years later, were all as a result of ban, a decade and a half ago, has been growing concerns for rising instances the end of open smoking along streets of noncommunicable diseases (NCDs). and other public places, which were Tobacco, according to latest health a common place before the ban. The studies, is among top four contributors same can be said about most other to the rising cases of NCDs that weigh tobacco products. heavy on the country’s free health care. No longer are people seen puffing Despite efforts on the part of relevant away along the streets, or out in authorities, tobacco black market, as the open. It is almost of a taboo to initially feared, has emerged. Shops be seen doing so today. Workplaces that thrive on illicit sale of tobacco and institutions decry such habits and its products have found a way contemptable. Nationally, it is an around the law. A steady stream of loyal offence punishable by law under the customers continue to sustain these Tobacco Control Act. shops that have, over the years, grown There were instances in the past, into a network of black market. where those caught on the other side Recent studies have found of this law faced imprisonment. Many Bhutanese youth, who are among today, continue to, every now and then, the highest in the region to be using face penalties in the form of fines tobacco and its products, to be at the and verbal warnings, sanctions far centre of this burgeoning contraband mellowed from the initial prison term good.

NO LONGER ARE PEOPLE SEEN PUFFING AWAY ALONG THE STREETS, OR OUT IN THE OPEN

18 The Big Ban PRESENT DAY

ROADSIDE ADVOCACY: One of few signs along Paro- Thimphu highway cautioning vistors to the capital city of the consequences of tobacco use.

19 The Big Ban PRESENT DAY

Sale ban, a national business

he national tobacco sale Assembly. ban was a culmination of All the members then, comprising numerous little efforts 99 chimis, (elected members from sparking off of public spaces the grassroots), 35 government likeT bus terminals, that were declared representatives (ministers, / dzongdas smoke-free, and communities that governors and the armed forces) 10 voiced against this social ill roused by from the clergy and six members of the religious sentiments. Royal Advisory Council, unanimously Such initiatives later rippled across agreed on the national ban of tobacco the country’s 20 sale. districts. A signatory to Before the WHO Framework nationwide ban of Convention on tobacco sale, save for 100% Tobacco Control Thimphu and Chukha, (FCTC) since 2003, SALES TAX ON 18 of Bhutan’s 20 it was in ratifying ALL TOBACCO districts had already the convention PRODUCTS initiated the move on during the 82nd ENTERING THE their own. A concern session of the COUNTRY FOR emerging from then National PERSONAL individual households Assembly of CONSUMPTION became an important August 12, 2004, agenda at the gewog that the members yargay tshogchhung saw an opportune (assembly of elected grassroots occasion to endorse it. representatives) that echoed with Along with the endorsement came the same urgency at the dzongkhag the resolution on a 100 percent sales yargay tshogdu (assembly of elected tax on all tobacco products entering representatives at district level) before the country for personal consumption eventually making its way into the of stipulated quantity. corridors of power, the earlier National

20 The Big Ban PRESENT DAY AROUND ASIA

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.

CHINA

PAKISTAN Smoking completely prohibited in at least 28 indoor public places, Smoking prohibited including medical facilities, in all places of public work restaurants, bars, and or use, and on all public transport. most public transportation. Smoking prohibited in outdoor waiting areas for buses and trains.

NEPAL BANGLADESH Smoking prohibited on public Smoking prohibited transport, most workplaces in the majority of indoor and public places. Outdoor public places and workplaces, areas include pilgrimage including children’s parks. and religious places, stadiums and children’s parks and clubs. THAILAND

Smoking prohibited in almost all indoor public SRI LANKA places, indoor workplaces, and public transport. Smoking prohibited Smoking prohibited in markets, in many indoor public facilities for exercise, places and workplaces and playgrounds, public, zoological on public transport. and amusement parks.

21 The Big Ban PRESENT DAY From the grassroots 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. BLike in other countries, spread of tobacco epidemic was facilitated by factors like crossborder effects and trade liberalisation.

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 2004 WHO awarded eight medals to Bhutan for Bumthang proposed nationwide ban during tobacco control initiatives the 82nd National Assembly, which was unanimously endorsed

Bhutan became the first country to ban sale of tobacco

22 The Big Ban PRESENT DAY

1980s Health ministry with support from WHO started a vigorous advocacy campaign across the country. Tobacco control activities were integrated into primary health care system 1991 During the fourth World No Tobacco Day, public places and transport were declared smoke-free GOING NATIONWIDE: Chamkhar-Ura Chimi (elected grassroots representrative) late Dorji Wangchuk 1993 proposes nationwide ban on tobacco sale at the National Assembly in 2004. Photo: Kuensel New approach to anti-smoking campaign was launched and hospitals and health centres were declared smoke-free 1995 First to ban Advertising of tobacco products in all media channels was banned tobacco sale 1998 A national Tobacco Control Programme was t was in 1989, during a dzongkhag Besides concerns over health instituted under the health ministry 2000 yargay tshogdu (assembly of implications, tobacco use among its Through task forces, districts passed elected village representatives) inhabitants was sacrilegious. regulations and monitored activities that the local government Bumthang is known for its spiritual concerning tobacco control leadersI proposed and unanimously heritage and is home to numerous endorsed a ban on tobacco sale in the monasteries and spiritual sites. 2003 district. In 2004, the same proposal was 18 of 20 districts banned sale of tobacco 2004 It became the first district to do so. made at the National Assembly, this WHO awarded eight medals to Bhutan for Bumthang proposed nationwide ban during The local leaders were representing time for a nationwide ban on sale tobacco control initiatives the 82nd National Assembly, which was people from their communities, who were of tobacco. It received the same unanimously endorsed worried about the rising trend in use of unanimous endorsement. Bhutan became the first country to ban tobacco products among its youth. sale of tobacco

23 The Big Ban PRESENT DAY

Q&A “Law on its own won’t move”

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 saleB 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. Bumthang’s disfavour for workers, bidi (unprocessed tobacco tobacco products... wrapped in leaves) and khaini (chewing A. Home to numerous sacred sites tobacco) began to appear in greater and monasteries, residence of Terton quantities in a few shops. Some of our Pema Lingpa and blessed by Guru people, including youth began using Rinpoche, Bumthang is the nation’s them. A concern arising from parents spiritual heartland. No one during in many communities, at a scheduled the time of our parents consumed meeting of the committee of local tobacco in any of its forms. A few leaders, led by the dzongda (district who did were often looked down for administrator), the issue was discussed desecrating the district’s sanctity. and we decided to ban smoking and sale of tobacco in the district. Q. Why did people of Bumthang want a ban on tobacco sales? Q. What did people of the district A. In time, with more travellers think of the decision? along the northern east-west highway, A. The dzongda, who was a smoker including expatriate road construction himself showed the way. He quit

