Achieving a tobacco-free Bangladesh by 2040: a qualitative analysis of the tobacco advertising environment and prohibitions in Bangladesh

Abstract

Objectives

This paper explores the Bangladeshi tobacco advertising, promotion and sponsorship (TAPS) legislative environment, to highlight any potential policy loopholes and to facilitate the identification of additional provisions for inclusion. The study also aimed to identify valuable lessons applicable to other low-income and middle-income countries (LMICs).

Methods

We conducted a qualitative health policy analysis using the health policy triangle model to frame the collection and extraction of publicly available information from academic literature search engines, news media databases and websites of national and international organisations, published up until December 2020. We coded and analysed textual data using the thematic framework approach to identify themes, relationships and connections.

Results

Four themes underpin the Bangladesh legislative environment on TAPS: (1) engaging international actor interest in TAPS policies, (2) the incremental approach to TAPS policy-making, (3) time-sensitive TAPS monitoring data and (4) innovative TAPS monitoring and policy enforcement system. The findings highlight the role of international actors (such as multinational organisations and donors), tobacco control advocates and the tobacco industry in the policy-making process and the competing agendas they bring. We also outline the chronology of TAPS policy-making in Bangladesh and the existing loopholes and policy changes over time. Lastly, we describe the innovative approaches to TAPS monitoring and policy enforcement in Bangladesh to combat the tobacco industry marketing strategies.

Conclusion

This study highlights the role of tobacco control advocates as crucial in TAPS policy-making, monitoring and enforcement in LMICs, and identifies good practices for the sustainability of tobacco control programmes. However, it also points out that tobacco industry interference, coupled with increasing pressure on advocates and legislators, may block progress in tobacco endgame approaches.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• We used the health policy triangle (HPT), a conceptual framework specifically designed for the analysis of health sector policies in low-income and middle-income countries, such as Bangladesh.

• We enhanced the HPT approach with the addition of a thematic framework analysis to uncover the challenges within each component of the HPT model and to provide a deeper understanding of the policy-making process.

• Our study is limited due to the reliance on publicly available data and documents, and the exclusion of non-English language resources.

• Future research could include additional data, such as interviews with the identified policy actor groups and multilingual resources.

Introduction

The complete ban on tobacco advertising, promotion and sponsorship (TAPS) is one of the requirements of the WHO Framework Convention on Tobacco Control (FCTC),¹ a global treaty which covers more than 90% of the whole population.² Bangladesh is one of the first countries to have signed and then ratified the treaty, in 2003 and 2004, respectively.

Twelve years later, at the ‘South Asian Speakers Summit to Achieve the Sustainable Development Goals‘ in 2016, the Prime Minister of Bangladesh declared³ the country would be tobacco-free by 2040. Nevertheless, tobacco use remains high in Bangladesh. Thirty-five per cent of the adult population (46% among males and 25% among females in 2017) consumes tobacco, with most of them (20.6% overall, 16.2% among males and 24.8% among females in 2017) in smokeless form (eg, betel quid with tobacco, gul, sada pata, khoinee).^{4 5} These data place Bangladesh in second place for country-level tobacco use in the South East Asia Region, preceded only by Myanmar⁶ and in third position for smokeless tobacco use, following Myanmar and India.⁷

The Prime Minister’s speech prioritised the effective implementation of the national tobacco control law (Act for the Amendment of Smoking and Using of Tobacco Products Control, 2013 and the Smoking and Tobacco Products Usage Control Rule, 2015)^{8 9} and whether it was necessary to improve the law to meet the WHO FCTC standards.³ While TAPS was not explicitly mentioned, notable measures have been introduced in this regard including: a 2013 amendment⁸ of TAPS-related provisions in the Smoking and Tobacco Products Usage (Control) Act of 2005,¹⁰ introduction of additional amendments, such as displaying health warnings during tobacco use depictions in movies, as part of the Tobacco Usage Rule in 2015,⁹ and the introduction of a TAPS ban enforcement mechanism (eg, mobile courts).¹¹

Due to the relatively recent policy developments and delays in collected tobacco use data, the WHO international surveys, including the most recent Global Youth and Adult Tobacco Surveys conducted in Bangladesh (2013 and 2017, respectively)^{4 12} do not reflect the potential impact of the above policy measures on smoking prevalence. The Global Youth Tobacco Survey¹² highlights that no significant reduction occurred in youth exposure to TAPS between the 2009 and 2013 survey rounds. For the adult population,⁴ the report states that between 2009 and 2017, while the exposure to any cigarette related advertisements decreased from 48.7% to 39.6%, respectively, it increased for bidi (from 29.8% to 36.5%) and smokeless tobacco (from 16.5% to 24.4%) advertisements.

