Three interrelated thematic areas relating to social determinants of tobacco and alcohol were derived, which are as follows:
Theme 1: Exposure and availability of tobacco and alcohol products
According to KI and FG participants, awareness of the impacts on health of tobacco and alcohol use was widely present among the general population in both rural and urban areas. However, despite this knowledge about risks of smoking and drinking, it was reported that people continue to indulge in these risky behaviours. Participants reported that adults from the study areas were often exposed and thus become addicted to these products at a younger age. Young people have easy access to products from liquor and tobacco shops despite being under the legal purchasing age. A health worker from urban Bhaktapur stated:
“8–9 class students smoke tobacco who can get them easily from the shops.” (ID: 42)
Some participants reflected that the use of tobacco and alcohol was also driven by misconceptions. One common misconception was that tobacco and alcohol offered the user relaxation and reduced physical and mental stress. An FG participant candidly shared:
“Not only smoking alleviates tiredness, if one smokes, then one gets some rest from work.” (ID: 74)
KIs and FG participants suggested that community capital and cohesion were declining, which was contributing to limited community action by concerned citizens. When potentially effective actions were initiated by communities, especially those by women’s groups, for example to reduce alcohol abuse, they were often short-lived due to the lack of support from male members of the community and community leaders.
“We have tried to address this many times. But whenever women raise their voice against these, pub and shop owner quarrel with them. Police was sought for help but they didn’t take any action.” (ID: 56; Village level KI; Rural Bhaktapur)
Local shop owners within these same communities often diversify their sales to include the supply of alcohol, as this can help to supplement their income when they themselves are facing economic hardship. An FG participant from rural Morang stated:
“They (shopkeepers) say they won’t make money if they do not sell alcohol.” (ID: 68)
KIs suggested that local shop owners frequently put personal economic benefits before social and health consequences, and were selling products without conscience, even to underage groups. A social worker from urban Bhaktapur shared:
“And why would business people think before selling; those college students are the source of profit. Profit margin is high in alcohol and cigarettes. Ethics and values are neglected by such business owners.” (ID: 44)
It was reported that home-made alcohol producers sometimes used hazardous chemicals and toxic substances to amplify alcohol strength as a means of attracting more customers.
“What I have heard is that they use inedible substances including animal remains. They try to make strong alcohol using urea fertilizer. That can severely affect our health.” (ID: 76; FG participant; Rural Bhaktapur)
Alcohol and tobacco were not considered a significant problem by local authorities. This was illustrated when one of the district level KIs from Morang shared that concerns about tobacco and alcohol use never entered the local planning agenda.
“Due to this, during planning process from the community level (planning must start from the community level) the issues regarding the prohibition of alcohol and tobacco products etc. aren’t arisen while discussing about the plans.” (ID: 50)
Theme 2: Limited focus on prevention of tobacco and alcohol use by the health system
It was clear through the interviews that there has been a lack of focus on system strengthening and preventative approaches for addressing NCDs. A curative orientation was clearly dominant at both policy and implementation levels. Revenue raised through tobacco and alcohol taxes was more often used for curative and other non-health budgetary purposes. Very rarely, if ever, would these resources be used for preventing tobacco and alcohol use.
“Finance Ministry do not provide enough resources (for prevention) despite huge amount is generated from health tax.” (ID: 14; Policy level KI)
Participants argued that weak monitoring and enforcement of regulations were leading to unabated production, marketing and availability of tobacco and alcohol products.
“Implementation of tobacco control policies is not effective at all. Is 500 meters no sale near school effective? It cannot be possible under current system.” (ID: 35; Village level KI; Bhaktapur)
Participants indicated that that tobacco and alcohol companies are the major source of revenue and have strong linkage with policy makers. They have been influencing policy decisions in their favour. A policy stakeholder shared one of his experiences as follows:
“Tobacco production companies filed a case in Prime Minister’s office and the Prime Minister directed officials not to change the existing rule till the [proposed Tobacco Control Law] law was passed and to reconsider the practicality to change [pictorial warning image] from 75% to 90% within the law and take decision accordingly.” (ID: 23; Policy level KI)
Participants at both policy and district level also expressed that the district and community health system did not have any well-resourced programmes for preventing tobacco and alcohol use. Neither were there any counselling support services for those already addicted to tobacco and alcohol.
