ArticlePDF AvailableLiterature Review

History of Bhutan's prohibition of cigarettes: Implications for neo-prohibitionists and their critics

Authors:

Abstract

Recently, cigarette neo-prohibitionists have argued that a cigarette ban can be obtained from a de-facto phase-out of cigarettes based on a combination of effective anti-tobacco regulations and high taxes in conjunction with aggressive application of nicotine replacement therapies. The purpose of this study was to ascertain whether these claims were valid in Bhutan, which enacted a national cigarette sales prohibition law in 2004. Did Bhutan from 2004 to 2009 eliminate or nearly eliminate cigarette consumption and avoid a significant cigarette black market and smuggling? This study is a historical, qualitative, descriptive statistical, and archival content overview from 2004 to 2009 of smoking prevalence rates and smuggling and black market trends subsequent to the enactment of the Bhutan Penal Code Act of 2004. For adults in Bhutan, tobacco prevalence rates are fairly low compared with other nations but in 2008 remained a serious health issue for those who consumed cigarettes. For minors, tobacco consumption and second hand smoke exposure in 2008 was a significant health issue. In addition, the best available evidence indicates that illegal tobacco smuggling including black market sales due to the sales ban in Bhutan remains robust. So far, in Bhutan, cigarette neo-prohibitionist arguments that stringent anti-tobacco tax and regulatory approaches including a sales prohibition will induce tobacco consumption to cease or nearly cease has not occurred. In addition, the best scientific evidence indicates that a harm reduction-oriented nicotine replacement therapy approach will not be entirely effective. The results of this study provide an important lesson learned for health practitioners and advocates considering or advocating, albeit a gradual, but total cigarette ban as public policy.
... In Bhutan, the only nation to ban tobacco sales (in 2004), cigarette smuggling is reportedly 'significant'. 130 However, currently, the most problematic black markets rely on the tobacco industry for their product; [131][132][133] thus, proposals that increase government authority over the industry or reduce or closely monitor production would likely have less potential to create such markets. In addition, although black markets are certainly a downside, endgame proponents should consider the likely size and specific consequences of their proposals in order to estimate whether they outweigh the potential benefits. ...
Article
Full-text available
The tobacco endgame concept reorients discussion away from the persistent control of tobacco toward plans for ending the tobacco epidemic, and envisions a tobacco-free future. A variety of policy approaches have been proposed, with many offered prior to the introduction of the unifying term 'endgame'. We conducted a qualitative synthesis of the literature on tobacco control endgames, and drew on media accounts and discussion of analogous ideas for illustrative purposes. We identified proposals focused on the product, user, market/supply or larger institutional structures. Research on public support for these proposals was limited, but suggestive of some public appetite for endgame ideas. Advocates should be encouraged to explore new policy options and consider the goal of a tobacco-free future. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
... 55 59 60 Consistent with the findings of the NZ simulation modelling, which demonstrated that this policy would be insufficient to achieve the country's endgame goal, 60 the proposed law will be introduced as part of a comprehensive plan that also addresses adults who currently smoke. 8 Ending commercial tobacco sales has also been implemented in Bhutan (although recently reversed) 83 and two local government areas in the USA (Beverly Hills and Manhattan Beach). 84 In Hungary, legislation introduced in 2013 forced a reduction in the number of tobacco retailers from more than 40 000 to 7000 retail outlets, 85 and reducing the number of tobacco retailers or the availability of tobacco are government policy goals in NZ and Australia. ...
Article
Objective Tobacco endgame policies aim to rapidly and permanently reduce smoking to minimal levels. We reviewed evidence syntheses for: (1) endgame policies, (2) evidence gaps, and (3) future research priorities. Data sources Guided by JBI scoping review methodology, we searched five databases (PubMed, CINAHL, Scopus, Embase and Web of Science) for evidence syntheses published in English since 1990 on 12 policies, and Google for publications from key national and international organisations. Reference lists of included publications were hand searched. Study selection Two reviewers independently screened titles and abstracts. Inclusion criteria were broad to capture policy impacts (including unintended), feasibility, public and stakeholder acceptability and other aspects of policy implementation. Data extraction We report the results according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Data synthesis Eight policies have progressed to evidence synthesis stage (49 publications): mandatory very low nicotine content (VLNC) standard (n=26); product standards to substantially reduce consumer appeal or remove the most toxic products from the market (n=1); moving consumers to reduced risk products (n=8); tobacco-free generation (n=4); ending sales (n=2); sinking lid (n=2); tax increases (n=7); and restrictions on tobacco retailers (n=10). Based on published evidence syntheses, the evidence base was most developed for a VLNC standard, with a wide range of evidence synthesised. Conclusions VLNC cigarettes have attracted the most attention, in terms of synthesised evidence. Additional focus on policies that reduce the availability of tobacco is warranted given these measures are being implemented in some jurisdictions.