To achieve the Prime Minister’s goal of a tobacco-free Bangladesh by 2040,³ a comprehensive ban on TAPS to the standard of the WHO FCTC Article 13 (Tobacco advertising, promotion and sponsorship(TAPS))¹ is required. Under this Article, Bangladesh must meet six obligations: to prohibit deceptive promotion of tobacco products, to comprehensively ban TAPS in all media, to put health warnings on all TAPS, to prohibit tobacco sponsorship of international events and/or the participation therein, to restrict direct or indirect incentives encouraging tobacco product purchase, and, in case of a non-comprehensive ban adoption, to disclose tobacco industry expenditure on any TAPS not yet prohibited to governmental authorities. Given the crucial role TAPS bans play in reducing tobacco use, it is important to develop a holistic perspective on the current TAPS legislative environment in Bangladesh, as well as to identify the policy priorities remaining to be addressed.

The aim of our study was to examine the TAPS legislative environment in Bangladesh, to highlight any potential loopholes and to facilitate the identification of additional provisions for inclusion. The study also aimed to identify valuable lessons for application in other low-income and middle-income countries (LMICs). For this purpose, we formulated three research questions: What is the context surrounding the current TAPS policy in Bangladesh? Which circumstances led to the development of the current legislative text? Finally, what is the involvement of the different actors, including policy-makers, industry and advocates, in developing and monitoring legislation?

Methods

Study design, data collection and analysis

Drawing on the health policy analysis literature,^{13 14} we used the health policy triangle (HPT) model,¹⁵ as a guiding conceptual framework to answer our research questions, and the READ technique (Readying the materials, Extracting data, Analysing data and Distilling findings)¹⁶ to increase the study procedure rigour.

The HPT model is specifically designed for the analysis of health sector policies in LMICs¹⁵ and has already been employed in various health policy areas,^{17 18} including tobacco control.¹⁹ The HPT investigates the contextual factors that influence the policy, the processes by which the policy was initiated, formulated, developed, implemented and enforced, the content of the health policy and finally, the actors involved in the policy-making and implementation.²⁰ The READ technique facilitates the collection of relevant documents and eliciting information.¹⁶

We searched for information in academic literature search engines (PubMed, Embase, Scopus, Science Direct and Web of Science), news media databases (Nexis and ProQuest), websites containing tobacco control policy documents for Bangladesh (eg, Campaign for Tobacco Free Kinds (CTFK)-Tobacco Control Laws), websites of key transnational tobacco industries operating domestically (eg, British American Tobacco Bangladesh (BATB)), websites of national or transnational organisations or coalitions focused on tobacco control (eg, Work for a Better Bangladesh (WBB), WHO, Bangladesh’s Anti-Tobacco Alliance, BATA) (see detailed list in online supplemental file 1). We also extracted references in all the acquired documents (snowballing) and used identified key information items (eg, specific legislation) to find additional information (pearl growing).²¹ To identify the literature, we used the combination of the keywords ‘Bangladesh’ and ‘tobacco advertising’ (or ‘tobacco marketing’ or ‘tobacco promotion’). We used the same keyword combinations within the documents to confirm their relevance to the study research questions. The study data collection time frame was November–December 2020, and no retrospective chronological limit was set.

Although the HPT model is an effective tool in identifying relevant data, it leads to results that are overly descriptive and do not provide a deep understanding of policy-making processes.¹⁸ As we were aiming for a critical approach to uncover the challenges within each component of the HPT model (context, policy process and content, actors), we also employed the thematic framework approach.²² This enabled us to identify commonalities or differences within the investigated policy data and to draw descriptive and/or exploratory relationships clustered around themes.²² The defining feature of the thematic framework approach is the ‘matrix’ output, a spreadsheet that summarises data by codes and analysed units. This allows comparison and contrasting of themes from a variety of the views expressed from the data sources, connected both within the individual source and across all analysed sources.

We started the analytical procedure²² with data familiarisation and then we applied a descriptive label (a ‘code’) to text passages with thematic relevance to the HPT’s model concepts and the research questions. We particularly focused on how the TAPS environment is formulated (eg, advertising activities, exposure, existing policies), what factors had supported or obscured the adoption of a TAPS policy in Bangladesh, and how these had influenced the adopted legislative text. All data was coded using NVivo V.12.0 software.

