Doma and Cigarettes: an Unholy Bhutanese Alliance

On average, a Bhutanese cigarette smoker smoked 111 cigarettes per month and spent an average of Nu 1,416 a month

BY Chimi Wangmo

The prevalence of use of any tobacco product Bhutan was 23.9% (32.9% for men, 11.8% for women), as per WHO’s STEP survey released recently.

WHO also states that amongst the current tobacco users, 10.6% used smoked tobacco, 14.7% used smokeless product and 1.4% used both smoked and smokeless tobacco products.

The study also reveals that overall 70.6% of respondents never used smoked tobacco, 18.8% smoked formerly (8.7% daily 10.1% non daily) and 10.6% were current smokers (5.8% daily and 4.6% non daily).

Further, 77.8% of respondents never used smokeless tobacco, 7.5% used formerly and 14.7% were current users (12.8% daily and 1.9% non daily users) of smokeless tobacco.

“Men are nearly three times more likely to smoke than women. Smoking is more prevalent in the western (26.1%) and central (26.7%) region than in eastern region (9.9%),” the WHO report states.

In addition, the prevalence of smoking tobacco was lower in the rural areas compared to urban areas (21.4% versus 25.1%). However, the use of smokeless tobacco was slightly higher in rural areas (15.8%) compared to urban areas (13.2%).

It also revealed that those with higher educational level smoked cigarettes whereas those with no/less than primary education level used smokeless tobacco. Similarly, people in lower wealth quintiles used smokeless tobacco compared to people in the higher wealth quintiles who used more cigarettes.

“The average age at initiation of smoking tobacco in Bhutan was 20.1 years (19.9 years for men and 20.3 years for women). The median age or the age by which 50% of current smokers started smoking was 19 years (18 years for men and 20 years for women),” it states.

Amongst the current users of tobacco, 75.3% tried to stop smoking and only 20.7% were advised to quit smoking by a doctor or health worker.

Further, 69.3% said they received anti-tobacco information from television, 28.8% from radio, 23.9% from newspapers or magazines, and 46.2% from poster, banners and signboards. Exposure to graphic health warnings

A good proportion, 57.2%, who saw a cigarette package, reported noticing health warnings on tobacco packages. Amongst the current users who noticed these health warnings, 83.1% thought about quitting smoking. Expenditure on Tobacco

It also reveals that on an average, a cigarette smoker smoked 111 cigarettes per month and spent an average of Nu 1,416/ month. The average price of 20 cigarettes was estimated to be about Nu 249/.

Around 10% of respondents smoked cigarettes, 2.1% smoked bidis, and 0.5% smoked products like cigars, cheroots and cigarillos. Amongst the current users, cigarettes and bidis were the most commonly used smoked tobacco products reported by 88% and 22.7% of current tobacco smokers respectively.

While surveying on access to tobacco products, 51.2% stated that people usually bought smoked tobacco products from outside of Bhutan and 29.4% stated they purchased from within the country.

54.3% reported that procuring tobacco products was very difficult and 28.5% reported that it was easy or very easy.

Amongst the current users of smokeless tobacco, 82.4% chewed tobacco, 33% reported using snuff by mouth or nose, and, 2.2% used betel leaves with tobacco.

Men (32.9%) are nearly three times more likely to smoke than women (11.8%). Smoking is more prevalent in the western (26.1%) and central (26.7%) region than in eastern region (9.9%).

The prevalence of smoking tobacco was lower in the rural areas compared to urban areas (21.4% versus 25.1%). However, the use of smokeless tobacco was slightly higher in rural areas (15.8%) compared to urban areas (13.2%).

Interestingly, those with higher educational level smoked cigarettes whereas those with no/less than primary education level used smokeless tobacco. Similarly, people in lower wealth quintiles used smokeless tobacco compared to people in the higher wealth quintiles who used more cigarettes.

The number of cigarette smokers has increased to 9% in 2019 as compared to 6% in 2014. However, the age of initiation remained almost the same (18 years in 2014 and 19 years in 2019).

Annual expenditure on tobacco products has also increased to 7% in 2019 from 5% of GDP in 2014.

The mean number of cigarettes smoked per month also increased to 112.8 cigarettes from 98.3 cigarettes.

Overall, the levels of exposure to second-hand smoke at home declined to 13% in 2019 as compared to 21% in 2014, On the contrary, exposure to second-hand smoke at work increased to 41% in 2019 compared to 25% in 2014.

While there was an increase on exposure to anti-tobacco messages on television and newspapers/magazines, there was a slight decrease on exposure from other sources.

Tobacco kills more than 8 million people each year. More than 7 million of those deaths are the result of direct tobacco use while around 1.2 million are the result of non-smokers being exposed to second-hand smoke.

WHO further states that under the Framework Convention on Tobacco Control, Bhutan had adopted the MPOWER policy packages to reduce the use of tobacco. Further, Bhutan has set a target to reduce by 30% the prevalence of current tobacco use in persons aged 15+ years by 2025.

The national multisectoral action plan (2015-2020) for NCDs and Tobacco Control Amendment Act 2014 also gives the necessary impetus in its endeavour to curtail the use of tobacco.

Doma or Areca Nut Use

The report also states that the use of betel nut or areca nut is very common in Bhutan. The survey collected information on its use, different forms of betel nuts used and frequency of consumption from all respondents and amongst current and former users.

Of all the respondents, 56.7% were current users of betel nut or areca nut while 13% were former users and only 30.2% never used it. And amongst the current users, 65% used it daily while the other 35% used it on non-daily basis.

“More number of respondents in the younger age group and those with higher education level consumed betel nut or areca nuts on a non-daily basis,” it ststes.

In addition, the daily use of betel nut was slightly higher among men (21.3%) compared to women (9.81%).

The daily use of betel nut or areca nut was found to be more pronounced among less educated respondents (22.6% among no/less than primary education) as compared to higher educated respondents (17.7% among primary to less than middle secondary, 17.7% among middle secondary and higher education).

Overall 51.8% used betel nut (doma and paan), and 14.9% used supari and other products. Amongst the current users of betel or areca nut, 90.2% were current user of betel nut (doma and paan) and 26.5% were current user of supari and other products.

On an average, 32.7% betel nuts were used per person per week and 7.3 supari and other products were used per person per week.

Respondents with no or less than primary level education level, mean of 40 numbers a week, and older age group (55-69 years) consumed more betel nuts than other categories with a mean of 50 numbers a week.

Apart from these vices, an unhealthy diet is one of the 5 main risk factors for NCDs and the promotion of a healthy diet is one of the recommended components for policies and programs in the Global Action Plan against NCDs15.

The Ministry of Education has also introduced school agriculture programme and encouraged the consumption of fruits and vegetables in the schools. In the hospitals, the dieticians also advocate good dietary habits to the patients.