RESEARCH PAPER
 
Policy priorities for strengthening smokeless tobacco control in Bangladesh: A mixed-methods analysis
KEYWORDS
TOPICS
ABSTRACT
Introduction:
Smokeless tobacco (ST) remains poorly regulated in Bangladesh. This study describes the prevalence and trends of ST use in Bangladesh, presents ST-related disease burden, identifies relevant policy gaps, and highlights key implications for future policy and practice for effective ST control in Bangladesh.

Methods:
We analyzed secondary data from the two rounds (2009 and 2017) of The Global Adult Tobacco Survey, estimated ST-related disease burden, and conducted a review to assess differences in combustible tobacco and ST policies. In addition, we gathered views in a workshop with key stakeholders in the country on gaps in existing tobacco control policies for ST control in Bangladesh and identified policy priorities using an online survey.

Results:
Smokeless tobacco use, constituting more than half of all tobacco use in Bangladesh, declined from 27.2% (25.9 million) in 2009 to 20.6% (22 million) in 2017. However, in 2017, at least 16947 lives and 403460 Disability-Adjusted Life Years (DALYs) were lost across Bangladesh due to ST use compared to 12511 deaths and 324020 DALYs lost in 2010. Policy priorities identified for ST control have included: introducing specific taxes and increasing the present ad valorem tax level, increasing the health development surcharge, designing and implementing a tax tracking and tracing system, standardizing ST packaging, integrating ST cessation within existing health systems, comprehensive media campaigns, and licensing of ST manufactures.

Conclusions:
Our analysis shows that compared to combustible tobacco, there remain gaps in implementing and compliance with ST control policies in Bangladesh. Thus, contrary to the decline in ST use and the usual time lag between tobacco exposure and the development of cancers, the ST-related disease burden is still on the rise in Bangladesh. Strengthening ST control at this stage can accelerate this decline and reduce ST related morbidity and mortality.

ACKNOWLEDGEMENTS
We are grateful to the participants of the workshop and the online survey for their valuable contribution.
CONFLICTS OF INTEREST
The authors have each completed and submitted an ICMJE form for disclosure of potential conflicts of interest. The authors declare that they have no competing interests, financial or otherwise, related to the current work. J.S. Ahluwalia reports that a payment was made to his institution from National Institute of Health (NIH) in the past 36 months. K. Siddiqi reports that a research grant was paid to his institution (University of York) since the initial planning of the work, from National Institute for Health Research, a public interest body.
FUNDING
This work was supported by the National Institute for Health Research (NIHR) by a Grant No. 17/63/76 to support a Global Health Research Group on Addressing Smokeless Tobacco and building Research capacity in south Asia (ASTRA).
ETHICAL APPROVAL AND INFORMED CONSENT
Ethical approval for the study was obtained from the Bangladesh Medical Research Council (BMRC/NREC/2016-2019/961, 7 January 2019). Informed consent was not required as we analyzed secondary data from the Global Adult Tobacco Survey. Participants attending the study workshop and taking part in an online survey gave their written informed consent.
DATA AVAILABILITY
The data supporting this research are available from the authors on reasonable request.
AUTHORS' CONTRIBUTIONS
RH, ZAA, AS, SMA and KS conceptualized the study. ZAA collected the data. RH, ZAA, SMA and KS analyzed the data. RH and ZAA drafted the manuscript. All authors reviewed and approved the submitted manuscript.
PROVENANCE AND PEER REVIEW
Not commissioned; externally peer reviewed.
 
REFERENCES (27)
1.
Huque R, Zaman MM, Huq SM, Sinha DN. Smokeless tobacco and public health in Bangladesh. Indian J Public Health. 2017;61(Suppl 1):S18. doi:10.4103/ijph.IJPH_233_17
 
2.
Siddiqi K, Shah S, Abbas SM, Vidyasagaran A, Jawad M, Dogar O, Sheikh A. Global burden of disease due to smokeless tobacco consumption in adults: analysis of data from 113 countries. BMC Med. 2015;13:194. doi:10.1186/s12916-015-0424-2
 
3.
Siddiqi K, Islam Z, Khan Z, et al. Identification of Policy Priorities to Address the Burden of Smokeless Tobacco in Pakistan: A Multimethod Analysis. Nicotine Tob Res. 2019;22(12):2262-2265. doi:10.1093/ntr/ntz163
 
4.
Boffetta P, Hecht S, Gray N, Gupta P, Straif K. Smokeless tobacco and cancer. Lancet Oncol. 2008;9(7):667-675. doi:10.1016/S1470-2045(08)70173-6
 
5.
Zaman MM, Ahmed J, Choudhury SR, Numan SM, Parvin K, Islam MS. Prevalence of ischemic heart disease in a rural population of Bangladesh. Indian Heart J. 2007;59(3):239-241. Accessed April 4, 2021. https://pubmed.ncbi.nlm.nih.go...
 
