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Original research
Tobacco industry interference to undermine the development and implementation of graphic health warnings in Bangladesh
  1. Md Hasan Shahriar1,
  2. Md Mehedi Hasan1,
  3. Md Shahedul Alam1,
  4. Britta K Matthes2,
  5. Anna B Gilmore2,
  6. A B M Zubair1
  1. 1PROGGA: Knowledge for Progress, Dhaka, Bangladesh
  2. 2Department for Health, University of Bath, Bath, UK
  1. Correspondence to A B M Zubair, PROGGA: Knowledge for Progress, Dhaka, Mirpur, Bangladesh; progga.bd{at}gmail.com

Abstract

Background In Bangladesh, the 2013 Amendment of the Tobacco Control Act made graphic health warnings (GHWs) on the upper 50% of all tobacco packs obligatory. However, at the time of writing (May 2022), GHWs are still being printed on the lower 50% of packs. This paper seeks to explore how the tobacco industry undermined the development and implementation of GHWs in Bangladesh, a country known for a high level of tobacco industry interference (TII) that has rarely been examined in the peer-reviewed literature.

Methods Analysis of print and electronic media articles and documents.

Results Cigarette companies actively opposed GHWs, while bidi companies did not. The primary strategy used to influence the formulation and delay the implementation of GHWs was direct lobbying by the Bangladesh Cigarette Manufacturers’ Association and British American Tobacco Bangladesh. Their arguments stressed the economic benefits of tobacco to Bangladesh and sought to create confusion about the impact of GHWs, for example, claiming that GHWs would obscure tax banderols, thus threatening revenue collection. They also claimed technical barriers to implementation—that new machinery would be needed—leading to delays. Tensions between government bodies were identified, one of which (National Board of Revenue)—seemingly close to cigarette companies and representing their arguments—sought to influence others to adopt industry-preferred positions. Finally, although tobacco control advocates were partially successful in counteracting TII, one self-proclaimed tobacco control group, whose nature remains unclear, threatened the otherwise united approach.

Conclusions The strategies cigarette companies used closely resemble key techniques from the well-evidenced tobacco industry playbook. The study underlines the importance of continuing monitoring and investigations into industry conduct and suspicious actors. Prioritising the implementation of WHO Framework Convention on Tobacco Control Article 5.3 is crucial for advancing tobacco control, particularly in places like Bangladesh, where close government–industry links exist.

  • Low/Middle income country
  • Packaging and Labelling
  • Advocacy
  • Tobacco industry
  • Public policy

Data availability statement

No data are available.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

https://doi.org/10.1136/tc-2022-057538

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Graphic health warnings (GHWs) raise awareness about the dangers of smoking; they can discourage people who do not smoke from starting to smoke and increase quit intentions of those who smoke.

    • In Bangladesh, GHWs were part of the 2013 Amendment of the 2005 Smoking and Tobacco Products Usage (Control) Act but remain only partially implemented as of May 2022 (time of writing).

    • Several case studies from around the world document how the tobacco industry has worked against GHWs, but no study has explored tobacco industry interference (TII) in GHW development and implementation in Bangladesh, a country with a high level of TII.

    WHAT THIS STUDY ADDS

    • The paper identifies a range of strategies cigarette companies used to delay and weaken GHW guidelines and delay their implementation in Bangladesh, including working through an industry association, lobbying policymakers and public bodies, creating confusion, and taking legal action.

    • Companies argued for GHWs to be printed on the lower, instead of the upper, half of tobacco packs, which was against the 2013 Amendment. They also made claims about technical barriers to delay the GHW implementation.

    • Advocates engaged in several activities to push for strong guidelines and support GHW implementation.

    • Although advocates were partially successful in counteracting TII, one self-proclaimed tobacco control organisation, whose nature remains unclear, sought to undermine tobacco control efforts.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • The study highlights the importance of continued monitoring and investigative work to better understand links between industry and government actors, as well as the nature of the organisation that created confusion in the tobacco control community.

    • Implementing WHO FCTC Article 5.3 needs to become a priority to counteract TII and protect public health policymaking in Bangladesh.

    Introduction

    With over 160 million inhabitants, Bangladesh is the eighth largest cigarette market in the world.1 2 In 2017, around 35.3% of adults (male 46%, female 25.2%) used smoked and/or smokeless tobacco.3 While around one in five adults (male 16.2%, female 24.8%) consume smokeless tobacco, around 18% of adults smoke (male 36.2%, female 0.8%).3 Approximately three-quarters of people who smoke consume cigarettes and the rest use bidis (cheap hand-rolled cigarettes).3 In recent years, tobacco use has declined (43.3% in 2009, 35.3% in 2017), but remains high, and cigarette smoking rates have barely changed (14.2% in 2009, 14.0% in 2017).4 5 This indicates that tobacco use remains a key public health challenge in Bangladesh; every year, around 57 000 people die and around 400 000 people become disabled because of tobacco.6

    One measure found to be effective in reducing smoking prevalence is graphic health warnings (GHWs), which warn (potential) consumers of the health risks and influence the attitudes and beliefs of those who smoke.7–12 Article 11 of the 2003 World Health Organization Framework Convention on Tobacco Control (WHO FCTC) recommends that parties enforce large, rotating GHWs on all tobacco packs.