24 The Big Ban PRESENT DAY

Jamphel Dorji, Chumey Gup

immediately and expected the same Q. Your take on the existing of its residents. We did not experience Tobacco Control Act? any defiance from anyone. It was a A. When we first initiated this ban rule the district set for the good of its on sale of tobacco in Bumthang, we residents and visitors had to respect had a rule. We had the head of the that too. district and other local leaders lead by example and we had the residents of Q. How was the rule implemented? the district take ownership of this rule. A. We took it on ourselves, local We felt strongly for our district and leaders in collaboration with police, the sanctity of it. We were concerned the responsibility of supervising and about the future of our youth. We are monitoring. Shops found selling still on high vigilance today, just to be tobacco and its products were sure that complacence does not allow warned in the first instance, and this social evil to take root again. their licences were cancelled if found The law is there, but it will not repeating the offence. We burnt move on its own. tobacco products that were seized.

25 The Big Ban PRESENT DAY

2003 TIMELINE Bhutan signed the Framework Convention on 2005 Tobacco Control Smoke-free (FCTC) zones declared During the 56th 2000 session of the World Paro banned Health Assembly sale of tobacco a commitment was made to declare 2007-09 1980s Chukha banned sale Bhutan as the first Drafting of Started tobacco of tobacco tobacco-free nation Tobacco bill 1651 control initiatives� Zhabdrung laid down Trashigang banned a law prohibiting use of 1997 sale of tobacco 2011 intoxicating substances, Zhemgang banned Tobacco Rules specifically, tobacco sale of tobacco and Regulations adopted and alcohol within the walls of the fortresses and other important institutions 2012 Tobacco Control Act ammended

2004 18 districts declared themselves tobacco- free except 2001 Chhukha and Thimphu The South East 1998 Asia Anti-Tobacco Ratification of FCTC 1729 Created Tobacco (SEAAT) Flame, a and endorsement 2010 Control Programme regional initiative, by the 82nd session Enactment of Tobacco control laws date back under health ministry was launched in of the National Assembly Tobacco Control Act 2014 to this year and it ensured with WHO support Bhutan leading Tobacco Control Act religious institutions and second ammendment to a nationwide Thimphu banned dzongs remained tobacco free� anti-tobacco sale of tobacco campaign 1989 Nationwide ban on Bumthang banned sale of any forms of sale of tobacco� tobacco products

26 The Big Ban PRESENT DAY

2004 18 districts declared themselves tobacco- free except 2001 Chhukha and Thimphu The South East 1998 Asia Anti-Tobacco Ratification of FCTC 1729 Created Tobacco (SEAAT) Flame, a and endorsement 2010 Control Programme regional initiative, by the 82nd session Enactment of Tobacco control laws date back under health ministry was launched in of the National Assembly Tobacco Control Act 2014 to this year and it ensured with WHO support Bhutan leading Tobacco Control Act religious institutions and second ammendment to a nationwide Thimphu banned dzongs remained tobacco free� anti-tobacco sale of tobacco campaign Nationwide ban on SOURCES: Kuensel & International 1989 sale of any forms of Bumthang banned tobacco control Bhutan project report, tobacco products sale of tobacco� 2011, Ministry of Health

27 The Big Ban THE INCEPTION

The role of spirituality, leaders of the past and the timely health interventions that reinforced the ban on sale of tobacco in Bhutan.

THE INCEPTION

A spiritual tale

ncient Buddhist scripts stories they told. carry no proscription The consequence of that, people against the use of would be warned of diseases, famine tobacco, for that matter, it and disharmony in communities they is saidA there is no mention of tobacco lived in and the society at large. as it was non-existent during the time How effective it is today, monks in of the Buddha. monastic institutes express uncertainty. To not lie, kill, steal, to not engage “There was a generation of people in sensual misconduct and to abstain who received the story well,” a from intoxication were the basic values central monastic body (Dratshang then. Lhentshog) representative said. The It is believed that tobacco was in new generation of tobacco users, he use in the 8th century, around the time said were more sophisticated to be of the Buddhist saint, Guru Rinpoche, convinced by such stories. “Besides, who was born in India and visited substance abuse is a more serious Bhutan, Nepal and Tibet. issue today for tobacco to receive any “By smoking, people will invite focused intervention.” demons and chase away the dharma That notwithstanding, at every protectors,” it is believed, the Guru religious gatherings in the country, whom Bhutanese revere as the second revered monks led by the country’s chief emanation of the Buddha and the abbot, the Je Khenpo, make it a point protector, was said to have written as a to educate people of the consequences warning then. of tobacco and alcohol consumption, For decades this was the story including substance abuse. monks at Bhutan’s many monastic Apart from the sin of wasting this institutions and monasteries told lifetime, the Dratshang Lhentshog people to prevent them from taking to representative said they explained to tobacco and its products. That it caused people, especially the youth engaging the god and other protecting deities in such vices, that it dragged others to forsake people, that it offended close to them into the ordeal as well. spirits in the intermediate space and displeased semi-divine nāga in the ARTISTIC EXPRESSION: Drawing essence from underground realm were additional religious beliefs, an art depicts awaiting consequences of tobacco use in the afterlife.

30 The Big Ban THE INCEPTION

31 The Big Ban THE INCEPTION

Early codified laws

o have found and later consumption of alcohol and tobacco, unified Bhutan, Zhabdrung the prevalence of which he observed Ngawang Namgyel, was among Bhutanese. It specifically said to have crafted laws prohibited tobacco and alcohol to pacifyT the within the walls otherwise unruly of fortresses land of, what was and other such then referred to important as, Monyul, or institutions the land of the for its officials Mons (referring 1651 and servants to people living in irrespective of ZHABDRUNG LAID darkness). their ranks or DOWN A LAW One of status. PROHIBITING USE Zhabdrung’s It was believed OF INTOXICATING remarkable to be in violation SUBSTANCES, achievements of the dharma and SPECIFICALLY, in Bhutan, the obstruction in its TOBACCO AND land he chose to practice. ALCOHOL WITHIN flee to following Almost a THE WALLS OF THE apparent threat century after FORTRESSES AND to his life in Tibet, the Zhabdrung’s OTHER IMPORTANT his homeland, was legal edict, the INSTITUTIONS the introduction 10th Druk Desi of law and order (the secular head for the people. under Bhutan’s Drawn dual system of up around 1651 before his final governance until the 19th century), retirement into meditation, the Mipham Wangpo was said to have first legal code of Bhutan known as issued his own legal code in 1729 “The Golden Yoke of Legal Edicts” that specifically condemned use of prescribed, among others, against tobacco.