“These tobacco, tobacco products and drugs become addiction to people. We apply the prevention approach to those who don’t consume these substances. For those who consume these substances, rehabilitation and counselling must be strengthened.” (ID: 50; District level KI; Morang)
Most of the policy KIs described a lack of a focused policy structure and leadership for initiating any kind of NCD preventive action. According to one policy stakeholder, a division within the Ministry of Health responsible for curative services by hospitals around the country was leading the multi-sectoral action for prevention of NCDs, which indicated gaps in the prevention structure. The policy stakeholder shared:
“Curative Service Division is leading this fight against NCD but more from curative perspective and less from Health promotion.” (ID: 15)
Even where resources have been explicitly allocated to NCD prevention, KIs argued that their use has been ineffective because of fragmentation and misallocation.
“There is budget for NCD prevention but they are scattered in various places. That has to be managed through certain centre in an effective way.” (ID: 12)
Theme 3: Gender and socio-economic status as the root drivers of tobacco and alcohol use
Gender and socio-economic status have been identified as key drivers of tobacco and alcohol use. From a gender perspective, participants reported that tobacco and alcohol use were implicitly driven by gendered social constructs and the way in which power relationships played out. Study participants shared that it was mainly men within their communities that demonstrated addictive behaviours. They further suggested that this situation of widespread addiction among men could be linked to a combination of factors, including the need to relieve stress, financial autonomy, and the perceived lower social status of females.
“Male are more intensely involved in alcoholism. They earn money during day time and spend it on drinks at night. This problem is more intense among 6–7 household in our locality. Even domestic violence is common in those houses.” (ID: 56; Village level KI; Morang; Health)
One FG participant from rural Morang was vocal about the increased stress on women due to the drinking habits of men, and their inability to do anything to address it.
“You males drink, smoke and this problem [hypertension and diabetes] is because we take stress about that.” (ID: 67; Female FG Participant; Rural Morang)
Some KIs also noted there is a recent, increasing trend in tobacco and alcohol use among females, with one policy informant suggesting that there might be an underestimation of female tobacco and alcohol use within national surveys. This may be due to the social pressure on women to not be seen as consumers of these products.
“There is the perception in our society that females shouldn’t be consuming such substances and so females do not give true answers and also our enumerators may not have been able to explore effectively.” (ID: 5)
Participants shared that tobacco and alcohol consumption were a major community problem among low-income groups. Tobacco and alcohol were seen as a way to ward off the stresses of daily life.
“Most of the people here are engaged in labour work. They have to do hard work like carrying stones and get tired and do not even eat their food on time. In the evening to get rid of their tiredness, they consume alcohol.” (ID: 37; Village level KI; Bhaktapur)
A community level KI reported that those from low-income communities operated many shops selling alcohol and tobacco. Many of these businesses have been borne out of a need to earn money amidst a dire lack of job opportunities.
“However, these home-made alcohols are the means to earn money for the small shops and poorer households.” (ID: 55; Village level KI; Morang)
There is evidence of diminishing boundaries between traditional drinkers (Gurung, Rai, Magar, Newar and similar ethnicities – collectively referred as Matwali – who are culturally allowed to drink alcohol) and traditional non-drinkers (Brahmin, Chhetri and similar ethnicities – collectively referred as Tangadhari – who are culturally forbidden to drink alcohol). This has led to increased total alcohol consumption within the case districts, especially among those who are poor, irrespective of ethnicity.
