Tobacco control in Nepal during a time of government turmoil (1960–2006)

Abstract

Background

Nepal was a monarchy, then a dictatorship, then a democracy. This paper reviews how tobacco control progressed in Nepal in the context of these changes in government from 1950 through 2006.

Methods

We triangulated tobacco industry documents, newspaper articles and key informant interviews.

Results

Until 1983, the tobacco industry was mostly state owned. Transnational tobacco companies entered the Nepalese market through ventures with Surya Tobacco Company Private Limited (with Imperial Tobacco Company and British American Tobacco) in 1983 and Seti Cigarette Factory Limited (with Philip Morris International [PMI]) in 1985. Seminars and conferences on tobacco, celebrations of World No Tobacco Day (WNTD) and efforts by WHO helped promote tobacco control in Nepal beginning in the 1970s. Tobacco advocates in Nepal pushed the government to issue executive orders banning smoking in public places in 1992 and tobacco advertising in electronic media in 1998, and to introduce a tobacco health tax in 1993. The tobacco industry lobbied against these measures and succeeded in keeping the tobacco tax low by challenging it in court. Tobacco advocates sued the government in 2003 and 2005, resulting in a June 2006 Supreme Court decision upholding the smoking and advertising bans and requiring the government to enact a comprehensive tobacco control law.

Conclusions

Political instability, conflict, weak governance and the dictatorship significantly affect tobacco control activities in low-income and middle-income countries. Nepal shows that tobacco control advocates can take advantage of global events, such as WNTD, and use domestic litigation to maintain support from civil societies and to advocate for stronger tobacco control policies.

INTRODUCTION

Prior to Nepal’s ratification of the WHO Framework Convention on Tobacco Control (FCTC) in 2006, it was a substantial market for the tobacco industry. The government supported tobacco farming and manufacturing, and its corruption and unstable governance led to lack of regulation and enforcement. Despite this history and political and economic opposition, tobacco control) advocacy made substantial progress even as the country went through a monarchy and dictatorship and suffered political conflict. During this time, transnational tobacco companies (TTCs) ignored statutory mandates to implement health warning labels (HWLs) and executive orders banning smoking in public places and tobacco advertisements, defeated a tobacco health tax and Nepal’s first tobacco control draft law in 2000, and initiated numerous lawsuits against tobacco control policies.

To counter TTC influence, tobacco control advocates took advantage of World No Tobacco Day (WNTD), partnered with international tobacco control networks and used litigation to advance tobacco control. In 2003, Nepal was among the first low-income and middle-income countries (LMICs) where tobacco control advocates sued the government to force implementation of tobacco control policies even though martial law was in place. This progress in Nepal provides important lessons for LMICs that are, at times, operating in environments of political instability.

METHODS

We searched internal tobacco industry documents from the Truth Tobacco Industry Documents Library (https://www.industrydocumentslibrary.ucsf.edu/tobacco/) between October 2018 and January 2019, yielding 70 relevant documents. We assessed 5000 media stories from Nexis Uni (https://advance.lexis.com/), yielding 72 relevant stories through 2006. We retrieved tobacco policy documents from Nepal Ministry of Health (MoH), tobacco control Laws, Supreme Court and Law Paper, FCTC and Campaign for Tobacco-Free Kids’ websites. We searched Google for news stories and relevant reports and articles published through 2006 using standard snowball technique.¹ All searches started with ‘Nepal’, ‘tobacco control’, ‘tobacco industry interference’, ‘tobacco legislation’, ‘tobacco ban’, ‘tobacco advertisement’, ‘tobacco health warnings’, ‘tobacco policy’ and ‘tobacco tax’. In June and July 2018, we conducted nine key informant interviews (one Parliament member, two policymakers, three advocates and three MoH officials). Interviews were recorded and transcribed.

RESULTS

From 1768 to 2006, Nepal’s monarchy held all executive, legislative and judicial powers² and maintained a monopoly over all businesses, including tobacco. The King authorised creating a cigarette manufacturer in 1948 (table 1),³ formed a national tobacco development committee to promote tobacco agriculture in 1960 and planned to increase tobacco production from 1959 to 1990.⁴ During the 1960s-1970s, China and the Soviet Union partly financed cigarette manufacturing in Nepal,^5,6 including building a state-owned factory (table 1).⁵ While the King initially denied British American Tobacco (BAT) entry into the market,⁷ in 1980s, under BAT’s lobbying pressure,^8-10 he allowed it (with Imperial Tobacco Company) into Nepal to manufacture cigarettes through a joint venture with Surya Tobacco Company Private Limited (STC).^11-14

Table 1.