32 The Big Ban THE INCEPTION

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.

33 The Big Ban THE INCEPTION

Trade linked

HO FCTC was developed in response to the globalisation of the tobacco epidemic. Trade liberalisation and foreign direct investmentW 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).

34 The Big Ban THE INCEPTION

POINT OF ENTRY: The border town of Phuentsholing is the main thoroughfare for trade with India.

35 The Big Ban THE INCEPTION

WHO FCTC

he World Health is now closed for signature, has 168 Assembly adopted signatories, including the European the WHO Framework Union. Convention on Tobacco Currently there are 181 Parties ControlT (FCTC) on 21st May 2003 covering more than 90 percent of and it came into force on 27th the world population. Countries February 2005. wishing to become a Party, but did It is the first international treaty not sign the Convention by 29th negotiated under the auspices of June 2004, can do so by means WHO and one of the most rapidly of accession, which is a one-step and widely embraced treaties in the process equivalent to ratification. United Nations history. To accelerate action on WHO It was developed in response FCTC implementation, Conference to globalisation of the tobacco of the Parties (COP) agreed on the epidemic and represents a milestone need for a longer-term plan during for the promotion of public health. its seventh session. The WHO FCTC opened for A Global Strategy to Accelerate signature from 16th to 22nd June Tobacco Control, Advancing 2003 in Geneva, and thereafter, at Sustainable Development through the United Nations Headquarters in Implementation of the WHO FCTC New York, from 30th June 2003 to 2019–2025, also known as Global 29th June 2004. The treaty, which Strategy 2025, has been developed.

36 The Big Ban THE INCEPTION

The first No Tobacco Day

s the world observed the second World No Tobacco Day on May 31 MAY 31 1989, Bhutan joined, forA the first time, the international community to mark the day. 1989 The sale of any tobacco product was disallowed between 6am and ‘NO TOBACCO DAY’ 6pm on the day. Students from OBSERVED FOR Yangchenphug and Motithang Higher THE FIRST TIME IN Secondary schools in Thimphu BHUTAN organised a debate on the ill effects of tobacco use. Simtokha Rigney School students performed a drama along a similar theme. Posters, leaflets, books and stickers Carrying the theme, Women and depicting negative consequences of Tobacco, the National Women’s tobacco use were distributed to the Association Of Bhutan in Thimphu took public. An audio-visual presentation the lead in disseminating information on the harmful effects of tobacco was among the public, especially women, also screened. on the harmful effects of tobacco.

37 The Big Ban IN THE MIDDLE

Developments and challenges in implementing the Tobacco Control Act.

IN THE MIDDLE AWARDS

Recognition from WHO for promoting tobacco free societies

LHUENTSE 1998

TRASHIYANGTSE 1996

TRASHIGANG 1993

BUMTHANG 1994

PEMAGATSHEL 1997

2011 World No Tobacco World No Day Award presented 2012 to former health Tobacco World No Tobacco Day minister Dasho Zangley Dukpa Day Award award presented to trade department and assistant legal officer, BNCA 2017 World No Tobacco Day award presented to Former health minister Tandin Wangchuk 40 The Big Ban IN THE MIDDLE

EARLY RECOGNITION: WHO recognises Bumthang for its efforts in carrying out public awareness and advocacy on ills of tobacco use.

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Tobacco-biz goes underground

uch before the products span as far as its nationwide nationwide ban of sale ban. It continues to progress in tobacco sales, instances hiding, quite contrary to the intent with of emerging illegal which the law was initially designed. trafficM in tobacco and its products was Of a thriving black market, many already apparent in the very districts outside the National Assembly then, that had initiated such a move on their expressed fear through the national own. media besides also suggesting When representatives of these alternatives. One such caution came districts later proposed and agreed to from WHO’s Tobacco-Free Initiative’s the national ban of tobacco sale at the Acting Coordinator, Dr Armando Peruga, highest decision-making body then, who said an all-out ban risked creating the looming issue of illegal trade that a black market for tobacco products. had begun to surface received little He had instead suggested that attention. If the import was banned, countries considering similar decisions the question of illegal sale did not to first ban smoking in public places arise, was the prevailing logic among and making it socially unacceptable. decision-makers then. Public smoking is almost non- The understanding was that the existent in the country and socially country did not grow tobacco and it did unacceptable too. The challenge, not have manufacturing plants that it however, is the illicit trade in tobacco should worry about illegal feed into the and one that is proving inconvenient market. to act on, despite the very law that was Today, illegal trade in tobacco and its crafted to counter it.

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UNDERHANDED: What the tobacco sale ban also did was fuel black market in the country.

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The Act in effect

lightly over six months beyond permissible limit, which he since enactment on 16th claimed was for self-consumption to June 2010, the Tobacco last a year. Control Act netted its first Following the 23-year-old monk, case.S in the subsequent weeks, months, On 24th January 2011, a 23-year- until early 2012, more than 80 old Bhutanese monk travelling from people including farmers, expatriate the border town of Phuentsholing to workers, students, shopkeepers, the capital city of Thimphu was caught public transport drivers, armed force in possession of 48 packets of chewing personnel and airline staff were caught tobacco (baba) worth Nu 120. and charged for violating the country’s After being detained for over a tobacco law. month, the Thimphu district court Voices of dissent, mainly of urban sentenced him to three years in prison residents, and from among them a on 3rd March 2011, guilty of violating few who were active on social media, the tobacco law. It was a non-bailable or were either consumers of tobacco offence according to the provisions of themselves, or against the ban of the Act. tobacco sales, began appearing on Unchecked at the point of entry, the Facebook. man, with the tobacco product, entered Bhutan’s tobacco consumers, the country. Undeclared, he brought it authorities of the time had said made without paying tax as mandated by the up about 10 percent of the national law. Unaware, he brought in an amount population of about 750,000.

NEWS CLIPPINGS: The aftermath of the To- bacco Control Act in implementation received wide news coverage.