After coding 40% of the collected documents to ensure that we would cover the most important aspects described within the total volume of the documents, we grouped together similar codes into categories. This formed a ‘working analytical framework’,²² which we applied to the rest of documents (‘indexing’), while iteratively expanding and amending until reaching the final format (‘framework index’) (see table 1). Following this, we ‘charted’ the data on a spreadsheet (summary of data per category from each document) and generated a ‘framework matrix’ (see online supplemental file 2). The final stage involved the ‘data interpretation’, where we mapped connections across the categories and explored any relationships (as clustered around ‘subthemes’ and ‘themes’).

Table 1.

Framework index for the tobacco advertising, promotion and sponsorship (TAPS) policy in Bangladesh

Themes	Definition	Subthemes	Categories
Engaging international actor interest	International actors entered Bangladesh TAPS policy-making arena via identified opportunities	Technical assistance	Contributions to TAPS policy-making Facilitation to policy implementation and enforcement Identification of funding sources
		Capacity building and sustainability	Grant schemes Funding relationships with international and local organisations
		Corporate political activities	First interference and marketing activities Aligning with political situation Current criticism and advocacy for inclusion
Incremental approach to TAPS policy-making	Actor engagement led to incremental TAPS policy changes due to identified loopholes	First TAPS legislation and actor engagement	Early tobacco industry’s policy infiltration Voyage of discovery marketing campaign and advocacy response Act of 2005: industry and policy content Policy loopholes and advocacy Industry’s policy response
		Policy loopholes and amendments after WHO FCTC adoption	Rules of 2006: content and identified loopholes Gazette of 2013: content and identified loopholes Tobacco industry’s interference Rules of 2015: content
		Late policy developments	National tobacco control policy draft Stakeholders’ response to the drafted measures Government’s measures against pandemic: industry’s and advocates’ response
Time-sensitive TAPS monitoring data	High frequency documentation of tobacco industry marketing practices providing time sensitive information	Documentation of marketing practices	Smokeless tobacco products Cigarette packages Point-of-sale Cultural activities Market segmentation (students and women) Corporate social responsibility activities Other practices TAPS exposure data
Innovative TAPS monitoring and policy enforcement system	An approach involving a vigilance system with a mobile enforcement system	Multistakeholder task forces and mobile courts	Multistakeholder approach for TAPS monitoring Mobile courts for legislation enforcement Indicators for TAP ban implementation Challenges and recommendations

FCTC, Framework Convention on Tobacco Control.

Patient and public involvement

No patients or members of the general public were involved in the design, or conduct, or reporting, or dissemination plans of the research.

Results

The aim of our study was to examine the TAPS legislative environment in Bangladesh, to highlight any potential loopholes and to facilitate the identification of additional provisions for inclusion. For this reason, we explored the context surrounding the current TAPS policy in Bangladesh, the circumstances which led to the development of the current legislative text, as well as the involvement of the different actors in developing and monitoring legislation. By using the thematic framework, we found that four themes underpin the Bangladesh’s legislative environment on TAPS: (1) engaging international actor interest, (2) incremental approach to TAPS policy-making, (3) time-sensitive TAPS monitoring data and (4) innovative TAPS monitoring and policy enforcement system (see table 1).

Engaging international actor interest

The TAPS policy-making processes in Bangladesh engaged international actors, such as multinational organisations, key donors and transnational corporations, who entered the policy-making arena through local government, tobacco control advocates and businesses.²³ Actor engagement opportunities were via providing technical assistance, addressing funding needs and deploying corporate social responsibility (CSR) activities. These opportunities reflect international actor agendas to either progress, or obfuscate, the implementation of TAPS legislation in Bangladesh.