Key players and their roles in tobacco control in Nepal

Government organisations	Role/position/purpose	Involvement
National Health Education, Information and Communication Centre	Develop, implement and monitor tobacco control policy and programme, MoH liaison office for tobacco control (http://nheicc.gov.np/).
Non-government organisations
Mrigendra Samjhana Medical Trust, Dr Mrigendra Raj Pandey (founder), funded by WHO and other agencies	Research on tobacco and indoor pollution, advocacy for tobacco control policy and programme (https://www.msmt.org.np/) established in 1975, with the aim to provide health and social services to the underprivileged community, and to improve indoor environment and tobacco control activities in the country.	1975–2000
Nepal Medical Association	Advocacy for tobacco control policy and programme (provide technical support and consultation and discussion with different stakeholders)	1990–2000
NCRS, Dr Anjani Kumar Sharma (founder/chairman), funded by different international organisations and the Rotary Club	Advocacy for tobacco control policy and programme. NCRS (http://www.ncrs.org.np/) is a non-profit community based nationwide social organisation founded in 1982 with the aim of fighting the spread of cancer, including advocating for tobacco control.	1982 onward
PROPUBLIC, Mr Prakash Mani Sharma (chairman)	Case file in the Supreme Court for smoke free environment, tobacco ban on advertisement in 2005. PROPUBLIC (http://propublic.org/) is a non-profit, nongovernment organisation founded in 1991.	1998 onward
RECPHEC, Mr Shanta Lal Mulmi (chairman), funded by different international agencies	Advocacy for tobacco control policy and programme. RECPHEC (http://recphec.org.np/) is a non-government organisation established in 1991. Organisation’s goal was right for health and worked on tobacco control.	1991 onward
Non-Smokers’ Rights Association of Nepal	Filed a case in the Supreme Court against tobacco sponsorship and advertisement in 2003. A national right-based volunteer advocacy organisation established in 2003 in Nepal to protect human right of present and future non-smokers to breath smoke-free air at smoke-free environment (contact details are not available for this organisation)	2000–2010
International organisation
WHO104	Technical support to health and population ministry
Tobacco industry, persons and others working to advance the tobacco industry’s agenda
Nepal Cigarette Factory Birgunj	Private company established in 1948.3
Janakpur Cigarette Factory	Government established in 1960s (inaugurated in 1965) and shut it down in 2013 after pressure created by civil society.
BAT	BAT provided technical support to ITC India and STC, Nepal.
STC (now: Surya Nepal Private Limited (SNPL)	Filled the case in Supreme court against Inland Revenue Department in 1998 and involved against ban on TAPS and smoking in public places. In August 2002, ITC raised its stake in SNPL from 49% to 59%105; 70% share of market.
Seti Cigarette Factory Ltd	Involved against ban on TAPS and smoking in public places. In 1985, Seti Cigarette Factory Ltd was established as a subsidiary of Philip Morris International (PMI).53
Perfect Blends Nepal Pvt. Ltd106	Involved against ban on TAPS and smoking in public places, received technical support from KT&G.
Gorkha Lahari Pvt. Ltd	Involved against ban on TAPS and smoking in public places.

BAT, British American Tobacco; ITC, Imperial Tobacco Company; NCRS, Nepal Cancer Relief Society; PROPUBLIC, Forum for Protection of Public Interest; RECPHEC, Resource Centre for Primary Healthcare; SNPL, Surya Nepal Private Limited; STC, Surya Tobacco Company Private Limited; TAPS, tobacco advertisement, promotion and sponsor.

Early tobacco control advocacy

Tobacco control activities began in the 1970s (table 2). Following WHO’s 1974 recommendation to require text HWLs on cigarette packs, to ban tobacco promotion and to develop a smoking prevention programme,¹⁵ Nepalese tobacco control advocates lobbied government to implement HWLs. In April 1976, the MoH decreed that the warning ‘Cigarette smoking is injurious to health’ appear on cigarette packs in English and Nepali.^16,17 The decree did not include bidis or smokeless tobacco. Lack of enforcement allowed TTCs to avoid adding HWLs on their products until 1993.^18-21 We do not know whether tobacco control advocates tried to enforce this decree.