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45 The Big Ban IN THE MIDDLE

Act of a biting kind

he Tobacco Control Act of 2010 that came into being JUNE 16 during the tenure of the first Parliament of the constitutionalT democratic monarchy 2010 was in response to the sprouting PARLIAMENT tobacco black market. PASSES THE The resolution of the 82nd session TOBACCO CONTROL of the earlier National Assembly of ACT 2004, much before the country’s transition to a democracy, was deemed Cultivating, manufacturing and a paper tiger. trade in tobacco and its products were In the face of growing tobacco black banned, therefore, to be found doing so market and following derision from carried a heavy penalty of fourth degree certain sections of the population of felony of three to five-year prison term. the law’s inefficacy, the newly elected The same penalty applied to government was compelled to resolve those failing to declare tobacco of, on a legislation. law-specified, permissible quantity The 2004 resolution needed teeth. at the identified ports of entry – It came in the form of an Act. It would Gelephu, Phuentsholing, Samtse, not just dissuade consumers of tobacco Samdrupjongkhar – or failing to pay but curb the puffing illegal traffic in tax on the permissible amount, or in tobacco. possession of tobacco without a receipt Drawing its essence from the WHO of paid tax. Framework Convention on Tobacco Control, the Parliament on 16th June 2010 passed the Tobacco Control Act. ven without a specific Sixty-one of the 65 parliament members EAct, under the previous present on that day voted in favour of the Assembly resolution, relevant law. authorities had cancelled 40 It was, however, the severity of business licences across the certain provisions of the Act that did country of those found in violation not go down well with a few sections of of the decision between 2004 and the population, particularly, the urban- 2008. In fines, authorities had centric social media activitists. collected around Nu 400,000.

46 The Big Ban IN THE MIDDLE TOBACCO CONTROL ACT OF BHUTAN, 2010 Salient Features

Smuggling tobacco or tobacco products punishable with petty misdemeanor and Any person with penalised as per Penal Code more than permissible of Bhutan quantity for personal consumption punishable with minimum sentence No smoking in commercial of fourth degree felony centers, recreation centers, institutions, public transportation and public gatherings

No cultivating, harvesting, manufacturing, supplying, distributing, or trading tobacco and tobacco products

Tobacco Control office to Import tobacco and tobacco promote cessation of tobacco products for personal consumption use and adequate treatment as per quantity approved by for tobacco dependence the Tobacco Control Board

47 The Big Ban IN THE MIDDLE

Trimming the c(law)s

he case of the Bhutanese The Tobacco Control Rules and monk and the first to be Regulations came about on January improsoned under the 1, 2013. Between the implementation Tobacco Control Act stirred of the Tobacco Control Act and the someT movement on Facebook among a coming of the rules and regulations, few urban dwellers, who were against more than 80 people were imprisoned. the law. Among others, the rules and With more people facing regulations spelt out responsibilities of imprisonment, the Facebook group relevant agencies identified by the Act. that called for amendment of the Act It also stipulated the amount of tax grew to some 3,000 members. and duties applicable, the permissible That the law was draconian and amount for self-consumption and that it was passed to gain international penalties if found in violation of the recognition were the grounds for provisions of the Act. opposing the law. They later argued But most notably, instead of straight that the penalty was more severe imprisonment, monetary compensation than other bigger crimes and that in a made up for most offences like failure democracy, it neglected the rights of to declare tobacco and its products to individuals. relevant authorities, failure to pay tax Although those voices were not and duties and smoking in public places. representative of the Bhutanese Likewise, instead of fourth degree majority, agreeing that the penalties felony, which equated with an un- the Act prescribed were harsh and compoundable three to five-year considering the plight of people prison term, the amended law replaced falling behind bars, the government it with misdemeanour and petty- instructed the drafting of a separate misdemeanour with prison terms rules and regulations. It would render ranging between one month and less the law some clemency. The Act had than three years. It also allowed for been in implementation for only six payment in lieu of prison term. months then.

48 The Big Ban INCREASE IN PERMISSIBLE QUANTITY PER MONTH

2010 2013 2014

Cigarette sticks 200 300 + 400 800+1,200 bidis bidis

Cigar 30 50 150 pieces

Chewing and other tobacco 150 250 750 products in grams

49 The Big Ban IN THE MIDDLE

Chhimi Dorji, Deputy Chief Programme Officer, BNCA Supply Reduction Division Nascent organisation, formidable responsibility

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 overviewE of the authority’s efforts in controlling tobacco sales and use in Bhutan.

Achievements advanced. We are the first country to ban The provisions of the law are such sale of tobacco. We have a good law, that it discourages tobacco use. For the Tobacco Control Act, in place and example, one can legally import we are signatory to WHO Framework certain amount of tobacco by paying Convention on Tobacco Control (FCTC). 100 percent tax. But how many tobacco In terms of implementation of the users actually travel to the border or fly provisions of the Act, we are more abroad to buy tobacco? Moreover, the

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customs procedure to bring in tobacco dzongkhags (districts). They are is cumbersome, done deliberately to provided some fund for advocacy and dissuade import. are encouraged to conduct inspections Despite challenges, to call tobacco without us. So far, we have drawn an control efforts in Bhutan inefective would agreement with Phuentsholing and be false. Visible achievements have been Gelephu municipalities, and Paro, made. During joint inspections carried Wangduephodrang and Punakha out with enforcement agencies, we rarely districts. come across people smoking in public Besides the collaborative effort of the spaces. This indicates behavioral change. various stakeholders, tobacco control We have also had cases of shopkeepers would also be effective with community discontinuing sale of tobacco, after being support. It is one thing to agree that sensitised about the legal consequences. tobacco should be controlled and quite another to be a part of the process. It Challenges could be as simple as asking someone The porous international border stokes smoking in public to stub the cigarette, the black market and, often, enforcement or reporting a person selling tobacco, to agencies find themselves a step behind the authorities. smugglers and sellers. The agencies, which have their own responsibilities and About the authority priorities, are limited by human resource. As required under the Tobacco For example, the prime concern of the Control Act 2010, Bhutan Narcotics revenue and customs office is to check Control Authority (BNCA) was import of taxable items and tax-evasion instituted in 2013. Custodian of two cases. Lack of scanners at the border Acts, Bhutan Narcotic and Psychotropic makes goods inspection, coming in by Substance Abuse Act and the Tobacco the truckloads, cumbersome. The police, Control Act, it is the secretariat to on the other hand, have law and order to the Tobacco Control Board and the maintain, which is their priority. implementer of the provisions of the Tobacco Control Act of Bhutan. Strength in collaboration BNCA has two divisions that deal Being a small organisation and with demand reduction through having to monitor the whole country is rehabilitation and counselling unfeasible. Often when officials from and supply reduction through our agency visit other districts, we enforcement, complaint management collaborate with other enforcement and material development for capacity agencies and carry out inspections. building of enforcement agencies. We are in the process of decentralising to thromde (municipalities) and