For example, Bangladeshi policy-makers have acknowledged and appreciated the contributions received from the WHO and the Bloomberg Initiative (BI),²⁴ and have engaged with both groups as official governmental partners.²⁵ Namely, the WHO has provided technical assistance, such as contributing to drafting the national tobacco control law of 2005 and its amendment in 2013, and assistance with policy implementation and enforcement direction).²⁶ The WHO has also facilitated governmental officials in approaching international donors for tobacco control programme funding.²⁷ The BI responded to this call and secured programme capacity building and sustainability^{28 29} by supplementing the implementation infrastructure via a grant.³⁰ The BI also maintains funding relationships with several international and local tobacco control organisations (CTFK, The Union, WBB Trust and Knowledge for Progress (PROGGA)) which contribute to exposing tobacco industry interference tactics in Bangladesh²⁵ through very low budget but effective advocacy.³¹

On the other side, the transnational tobacco companies, primarily market leader BATB, have employed CSR activities to infiltrate the policy arena. In the early 2000s, the tobacco industry in Bangladesh was increasingly under public pressure from tobacco advocacy organisations due to its marketing activities³² and the antitobacco stance of the news media.³¹ As a response, the tobacco industry started promoting itself as a responsible company³¹ by deploying CSR activities which were aligned with the governmental policy agenda,³² namely around climate change, community development and harm reduction via product development.³² The industry also uses its CSR reports and related websites³³ to criticise TAPS policies (specifically the one preventing the industry from donating or using its brands in CSR activities), and to advocate for involvement in policy-making processes.³³

Incremental approach to TAPS policy-making

Inevitably, these competing agendas led to lobbying engagement within the TAPS policy arena. As a consequence of this engagement, TAPS legislation loopholes have been highlighted and the Bangladeshi government has attempted to address this with incremental policy changes. This engagement activity and policy incrementalism are chronologically detailed below.

The tobacco industry entered the policy arena as early as 1990, when the first TAPS media ban was introduced but never enacted due to industry claims the media would suffer income loss.^{32 34} However, when a BAT’s campaign (Voyage of Discovery, 1999) was introduced in Bangladesh, followed by billboard, newspaper and television (TV) advertisements promoting the initiative,^{31 35} tobacco control advocates responded by forming the BATA.³⁶ BATA litigated against the government on the grounds that BAT’s campaign was a contravention of the government’s obligation to uphold the right to life,³⁷ which then forced the revision of tobacco control laws.^{31 32 38}

The tobacco industry was consulted, via the Bangladesh Cigarette Manufacturers’ Association,³² for the development of the ‘Smoking and Tobacco Products Usage (Control) Act 2005,¹⁰’ following the WHO FCTC enactment that same year.³⁹ This legislation defined tobacco products, the extent of the TAPS ban coverage, and the fines for any violations (see details in table 2). According to tobacco control advocates,^{29 40–44} the legislation included loopholes, such as the non-inclusion of provisions related to: chewing products, CSR activities, advertising and promotion at point of sale (PoS), misleading descriptors (eg, ‘light’, ‘blue’), or items resembling tobacco products. After the policy implementation, the tobacco industry removed most of its advertisements from billboards, TV and newspapers,⁴⁵ but started advertising at PoS and by producing flyers/posters without specifying the company or brand.^45–47 The tobacco control organisations highlighted these loopholes and started advocating for policy amendments.⁴⁸

Table 2.

Tobacco advertising, promotion and sponsorship legislation progression at national and state level in Bangladesh and legislative loopholes identified