Table 2.

Tobacco control events

Year	Political actions (including by the government)	Tobacco control actions	Tobacco industry actions
April 197616,17	Nepal required statutory health warning labels (‘Cigarette smoking is injurious to health’). The warning with 3 mm type was to cover 5% on the front panel of the pack (within WHO’s recommendation of 4%−8%107,108)		Ignored the law.
September 1986109	The Transportation Ministry banned smoking inside ministry premises in 1986 but never implemented it.38	Tobacco control campaign committee formed by NCRS as an informal group from different sectors. NCRS was founded by a physician for the royal palace, and the committee included royal family members and former ministers.
April 198824		First no-smoking day organised by NCRS. On 1988 World Health Day, NCRS and the informal tobacco control committee requested that the government ban tobacco advertising on radio and television, and ban smoking in hotels, bars, restaurants, public places, government offices and buses, and, on domestic flights and for at least 1 hour on international flights.
November 1990	King permitted a new democratic constitution.	In 1991, Nepal established a multiparty parliament and its first democratic government. Tobacco control advocates pursued democracy alongside political leaders and parties, especially the Nepali Congress and Nepal Communist Party,8,9,23 which fostered favourable relations between politicians and advocates.
May 199227	Council of Ministers passes executive order banning tobacco smoking in public places (government offices, hospitals, public transportation (except taxis), airports, theatres/cinemas, public meeting places and airline flights not covered by the 1990 ban)		Ignored the law.
July 199329	Nepal government started collecting health tax on tobacco products.		Lobbied government to block additional increases.
March 1995110	State-owned Radio Nepal announced it would no longer accept tobacco and beer advertising.
May 199733		Memorandum against tobacco advertising, along with 100 000 signatures collected by NCRS and MSMT and submitted to the Health Minster
April 199841	Inland Revenue Department claimed excise tax underpaid by STC and filed case in court asking that the STC pay tax based on their actual production.		Sued to block implementation.
June 199834	Council of Ministers passes executive order banning cigarette advertisement in all electronic media.		Ignored law.
December 20004	Ministry of Health Nepal drafts tobacco control bill but did not submit it to Parliament. Bill not introduced. Bill included to ban advertising cigarettes and liquor in electronic and print media, prohibit smoking in public places (government offices, parks, hospitals, schools, colleges and universities) but not private workplaces, require textual health warning labels, require a retail license to sell tobacco, prohibit financial institutions from making loans to cigarette and liquor producers and establish fines up to 25 000 Nepali rupees (US$350) for violators.		Lobby against the bill through different allies.
February 2001	Following the royal palace massacre in February 2001,2 successful businessman and STC shareholder Prince Gyanendra Shah was crowned King. As a prince, he had refused to pay several government fines and avoided conviction for corruption, tobacco and other smuggling.48,49 The new King declared a state of emergency in November 2001, dissolving Parliament and enforcing martial law in February 2002.
May 200354		Non-smokers’ Rights Association of Nepal files case in the Supreme Court against advertisement and promotion activities of tobacco industry.	Defended in the Court and ignored to apply existing rules.
December 20038,23	Nepal signs the WHO FCTC.		Lobbied government and tried to block.
May 200560		Motor rally campaign against tobacco organised by NCRS.
June 200555		Forum for Protection of Public Interest files case in the Supreme Court against the government of Nepal, asking to ban smoking in all public places and all types of advertisements related to tobacco products and demands implementation of tobacco control policy. There was no policy on tobacco control in Nepal, and these bans were based on the executive orders that were not implemented.	Defended in the court and ignored law existing rules.
May 200661,62		Anti-smoking rally in different cities organised by NCRS.
May 200661,62		NCRS submits memorandum to the government demanding ratification of the FCTC and a tobacco control policy in Nepal.	Lobbied government, legislatures, bureaucrats and tried to block.
June 200655-57	Supreme Court of Nepal orders the government to ban smoking in public places, tobacco promotion and tobacco advertisement; to promote awareness against tobacco; and to enact a comprehensive tobacco control law.		Ignored the court order to apply existing rules.
November 200663	House of Representatives (Parliament) ratifies the WHO FCTC.		Ignored rules.

FCTC, Framework Convention on Tobacco Control; MSMT, Mrigendra Samjhana Medical Trust; NCRS, Nepal Cancer Relief Society; STC, Surya Tobacco Company Pvt. Ltd.