    Bangladesh was the first signee and an early ratifier of the WHO FCTC, which entered into force in 2005.13 In the same year, the Bangladesh government adopted the Smoking and Tobacco Products (Usage) Control Act,14 which included, among other measures, a provision on textual health warnings on smoked tobacco products. This was inconsistent with WHO FCTC Article 11 in terms of the type and scope of warning—the warnings were not graphical and did not cover all products. The 2005 Act also had other gaps: while it banned advertisement of tobacco products, it did not, for example, cover sponsorship in a comprehensive way. These shortcomings of the 2005 Act were addressed in a 2013 Amendment,15 which, among other reforms, made GHWs obligatory on the upper 50% of both sides of all tobacco packs and broadened the definition of tobacco products to include smokeless tobacco products. The Amendment also banned the depiction of tobacco use on television; the use of tobacco companies’ or products’ names, signs, trademarks or other symbols for sponsorship purposes; and increased fines for violating smoke-free and advertising, promotion and sponsorship provisions. To support the implementation of the Amendment, the government issued the Smoking and Usage of Tobacco Products (Control) Rules (referred to as implementation guidelines) in 2015.16

    Despite the government’s apparent commitment to tobacco control—in 2016, the prime minister declared the country would be tobacco-free by 204017 18—the application of the new policy has proven challenging, particularly regarding GHWs. The 2015 implementation guidelines gave companies six months to comply with the new requirement, but it has yet to be achieved. At the time of writing (May 2022), GHWs are still printed on the lower, instead of the upper, 50% of all tobacco packs. This placement can significantly weaken the effect of GHWs, which for someone who smokes a pack of cigarettes a day can deliver antismoking messages 7000 times per year.8 This is because the lower part of the pack is often hidden by the hand holding the pack or when the packs are being sold. In Bangladesh, tobacco products are often sold by mobile sellers who carry goods in steel trays (see figure 1), which obscure the lower 50% of the packs.

    Figure 1
    Figure 1

    Mobile sellers offering cigarette packs in steel trays. Source: PROGGA.53

    To date, no peer-reviewed work has focused on the development and implementation of GHWs in Bangladesh, where recent studies illustrate how close links between the tobacco industry and some government sectors hinder tobacco control progress.19 20 For example, in 2018, a former independent director of British American Tobacco Bangladesh (BATB), who was a high-level government official from the Ministry of Industries, became the new chairman of the National Board of Revenue (NBR),21–24 a body which repeatedly gave awards to the BATB for being a top taxpayer in the country.22 25 The government also holds an almost 10% share in BATB (see Box 1) and some government officials sit on BATB’s Board of Directors.26 The 2018–2021 Tobacco Industry Interference Indices suggest that Bangladesh faces one of the highest levels of tobacco industry interference (TII) in the South Asian region.26–29 With this study, we aim to enhance our understanding of the incomplete GHW implementation and use this as a case study to understand TII in Bangladesh. In doing so, we seek to examine which industry actors were involved; what were their targets of influence, tactics and arguments; as well as the role of tobacco control advocates in GHW development and implementation.

    Box 1

    Background: the tobacco industry in Bangladesh

    • There are 12 cigarette and 117 bidi manufacturers in Bangladesh,6 which in financial year 2016–2017 produced an estimated 128 billion sticks of cigarettes and bidis.5 While the bidi market is very diverse, three large producers dominate around 97% of the cigarette market: British American Tobacco Bangladesh (BATB), the Dhaka Tobacco Company (previously owned by the local Akij Group and acquired by Japan Tobacco in 2018) and the Abul Khair Tobacco Company.5 BATB holds around 70% of the market.5 In 2016–2017, at least 8.8% of all taxes collected by the National Board of Revenue (NBR) stemmed from tobacco trade.5 In addition, the Bangladesh government holds an almost 10% share in BATB, distributed under different government-owned enterprises (0.33% under Bangladesh Development Bank, 6.11% under Investment Corporation of Bangladesh and 2.82% under Sadharan Bima Corporation), as well as 0.64% under the position of the President of the People’s Republic of Bangladesh.26–28

    Methods

    Data sources and collection

    Media data

    This study draws primarily on media articles, an important data source for researchers across disciplines,30 31 including tobacco control.32–34 Media articles are useful when conducting research on sensitive and contested issues like TII and when public access to government data is limited. The Government of Bangladesh is yet to implement WHO FCTC Article 5.3 guidelines, which require disclosure of interactions with the tobacco industry and registration of tobacco industry-affiliated entities, including lobbyists.35

    Media articles were obtained through a pre-existing system of media monitoring established by PROGGA (Knowledge for Progress), a national think tank in Bangladesh. PROGGA has a dedicated Media Monitoring Cell that has monitored media coverage of tobacco-related issues in 59 daily newspapers, 31 internet-based media outlets, 30 broadcast media channels and two news agencies since 2011. The Media Monitoring Cell also monitors online versions of the 12 most circulated daily newspapers at the division level. For the regular monitoring, a list of keywords (e.g, tobacco control law, health warnings) in both English and Bengali is used to identify tobacco-relevant articles from these sources (see online supplemental table 1), which are then systematically categorised and stored in a database in Statistical Package for the Social Sciences (SPSS) V.23 (see online supplemental table 2).

    Supplemental material

    For the present study, we focused on a period of around 4.5 years: from 1 March 2013 to 31 November 2017. This timeframe covers the two years before the 2015 implementation guidelines16 were gazetted, to capture their development, and around 2.5 years afterwards, including the official six-month transition period, to cover the implementation process. We extracted articles from the media monitoring database that were published during the period of interest. Potentially relevant articles were identified on the basis of the issues they covered as recorded in the database (packaging and labelling, industry influence, accountability and corporate social responsibility, tobacco law amendment), where they had been published (print or electronic media) and the type of article (news reports). In total, 5287 articles met these criteria (see online supplemental table 3).

    MMH, MSA and MHS read all articles to identify those relevant to the development and implementation of GHWs. The authors regularly met to discuss the selection process, and decisions were made by consensus. In total, 161 articles were included in the study.

    Additional documents

    We obtained 11 industry, government and court documents through journalists and personal networks. These documents include correspondence from industry actors, government units and others that took place during the period of interest (March 2013–November 2017) (see online supplemental table 4). Reports published by PROGGA during the study period were also considered.

    Data analysis

    Media articles and documents were read in detail and triangulated. We identified actors involved in the formulation and implementation of GHW guidelines and established a timeline (figure 2). We analysed how the tobacco industry sought to influence the process and what role tobacco control advocates played. The authors regularly met to discuss findings.

    Figure 2
    Figure 2

    Overview of industry interference in relation to GHWs (2013–2017). ASH Bangladesh - Action on Smoking and Health Bangladesh; BATB, British American Tobacco Bangladesh; BCMA, Bangladesh Cigarette Manufacturers’ Association; GHWs, graphic health warnings; MoF, Ministry of Finance; MoHFW, Ministry of Health and Family Welfare; MoLJPA, Ministry of Law, Justice and Parliamentary Affairs; NBR, National Board of Revenue; NTCC, National Tobacco Control Cell.