Year	Legislation	Definitions	TAPS ban related key-points	Sanctions	Gaps identified
2005	Act no XI of 2005 or ‘Smoking and Tobacco Products Usage (Control) Act 2005’	Tobacco product: Any product made from tobacco which can be inhaled through smoking, and also includes bidi, cigarette, cheroot, cigar and mixture used by pipe	Ban coverage: tobacco ads display in cinema halls, public and private radio and television (TV) stations, printed and electronic media, depiction of tobacco ads on films or videos, billboards, distribution of leaflets, sponsorship of events and individuals, promotional activities (free product distribution, awards, stipends, scholarships) vending machines	BDT1000 or imprisonment up to 3 months or both	Definition does not include: smokeless tobacco. Ban coverage does not include: Corporate Social Responsibility (CSR) activities, advertisements and promotions at PoS, use of misleading descriptors (eg, ‘light’), manufacturing items resembling tobacco products.
2006	The Smoking and Using of Tobacco Product (Control) Rules	(None stated)	Ban of direct and indirect exhibition of tobacco products at PoS Exception: Distribution and supply of leaflets, handbill or any document	(None stated)	Absence of bans related to smoking depiction in plays and movies, gifting items and marketing through brand name, logo or colours
2013	Gazette of 2013 or ‘Act for the Amendment of Smoking And Tobacco Products Usage (Control), 2005’	Tobacco product: Any product made from tobacco, its leaves or its extract which can be sucked or chewed, or inhaled through smoking, and also includes bidi, cigarette, cheroot, granulated, pug cats, snuff, chewing tobacco, cigar and mixture used in pipe Tobacco advertisement: Means conducting any kind of commercial programmes for encouraging the direct or indirect usage of tobacco or tobacco products	Ban coverage: (everything included in 2005 legislation, plus) depiction of tobacco use on local and international movies, TV programmes, radio, internet or any other public media, products’ resemblance with the cover, packet or box of a tobacco product, display of tobacco products’ advertisement at PoS in any way, using tobacco company name, sign, trademark, symbol against sponsoring CSR programmes, use of brand elements (eg, light, mild) Formation of National Tobacco Control Cell, under the Ministry of Health and Family Planning, for the proper implementation of the Act, observation of the tobacco control activities, research and completion of other relevant activities. Exception: Depiction on movies with the necessity of plot (however, scene should be accompanied with a health warning message displayed on the screen)	BDT100 000 or imprisonment up to 3 months or both If he contravenes the provisions more than once, every time the amount of fine or punishment shall be doubled	Absence of code of conduct for interactions with tobacco industry and no protection of policy-making from tobacco industry interference. Tobacco product display at PoS is a form of tobacco advertisement, but the legislation should explicitly ban it greater clarity.
2015	Gazette 2015 or ‘Smoking and Tobacco Products Usage (Control) Rule 2015’	(None stated)	A health warning shall be displayed in the middle of the screen covering at least one-fifth of the screen, in white letters against a black background, in Bengali with the following words ‘smoking/consuming tobacco causes death’, and the health warning shall be continuously displayed as long as the scene continues. In case of telecasting, after the first advertisement break that is, before starting the scene and also before the second advertisement break, that is, after the completion of the scene, a health warning shall be displayed in full-screen for at least 10 s in white letters against a black background, in Bengali with the following words ‘smoking/consuming tobacco causes death’. In case of a movie showed in a cinema hall which has scenes of tobacco consumption, a health warning shall be displayed before starting the movie, before and after the break and after completion of the movie, the health warning shall be displayed in fullscreen for at least 20 s in Bengali with the following words ‘smoking/consuming tobacco causes death.’	(None stated)	(None stated)

PoS, point of sale.

The following year, the government enacted the ‘Smoking and Using of Tobacco Products (Control) Rules, 2006’⁴⁹ which only included a ban of direct and indirect exhibition of tobacco products at PoS. Tobacco advocates suggested further bans (eg, on smoking depictions in plays and movies, tobacco branded gifted items and marketing through the use of brand name, logo and colours),^50–52 which were not addressed until the following legislation, the Gazette of 2013 (‘Amendment of Smoking and Tobacco Products Usage (Control) Act, 2005’).⁸

Despite the tobacco industry’s opposition⁵³ which led to a 4-year enactment delay,^{54 55} the adopted 2013 Gazette included smokeless tobacco products, defined ‘tobacco advertising’ as per the WHO FCTC (see table 2), and banned the promotion of the CSR activities, misleading descriptors and marketing at PoS.⁵⁶ Once again, new loopholes were identified by tobacco control advocates, such as the absence of provisions that would protect policy-making from industry interference,^{25 57} and the lack of an explicit ban on tobacco product displays at PoS.^{57 58} The following Ministry of Health’s ‘Smoking and Tobacco Products Usage (Control) Rule, 2015’⁹ did not address these gaps either, but it provided additional details about displaying health warnings during tobacco depictions in movies (see details in table 2). A provision though not enforced.⁵⁹

Two more events occurred after the adoption of the 2015 Rule. Initially, in 2019, a new national tobacco control policy was drafted⁶⁰ with the aim to include all electronic (non-)nicotine delivery systems and devices under the ‘tobacco products’ definition. The Bangladesh Cigarette Manufacturers’ Association questioned⁶¹ the measures proposed, while tobacco control advocates and the World Bank suggested^{61 62} further measures (eg, disclosure of marketing expenditures and funds given as philanthropical or political contributions, and a ban on internet sales and tobacco industry sponsorship publicity). As of this writing, the legislation has not been adopted. The following year (2020), during the initial outbreak of the COVID-19 pandemic, the Bangladeshi government decided to stop the production, supply, marketing and sale of all tobacco products as part of the nationwide shutdown. In response to these measures, the tobacco industry sent letters to the Ministry of Industry^{61 63 64} and managed to acquire special permission to continue their activities. Tobacco control advocates protested and requested that the Ministry resistant this shutdown measures.^64–66 However, the request was rejected on the grounds that tobacco products are an essential product (Essential Commodity Act 1956) and over fears of the impact of an economic recession.⁶⁵

Time-sensitive TAPS monitoring data

The tobacco industry is actively advertising in Bangladesh, however, local tobacco control advocates monitor and publish evidence of these activities (see an extensive but not exhaustive list of identified practices’ examples in table 3). The magnitude of these documented tobacco industry marketing practices demonstrates that the industry does not comply with the local TAPS legislation.

