Bhutan is a low-middle income country that, like many others, experiences significant alcohol-related harm and low compliance with laws restricting availability and promotion. This study assessed changes in compliance of alcohol outlets with sales restrictions following a multi-sector programme aimed at improving this.Design
Pre–post design with covert observation of service practices.Setting
Thimphu, Bhutan, June–November 2013. Alcohol is not permitted for sale except from 1 to 10 p.m. Wednesday–Monday. Serving minors (< 18 years old) or intoxicated patrons is illegal.Participants
Seventy-one outlets selected randomly from all 209 on-premises outlets in downtown Thimphu.Intervention
Multi-sector programme involving visits to outlets, education of owners and staff, a toolkit and implementation checks.Measurements
Ten mystery-shopper visits were made to each outlet both before and after the intervention. We assessed compliance in five purchasing scenarios: (1) before 1 p.m., (2) after 10 p.m., (3) on Tuesdays and (4) shoppers who appeared to be underage or (5) intoxicated. Changes in compliance rates were assessed using multi-variable logistic regression models.Findings
Overall compliance increased from 20 to 34% [difference: 14%; 95% confidence interval (CI) = 7–22%]. Improvement was found in refusals of service before 1 p.m.: 10–34% (differenceadj = 24%; 95% CI = 12–37%) and on Tuesdays: 43–58% (differenceadj = 14%; 95% CI = 1–28%). Differences in refusal to serve alcohol: after 10 p.m. (differenceadj = 15%; 95% CI = –8 to 37%); to underage patrons (differenceadj = –5%; 95% CI = 14 to 4%); and to intoxicated patrons (differenceadj = 7%; 95% CI = –7–20%) were not statistically significant. Younger servers, stand-alone bars and outlets permitting indoor smoking were each less likely to comply with the alcohol service laws.Conclusion
A multi-sector programme to improve compliance with legal restrictions on serving alcohol in Bhutan appeared to have a modest effect but even after the programme, in two-thirds of the occasions tested, the laws were broken.