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Routine inspection

ince 2014, BNCA has in the south. organised an annual joint More than Nu 130,000 was inspection of the tobacco collected in fines for illegal possession law in implementation of tobacco and its products within in Sall districts. In a few selected permissible quantity. The team also districts, where instances of violation seized over 5,400 cigarettes and more of the tobacco law are high, a surprise than 400 packets (4,140 grams) of inspection is also carried out. chewing tobacco. Four people were Officials from implementing fined for smoking in public places agencies like the Department of designated as smoke-free zones. Revenue and Customs, police and Narcotics control officials said Ministry of Health join the narcotics the joint inspections were effective, control officials to search shops and although an impact assessment is yet inspect public areas for offenders. to be carried out. Officials of the joint inspection team With decentralisation programme also carry out advocacy campaigns. underway in Phuentsholing and The last joint inspection was Gelephu, it is expected that such carried out between May and June inspections can be carried out without 2019 in Bumthang, Dagana, Trongsa narcotics officials having to take a lead. and Zhemgang in central Bhutan In other districts, narcotics control and Gelephu, Phuentsholing, officials have advised stakeholders to Samdrupjongkhar, Samtse and Tsirang work together to carry out inspections.

Joint inspections Seized May-June, 2019 : Bumthang, Dagana, Gelephu, Phuentsholing, Samdrupjongkhar, Samtse, Tsirang, Trongsa and Zhemgang. 5,492 Cigarettes Fined

4 414 People fined for smoking Packets of chewing in smoke-free zones tobacco

Source: BNCA

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FUEL TO FLAME: Seized tobacco products outside the inceneration facility at Gedu, Chhukha Photo: BNCA

Fines collected

July 2017 - June 2018 Nu 0.7M

July 2018 - June 2019 Nu 1.2M

Source: BNCA 53 The Big Ban IN THE MIDDLE

Policing the black market

n the capital city of Thimphu, claim the tobacco in possession to comprising 20 percent of the be for self-consumption. Police also country’s population, police find themselves several steps behind apprehended 203 people for offenders. During inspections, police sellingI tobacco in the last three years. realised that shopkeepers received The capital has the biggest information beforehand, giving them population of about 200,000 residents. enough headway to conceal tobacco In Bumthang, the first district to possession. ban sale of tobacco, the numbers were Those caught are usually warned, comparatively smaller with only six save for repeat offenders, who are people caught selling tobacco in the charged with fourth degree felony past three years. with choice of payment in lieu of The figures, however, are only the imprisonment. tip of an iceberg that is the thriving Tipoffs are few and far between, black market. including information on those Random and scheduled inspections smuggling tobacco into the country with other tobacco control agencies from border towns. are a regular activity. Thimphu has over 1,200 paan shops However, police often find (countertop stalls selling areca nut themselves powerless owing to some wrapped in betel leaf) and Bumthang ambiguities in key provisions of the has 36. It is from these shops, according tobacco control law. The Tobacco to police and other implementing Control Act allows a certain amount agencies, that tobacco products are of tobacco to be imported. It also has usually sold. provisions for smoking zones and In the southern districts, the police rooms. maintain cordial relationship with their If caught smoking in public, counterparts across the border. Border offenders demand an alternative, a coordination meetings are carried out, designated space or facility the law where police superintendents meet prescribes. annually or biannually and submit At other times, taking advantage of agenda to their counterparts regarding the permissible quantity, shopkeepers substance abuse and tobacco control.

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Caught selling tobacco (Figures are for Thimphu only, 2016-18)

Female Male

34 15 29

44 48 33

Source: Royal Bhutan Police

Monitoring and enforcing tobacco check import vehicles for controlled control measures in the border towns substances and tobacco. This is not are a challenge. A designated revenue only cumbersome but also causes and customs checkpost at the entrance traffic jam. is absent. If caught with tobacco, Highway patrol teams occassionally people often claim they were yet to check vehicles coming from border declare to the customs office. towns for illegal substances, including Like customs officials, police in tobacco following tipoffs and at regular border areas are constrained by lack intervals. of space and requirement to manually

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Few declares to customs

he border town of declaring tobacco at the customs office Phuentsholing, the port of and paying duty. In 2006, two years entry, has between 200- after the implementation of tobacco 300 trucks ferrying in sales ban, tobacco products worth Nu consignmentsT of imported goods via 7,852 were declared. India on any given day. The figure increased to over Nu 1M The consignments range from tonnes in 2018, of which, Nu 514,391 worth of of basic food items to construction tobacco was imported from India and materials, but only a handful declare Nu 554,692 from other countries. tobacco to the Regional Revenue and In the initial years after the ban, Customs officials. customs officials apprehended a Trade statistics, however, indicate few consignments of tobacco being an increasing number of people imported into the country illegally.

Value of imported tobbaco and manufactured tobacco substitutes 1.0M (Figures in Nu/Million) others

0.55M others 0.49M others 0.71M From India 0.51M 0.35M From India 7,852 24,972 From India

2005 2010 2015 2017 2018

Source: Bhutan Trade Statistics

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Today, officials hardly come across smuggling. tobacco when carrying out random When customs officials come physical inspections of trucks bringing across people in possession of tobacco in imported goods. products, they are made to pay tax for However, without a scanner the the permissible amount. The rest are consignments have to be verified confiscated and handed to BNCA. The manually. This limits inspection to agency disposes the tobacco in Gedu, about five percent of the trucks coming a neighbouring settlement under in each day. the same district, where it burns the Besides facilitating trade, given tobacco products in an incinerator. the limited parking space and traffic Customs officials believe smugglers jams the caravan of trucks cause in the used other routes in small vehicles already crowded Phuentsholing town, to traffic in small consignments of customs officials are compelled to tobacco. promptly clear consignments. For better coordination among Limited by these factors, customs stakeholders, customs officials officials rely on informants, although suggest a narcotic control regional tipoffs are hardly about tobacco office in Phuentsholing.

PHYSICAL VERIFICATION: A customs official in Phuentsholing oversees inspection of imported goods.