Table 3.

An extensive but not exhaustive list of the documented advertising practices deployed in Bangladesh

Advertisement types	Examples of practices
Smokeless tobacco products	Use of flavour Low pricing Packages bearing headshots of people (men dressed in western-style business wear or in traditional dress, women in bridal veils or other non-western attire, children and infants with similar to men dress wear) Free tokens (that can be exchanged with cash) for each bidi package bought annually.
Cigarette packages	Use of English (eg, English brand name or English textual communication or both) Use of alternative than the legislative banned descriptors (eg, ‘light’, ‘mild’, ‘ultra’), such as coloured (eg, ‘blue’, ‘gold’) or taste (eg, ‘soft’, ‘smooth’) related descriptors. Free tokens (that can be exchanged with cash) for each cigarette package bought annually. Rewards for returning empty packets
Point of sale (PoS)	Tobacco advertisements (eg, posters, signs), promotions (eg, discounts, free gifting), product display (eg, in shelves, on a tray, power wall) Stores’ decoration in colours matching particular cigarettes packs of foreign tobacco companies Stores located around bus stands, near bazaars, hospitals or clinics, entertainment centres and educational institutions Around schools, PoS deploy practices directed to youth (eg, signages advertising tobacco flavours, free tobacco give away, free promotional gifts, displayed tobacco products next to candy, sweets or toys, or displayed at the eye level of the children) Tobacco industry’s representatives visits for providing advertising materials (eg, free samples, cash money), brand stretching and/or sharing items (eg, T-shirts with brand names and colours, Union Jack flags) or incentives (eg, discounts on bulk procurement, organised picnics and tours, easy payment methods, prizes or additional opportunities when meeting sales targets, financial support for decoration purposes) Industry provides misleading information about the law and encourages PoS owners to use different promotional practices Industry lends money to the vendors who violated the law, for paying the fines Industry initiated a toll-free call centre for providing services (no posted at stores with a brand logo)
Cultural activities	Concert contests and culture related camps (eg, Star Search and Art Camps by British American Tobacco Bangladesh -BATB, ‘Road to Rock Nation’ and ‘Rock City’ by Philip Morris International) Sponsorship of sports events (eg, Asia Cup football competition by BATB) Use of celebrities as brand ambassadors (eg, singer Tahsan Khan by Japan Tobacco International) Display and sale of tobacco brands together with free gifting during the events
Market segmentation (students and women)	Studentships and school programmes’ funding Recruitment of Campus Ambassadors for accessing university students Distribution of cigarettes with gift items (eg, lighters, bags, caps) with brand logos at campuses Fly-posters at universities with slogans such as ‘smoking makes you smarter and more manly’ Establishment of e-cigarette shops nearby universities and selling products directly or via online shopping system Direct promotions via an invitation-only student festivals (eg, promotional agents collect students’ contact information at different stores and later send invitations for the festival) Tobacco advertisements addressed to women students ‘Battle of Minds’ campaign targeting university students every year Public awareness campaigns focused on school education or environmental issues Job fairs at private universities Concert and cultural events at universities Tobacco promotion via Facebook pages
Corporate social responsibility (CSR)	Climate and environmental conservation activities (eg, afforestation programmes, clean water initiatives, solar home system instalments) Promotion of women empowerment and industry’s won gender equality awards Rebranding (eg, ‘A Better Tomorrow’) Promotion of harm reduction initiatives (eg, development of alternative tobacco products) Incentives for farmers (eg, in a form of cash or in kind like seeds and equipment) Funding health related non-governmental organisations through the Foundation for Smoke Free World (eg, BRAC-Bangladesh)
CSR activities related to COVID-19 pandemic	Donation of personal protection equipment to Central Medical Stores Depot Donation to the Bangladesh Labour Welfare Foundation and promotion on the media Promotion of tobacco industry’s activities against the pandemic (eg, efforts for developing vaccine derived from tobacco leaves, home delivery of vaping products as part of the ‘stay at home’ advice)
Other activities	Declaration of expenses on promotion (the legislation prohibits this kind of activity) Tobacco advertisements on hospital websites Creation of products (eg, electronic gadgets like computer speakers, or boxes, trays and youth clothes) resembling tobacco packets Display of mini billboards behind bicycles Production of music videos that include brand advertisements

