Alcohol Policy Compliance among Retailers in Bhutan: A Multisite Community Intervention Study

This study is the first multisite evaluation of alcohol sales compliance in Bhutan, addressing a major public health issue given the high burden of alcohol-related disease and mortality.

Background

• Alcohol-related liver disease is the leading cause of mortality in Bhutan’s hospitals, contributing to 11% of facility deaths in 2019.
• Despite a comprehensive set of alcohol laws (age restrictions, prohibition of sales to intoxicated persons, limited hours, and Tuesday bans), enforcement has historically been weak.
• Drinking begins early in Bhutan; one-third of adults are current drinkers, and 24% of students under 18 report current alcohol use.

Methods

• Design: Pre- and post-test community intervention in four district towns (Damphu, Pema Gatshel, Khuruthang, and Bajo).
• Retailers: All licensed outlets were included, both on-premise (bars, hotels, restaurants, karaoke) and off-premise (grocery shops).
• Intervention: Retailers received:
  • Briefings by district officials (health, trade, and police).
  • A laminated notification of alcohol rules to display prominently.
  • Warnings of enforcement and legal consequences.
• Compliance Testing: Purchases attempted by:
  • Underage-looking young adults (>18 but appearing <18).
  • Adults feigning intoxication.
  • Sober adults.
• A total of 854 purchase attempts were recorded.

Results

• Baseline compliance was poor: only 17.3% refusal of illegal sales overall.
• Post-intervention, compliance increased by 22.7% (95% CI: 8.6–37.0).
• Improvements were strongest in refusal to:
  • Underage-looking patrons (increase of 27.8%).
  • Pseudo-intoxicated patrons (increase of 21.9%).
  • Sales on Tuesdays (increase of 19.3%).
• Establishments displaying alcohol regulation signage were 3 times more likely to comply with laws (OR 3.01, 95% CI: 1.67–5.36).
• Compliance was weaker in busy establishments, highlighting operational challenges.

Discussion & Implications

• The intervention demonstrated that brief education and legal reinforcement can significantly improve compliance, but absolute compliance levels (38% post-intervention) remained low.
• Tuesday bans were relatively better enforced than hour restrictions, likely due to ease of implementation.
• Stronger and sustained enforcement mechanisms, combined with periodic retailer education and mandatory signage, are needed.
• Findings highlight the importance of targeting underage sales prevention to reduce early initiation of alcohol use in Bhutan.

Conclusion

The study underscores that while Bhutan has strong alcohol laws, compliance is weak without active enforcement and education. A community-based intervention improved outcomes but must be complemented by regular inspections, stricter penalties, and public awareness campaigns to sustain progress.

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Recommended citation: Gyeltshen T, Penjor T, Dorji L, Tshering L, Dorji K, Subedi BN, Tshering D, Xu YY, Dorji G, Gueye GN (2021). Alcohol policy compliance among retailers in Bhutan: A multisite community intervention study. BMC Public Health 21, 1893. https://doi.org/10.1186/s12889-021-11932-0
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