During the 1980s, tobacco control advocates partnered with international health groups to establish tobacco control programmes. WHO’s South East Asia Regional Office held its first regional ‘Smoking and Health’ seminar in Kathmandu, Nepal, in March 1984 to review the regional situation and to develop national guidelines.^9,22 These efforts led the Mrigendra Samjhana Medical Trust (MSMT) and the Nepal Cancer Relief Society (NCRS) to establish an informal tobacco control committee in 1986 (Table 2) to pressure the government to ban all tobacco smoke in public places and all tobacco advertising. ^{8, 9, 23} The WHO, Cancer Council Queensland (Australia), American Cancer Society and local sources²³ provided financial and administrative support.

On 1988 World Health Day, NCRS and the informal tobacco control committee requested that the government ban tobacco advertising and smoking in public places (table 2),²⁴ but progress was hindered by the royal palace’s political and administrative protection of TTCs.^8,10

Democracy opens political and advocacy opportunities for tobacco control

In 1990, the King permitted a new democratic constitution and government, which improved the tobacco control advocates’ political situation (table 2)² and fostered favourable relations with policymakers. After discussions with tobacco control activists on WNTD 1990, the prime minister publicly encouraged people to quit smoking and promised to support tobacco control.²⁵ The NCRS issued a nationwide appeal for the government to stop promoting tobacco and develop tobacco control programmes,²⁵ which resulted in the government dropping tobacco farming and manufacturing from its 5-year development plan.^8,26

Executive order and health tax

Tobacco control advocates and NCRS continued to pressure the government to ban smoking in public places and tax tobacco products.^8,9,23 On WNTD 1992, the Council of Ministers issued an executive order prohibiting all types of tobacco smoking in public places (table 2).^27,28 The order justified the restrictions to reduce fire hazards, not to protect public health¹⁷; it did not specify penalties²⁷ or an implementation plan.

In June 1992, the MoH formed a national tobacco control committee with non-government organizations (NGOs) (MSMT and NCRS) and the private sector (excluding tobacco companies) to develop guidelines for a health tax on cigarettes and a tobacco control programme.^3,9 Based on the committee’s recommendation, parliament enacted a 1-paisa tax (US$0.0008) per manufactured cigarette in July 1993,²⁹ allocating 75% of the new funds to the B.P Koirala Memorial Cancer Hospital Bharatpur and 25% for preventing tuberculosis and other tobacco-caused diseases.^3,29 (The health tax applied only to cigarettes; the tobacco tax applied to cigarettes and bidi but not to smokeless tobacco.) In 1994, parliament doubled the health tax to 2 paisa.³ STC coordinated with BAT to lobby against the tax,^10,30,31 blocking additional increases.³²

Advocacy to ban tobacco advertising

In 1994, the Resource Centre for Primary Healthcare (RECPHEC), a health promotion NGO (table 1), organised a meeting of NGOs, the president of the Advertising Agency Association of Nepal and health workers to discuss the negative impacts of tobacco advertising and to pressure the government to ban it.⁸ In 1996, the Nepal Medical Association, NCRS and MSMT discussed tobacco advertising’s negative impact with the prime minister and ministers of health, finance, communication and industry, and commerce. On WNTD 1997, NCRS and MSMT delivered a petition to ban tobacco advertising with 100 000 signatures to the health minister,³³ who promised to play an active role to stop tobacco advertising and to develop a public education media campaign on tobacco harms.³³ However, he did not act.

In June 1998, the Council of Ministers issued an Executive Order banning tobacco advertising in electronic media (TV/radio) effective on July 1998,⁴ but did not address print media, promotions or sponsorships or smokeless tobacco.³⁴ Advocates met ministers and political leaders to pressure the government to ban all tobacco advertising.^8,9,23 In January 1999, the communication minister promised to implement the executive order banning all tobacco advertisements on electronic media.^35-37 TTCs worked through business associates and tobacco farmers to lobby against the ban^8,38 and directly lobbied the communication minister claiming the ban would cause significant economic and employment losses.³⁵ TTCs claimed tobacco advertising provided around 40% of revenue for various media,^37,39 a claim never independently verified.