    Results

    Figure 2 provides a timeline of key events in the development and implementation of GHWs, including relevant actors.

    Industry actors involved in the process

    All three major cigarette manufacturers—BATB, United Dhaka Tobacco Company and Abul Khair Tobacco Company—sought to influence the process. No evidence of bidi manufacturers’ interference was found. The cigarette companies operated primarily through the Bangladesh Cigarette Manufacturers’ Association (BCMA), an organisation formed to represent and protect the interests of cigarette manufacturers. Among the companies, BATB was most active and was also the only company acting alone. As explained in more detail in the following section, the BCMA enjoyed high-level access to and maintained close communication with key government agencies, such as the Ministry of Law, Justice and Parliamentary Affairs (MoLJPA) and the Ministry of Finance (MoF), as well as the NBR. We did not find evidence of covert approaches to the government via front groups or third parties.

    Targets of influence: the government offices involved

    Key ministries in the development and implementation of GHWs were the Ministry of Health and Family Welfare (MoHFW) and the MoLJPA. The former was the lead ministry for the legislation and the latter was responsible for vetting new legislation to ensure its consistency with existing laws and regulations.

    Despite having no official role in GHW policymaking, the NBR became heavily involved in the process after being approached by the cigarette companies. When the gazette was published, tobacco companies raised concerns that GHWs would hamper revenue collection, a claim which facilitated the NBR’s involvement.36 37

    The development of the implementation guidelines

    On 30 October 2013, the MoHFW published the draft implementation guidelines for the 2013 Amendment of the Smoking and Tobacco Product Usage (Control) Act on its website for public comment.38 The draft rules gave tobacco companies six months to comply with the Amendment, which included printing GHWs on the upper 50% of both sides of all tobacco packs.38

    Shortly afterwards, the BCMA met with the secretary of the MoHFW and expressed concerns about the guidelines, which were also shared in a follow-up letter.39 40 The BCMA claimed that manufacturers would not be able to comply with the rules within 6 months as they needed to import machinery from Germany and France; therefore, the transition period should last 18 months.39 40 Furthermore, they stated that printing GHWs on the upper 50% of packs would be in conflict with a 2006 tax stamp and banderoles-related Statutory Regulatory Order; therefore, GHWs should be placed on the lower 50% of packs.40

    In March 2014, the MoLJPA’s legislative secretary arranged a meeting of different ministries, including the MoHFW, as well as the cigarette companies, to finalise the guidelines.41 On invitation, the BCMA shared in writing its reasons for demanding now a 24-month transition period, explaining that due to technical limitations it would be impossible to print ‘six concurrent designs’ as the draft guidelines required.42 It asked for ‘realistic and implementable’ rules that considered companies’ technical capability.42

    The MoLJPA revised the draft guidelines seemingly in response to the BCMA’s demand and extended the transition period from 6 to 18 months.43 This led to a tug-of-war between the MoLJPA and the MoHFW: when the MoLJPA shared the new draft with the MoHFW, the latter sent the original draft implementation guidelines back to the MoLJPA.43

    In July 2014, a BATB delegation met the health minister, seeking to push again for a delay in the implementation of GHWs,44 which did not result in an amendment of the draft guidelines. The BATB also wrote another letter to the MoHFW’s additional secretary, where it raised ‘critical concerns’ regarding GHW implementation and again demanded an 18-month transition period.45

    In January 2015, the MoHFW organised a meeting with the cigarette companies.41 Two months later, seemingly under pressure from the MoLJPA and the cigarette companies, the MoHFW revised the draft implementation guidelines,46 recommending ten (instead of six) months for the transition period. The MoLJPA added 2 more months, setting the transition period at 12 months.47 On 19 March 2015, around 1.5 years after the draft was first publicised, the guidelines were gazetted, requiring GHW implementation by 19 March 2016.48

    Industry efforts to prolong the transition period and weaken GHWs

    Around halfway through the transition period, the cigarette companies sought to extend the deadline once more: in September 2015, the BCMA sent a letter to the MoHFW claiming that it had only learnt about the finalisation of the GHW image selection through a financial newspaper (The Financial Express) and had not received an electronic copy of the images.49 Its members should be allowed a 12-month transition period following receipt of the images.49 The letter also repeated its demand for GHWs to be printed on the lower 50% of packs, claiming this was necessary for compliance with the VAT (Value Added Tax) Act 1991, which requires banderols (strips of machine-readable tax stamps) vertically affixed around the upper part of cigarette packs.50 The 2013 Amendment did not specify the placement of banderols; it only required them not to cover GHWs.38 The BCMA also reiterated that more time was needed to prepare for implementation, including for importing new printers and training staff.50 Raising the same issues, the BCMA wrote another letter to the MoHFW’s secretary.51 It also claimed that GHWs, by obscuring banderols, could affect national revenue collection.

    The BCMA also approached a renowned law firm for an interpretation of the implementation guidelines and forwarded the letter to the secretary of the MoHFW.52 The letter claimed, for example, that printing GHWs on the lower 50% of packs would still comply with the 2013 Amendment.52 Furthermore, it argued that if GHWs were printed on the upper 50% of packs, these would be hidden by banderols and tax stamps, which would be in conflict with the implementation guidelines.52

    The NBR also put pressure on the MoHFW to allow GHWs on the lower 50% of packs. It sent at least four letters regarding the issue and organised a meeting with cigarette company representatives and the MoHFW in late 2015.36 Echoing the BCMA’s claims, it also repeatedly stressed the ‘detrimental effect’ of printing GHWs on the upper 50% of packs’, claiming that it might hurt government revenue collection.36

    To address the concerns regarding the placement of banderols in relation to GHWs which the BCMA and the NBR had raised, the MoHFW recommended that tax stamps and banderols to be attached to the side of the packs.53 Ignoring this recommendation, the MoLJPA signed an order requiring GHWs to be printed on the lower 50% of packs.54 The National Tobacco Control Cell (NTCC), a body under the MoHFW, issued a public circular on the same day, announcing GHWs would be printed on the lower 50% of tobacco packs.55 The order came into force as scheduled on 19 March 2016, but the placement of the GHWs was in contradiction to the 2013 Amendment and the implementation guidelines adopted the previous year.