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Change with behavior

he health ministry with levels in both rural and urban areas. WHO’s support, has been It has also conducted several instrumental in control of researches on tobacco use as part of sale and use of tobacco in STEPwise approach to Surveillance Bhutan.T (STEPs) survey, national health surveys, In the 1990s, former health minister and Global Youth Tobacco Survey (GYTS) Sangay Ngedup toured the country with support from WHO. All of it indicates advocating against tobacco use and its an increasing trend in tobacco use, impact on people’s health. especially among youth. Health ministry This led to informed communities, officials, however, hope to carry out who pushed the local government more in-depth studies on tobacco use. heads to take the issue to Parliament, Besides advocacy and studies, health following which a nationwide ban on ministry has developed tobacco cessation tobacco sale was imposed. guideline and trained health workers A separate tobacco control on brief intervention using screening programme was instituted within the tools. These interventions are for alcohol health ministry, which led relevant and tobacco users. The psychiatric stakeholders to draft the Tobacco department offers counselling, but only Control Act. a handful have, so far, availed of this To this day, the health minister of service to quit tobacco use. an elected government remains the Moreover, drugs required for weaning chairperson of the Tobacco Control tobacco addiction were unavailable in Board. After enactment of the Act, BNCA the country. They were not under the took over as the nodal agency with health essential drugs list. ministry remaining a critical partner. The health emergency line, 112, Its two major mandates to bring which also caters to those wishing about behavioral change lies in to quit tobacco is little known about providing health services and preventing among public. A separate quit line, diseases through awareness creation specifically for the purpose and with and advocacy. greater awareness creation, health Numerous advocacy and awareness ministry officials believe, would be campaigns have been conducted at various more effective.

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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.

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For people’s wellbeing

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 theF nationwide ban and the enactment of the Tobacco Control Act.

Fifteen years after the ban on sale recognised how manufacturers were of tobacco and consumption in public targeting the youth and it was fast places, people are still of the opinion becoming a global health issue. that the draft bill was not thoroughly In 1997, when I was the Chhukha discussed. dzongda (district administrator), It is not true. The issue of tobacco former health minister Sangay Ngedup came about in the 1980s and WHO and former Prime Minister Tshering

Dasho Zangley Dukpa, Former Health Minister

60 The Big Ban IN THE MIDDLE

Tobgay were visiting districts, creating To give the ban legality, a bill awareness on noncommunicable was drafted before the institution of diseases and advocating against risks parliamentary democracy in 2008. associated with sedentary lifestyle The health ministry and other and tobacco. stakeholders Before the found it difficult tobacco control to implement bill was presented the countrywide to the Parliament, NO BILL WOULD ban on tobacco it was extensively HAVE RECEIVED sale without an discussed since the AS THOROUGH A Act. early 1990s. It was DELIBERATION The bill was taken across the AS THE TOBACCO thoroughly country and meetings CONTROL ONE. discussed. were conducted No bill would with dzongdas, have received local government as through a leaders, in thromdes deliberation (municipalities) and as the tobacco development project control one. sites. After about 10 years of advocacy The first district to be declared against tobacco, reiterating what it tobacco-free was Bumthang, meant for a spiritual country like ours because of its historical and spiritual and the impact it has on the health legacy. Following these advocacy of its citizens, particularly our youth, talks, people submitted a letter of I took it up as a responsibility and a commitment, declaring the initiative contribution to the wellbeing of our appropriate and they supported it people, to table it. unanimously. I was an educationist before It culminated in a nationwide becoming an administrator, and to see ban, with representatives from the tobacco companies target youth was country’s 20 districts supporting the disturbing. resolution. The nationwide ban was When I became the health minister declared during the National Day in 2008, I presented the Tobacco (December 17) of that same year Control Bill to the Parliament, which (2004). was endorsed by a majority. The Led by the health ministry, related intention was never to punish tobacco agencies took up the work of drafting users but to deter them. the rules and regulations.

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Tobacco use high among youth

hutan has the highest enforcement of the ban. GYTS 2006 prevalence of tobacco pointed out that a majority of students users among youth, both at were still exposed to pro-tobacco regional and global levels, messages. accordingB to the Global Youth Tobacco Despite the ban and their age, Survey, 2013. students could still buy tobacco from The GYTS looked at school students shops. Half the students who smoked, between ages 13-15 studying in according to GYTS 2006, reportedly classes VII-IX. bought tobacco from shops. The report Bhutan, Myanmar and Nepal were deemed the ban ‘not effective’ and attributed with the highest number of called for ‘stricter enforcement’ of law. youth using smokeless tobacco. GYTS 2013 had similar findings Use of any tobacco products among with half of the tobacco users buying it students in Bhutan increased from 24 from shops. It also found that teaching percent in 2006 to 30 percent in 2013. students of the dangers of tobacco use The rise was attributed to in school had not improved over the widespread black market, which last decade. emerged with the implementation of Not limiting to smoking, the survey nationwide ban in 2004. Research also also recommended inclusion of indicated a decline in anti-tobacco smokeless tobacco control programmes mass media campaigns and limited in communities and schools. Although health education programmes on about 82 percent of students who dangers of tobacco use. currently smoked cigarettes reported to In 2005, following the ban in 2004, have quit and 83 percent had attempted the government issued a notification to, only 25.3 percent had received prohibiting smoking in public places help or advice to quit smoking from throughout the country. professionals, according to GYTS 2013. Advertisement of tobacco products Bhutan’s efforts to control tobacco in all media channels was banned use have, however, resulted in since 1995. Crossborder advertisement significant decrease in exposure to through foreign television channels tobacco smoke at homes and public and movies and other print media places. continued in the early years after Survey results show that, 15.3

62 The Big Ban IN THE MIDDLE 24% 30% 2006 2013 13% 23%

34% 39%

Tobacco users among students (13-15 years) (Sample size 2,012 in 2006 and 2,388 in 2013) Source: GYTS percent of youth surveyed were exposed to smoke in their homes and 42.8 percent were The GYTS uses a standardised methodology exposed to secondhand smoke in enclosed for constructing sampling frames, public places. selecting schools and classes, preparing questionnaires, carrying out field procedures Less than half the students were in and processing data. It includes data on favour of banning smoking in public places prevalence of cigarette and other tobacco according to GYTS 2006. GYTS 2013 reported use, perception and attitudes about tobacco, one in two student favouring smoking ban access to and availability of tobacco inside enclosed public places and four in five products, exposure to secondhand smoke, thought other people’s smoking was harmful school curricula, media and advertising and to them. smoking cessation.

(13-15 years) in Bhutan, Nepal and Timor- In the region Leste. Most countries have policies in place to moking rates among youth (boys prevent youth’s access to tobacco products. and girls) were high in Timor- S Factors such as high prevalence Leste, Thailand and Indonesia. Smokeless of tobacco use among adults, ease of tobacco use was found to be high in Bhutan availability, accessibility, sociocultural and Nepal. milieu, low prices of tobacco products and Bangladesh, Bhutan, India, Nepal gaps in implementation of tobacco control and Sri Lanka have higher prevalence of policies were factors contributing to youth smokeless tobacco use compared with taking up tobacco use. smoking. The high prevalence of smokeless Source: Tobacco Control for Sustainable Development, WHO SEA-Region tobacco use was seen among young girls

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Catching them young

he country’s school curriculum does not include, in any of its subjects, lessons on the harmful effects of tobacco. TBut 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

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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.