Despite this lobbying, the communication minister urged media companies to comply with the ban.⁴⁰ The Advertising Agency Association of Nepal objected, arguing the tobacco advertising ban would not reduce tobacco use,⁴⁰ asserted that if tobacco was seriously harmful, the government should ban its manufacture and sale.³⁷ The government issued an executive order banning tobacco advertising in electronic media in January 1999. It was not enforced and was ignored by TTCs until 2011.

STC challenges the tax authority in court

In 1998, the Inland Revenue Department (IRD) analysed STC’s reports (import, export, production, distribution, sales and income) and taxes paid⁴¹ and found STC underpaid taxes from 1993 to 1998 by 136 million Nepali rupees (US$3 million).⁴¹ STC refused to pay back taxes and sued IRD in the Supreme Court.⁴¹ In April 1998, a court’s two-judge panel ruled that STC did not need to pay the taxes.^41,42

Tobacco control advocates, members of parliament and the parliament’s public account committee requested that the office of the attorney general appeal the case and that the two judges be removed from the court.⁴¹ The case was the most controversial in Nepal’s judicial history because it involved Prince Gyanendra Shah, who became king in 2001, who was STC’s part-owner and tobacco businessman since the 1980s.⁴¹ In October 1998, IRD appealed to the Court through the Attorney General’s office.^41,44 The appeal failed in 2009.⁴²

Attempts to pass first comprehensive tobacco control bill

As elsewhere, executive orders issued in Nepal are not legislative laws and can be dismissed by subsequent Councils of Ministers. Tobacco control advocates met political leaders and ministers in 2000 to demand a comprehensive tobacco control law, which the government promised to pass.^8,9,23 In December 2000, the MoH drafted the Smoking (Prohibition and Control) Act 2000 (table 2).⁴ The health minister told tobacco control advocates that the bill would be submitted to the 2001 parliamentary session and would probably take effect in April or May 2001.^45-47

After the minister’s announcement, newspaper owners held a press conference and claimed the advertising ban would cost print media millions of dollars.^46,47 TTCs lobbied ministers, political leaders and bureaucrats through lobbyists, business associates and tobacco farmers against the bill.^8,9,23,38 In December 2000, tobacco manufactures held a meeting in Kathmandu to protest the proposed advertising ban, claiming it restricted citizens’ right to information in a free society.³

Following the royal palace massacre in February 2001,² successful businessman and STC shareholder Prince Gyanendra Shah was crowned king. As a prince, he had refused to pay several government fines and avoided conviction for corruption, and involved on smuggling tobacco and other products.^48,49 The king declared a state of emergency in November 2001, dissolving parliament and enforcing martial law in February 2002. Tobacco control stalled and advocacy was severely limited.^8,9,23,50 Political unrest, an inactive parliament and unwilling government prevented action on the tobacco control bill of 2000.^8,23,50

On WNTD 2002, the NCRS chair demanded that the government pass the tobacco control bill drafted in 2000.⁵¹ This demand was made possible by the participation of several international organisations in WNTD events as the monarchy would not suppress international organisations’ advocacy. In January 2003, NRCS, MSMT, RECPHEC and others organised a meeting with the health minister to request that the king enact the 2000 bill with the intent that it would be made permanent once parliament was restored. The minister told activists the government was preparing to pass the bill.⁵² However, his appointment was not renewed by the king when it ended in June 2003 and the bill was never submitted.

CIVIL SOCIETY SUES IN THE SUPREME COURT

TTCs, ignoring the government’s executive orders, continued advertising, promotion and sponsorship.⁵³ On WNTD 2003, TTCs advertised and promoted cigarette brands through a televised concert, together with free distribution of cigarettes to youth⁵⁴ in violation of the 1998 Executive Order. In response, in 2003, the Non-Smokers’ Rights Association of Nepal (table 1) filed a case requesting that the Supreme Court issue an interim order against the TTCs’ marketing activities, which was decided in June 2006.⁵⁴

In June 2005, the NGO Forum for Protection of Public Interest (PROPUBLIC; table 1) sued the government in the Supreme Court seeking an order requiring the government to ban smoking in all public places and all types of tobacco advertising and enact the tobacco control law because the Executive Orders of 1992 and 1998 were not being enforced. ⁵⁵ (The Supreme Court can order the government to enact and implement the law using its extra ordinary jurisdiction power secured by the Constitution.) PROPUBLIC financed the case with its own resources. The case was based on the fundamental right to breathe clean air under Article 26(4), fundamental right to personal freedom under Article 12(1), fundamental right to protect the individuals under Article 25(1), fundamental right to protect health of the individual under Article 26(1) of the Constitution of Kingdom of Nepal 1990; protect environment and public health under Section 28, ban on consumption, buy and sale of harmful things for health and environment under Section 96 and Article 189 of the Local Self-governance Act 1997; and prohibiting actions polluting or harming environment and public health under Article 7 of the Environmental Protection Act 1997. PROPUBLIC also argued it was the state’s responsibility to protect people’s lives from secondhand smoke because Nepal signed the FCTC in 2003 and ratified the Universal Declarations of Human Rights.⁵⁵

