Policy priorities for strengthening smokeless tobacco control in Bangladesh: A mixed-methods analysis
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.

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.

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.

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.

We are grateful to the participants of the workshop and the online survey for their valuable contribution.
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.
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 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.
The data supporting this research are available from the authors on reasonable request.
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.
Not commissioned; externally peer reviewed.
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