The magnitude and the frequency of industry marketing practices documentation is valuable, as it provides timely sensitive information. For example, a national TAPS monitoring survey⁶⁷ was conducted by tobacco control organisations between June and August 2020, as a response to the tobacco advertising practices taking place during the SARS-CoV-2 infection pandemic. Such an information would not be captured by the WHO’s global standardised tobacco surveys, as these are not time-sensitive in documenting marketing practices adjusted to specific circumstances (eg, SARS-CoV-2 infection pandemic).

Innovative TAPS monitoring and policy enforcement system

The collection of TAPS evidence data is attributed to the Bangladesh’s TAPS monitoring and enforcement system. To achieve a comprehensive ban on all forms of TAPS, the Bangladeshi government has established a unique approach, which includes a multistakeholder task force (vigilance) system and mobile courts as key enforcement tools.^{68 69} The vigilance system, each district and subdistrict has its own, consists of expert groups (eg, health professionals, lawyers, media) working closely with civil society or tobacco control organisations—who report any violations—and the public authorities (eg, health and police departments)—who enforce tobacco control policy in their local communities. The outcome of this collaboration is the creation of a very low cost, yet tailored to local needs, system with the ability to address any TAPS related violations in a timely and public manner.⁶⁹

The task force system is also supported by mobile courts which conduct random inspections, or they are dispatched when authorities receive report of a violation. Their tasks include: try offences at the scene,^{68 70} impose penalties⁷¹ and destroy any illegal advertisements,⁶⁹ specifically those related to tobacco advertising displayed at PoS.^{68 72} Since 2005, more than a thousand mobile courts have been conducted,⁴⁵ with all enforcement activities (eg, number and types of TAPS removed, fines distributed, reports received from the district task force committees) being publicly posted on a regular basis on the National Tobacco Control Cell website.²⁶ The annual number of these enforcement activities is then used as an indicator of the national TAPS ban implementation.^{27 73} This judicial system has been acknowledged at the WHO FCTC Conference of the Parties (FCTC/COP/6/5)¹¹ as a unique approach for the enforcement of national advertising ban legislation. Additionally, the WHO has characterised⁴ the mobile courts’ strict penalties as an effective deterrent to offenders, ensuring the implementation of the TAPS-related provisions in Bangladesh.

Some administrative issues remain to be addressed. Members of the task force committee have highlighted⁷⁴ the lack of logistic support for conducting the mobile courts, while police personnel have acknowledged⁷⁵ having limited education on the existing TAPS bans and what sanctions follow violations. Lastly, some critics have requested⁶⁸ the government provide a more sustainable enforcement mechanism by reducing the operational costs of the task forces. Three solutions have been proposed: (A) introducing a 1% health tax on cigarettes, which could be allocated to the task forces (B) allowing the district task forces to use revenue collected from the local law violation fines and (C) expanding the activities of task forces by increasing the number of the mobile courts conducted and the fines issued.⁶⁸

Discussion

This case study scrutinised the main characteristics and processes underpinning Bangladesh’s legislative environment on TAPS: engagement of international actor interest (through, eg, technical assistance, funding and CSR) on the TAPS policies, the incremental approach to TAPS policy-making, the collection of time-sensitive TAPS monitoring data, and the innovative TAPS monitoring and policy enforcement system. The findings highlight two good practices which could be transferable to other LMICs encountering related challenges, as well as two challenges for Bangladesh policy-makers and advocates to consider.

One of the valuable lessons which can be drawn from this Bangladeshi case and be transferable to other LMICs settings is the importance of tobacco control advocate involvement in TAPS policy monitoring, enforcement and development, as this strengthens tobacco control policies overall.^{76 77} The participation of the Bangladeshi tobacco control advocates in the multistakeholder task force (vigilance) system, by conducting frequent compliance monitoring, publicly highlighting the advertising activities of the tobacco industry and informing the mobile courts about any TAPS violations, reinforces legislation enforcement. Such collaborations have been proven successful for the implementation of TAPS policies in other LMIC contexts too, like Thailand⁷⁸ and Nepal.⁷⁹ In the case of Bangladesh, advocate engagement with government led to the amendment of TAPS related policies and closed several loopholes. According to the BATA’s view,³¹ the key to this continuous success is maintaining a close working relationship with policy-makers and providing voluntary services to the government (eg, organising governmental events, briefing government on WHO FCTC) rather than just criticising existing policies and advocating for changes.