65 The Big Ban IN THE MIDDLE

capacity. education also trains students to think After the survey, with support from critically and make decisions based WHO, about 45 guidance counsellors on sound judgment. Peer helpers were trained in brief intervention. The programmes was initiated with support latest train-the-trainer workshop on from Career Education and Counselling brief intervention for tobacco, alcohol Division, under education ministry, which and beetle nut use in school settings in is proving to be more effective. Bhutan was carried out from April 23- While schools maintain a record 30 2019. of students seeking counselling for “If done properly, it takes about substance use, there are no segregated three minutes for an impact,” Sangay figures. From February to June 2018, Thinley said. “We’ve found that 467 male and 54 female students teachers don’t have time to indulge or sought brief intervention on substance talk to students for long duration.” use, which includes, besides other To understand the impact of the narcotics and psychotropic substances, brief intervention programme, he said tobacco. it would have to be assessed in the next Career Education and Counselling three or four years. Division collected the data from 96 Besides brief intervention, life skills secondary schools across the country. education, which looks at wholesome

Brief intervention

he intervention is developed from WHO FCTC Article 14 guideline, Tdeveloped 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.

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Dragged into the habit

ome called it curiosity, when her mother was not around. others peer pressure. Some Pema Wangmo said she tried thought it was cool, others quitting but to no avail. She said her saw in it, stress reliever. determination gave way when she was SFor whatever reason, many took to with her smoker friends. smoking as a “fad”. Before they knew “I think it is also the availability in it, they were dragged into the habit. the market that makes it difficult for Five years ago Kuenzang Namgay some of us to quit,” she said. thought that was the only way to bond Some youth in Thimphu said it with people, make friends and maintain was easy to locate shops that sold a circle. Today, a high school drop-out, cigarettes. After frequent visits, they he recalls all the retributions he faced built contacts and maintained a steady in school for being caught smoking. supply. It was also their friends who Ultimately, that led to suspension travelled to border towns and returned from school. Life, since then, changed. with several packets as gifts. The same could not be said about his Youth who were interviewed said, smoking habit. despite knowing the ill effects of For another drop-out, who works in cigarettes and tobacco, they were a restaurant in Thimphu town, her early unable to rise from its smoky veil. exposure to cigarettes was through her A few had resorted to online tips mother’s handbag. and quitline services only to be met She could pull out a stick or two with disappointments.

67 The Big Ban HEALTH BURDEN

69% 221 34% 14% 120,000 Tobacco related deaths Female Tobacco users in the of all deaths Male in the country (2018) country and people (4,700) NCD Tobacco use (adult) exposed to second related (2018) hand smoking Tobacco is one of the four main risk factors of NCDs

Government expenditure on NCDs Biggest current health expenditure Expenditure incurred in referring attributed to NCDs complicated NCD cases to India for treatment

42% million 25% 14% (FY34% 2016-17) Nu 1,633 Chronic respiratory diseases Cancer Cardiovascular diseases FY 2014-15

million (FY38% 2017-18) Nu 1,693 FY 2015-16 Source: Fourth National Health Accounts study

Source: Factsheet Bhutan, 2018 (tobacco) Source: STEPS survey 2014

68 The Big Ban HEALTH BURDEN

Government expenditure on NCDs Biggest current health expenditure Expenditure incurred in referring attributed to NCDs complicated NCD cases to India for treatment

42% million 25% 14% (FY34% 2016-17) Nu 1,633 Chronic respiratory diseases Cancer Cardiovascular diseases FY 2014-15

million (FY38% 2017-18) Nu 1,693 FY 2015-16 Source: Fourth National Health Accounts study

Source: Factsheet Bhutan, 2018 (tobacco) Source: STEPS survey 2014

69 The Big Ban COST OF TOBACCO

Nu 350

A pack of 20 cigarettes A tray of eggs

Nu 20

10 grams of chewing tobacco 200ml milk

70 The Big Ban Calling it quits

t was only when Sangay found out about the baby she was carrying within her, that her impetuous life beamed glaring back at her. IHer 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.”

71 The Big Ban Impact of Secondhand

On passive smokers During Pregnancy • Low birth weight • Cardiovascular • Poor lung function diseases • Lung cancer • Ear infections • Sudden infant death • Abnormal or delayed syndrome (SIDS) growth and development • Heart disease • Secondhand smoke • Asthma • Congenital malformations • Stroke 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

72 The Big Ban Heart disease and stroke are the most common ways tobacco kills people 5.7% 13% of all deaths caused by tobacco Communicable, maternal, (221 deaths each year) neonatal & nutritional 6% diseases Others 25% Chronic respiratory Tobacco deaths diseases by cause (221 annually) Most people start early, increasing the risk of heart disease in younger people. Mean age at initiation of daily smoking: 14% 42% Cancers Cardiovascular diseases (CVDs) 18.9 Years

CVDs in younger people BHUTAN 19% are more likely to be FACTSHEET 2018 caused by tobacco use USD 2,510 Gross national income per People who quit 14% capita (lower tobacco use middle-income country) 10% Former daily 808,000 Total population 75% smokers 5% 9% Youth population Former daily (13-17 years) smokeless users 38% 30-44 45-59 60-69 70+ 41% Age in years Economically productive population (30-69 years)

SOURCE: Bhutan tobacco fact sheet 201873 The Big Ban WAGING ON Challenges and opportunities in addressing public health issues of tobacco use.

WAGING ON

A block en route to SDGs

n a time of increasing instances and cancer cause nine and 10 percent of noncommunicable diseases of the deaths respectively. (NCDs) and spike in preventable According to WHO SEA-Region’s deaths, the need to strengthen Tobacco Control for Sustainable tobaccoI control implementation under Development report, toxic chemicals the Sustainable Development Goals present in tobacco smoke are (SDG), is timely. responsible for adverse birth outcomes SDG 3 is about ensuring healthy in pregnant women exposed to tobacco lives and promoting wellbeing for all at smoke, either directly or passively. all ages. Among other targets, the goal This has implications on SGD 3 calls for strengthening implementation targets of reducing global maternal of the WHO FCTC in all countries. mortality ratio to less than 70 per In Bhutan, NCDs account for about 100,000 live births, and ending 69 percent of all deaths, making it the preventable deaths of newborns and leading cause of preventable deaths. children under five years. Deaths from NCDs in the country SDG 3 also looks to strengthening spiked from 53 percent in 2011 to 69 prevention and treatment of substance percent in 2018. abuse. Tobacco is a gateway for Tobacco is one of the four risk factors other substance abuse, with nicotine associated with NCDs. Nutrition, contained in tobacco, being a highly sedentary lifestyle and alcohol are the addictive substance. other three. Recognising tobacco as a threat It is also linked to cardiovascular to development, strengthening the diseases, which causes about 28 implementation of WHO FCTC is of percent of deaths in the country. utmost importance and would be Various chronic respiratory diseases critical in realising the SDGs.