    Before the order had been signed by the minister of the MoLJPA and published in the gazette, the BCMA and the BATB had circulated posters (see figure 3) all over the country that stated that GHWs would be printed on the lower 50% of packs.53 This suggests that they already knew of the decision before it had been made public.

    Figure 3
    Figure 3

    Posters circulated by the Bangladesh Cigarette Manufacturers’ Association and British American Tobacco Bangladesh on 12 March 2016. Source: PROGGA.53T

    Tobacco control advocates push for GHW implementation

    Tobacco control advocates closely monitored the entire process and repeatedly voiced concerns about the delay and weakening of the policy and the indsutry influence on the process.56 For example, Saber Hossain Chowdhury MP, then chairman of the Inter-Parliamentary Union and convenor of Tamakmukto Bangladesh Mancha (Tobacco-free Bangladesh Platform, a coalition of antitobacco organisations), had written a letter to the health minister in late 2015, where he expressed concerns about the length of the process. He suggested that rather than shifting GHWs to the lower 50% of packs, stamps and banderols should be attached to the sides of the packs.57 58 This was later proposed by the MoHFW, but disregarded by the MoLJPA (see above).

    To push for a timely implementation of GHWs and expose industry attempts to weaken the rules, tobacco control advocates also engaged in nationwide public events and worked with earned media, social media campaigns and community radio stations to bring more attention to the issue.59 In March 2016, nine days before the end of the transition period, a day-long exhibition of the GHW images set by the MoHFW was organised in front of the Bangladesh National Museum in Dhaka, the capital. The event was attended by members of parliament and representatives from civil society. Dummy cigarette packets with GHWs were exhibited in different parts of the country.59 Around the same time, tobacco control groups organised a discussion event on GHWs which was chaired by the health minister, and journalists from all major mainstream media platforms participated.59

    In addition, in the last weeks of the transition period, at least six human chain events were organised in six districts, and road shows along with mobile musical concerts took place in the capital54 and other divisional capitals.59 Furthermore, a commercial on GHW implementation was aired on all community radio stations across Bangladesh just before the transition period ended.59

    Further delay and confusion: civil society and cigarette companies going to the High Court

    Tobacco control advocates heavily criticised the NTCC’s move to issue a public circular in line with the MoLJPA’s order, which contradicted the guidelines set by its controlling ministry (MoHFW). Some tobacco control organisations (PROGGA, UBINIG and Pratyasha) issued a writ petition (no 11785 (2016)) to the High Court questioning the legality of NTCC’s circular.60 In its ruling, the High Court agreed with the concerns raised, which led the NTCC to withdraw the circular.61

    However, discord within the coalition emerged when Action on Smoking and Health (ASH) Bangladesh filed a writ petition (no 498 (2017)) to validate NTCC’s public circular, arguing—echoing the cigarette companies’ position—that GHWs should be printed on the lower 50% of packs.61 They accused the MoHFW and the NTCC of ‘illegal and arbitrary actions’. The High Court dismissed ASH Bangladesh’s petition due to the lack of ‘necessary logic and evidence’.55 The High Court also stated that although ASH Bangladesh had been ‘established with an aim to reducing tobacco manufacturing and consumption’, it was ‘clear’ from the petition that it ‘has come in aid of the tobacco manufacturers’.55 More concerns about the nature and role of ASH Bangladesh were raised: a report showed that the organisation was registered in 2003, but only became active in February 2017 in the context of the GHWs.61 There is no evidence that ASH Bangladesh is linked to genuine tobacco control organisations of the same name.

    In line with the High Court’s stance, the NTCC issued a new public circular in July 2017, which made it mandatory to print GHWs on the upper 50% of packs from 19 September 2017, consistent with the 2013 Amendment and the implementation guidelines.55 62

    The BCMA held a joint meeting with the NBR, MoF and MoHFW, urging them to allow GHWs on the lower 50% of packs for one additional year.37 As before, the NBR took an industry-friendly approach: it sent a letter to the MoHFW highlighting the cigarette companies’ importance in generating government revenue and requesting a 12-month extension to provide cigarette companies time to import the machinery needed.37 The BCMA also filed two writ petitions in the High Court against the implementation guidelines in August and November 2017,63 which led to further delay.64 65 At the time of writing (May 2022), GHWs are still printed on the lower 50% of packs.

    Discussion

    This study explored the development and implementation of GHWs in Bangladesh following the 2013 Amendment of the Tobacco Control Act. It found that only cigarette manufacturers, no bidi manufacturers, sought to influence the process. The cigarette companies used several techniques to significantly delay the development and implementation of the guidelines, including working through a business association (BCMA), lobbying policymakers and government bodies (in particular the NBR), distorting information (eg, by obtaining and using a letter from a lawyer), and using legal tools such as writ petitions. These techniques are consistent with industry efforts to undermine health warnings66–69 and other tobacco control policies elsewhere.70–72 BATB was the most active company and the only one which acted alone. Deploying common industry arguments, the BCMA and BATB repeatedly claimed that the implementation guidelines would contravene existing laws and pointed to potential (macro)economic losses, arguing that revenue collection might be hampered if banderols were obscured.70 71 They sought to delay GHW implementation by pointing to technical barriers, including the lack of equipment, which tobacco companies had claimed before, particularly in Low and Middle Income Country (LMICs).71 Although the BCMA has repeatedly highlighted the issue of illicit trade—one of the most common arguments for opposing tobacco control regulation in LMICs71—in discussions on tobacco taxation in Bangladesh,73 it was not raised directly in this case. However, it was arguably implicit in the banderols/revenue argument. The importance of arguments around revenue collection is unsurprising given what we know from other countries; however, as elsewhere,74 the industry’s excise duties do not cover the costs tobacco imposes on Bangladeshi society.75