Article
Background Tobacco control policy audacity can make radical ideas seem possible, and set in motion a ‘domino’ effect, where precedents in one jurisdiction are followed by others. This review examines tobacco control policy audacity from seven countries to identify and compare factors that facilitated it. Methods A targeted search strategy and purposive sampling approach was used to identify information from a range of sources and analyse key supportive factors for policy audacity. Each case was summarised, then key themes identified and compared across jurisdictions to identify similarities and differences. Results Included cases were Mauritius’ ban on tobacco industry corporate social responsibility, Uruguay’s tobacco single brand presentation regulations, New Zealand’s Smokefree Aotearoa 2025 Action Plan proposals and 2010 parliamentary Māori Affairs Select Committee Inquiry into the Tobacco Industry, Australia’s plain packaging legislation, Balanga City’s (Philippines) tobacco-free generation ordinance, Beverly Hills City Council’s (USA) ordinance to ban tobacco sales and the Netherlands’ policy plan to phase out online and supermarket tobacco sales. Each case was one strategy within a well-established comprehensive tobacco control and public health approach. Intersectoral and multijurisdiction collaboration, community engagement and public support, a strong theoretical evidence base and lessons learnt from previous tobacco control policies were important supportive factors, as was public support to ensure low political risk for policy makers. Conclusions Tobacco control policy audacity is usually an extension of existing measures and typically appears as ‘the next logical step’ and therefore within the risk appetite of policy makers in settings where it occurs.
Article
This essay develops three central points: • Buddhist economics (BE), like most religion‐based economics, is not only an extrapolation from the basic texts but is also how BE has recently been practiced. Examples of that practice include the application of the concept of “Gross National Happiness” in Bhutan, the implementation of a “sufficiency economy” in Thailand, and action based on the principle of the Unification of King and People in Yogyakarta, Indonesia. • BE as a concept comes originally from an outside understanding of Buddhism that entails perspectives that text‐based BE might not have. • Buddhism, as such, is at odds with standard textbook economics (STE). BE thus potentially forms its own economic paradigm, but BE as practiced often coexists with STE. Discussing these points will hopefully result in seeing that there is considerable diversity within BE and that there is such a thing as real, existing BE that truly does matter.
Article
Full-text available
Important best practices anti-tobacco approaches include: counter-marketing, raising tobacco taxes, secondhand smoke bans in public places, and graphic and color warning labels with clear health warnings on cigarette packs. Further research is required for each of these practices to determine the precise impact on older adults 50 and older. Best practices that have a determined impact on older adults including litigation and cessation and should be continued. New research is also required to determine the impact on older adults of smoke-free movie restrictions. Policy efforts that should be currently deemphasized, until further research evidence is available, due to insignificant information on effectiveness and possible or actual safety issues are product modification, cigarette neo-prohibitionism, and e-Cigarettes. Substituting smokeless tobacco products with cigarettes should not be implemented. Preferred policy approaches require astute political advocacy and mobilization of resources, financial and otherwise. This should include, when warranted, outsider advocacy approaches like media coverage and advertising, forums, or public demonstrations that hold politicians at all levels of government publicly accountable for their pro-tobacco actions.
Technical Report
Full-text available
Findings from the Bangladesh Global Youth Tobacco Survey (GYTS), 2013 provides important indicators of tobacco control among youth in the country. It also provides an opportunity to compare the findings of the GYTS 2007, better understand the effect of interventions, and formulate strategies for better tobacco control interventions among the youth. The rich data contained in this document will be useful for programme managers, researchers, tobacco control advocates and other relevant stakeholders for generating credible evidence to promote tobacco control. In addition, these data can help Member States plan further epidemiological studies as per their need. - See more at: http://apps.who.int/iris/handle/10665/164335?mode=full&submit_simple=Show+full+item+record#sthash.Z39LMb9c.dpuf
Article
Full-text available
Rationale: This statement is an updated version of one released by the same authors in February 2003. The statement was produced to follow up the Royal College of Physicians (RCP) Tobacco Advisory Group report "Protecting smokers, saving lives: the case for a tobacco and nicotine regulatory authority", which argued for an evidence based regulatory approach to smokeless tobacco and harm reduction and posed a series of questions that regulators must address in relation to smokeless tobacco. The purpose of this statement is to provide arguments of fact and principle to follow the RCP's report and to outline the public health case for changing existing European Union (EU) regulation in this area. A review of regulation in relation to harm reduction and regulation of tobacco products other than cigarettes is required in Article 11 of EU directive 2001/37/EC, and this is a contribution towards forming a consensus in the European public health community about what policy the EU should adopt in the light of this review, or following ongoing legal action that may potentially strike out the existing regulation altogether. Public health case: We believe that the partial ban applied to some forms of smokeless tobacco in the EU should be replaced by regulation of the toxicity of all smokeless tobacco. We hold this view for public health reasons: smokeless tobacco is substantially less harmful than smoking and evidence from Sweden suggests it is used as a substitute for smoking and for smoking cessation. To the extent there is a "gateway" it appears not to lead to smoking, but away from it and is an important reason why Sweden has the lowest rates of tobacco related disease in Europe. We think it is wrong to deny other Europeans this option for risk reduction and that the current ban violates rights of smokers to control their own risks. For smokers that are addicted to nicotine and cannot or will not stop, it is important that they can take advantage of much less hazardous forms of nicotine and tobacco-the alternative being to "quit or die". and many die. While nicotine replacement therapies (NRT) may have a role in harm reduction, tobacco based harm reduction options may reach more smokers and in a different, market based, way. Chewing tobacco is not banned or regulated in the EU but is often highly toxic, and our proposal could remove more products from the market than it permitted. Regulatory options: We believe that the EU policy on smokeless tobacco should adapt to new scientific knowledge and that the European Commission should bring forward proposals to amend or replace Article 8 of directive 2001/37/EC with a new regulatory framework. Canada has developed testing regimens for tobacco constituents and these could be readily adapted to the European situation. A review of EU policy in this area is required no later than December 2004, and we believe the Commission should expedite the part of its review that deals with harm reduction and regulation of tobacco products other than cigarettes so as to reconsider its policy on smokeless tobacco. We held this view before Swedish Match brought its legal proceedings to challenge EU legislation and we will continue to hold these views if its action fails.