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1 17 NO POVERTY 2 PARTNERSHIPS ZERO HUNGER FOR THE GOALS 16 3 PEACE AND GOOD HEALTH JUSTICE AND WELL-BEING

15 4 LIFE QUALITY ON LAND EDUCATION

14 5 LIFE BELOW GENDER WATER WHO EQUALITY

13 6 FCTC CLEAN WATER CLIMATE AND ACTION SANITATION

12 RESPONSIBLE 7 CONSUMPTION AFFORDABLE AND AND PRODUCTION CLEAN ENERGY 11 8 SUSTAINABLE DECENT WORK CITIES AND AND ECONOMIC COMMUNITIES 9 GROWTH 10 INDUSTRY, REDUCED INNOVATION AND INEQUALITIES INFRASTRUCTURE

TobaccoTobacco Control Control for for Sustainable Sustainable Development Development

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Dr Ugen Dophu, Health Secretary 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.

n the long run, prevention is like diabetes, cancer, heart diseases indispensable to improving health and other chronic ailments, which are and lowering health care cost. all preventable through intervention in Instead of investing heavily on behavioral change. healthI infrastructure and facilities, which Apart from poor diet, alcohol, will only incur more cost in future since substance abuse and doma (betel nut), that is targeted at a medical care with tobacco consumption is one of the main focus on treating illnesses, we should contributors to the growing chronic plan towards a better health care through noncommunicable diseases, the main preventive measures. cause of death and disability today. Many of the diseases we see emerging These risk factors are preventable and today, are of the noncommunicable type, they call for measures that have to do with

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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.

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Phuntsho Wangdi, Director General, BNCA 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.

t was a courageous step taken issues and challenges, it has not been in by the government to implement vain, for people smoking openly in the the ban on sale of tobacco. What street, cars or other public places, have Bhutanese should understand is significantly reduced. thatI the proposal for the ban came from Bhutan has clear laws and BNCA the people. and other law enforcement agencies are Although there has been persisting committed to implementing the laws,

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although limited by inadequate resources they kept it for self-consumption. They and challenged by the porous border. can only be fined for illegal possession. These are not defenses against what Sympathy for offenders is, and will is not going right but a call to citizens continue to create a society of law un- to take that extra responsibility to abiding citizens. contribute to tobacco control measures When it comes to sensitisation in the country and not leave everything we leave no stone unturned, taking to law enforcement opportunity to agencies. create awareness It is important and educate for the society to shopkeepers, transform and WE ARE the public at recognise the BUILDING A gatherings, talking implications of COMMUNITY OF to local leaders, tobacco use on PEOPLE WHO CAN students and out health, economy and BREAK THE LAW of school youth. society at large. AND GET AWAY Perhaps the Abiding by the WITH IT. time calls for a law is every citizen’s little refinement responsibility. When in the policy. people break the law, Maybe we can we are building a have limited community of people outlets selling who can break the law and get away with it. tobacco. However, what’s important Following the implementation of is that we strike a balance looking at the Act, there has been a lot of hue all implications. Liberalisation can and cry, which brought down the sometimes make a situation worse. penal provisions. But what we see now If the society takes responsibility is people taking advantage of these and joins hands with law enforcement changes. Shopkeepers selling tobacco agencies, in a few years, we can have a keep a stock of tobacco within the country of only few tobacco users. permissible limit and maintain that

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Together for a cause?

he one thing all stakeholders agree to is the lack of coordination among themselves when it comesT 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 There exist obvious loopholes in the manual inspections of imports into the Act and a relook at it could help revise country. Among health officials, lack strategies to control sale and use of of in depth studies to move decisions tobacco. There are speculations and is an issue. limited evidence-based findings. The stakeholders agree that The GYTS indicates a rising trend in tobacco policies, rules and regulations tobacco use among students calling are in place and the Tobacco Control for stakeholders to work together. The Act gives them the legal teeth. health ministry with support from WHO Its implementation is, what they trains school counsellors and health metaphorically allude to a mountain coordinators. they have to scale and overcome. Tobacco users are often left without The health ministry has, even an alternative. Police officials feel it is before ratifying the FCTC, carried necessary to have smoking facilities out advocacies at various levels and in places, where public gatherings throughout the country. Studies have usually happen. been carried out, but not enough to Health officials feel tobacco provide an in-depth picture of the cessation drugs should be in the current scenario. essential drugs list, because when

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THE ACT SAYS

Impermissible but then...

• Available across the • Trade of tobacco border • Certain amount can be imported for self consumption

• Sale of tobacco and its • Available for purchase products under the table

• Smoking in public • Allowed in designated places smoking zones

someone wants to quit tobacco, all market, most stakeholders believe sale they can prescribe today is nicotine should be allowed, through limited gum. legal outlets and jacked up tax. This For change in behavior, health would also address the issue of officials feel it is not only their underage youth’s access to tobacco. responsibility, or that of other The issue of porous border stakeholders, but of every Bhutanese. calls for more coordination with The black market has made tobacco narcotics authorities from across the available to users, who have never been border. Today, coordination among pushed to the edge of not finding it. stakeholders is limited to joint Instead of having a flourishing black inspections.

83 The Big Ban WAGING ON In partnership

ligning more with disease thriving illicit trade in tobacco and its prevention and health products across the country. promotion, WHO will Apart from that, the support will continue to advocate also be in terms of surveillance, andA provide technical support, in including regular survey on tobacco collaboration with the government, in use, particularly among students and its efforts towards tobacco control. youth. Tobacco will be included as It will also take up advocacy for part of STEPS survey. WHO will extend the government to ratify the Protocol its support in implementing the PEN to Eliminate Illicit Trade in Tobacco protocol. Products, especially in light of the

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THE FUTURE: Every effort the country makes towards control of tobacco use , it owes it to its youth.

85 The Big Ban References

• 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

remote mystical Buddhist kingdom, clasped within the towering ranges of the mighty Himalayas, Bhutan made a bold, Aunprecedented 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.

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