These lawsuits were unique because (1) the cases were filed when political conflict was extreme and martial law was enforced, thus the public were unable to raise their voice against the dictator; (2) the cases were not based on an existing Tobacco Control Act; and (3) the government would be obligated to comply with the Supreme Court ruling even in the absence of a tobacco control law.

In June 2006, the Supreme Court (Judges Anup Raj Sharma and Rajendra Prasad Koirala) ordered the government to ban smoking in all public places, ban tobacco advertising and promotion, promote awareness against tobacco, inform people about the ban extensively through the media and enact a comprehensive tobacco control law within a year.^55-58 In August 2006, the Speaker of the Parliament Subash Newang and Deputy Prime Minister and Health Minister Amik Sherchan said that tobacco advertising in all billboards and media, and tobacco-sponsored programme and broadcasts would be stopped, and that an awareness programme against tobacco products would be launched in national television and radio.⁵⁹ Tobacco advertising billboards were removed immediately, but TTCs continued sponsorship activities in electronic media.

Nepal and the FCTC

Nepal began participating in the FCTC Intergovernmental Negotiation Body in October 2000.^8,23 Regional activities supported Nepal’s FCTC involvement, which it signed in December 2003,^8,23 while TTCs lobbied against the FCTC, arguing, as it had done elsewhere, that tobacco control would create economic losses that LMICs could not afford.²³

During this time, tobacco control advocates maintained their activities. For example, on WNTD 2005, NCRS organised a motorcycle rally in Kathmandu pressuring the government to support tobacco control and ratify the FCTC.⁶⁰

On WNTD 2006, NCRS organised an antismoking rally with students, MoH officials, health institutes, NGOs, the WHO Nepal office and tobacco control advocates.²³ On the same day, NCRS and tobacco control advocates submitted a memorandum to the MoH demanding FCTC ratification and passage of the tobacco control bill.^61,62 Speaker of the parliament Nemwang participated in the meeting and promised that the government would support tobacco control and would work with parliament to ratify the FCTC.⁶³ Nepal ratified the FCTC in November 2006.

The tobacco coontrol bill was not submitted to the Parliament because tobacco control advocates demanded that the bill be rewritten to be consistent with FCTC and applicable to all tobacco products. As a result of this advocacy, Nepal finally passed a comprehensive tobacco control law in 2011 that covered all the tobacco products.⁶⁴

DISCUSSION

The experience of Nepal before FCTC ratification provides a roadmap for other LMICs to maintain tobacco in the public and political agenda even in the face of political turmoil and opposition.

The entry of TTCs in Nepal is similar to joint ventures TTCs used to enter markets in Asia and Eastern Europe.^65-73 While fewer markets remain, the 2015 entry of JTI into Ethiopia⁷⁴ demonstrates that lessons from Nepal could be relevant to other countries experiencing changes in their tobacco markets. TTCs influence tobacco control policy in LMICs by taking advantage of low state capacity, unstable governments and corruption.^65,75,76

Royal family members were involved in tobacco business, and the palace politically supported TTCs in Nepal, which negatively influenced tobacco control efforts. For example, TTCs ignored rules requiring HWLs on cigarette packs for 16 years until 1993^8-10 and kept the MoH from submitting the 2000 tobacco control bill to parliament. Other studies determined that political instability, relationships between tobacco industry and high-level officials, and weak governance affect the development, implementation and enforcement of tobacco control policies, and allow TTCs to ignore regulations or litigate against these regulations.^65,73,75-84

Until 1990, before democracy, the dictator prohibited and controlled the civil societies’ activities in Nepal, which made advocacy difficult. After democracy, advocates had freedom to speak against government and were able to secure executive orders and apply the health tax to cigarettes. Immediately after democracy, Nepal experienced a civil war, a dictator again took power, and his involvement in the tobacco business prevented passing and implementing a tobacco control law. The Supreme Court made its decision on the health advocates’ cases, and the government quickly ratified the FCTC immediately after the dictator was deposed.