6.
Inamdar AS, Croucher RE, Chokhandre MK, Mashyakhy MH, Marinho VC. Maternal Smokeless Tobacco Use in Pregnancy and Adverse Health Outcomes in Newborns: A Systematic Review. Nicotine Tob Res. 2015;17(9):1058-1066. doi:10.1093/ntr/ntu255
 
7.
Sinha DN, Gupta PC, Kumar A, et al. The Poorest of Poor Suffer the Greatest Burden From Smokeless Tobacco Use: A Study From 140 Countries. Nicotine Tob Res. 2018;20(12):1529-1532. doi:10.1093/ntr/ntx276
 
8.
Bangladesh Bureau of Statistics, World Health Organization, Centers for Disease Control and Prevention. Global Adult Tobacco Survey: Bangladesh 2017. Accessed April 11, 2021. http://bbs.portal.gov.bd/sites...
 
9.
World Health Organization. WHO Report on the Global Tobacco Epidemic, 2013: Enforcing bans on tobacco advertising, promotion and sponsorship. World Health Organization; 2013. Accessed April 11, 2021. https://apps.who.int/iris/bits...
 
10.
Rahman MA, Mahmood MA, Spurrier N, Rahman M, Choudhury SR, Leeder S. Why do Bangladeshi people use smokeless tobacco products? Asia Pac J Public Health. 2015;27(2):NP2197-NP2209. doi:10.1177/1010539512446957
 
11.
Readshaw A, Mehrotra R, Mishu M, et al. Addressing smokeless tobacco use and building research capacity in South Asia (ASTRA). J Glob Health. 2020;10(1):010327. doi:10.7189/jogh.10.010327
 
12.
Siddiqi K, Husain S, Vidyasagaran A, Readshaw A, Mishu MP, Sheikh A. Global burden of disease due to smokeless tobacco consumption in adults: an updated analysis of data from 127 countries. BMC Med. 2020;18(1):222. doi:10.1186/s12916-020-01677-9
 
13.
Rockhill B, Newman B, Weinberg C. Use and misuse of population attributable fractions. Am J Public Health. 1998;88:15-19. doi:10.2105/AJPH.88.1.15
 
14.
Oberg M, Jaakkola MS, Woodward A, Peruga A, Prüss-Ustün A. Worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries. Lancet. 2011;377(9760):139-146. doi:10.1016/S0140-6736(10)61388-8
 
15.
Government of the People’s Republic of Bangladesh - Ministry of Health and Family Welfare, World Health Organization, Centers for Disease Control and Prevention. Global Adult Tobacco Survey: Bangladesh Report 2009. World Health Organization; 2009. Accessed April 11, 2021. https://www.who.int/tobacco/su...
 
16.
World Health Organization. WHO report on the global tobacco epidemic, 2017: Monitoring tobacco use and prevention policies. World Health Organization; 2017. Accessed April 11, 2021. https://apps.who.int/iris/bits...
 
17.
Nargis N, Hussain AK, Fong GT. Smokeless tobacco product prices and taxation in Bangladesh: findings from the International Tobacco Control Survey. Indian J Cancer. 2014;51(0 1):S33. doi:10.4103/0019-509X.147452
 
18.
Ahmed N, Mozumder TA, Hassan MT, Huque R. Demand for tobacco products in Bangladesh. Tob Control. 2021. doi:10.1136/tobaccocontrol-2020-056297
 
19.
National Board of Revenue, Bangladesh. Annual Report 2017-2018. Accessed April 11, 2021. https://www.nbr.gov.bd/uploads...
 
20.
Marquez PV, Guban I. What countries can learn from Moldova’s successful tobacco taxation efforts. World Bank Group; 2018. Accessed June 28, 2021. https://blogs.worldbank.org/he...
 
21.
Krasovsky K. Tobacco taxation policy in the Republic of Moldova. World Health Organization; 2016. Accessed April 11, 2021. https://www.euro.who.int/__dat...
 
22.
Siddiqui F, Croucher R, Ahmad F, et al. Smokeless tobacco initiation, use and cessation in South Asia: a qualitative assessment. Nicotine Tob Res. 2021:ntab065. doi:10.1093/ntr/ntab065
 
23.
Naznin E, Wynne O, George J, et al. Smokeless tobacco policy in Bangladesh: A stakeholder study of compatibility with the World Health Organization's Framework Convention on Tobacco Control. Drug Alcohol Rev. 2021;40(5):856-863. doi:10.1111/dar.13243
 
24.
Ahmed N, Hossain J, Huque R, Hassan MT, Mozumder TA. The Economics of Tobacco Taxation in Bangladesh. Brac Institute of Governance and Development; 2019. Accessed April 11, 2021. https://bigd.bracu.ac.bd/wp-co...
 
25.
Nargis N, Hussain AG, Goodchild M, Quah AC, Fong GT. A decade of cigarette taxation in Bangladesh: lessons learnt for tobacco control. Bull World Health Organ. 2019;97:221. doi:10.2471/BLT.18.216135
 
26.
Mehrotra R, Yadav A, Sinha DN, et al. Smokeless tobacco control in 180 countries across the globe: call to action for full implementation of WHO FCTC measures. Lancet Oncol. 2019;20(4):e208-e217. doi:10.1016/S1470-2045(19)30084-1
 
27.
Yadav A, Singh PK, Yadav N, et al. Smokeless tobacco control in India: policy review and lessons for high-burden countries. BMJ Glob Health. 2020;5:e002367. doi:10.1136/bmjgh-2020-002367
 
 
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