    The study also shows how industry argument-based and action-based strategies are tailored to a specific context. The insistence on the placement of GHWs on the lower, instead of the upper, part of tobacco packs may be particularly relevant where mobile selling is common. However, it may still be important elsewhere; even in shops, the lower part of a pack may be less visible. Furthermore, using the revenue authority (NBR) to exercise pressure was facilitated by an established link. For example, following the NBR’s invitation, the BCMA had repeatedly attended prebudget meetings and presented its proposals regarding tobacco taxation and other tobacco control measures.73 The relevance of this strategy goes beyond budgetary tobacco pricing, tax measures and GHWs: more recently, the NBR, apparently acting on the industry’s behalf, sought to undermine the national tobacco control policy76 77 and helped the industry to secure special permission to continue producing cigarettes during the COVID-19 pandemic.78

    This study both illustrates and supports recent findings on the stalled implementation of WHO FCTC Article 5.3 in Bangladesh, documenting extensive conflicts of interests among crucial government actors and institutional constraints on those seeking to strengthen tobacco control.20 The government’s share in BATB and the presence of high-level officials on the company’s Board of Directors are particularly concerning.26–28 The findings also illustrate how bureaucratic processes can favour the tobacco industry: the complex procedures delay in involving various government organisations helped the cigarette companies create conflict and confusion between these agencies, significantly delaying GHW development and implementation.79

    As in other LMICs,80 81 civil society organisations played key roles in exposing and countering cigarette companies’ efforts to weaken and delay GHW implementation. They combined several strategies: they used various media channels (press conferences, social media and radio) and organised public events such as road shows and human chains, as well as events that targeted policymakers more directly. However, they could not prevent the significant delay in implementation and were unsuccessful in convincing policymakers to respect WHO FCTC Article 5.3. The study further shows that discord and confusion within the tobacco control community can also undermine advocates’ efforts to push for strong tobacco control rules. A strong and united tobacco control coalition facilitates countering TII and protecting public health policies.29 82 The unclear nature of ASH Bangladesh makes it challenging for advocates to address the organisation’s conduct and its effects. This underlines the centrality of investigative and monitoring activities for tobacco control.82

    This study is the first to examine TII relating to GHWs in Bangladesh, but has a number of limitations. First, it relies on media articles and a limited number of additional documents. Full documentation of the meetings between the government and the industry, for example, would have provided a fuller picture of the process. Key informant interviews could also have added to the study. Second, the 4.5-year study duration means that it does not capture GHW policymaking and implementation in its entirety. We sought to cover key moments in the process, while ensuring that the number of articles to be reviewed was manageable. Finally, some authors are from PROGGA, which has been actively involved in the process and features in the findings. Some of PROGGA’s publications are also referenced. This could introduce bias into the analysis. We sought to address this by triangulating different data sources.

    Conclusion

    To our knowledge, this is the first peer-reviewed paper on TII linked to GHWs in Bangladesh. It documents how cigarette companies interfered in the development and implementation of GHWs. Over the seven years after the implementation guidelines that require GHWs to be placed on the upper 50% of packs, were gazetted, GHWs are still printed on the lower 50% of packs. Cigarette companies’ interference was facilitated by close ties with a government body that was not formally involved in GHW implementation. Tobacco control advocates were critical in countering TII but faced challenges when one self-proclaimed tobacco control organisation, whose nature remains unclear, sought to undermine their efforts. Continued monitoring of industry interference and suspicious activities is needed. Furthermore, implementing WHO FCTC Article 5.3 must become a priority to counteract industry interference and protect public health. Otherwise, tobacco control progress is likely to remain slow in Bangladesh.

    Data availability statement

    No data are available.

    Ethics statements

    Patient consent for publication

    Acknowledgments

    The authors wish to thank Arsenios Tselengidis and Tom Gatehouse for providing feedback on a draft of this paper.