“There was social rule that it is something to be consumed by Matwali but not by Brahmins and Chhetris but now the situation has just reversed. These days it is hard to find Brahmin/ Chhetris who do not drink.” (ID: 47; District level KI; Morang)
Alcohol is very much ingrained in the cultural practices of the Matwali ethnic group. Many of their rituals and cultural practices involve alcohol. Due to poor socio-economic status, home-brewing in Matwali communities is commonplace and these products are being supplied to shops around the locality as well as nearby cities. As such, Matwali have begun to use their traditional skills for home-brewing to produce on a commercial scale due to the monetary incentive. One policy stakeholder explained the situation:
“Matwali have cultural practice of brewing home-made alcohol and we do not infringe into that cultural practices. But, many have been exploiting this cultural aspect for economic benefits including those who were non-traditional brewers.” (ID: 16)
The Causal Loop Diagram (CLD): interactions of tobacco and alcohol use and NCDs
Three interacting CLDs or sub-systems and archetypes were developed to gain insights into the interactions of the social determinants of tobacco and alcohol use from a health system perspective. These interacting sub-systems displayed the sets of balancing and reinforcing loops that are possibly escalating the NCDs epidemic within these study case districts.
- Demand-supply sub-system. This sub-system illustrates that tobacco and alcohol use and addiction were being reinforced by the widespread availability and sales of such products in the case districts of Nepal (figure 3A). Companies that produce tobacco and alcohol have financial capacity for marketing to vulnerable groups as well as influence policy decisions (profit and influence reinforcing loop). One key mechanism within the demand-supply subsystem can be illustrated by drifting goal archetype (figure 3B) whereby policy makers may be succumbing to the pressure of tobacco and alcohol companies to not raise excise tax, despite prevention experts pushing for increases in excising tax as a key policy intervention, as per the WHO recommendation. Another key reinforcing loop was the illicit trading loop, which illustrated the role of marginalised or disadvantaged groups in the sales of home-made alcohol and tobacco products.
- Prevention delay sub-system. The prevention delay subsystem comprises of balancing loops (indicated by B at the centre of the loop). This indicates the goal-seeking or stabilising nature of the loop (figure 4A). The negative sign between “Government health system action” and “demand and supply” here means that increasing implementation of regulations and monitoring can decrease availability. However, in this circumstance the action is delayed (indicated by a delay sign in the arrow i.e. //), resulting in increasing exposure of the healthy population to tobacco and alcohol products, which leads to metabolic risks and NCDs (links have positive sign). This primary prevention delay loop is a balancing loop as the loop has a goal to reduce the supply and demand of tobacco and alcohol products but is suffering significant health systems action delays. All other balancing loops (primordial prevention, screening and treatment loops) indicate that the health system is failing to take concrete preventative actions, including effectively allocating resources for the prevention of NCDs both at the community and policy level. The prevention delay sub-system resonates with Fixes that fail systems archetypes (figure 4B), indicating a failed strategy of allocating more resources towards the treatment of NCDs rather than for prevention.
- Socio-economic influence sub-system. This sub-system contains reinforcing loops, which illustrate the social and economic influences contributing to the current environment for tobacco and alcohol (figure 5A). A reinforcing mechanism of the socio-economic hardship leading to stress, gender-based violence and misconceptions, and eventually to tobacco and alcohol addiction is shown. Further, socio-economic hardship among specific disadvantaged groups, for example Matwali, meant that the socio-economic status was reinforcing the supply of home-made alcohol through illicit trading. Blurring of social boundaries between traditional and non-traditional drinkers meant that more and more people were being exposed to such addictive products. Shifting the burden archetype (figure 5B) depicts the inability of the health system to see the bigger picture or broader influences driving the NCDs problem. This demonstrates that the Nepalese health system has been focusing on narrow sets of interventions driven by foreign support and ignoring the complexity of the issue, which is embedded in the socio-cultural context and therefore demands a more local solution.