Another transferable practice for other LMICs, is the three-tier approach to sustainable tobacco control programmes. Initially, Bangladesh introduced multistakeholder committees responsible for policy surveillance, then it established mobile courts for enforcement and finally it included international partners (eg, WHO and BI) for identifying solutions through technical and funding support that could not be addressed with local expertise and resource capacity alone. A similar approach could be used by other LMICs encountering sustainability challenges with their tobacco control programmes.⁷⁷ The tobacco control programme in Bangladesh is largely funded agenda by international organisations, as neither the programme or tobacco control organisations receive any permanent funding from government.⁸⁰ As such, the capacity to effectively deliver their responsibilities could be threatened⁸⁰ in the future so some caution is needed.

Two underlying challenges remain in Bangladesh. Tobacco endgame approaches, such as Bangladesh’s ‘tobacco-free by 2040’ initiative, are vulnerable to tobacco industry when health policy-making processes are not protected from actors with vested interests through interference legislation.⁸¹ The magnitude of the documented tobacco industry marketing practices illustrates that the industry succeeds in adjusting its practices in an evolving legislative environment. Bangladesh’s score on the Tobacco Industry Interference Index has increased between 2020 and 2021 (from 68 to 72 in 2021),^{61 76} suggesting a worsening trend of interference that threatens the realisation of Bangladesh’s vision of becoming tobacco-free by 2040.⁸⁰ Divestment of the government’s shares in BATB and introduction of policy protecting mechanisms to the standards of the WHO FCTC Article 5.3 (Protecting tobacco control policies from the influence of the tobacco industry) were recommended⁸² as solutions for resolving this conflict of interest with the tobacco industry. Similar studies^{80 81} investigating the implementation of tobacco control legislation in Bangladesh echo this argument.

And finally, new TAPS policy opportunities and legislative loopholes will continue to arise. For example, surveys^83–85 showcase that the Bangladeshi public is supportive towards further TAPS measures, such as the introduction of plain tobacco packaging,⁸³ a retailers’ licensing scheme which would reduce TAPS marketing at PoS,⁸⁴ and a ban on tobacco advertisements and tobacco industry events on campuses.⁸⁵ An investigation of tobacco control stakeholder perspectives on strengthening the existing TAPS legislations and advocacy⁸⁶ in Bangladesh could be explored. The gained knowledge from this investigation would inform policy and advocacy direction, and help prioritise needs to achieve a tobacco-free Bangladesh by 2040.³

Limitations

We were limited to data that were publicly available at the time of the data collection and to documents available in the English language. Despite these limitations, we collected large amounts of information, especially around the evolution of the TAPS legislation provisions (second theme) and the documentation of tobacco industry marketing practices (third theme, respectively). We prioritised the analysis of the historical context and the criticism circulated during these time periods, as we believe, they are important to the reader’s understanding of the Bangladesh’s TAPS context. To manage the magnitude of information around tobacco marketing practices, we decided to stratify this information under an extensive but not exhaustive list (see table 3). Future investigation can focus on these activities and provide explicit themes characterising them.

Conclusion

Bangladesh’s experience offers valuable lessons for LMICs seeking to implement tobacco control policies. Tobacco control advocates play a critical role in TAPS policy-making, monitoring and enforcement, working with governments to close loopholes. A three-tier approach, such as the one implemented in Bangladesh, involving multistakeholder committees for policy surveillance, mobile courts for enforcement and international partners for technical and funding support may support tobacco control programme sustainability. However, tobacco industry interference remains a significant challenge, and policy mechanisms should be introduced to protect health policy-making processes from actors with vested interests. Finally, new TAPS policy opportunities and legislative loopholes will continue to arise. Bangladesh must continue to strengthen existing TAPS legislation and advocacy to achieve a tobacco-free future. LMICs can benefit from the lessons learnt in Bangladesh and use them to inform their own tobacco control efforts, while also being aware of the tobacco industry pressures that occur during the policy-making process.

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information.

Ethics statements

Patient consent for publication

Not applicable.