    References

    1. ↵
      1. Bangladesh Bureau of Statistics
      . Report on Sample Vital Statistics 2016; 2017. Available: http://bbs.portal.gov.bd/sites/default/files/files/bbs.portal.gov.bd/page/6a40a397_6ef7_48a3_80b3_78b8d1223e3f/SVRS_REPORT_2016.pdf
    2. ↵
    3. ↵
      1. WHO
      . GATS Bangladesh 2017 Factsheet. 2017. Available: https://extranet.who.int/ncdsmicrodata/index.php/catalog/870/download/6177
    4. ↵
    5. ↵
      1. Dutta S
      . A global review of country experiences - bangladesh: illicit tobacco trade. World Bank Group, 2019.
    6. ↵
      1. Hossein M,
      2. Shahriar M,
      3. Alam M
      . Public health on top: unveiling tobacco industry strategies to combat tobacco epidemic in Bangladesh. 2013. Available: https://www.craftbd.org/assets/source/Public%20Health%20on%20Top.pdf
    7. ↵
      1. Ramanadhan S,
      2. Nagler RH,
      3. McCloud R, et al
      . Graphic health warnings as activators of social networks: A field experiment among individuals of low socioeconomic position. Soc Sci Med 2017;175:219–27. doi:10.1016/j.socscimed.2016.12.044
      OpenUrl
    8. ↵
      1. Hammond D
      . Health warning messages on tobacco products: a review. Tob Control 2011;20:327–37. doi:10.1136/tc.2010.037630
      OpenUrlAbstract/FREE Full Text
    9. ↵
      1. McCool J,
      2. Webb L,
      3. Cameron LD, et al
      . Graphic warning labels on plain cigarette packs: will they make a difference to adolescents? Soc Sci Med 2012;74:1269–73. doi:10.1016/j.socscimed.2011.12.043
      OpenUrlCrossRefPubMed
    10. ↵
      1. Noar SM,
      2. Francis DB,
      3. Bridges C, et al
      . The impact of strengthening cigarette pack warnings: systematic review of longitudinal observational studies. Soc Sci Med 2016;164:118–29. doi:10.1016/j.socscimed.2016.06.011
      OpenUrlCrossRefPubMed
    11. ↵
      1. Szklo AS,
      2. Volchan E,
      3. Thrasher JF, et al
      . Do more graphic and aversive cigarette health warning labels affect brazilian smokers’ likelihood of quitting? Addict Behav 2016;60:209–12. doi:10.1016/j.addbeh.2016.04.021
      OpenUrlPubMed
    12. ↵
      1. Miller CL,
      2. Hill DJ,
      3. Quester PG, et al
      . The impact of Australia’s new graphic cigarette packet warnings on smokers’ beliefs and attitudes. Australasian Marketing Journal 2011;19:181–8. doi:10.1016/j.ausmj.2011.05.004
      OpenUrl
    13. ↵
    14. ↵
      1. Government of Bangladesh
      . Smoking and Using of Tobacco Products (Control) Act, 2005 (act no.XI of 2005) (unofficial english translation). 2005. Available: https://www.tobaccocontrollaws.org/files/live/Bangladesh/Bangladesh%20-%20Tobacco%20Control%20Act.pdf
    15. ↵
      1. Government of Bangladesh
      . Amendment of Smoking and Tobacco Products Usage (Control) Act, 2005 (unofficial english translation). 2013. Available: https://www.tobaccocontrollaws.org/files/live/Bangladesh/Bangladesh%20-%20TC%20Amdt.%20Act%202013.pdf
    16. ↵
      1. Government of Bangladesh
      . The Smoking and Tobacco Products Usage (Control) Rules, 2015 (unofficial english translation). 2015. Available: https://www.tobaccocontrollaws.org/files/live/Bangladesh/Bangladesh%20-%20TC%20Rules%202015.pdf
    17. ↵
      1. Millat H
      . Tobacco free Bangladesh by 2040: How far are we? 2021. Available: https://tinyurl.com/muxuytxy
    18. ↵
      1. Hoque Moni M
      . World No Tobacco Day: Can Bangladesh be tobacco-free by 2040? 2020. Available: https://www.thedailystar.net/law-our-rights/news/world-no-tobacco-day-can-bangladesh-be-tobacco-free-2040-1906411
    19. ↵
      1. Hoque MM,
      2. Tama RAZ
      . Implementation of Tobacco Control Policies in Bangladesh: A Political Economy Analysis. PAR 2021;10:36. doi:10.5539/par.v10n2p36
      OpenUrl
    20. ↵
      1. Abdullah SM,
      2. Wagner-Rizvi T,
      3. Huque R, et al
      . “A contradiction between our state and the tobacco company”: conflicts of interest and institutional constraints as barriers to implementing article 5.3 in Bangladesh. Tob Control 2022;31(Suppl 1):s33–8. doi:10.1136/tobaccocontrol-2021-057142
      OpenUrlAbstract/FREE Full Text
    21. ↵
      1. TobaccoTactics
      . UK diplomats lobbying for BAT Bangladesh. 2020. Available: https://tobaccotactics.org/wiki/uk-diplomats-lobbying-for-bat-bangladesh/
    22. ↵
      1. TBSNews
      . NBR names BATB as one of the top tax payers in the country for FY- 2020-21. 2021. Available: https://www.tbsnews.net/economy/corporates/nbr-names-batb-one-top-tax-payers-country-fy-2020-21-302962
    23. ↵
    24. ↵
    25. ↵
      1. DhakaTribune
      . BATB awarded for being highest income tax payer in Bangladesh. 2017. Available: https://archive.dhakatribune.com/business/2017/11/13/batb-highest-income-tax
    26. ↵
      1. PROGGA
      . 2019 Bangladesh Tobacco Industry Interference Index. 2019. Available: http://www.tobaccoindustrywatchbd.org/contents/uploaded/TII%20Index%20Report%20Bangladesh%202019.pdf
    27. ↵
      1. PROGGA
      . 2018 Bangladesh Tobacco Industry Interference Index. 2018. Available: http://www.tobaccoindustrywatchbd.org/contents/uploaded/TII%20Index_Bangladesh%202018_Full%20Report.pdf
    28. ↵
      1. PROGGA
      . 2020 Bangladesh Tobacco Industry Interference Index. 2020. Available: http://www.tobaccoindustrywatchbd.org/contents/uploaded/Bangladesh%20Tobacco%20Industry%20Index_%202020.pdf
    29. ↵
      1. Assunta M
      . Global Tobacco Industry Interference Index 2021. 2021. Available: https://exposetobacco.org/wp-content/uploads/GlobalTIIIndex2021.pdf
    30. ↵
      1. Schafraad P,
      2. Wester F,
      3. Scheepers P
      . Using ‘new’ data sources for ‘old’ newspaper research: developing guidelines for data collection. Comm 2006;31:455–67. doi:10.1515/COMMUN.2006.029
      OpenUrl
    31. ↵
      1. Tanacković SF,
      2. Krtalić M,
      3. Lacović D
      . Newspapers as a research source: information needs and information seeking of humanities scholars. 2014. Available: https://www.ifla.org/wp-content/uploads/2019/05/assets/newspapers/Geneva_2014/s6-lacovic-en.pdf
    32. ↵
      1. Durrant R,
      2. Wakefield M,
      3. McLeod K, et al