Article
Varenicline is a licensed smoking cessation medication in the EU, USA and many other countries worldwide. This study was designed to assess its effectiveness in a UK general practice setting. The main outcome measure was the rate of smoking cessation, defined as the seven-day point prevalence after six months from starting varenicline. Varenicline users were identified from records in The Health Improvement Network (THIN) database. A questionnaire on smoking cessation was sent to patients who commenced treatment close to the selection date (six months prior to the date of questionnaire dispatch). The response rate was 26.4%: 193 responses were received. Ninety percent had previously attempted to stop smoking and 87.4% had used nicotine replacement therapy during the previous attempt to stop smoking. The overall smoking cessation rate was 49.5%. There was a strong association between the duration of varenicline treatment and smoking cessation. Patients who reported using varenicline for 9-12 weeks were 11 times more likely to stop smoking than those who completed less than two weeks of treatment. There was some evidence that patients with a longer history of smoking were less likely to stop. No association was observed between smoking cessation and: previous number of cigarettes smoked per day; number of previous attempts to stop smoking; or motivations for stopping. Varenicline appeared to be a useful pharmacological aid to smoking cessation in a general practice setting. The observed effectiveness was similar to the efficacy estimates from previously reported clinical trials. However, the response rate was lower than expected and responders tended to be older, more likely to suffer from chronic obstructive pulmonary disease and to live in more affluent areas than non-responders. Responses were self-reported and not clinically validated therefore recall bias may be an issue.
Article
Banning smoking could theoretically be an option if an alternative for addictive cigarettes would provide the same pleasure and glamour as cigarettes, if smoking rates are below 5% and if the country’s borders can …
Article
Richard Daynard’s suggestion that cigarettes be banned is hardly “unthinkable”—at least not to us in the tobacco industry. We’ve witnessed the discouraging worldwide trends in tobacco control, despite our best attempts to thwart them, and see where they could one …
Article
Despite great strides by the tobacco control movement in recent years, both in reducing the percentage of smokers and in dramatically increasing the number of smoke-free workplaces and public places throughout the world, advocates are understandably frustrated that, 45 years after the 1964 US Surgeon General’s report on smoking and health, millions of people continue to die each year from smoking-related diseases worldwide. Some advocates have concluded that it is finally time to consider the nuclear option—a prohibition on the manufacture and sale of cigarettes. While we all share the frustration, in the United States, at least, such a move towards prohibition is misguided, for both political and practical reasons. Prohibition should be rejected in the US primarily because is politically unfeasible. It is simply inconceivable that the same Congress that could not write a bill giving regulatory authority over tobacco to the Food and Drug Administration (FDA) without tobacco manufacturer Philip Morris’s permission, and then could not pass sensible amendments to the bill when they were opposed by Philip Morris, would even entertain a bill for prohibition, much less enact such a measure. Even the most ardent congressional friends of tobacco control would not spend their political capital on …
Article
In the 17 years since the journal Tobacco Control began, control of tobacco has made tremendous progress. Smoke-free laws are sweeping the globe. Voters in several US states went to the polls to raise cigarette taxes, funding tobacco control programmes and reducing smoking rates. A 1998 settlement of state lawsuits against the tobacco industry in the United States raised cigarette prices, eliminated most outdoor advertising, funded counter-advertising, greatly reduced youth smoking rates and put millions of documents evidencing industry misbehaviour around the world on the internet. More than 80% of the world’s population now live in countries that have ratified the Framework Convention on Tobacco Control (FCTC), thereby committing themselves to greatly limit cigarette advertising, ban misleading package labelling and require strong package warnings, protect non-smokers, control smuggling and take other steps to discourage smoking. And major foundations have committed over $500 million (£340 million; €390 million) to supporting tobacco control efforts worldwide. Aren’t we in (or at least fast approaching) the best of all possible worlds? Well, actually, no. There are currently over 40 million cigarette smokers in the US, and around 1.3 billion smokers worldwide. In the US half of all lifetime cigarette smokers will die from cigarette-caused diseases. Each year about 1% of US cigarette smokers die from these …
Article
Significant achievements in the area of tobacco control have been made in the kingdom of Bhutan in the Eastern Himalayas, following the initiation of several tobacco control activities.