Tobacco control advocates increased awareness of tobacco control after democracy was established and convinced the government to issue executive orders banning smoking in public places and tobacco advertising on electronic media. While executive orders are not law, they are a successful strategy to move the tobacco control agenda that was used in other LMICs.^85,86 As observed in other LMICs,^79,87 the celebration of WNTD and WHO support and events^22,87,88 provided a safe avenue for tobacco control advocacy and maintained the public debate in the media and policy circles. Additionally, as in other LMICs, Nepali civil society network with regional and international tobacco control advocacy groups was an effective tool to counter tobacco industry tactics.^78,85,89-95

It is well established that TTCs oppose tobacco taxes, particularly earmarking revenues for tobacco control,^65,75,78 often arguing (without evidence) that tobacco taxes have adverse social and economic consequences⁹⁶ and cause increased illicit trade.^77,97 TTCs had high-level political support,⁹⁸ directly lobbying legislators to stop and delay tax increases in Nepal, arguing that tobacco control measures would have a negative impact on revenue.⁹⁶ TTCs successfully blocked IRD efforts to collect back taxes in court. High-level political support and possible corruption in the court may have influenced the court to support TTCs’ tax position in Nepal.⁹⁹

Civil society groups in Nepal sued the government in the Supreme Court for failure to ban smoking in public places and tobacco advertising, promotion and sponsorship. They also sued TTCs for violating the ban on broadcast advertising. In contrast, most tobacco litigation in LMICs has been initiated by the tobacco companies to block regulation (Uganda,¹⁰⁰ Kenya,¹⁰⁰ Mexico,⁸⁹Argentina,^101,102 Brazil,¹⁰¹ Pakistan and the Philippines¹⁰³ (smoke-free public places); and South Africa,¹⁰⁰ Panama,¹⁰¹ Colombia,^90,101 Brazil¹⁰¹ (tobacco marketing bans); and Uruguay⁸⁵ and Costa Rica⁷⁸ (HWLs)). In Nigeria, one health group sued TTCs for violating the national tobacco control law after it passed.¹⁰⁰ Unlike Nepal, however, this litigation occurred after having a tobacco control law in place. Nepal is the only LMIC we know of in which a health group proactively sued the government to secure legislation. The Supreme Court ordered the government to immediately implement existing policies and to enact the tobacco control law. Advocacy groups in LMICs can apply this strategy to force governments to implement tobacco control policies even without a tobacco control law.

Limitations

Very few tobacco control advocates from before FCTC were available for interviews because of death,or old age, or were no longer involved in tobacco control. Older government records were unavailable to verify some claims made by key informants. Limited industry documents were available in the Truth Tobacco Industry Documents Library to obtain detailed information on TTC internal discussions. We did not find any evidence of opposition from the smokeless and bidi industries. However, in general, these industries were not as well organised as TTCs.

CONCLUSION

Political instability, conflict, weak governance and state-owned monopolies have a negative impact on tobacco control activities in LMICs, including Nepal. However, tobacco control advocates in Nepal took advantage of WNTD celebrations, participated in global networks and used the domestic court system to ensure that tobacco control stayed in the political and public agenda. As with many LMICs, implementation and enforcement of tobacco control policy are a challenge. Nepal’s early history shows that tobacco control advocacy resilience and persistence do lead to positive results. Understanding this history,⁷⁶ TTC political manoeuvres and the role of litigation can guide other LMICs that are trying to advance their tobacco control agendas despite political conflict and opposition.

What this paper adds.

What is already known on this subject

• The tobacco industry influences tobacco control policy in low-income and middle-income countries (LMICs) by taking advantage of low state capacity, unstable governments and corruption.

• Most litigation on tobacco control in LMICs has been initiated by the tobacco companies to block regulation.

What this paper adds

• In Nepal, political instability or conflict, direct investment on tobacco business by royal family members and the dictatorship had significant negative effects on tobacco control.

• Involvement in international activities, such as World No Tobacco Day, created opportunities for Nepalese tobacco control advocates to press government for change.

• Civil society groups in Nepal sued the government and tobacco companies in the Supreme Court to win bans on smoking in public places and tobacco advertising, promotions and sponsorship, a model that could be used in other LMICs.