      . Tobacco in the news: An analysis of newspaper coverage of tobacco issues in Australia, 2001. Tob Control 2003;12 Suppl 2(Suppl 2):ii75–81. doi:10.1136/tc.12.suppl_2.ii75
      OpenUrlPubMed
    33. ↵
      1. Lima JC,
      2. Siegel M
      . The tobacco settlement: An analysis of newspaper coverage of a national policy debate, 1997-98. Tob Control 1999;8:247–53. doi:10.1136/tc.8.3.247
      OpenUrlAbstract/FREE Full Text
    34. ↵
      1. Menashe CL,
      2. Siegel M
      . The power of a frame: An analysis of newspaper coverage of tobacco issues-united states, 1985-1996. J Health Commun 1998;3:307–25. doi:10.1080/108107398127139
      OpenUrlCrossRefPubMedWeb of Science
    35. ↵
      1. WHO
      . Guidelines for implementation of Article 5.3 of the WHO Framework Convention on Tobacco Control. n.d. Available: https://www.who.int/fctc/guidelines/article_5_3.pdf
    36. ↵
      1. National Board of Revenue (NBR)
      . Letter to the health Secretary. 2016. document, obtained in 2016; Available: https://aleph.occrp.org/datasets/7950
    37. ↵
      1. National Board of Revenue (NBR)
      . Letter to the health Secretary. 2017. Document, obtained in 2017. Available: https://aleph.occrp.org/datasets/7950
    38. ↵
      1. The New Age
      . Opinions sought on draft rules of tobacco control Act. 2013; Available: https://www.craftbd.org/assets/source/TII2021/The%20New%20Age_01%20Nov%202013.pdf
    39. ↵
      1. Hasib NI
      . Tobacco companies lobby hard. 2013. Available: https://bdnews24.com/health/2013/12/18/tobacco-companies-lobby-hard
    40. ↵
      1. Bangladesh Cigarette Manufacturers’ Association (BCMA)
      . Letter to the Health Secretary. 2013. Document, obtained in 2016; Available: https://aleph.occrp.org/datasets/7950
    41. ↵
      1. BDNews24.com
      . Furore as secretary meets tobacco bosses. 2014. Available: http://bdnews24.com/bangladesh/2014/03/13/health-secy-meets-tobacco-bosses
    42. ↵
      1. Bangladesh Cigarette Manufacturers’ Association (BCMA)
      . Letter to the Ministry of Law, Justice and Parliamentary Affairs (MoLJPA) Secretary. 2014. Document, obtained in 2015; Available: https://aleph.occrp.org/datasets/7950
    43. ↵
      1. Sultana J
      . GHW on tobacco pack: Law vs Health Ministry. 2014. Available: http://www.tobaccoindustrywatchbd.org/article/articledetail/Resource/221
    44. ↵
      1. British American Tobacco Bangladesh (BATB) Company Limited.
      . Minutes of the Board CSR Committee. 2014. Document, obtained in 2015; . Available: https://aleph.occrp.org/datasets/7950
    45. ↵
      1. British American Tobacco Bangladesh (BATB) Company Limited. 3 December 2014
      . Letter to the additional Secretary of Ministry of health and family welfare. document, obtained in 2016; 2014. Available: https://aleph.occrp.org/datasets/7950
    46. ↵
      1. H-u-Z M
      . GHW trapped in TC rules. 2015. Available: https://tinyurl.com/4a4sk8cz
    47. ↵
      1. Rahman T,
      2. Banarjee S
      . GHW implementation deadline extended. 2015. Available: https://ebhorerkagoj.com/city/2015/02/25/1/details/1_r6_c2.jpg
    48. ↵
      1. The Financial Express
      . Graphic warning coming on cigarette packet in 2016. 2015. Available: https://epaper.thefinancialexpress.com.bd/2015/09/06/images/19_103.jpg
    49. ↵
      1. Bangladesh Cigarette Manufacturers’ Association
      . Letter to the Additional Secretary of Ministry of Health and Family Welfare 2015. Document, obtained in 2016;
    50. ↵
      1. Alam SS
      . Tobacco companies against GHW printing. 2016. Available: https://tinyurl.com/yf9ew9kk
    51. ↵
      1. Bangladesh Cigarette Manufacturers’ Association
      . Letter to the Health Secretary. 2015. Document, obtained in 2016; Available: https://aleph.occrp.org/datasets/7950
    52. ↵
      1. Rokanuddin Mahmud and Associates
      . Letter to the Chairman of Bangladesh Cigarette Manufacturers’ Association regarding Legal Opnion of Placement of GHW on Tobacco Products. 2015. Document, obtained in 2016; Available: https://aleph.occrp.org/datasets/7950
    53. ↵
      1. PROGGA
      . Tobacco or Sustainable Development - Tobacco Industry Interference and Strategy in Bangladesh. 2016. Available: http://progga.org/wp-content/uploads/2011/01/Tobacco-or-Sustainable-Development.pdf
    54. ↵
      1. BDNews24.com
      . Anti-tobacco groups react angrily to law ministry’s reported decision on pictorial warning. 2016. Available: https://bdnews24.com/health/2016/03/14/anti-tobacco-groups-react-angrily-to-law-ministrys-reported-decision-on-pictorial-warning
    55. ↵
      1. BDNews24.com
      . Bangladesh changes graphic health warning rules in tobacco packs. 2017. Available: https://bdnews24.com/health/2017/07/06/bangladesh-changes-graphic-health-warning-rules-in-tobacco-packs
    56. ↵
      1. Debnath S
      . Anti-tobacco activists fear GHW implementation. 2016. Available: http://www.thedailysangbad.com/last-page/2016/03/14/55880
    57. ↵
      1. Ahmed Z
      . Govt adamant on implementing “pictorial warning message” on tobacco products 2016. n.d. Available: https://tinyurl.com/msfe9cfy
    58. ↵
      1. thereport24.com
      . Anti-tobacco orgs concerned: companies are against printing graphic health warning on cig packs. 2016. Available: https://bangla.thereport24.com/article/144867/
    59. ↵
      1. PROGGA
      . Latest achievement of bangladesh: graphic health warning implementation and plea to hike tobacco price and tax. 2017. Available: http://progga.org/wp-content/uploads/2011/04/Latest-Achievement-of-BD_GHW_Tobacco_Tax.pdf
    60. ↵
      1. Hasib NI
      . Graphic health warning on packs: tobacco companies “continue to flout rules” in Bangladesh. 2017. Available: https://bdnews24.com/health/2017/03/20/graphic-health-warning-on-packs-tobacco-companies-continue-to-flout-rules-in-bangladesh
    61. ↵
      1. Mallick B
      . Companies create ‘front group’ to thwart control. 2017. Available: https://www.observerbd.com/details.php?id=65469
    62. ↵
      1. Jibon G
      . NBR seeks more time from Health Ministry. 2017. Available: https://dailyasianage.com/news/85060/nbr-seeks-more-time-from-health-ministry
    63. ↵
      1. Anon
      . GHW to stay at lower part of tobacco packs. 2017. Available: https://www.kalerkantho.com/print-edition/news/2017/09/19/544407
    64. ↵
      1. The Supreme Court of Bangladesh
      . (high Court division). 2017a. document, obtained in 2017; Available: https://aleph.occrp.org/datasets/7950
    65. ↵
      1. The Supreme Court of Bangladesh
      . (high Court division). 2017b. document, obtained in 2017; Available: https://aleph.occrp.org/datasets/7950
    66. ↵
      1. Hiilamo H,
      2. Crosbie E,
      3. Glantz SA
      . The evolution of health warning labels on cigarette packs: the role of precedents, and tobacco industry strategies to block diffusion. Tob Control 2014;23:e2. doi:10.1136/tobaccocontrol-2012-050541
    67. ↵
      1. Chapman S,
      2. Carter SM
      . “Avoid health warnings on all tobacco products for just as long as we can”: a history of australian tobacco industry efforts to avoid, delay and dilute health warnings on cigarettes. Tob Control 2003;12 Suppl 3(Suppl 3):iii13–22. doi:10.1136/tc.12.suppl_3.iii13
      OpenUrlPubMed
    68. ↵
      1. Hoek J,
      2. Wilson N,
      3. Allen M, et al
      . Lessons from New Zealand’s introduction of pictorial health warnings on tobacco packaging. Bull World Health Organ 2010;88:861–6. doi:10.2471/BLT.10.076695
      OpenUrlCrossRefPubMedWeb of Science
    69. ↵
      1. Tan YL,
      2. Foong K
      . How the Malaysian tobacco industry exploits loopholes in pictorial health warnings. Tob Control 2012;21:55–6. doi:10.1136/tc.2011.042713
      OpenUrlFREE Full Text
    70. ↵
      1. Ulucanlar S,
      2. Fooks GJ,
      3. Gilmore AB
      . The policy dystopia model: an interpretive analysis of tobacco industry political activity. PLoS Med 2016;13:e1002125. doi:10.1371/journal.pmed.1002125
    71. ↵
      1. Matthes BK,
      2. Lauber K,
      3. Zatoński M, et al
      . Developing more detailed taxonomies of tobacco industry political activity in low-income and middle-income countries: qualitative evidence from eight countries. BMJ Glob Health 2021;6:e004096. doi:10.1136/bmjgh-2020-004096
    72. ↵
      1. Lee S,
      2. Ling PM,
      3. Glantz SA
      . The vector of the tobacco epidemic: tobacco industry practices in low and middle-income countries. Cancer Causes Control 2012;23 Suppl 1(0 1):117–29. doi:10.1007/s10552-012-9914-0
      OpenUrlPubMed
    73. ↵
      1. PROGGA
      . BCMA strong lobby in finance ministry: finalization of national tobacco control policy under threat. n.d. Available: http://www.tobaccoindustrywatchbd.org/article/articledetail/TobaccoWatch/445
    74. ↵
      1. Jacobs R,
      2. Gale F,
      3. Capehart T, et al
      . Tobacco control in developing countries. In: Jha P, Chaloupka F, eds. The supply-side effects of tobacco-control policies. Oxford: Oxford University Press 2000:311-41,
    75. ↵
      1. Tobacconomics
      . Raising tobacco taxes in FY 2022-2023. 2022. Available: https://tobacconomics.org/files/research/753/bangladesh-tax-factsheet-2022-2023-jan-21-2022.pdf
    76. ↵
      1. Parveen S
      . NBR facing allegation of favoring tobacco companies. 2019. Available: https://www.bbc.com/bengali/news-50379106
    77. ↵
      1. CRAFT
      . Bangladesh Cigarette Manufacturers’ Association (BCMA’s) Interference in National Tobacco Control Policy (NTCP) Finalization. 2020. Available: https://www.craftbd.org/articles/12/Bangladesh-Cigarette-Manufacturers-Association-BCMAs-Interference-in-National-Tobacco-Control-Policy-NTCP-Finalization
    78. ↵
      1. Zubair A
      . Tobacco Industry Lobbies Bangladesh Government Agency to Champion Its Business during COVID-19 Pandemic. 2020. Available: https://blogs.bmj.com/tc/2020/07/03/tobacco-industry-lobbies-bangladesh-government-agency-to-champion-its-business-during-covid-19-pandemic/
    79. ↵
      1. Gilmore AB,
      2. Fooks G,
      3. Drope J, et al
      . Exposing and addressing tobacco industry conduct in low-income and middle-income countries. Lancet 2015;385:1029–43. doi:10.1016/S0140-6736(15)60312-9
      OpenUrlCrossRefPubMed
    80. ↵
      1. Bhatta DN,
      2. Bialous S,
      3. Crosbie E, et al
      . Exceeding WHO Framework Convention on Tobacco Control (FCTC) obligations: Nepal overcoming Tobacco Industry Interference to enact a comprehensive Tobacco Control policy. Nicotine Tob Res 2020;22:2213–23. doi:10.1093/ntr/ntz177
      OpenUrl
    81. ↵
      1. Charoenca N,
      2. Mock J,
      3. Kungskulniti N, et al
      . Success counteracting tobacco company interference in Thailand: an example of FCTC implementation for low- and middle-income countries. Int J Environ Res Public Health 2012;9:1111–34. doi:10.3390/ijerph9041111
      OpenUrlCrossRefPubMed
    82. ↵
      1. Matthes BK,
      2. Robertson L,
      3. Gilmore AB
      . Needs of LMIC-based tobacco control advocates to counter tobacco industry policy interference: insights from semi-structured interviews. BMJ Open 2020;10:e044710. doi:10.1136/bmjopen-2020-044710

    Supplementary materials

    • Supplementary Data

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    Footnotes

    • Twitter @hshahriar79, @proggabd

    • Contributors ABMZ, MHS and MSA contributed to the study design. MMH, MSA and MHS contributed to data collection and led the data analysis. BKM and ABG supported the data analysis. MHS, ABMZ, BKM and ABG contributed to drafting and revising the manuscript. ABMZ is responsible for the overall content as the guarantor who has full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish. All authors approved the final version.

    • Funding This study and ABMZ’s, MHS’, MMH’s and MSA’s time were funded by PROGGA: Knowledge for Progress and the Bangladesh Center for Communication Programs (BCCP). BKM's and ABG’s time was funded by Bloomberg Philanthropies' Stopping Tobacco Organizations and Products project funding (www.bloomberg.org).

    • Competing interests Four coauthors (ABMZ, MHS, MMH, MSA) are based at PROGGA: Knowledge for Progress, which features in the study and has been closely involved in the advocacy for strong and timely GHW implementation.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.