Effective tobacco control measures in Bangladesh require a whole-of-government approach

Abstract In many low- and middle-income countries, the implementation of tobacco control measures is disorganized, and the activities of the various departments involved are often inadequately aligned with policy aims. This paper discusses some fragmented and conflicting approaches to tobacco control measures in Bangladesh, and how these can undermine public health interventions. The paper argues in favor of a whole-of-government approach. The Framework Convention on Tobacco Control (FCTC) created an unprecedented opportunity to reduce the use of tobacco substantially. While tobacco use declined in most countries that had signed the FCTC, including Bangladesh, the fragmented approach of various government departments and organizations in the country is hindering the proper implementation of tobacco control measures. There is tension between groups that focus on economic development, livelihood, and public health. There is also considerable uncertainty among government officials and an inadequate focus on several crucial aspects such as tobacco cessation services. However, in this rapidly developing country, where there are serious concerns around developing the economy and reducing poverty, it is challenging to separate tobacco control efforts from the promises of employment and tax revenues from tobacco industries. Indeed, this may well overshadow the tobacco control measures. It is necessary, then, to consider the complexity of this issue in Bangladesh by looking at the entire system and to adopt a whole-of-government approach to address the opposing forces. As an FCTC signatory, Bangladesh is obligated to implement tobacco control measures. However, it may not be possible to do this properly without a whole-of-government approach.


Introduction
Tobacco control is a public health challenge for many countries.Approximately 80% of the over 80 million tobacco-related deaths throughout the world each year occur in low-and middle-income countries (LMICs) (World Health Organization 2022).
Bangladesh is the 11th largest tobacco-producing country in the world.As in other South Asian countries, the prevalence of smoking and smokeless tobacco use in Bangladesh is relatively high (Islam, 2022;Islam, 2022).Large-scale tobacco control programmes have only recently become available in this country.In 2003, Bangladesh became one of the first signatories to the Framework Convention on Tobacco Control (FCTC) and since that time, tobacco control policies gained momentum.The country set a target to become tobacco free by 2040.However, its tobacco control measures appear to be fragmented and sometimes in conflict with one another.Tobacco industries are increasingly targeting LMICs for marketing by utilizing the opportunities that arise from poor legislation and implementations (Stubbs et al. 2022).This paper discusses the fragmented and conflicting approaches to tobacco control measures in Bangladesh, and how these create barriers to effective measures.The paper argues for a whole-of-government approach.Since the overall situation is similar in many ways to other LMICs (Male et al. 2022), this commentary is relevant to the international audience.

Whole-of-government approach
The whole-of-government approach often refers to the functioning of governments within the rigid structures of various institutions and emphasizes the need for collaboration and coordination across departmental boundaries to eliminate barriers and create synergies among agencies to achieve a specific goal.In a whole-of-government approach, agencies working across portfolio boundaries function coherently and generate integrated responses toissues of policy development, implementation and service delivery.Whole-of-society, another term that is sometimes used interchangeably, represents a broader approach, moving beyond public authorities and engaging all relevant stakeholders (World Health Organization 2016).These approaches are aligned with health in all policy tenets, which recognizes the essential role of intersectoral action in improving population health and health equity.The common rationale for these approaches is that health is highly dependent on sectors that are beyond healthcare, and therefore, it is critical to overcoming departmentalism and siloed work, to increase policy coherence and effectiveness (Ortenzi et al. 2022).A whole-of-government response may not necessarily require the collaboration of every government agency, but it must include the engagement of the relevant agencies.
Regarding the tobacco control measures, the lack of a whole-of-government approach creates an opportunity for the tobacco industries to use political influence and lobbying practices and obtain benefits from complex bureaucratic processes (Stubbs et al. 2022).With such opportunities, the tobacco industry may build a public image as a provider of employment and economic development and hence campaign against the restrictions on the manufacturing and marketing of tobacco.

Some key observations
Conflicting mandates among various government organizations concerning tobacco production and control efforts greatly hinder a whole-of-government approach (Male et al. 2022;Barry et al. 2022).In Bangladesh, tobacco control is perceived as being the sole responsibility of the ministry of health.Other relevant ministries such as commerce, industry, education and agriculture are particularly difficult to sensitize regarding tobacco control.As a result, promising multi-sectoral strategies are poorly implemented.For instance, the ministry of finance wants to maximize revenue collection for which tobacco industries and associated activities are a valuable source.The ministry of labor and employment wants to protect tobacco workers' jobs in this sector.The ministry of industries attracts foreign investment in the country, including investment in tobacco industries.Indeed, Bangladesh recently approved foreign investment for establishing a tobacco processing plant in an export processing zone where the company will enjoy tax exemption and other facilities (Staff Correspondent 2021).Furthermore, the national board of revenue awarded British American Tobacco Bangladesh, the largest tobacco industry in the country, the top taxpayer award in 2021 for the fourth consecutive year.A smokeless tobacco company owner has also received this award since 2010-11 (Zubair, 2021).
When a whole-of-government approach is properly in place, the programmes are designed to produce policy integration and synergy or at least to reduce conflicts (Candel and Biesbroek 2016).The relevant organizations reach some basic agreements on the way to address the problem (Peters 2018).However, such coherence is absent among the key organizations in Bangladesh.During the recent pandemic, conflicting roles attracted considerable attention when the ministry of industries turned down a call from the ministry of health, which was seeking a ban on the production, supply, marketing and sale of tobacco products to prevent the spread of the COVID-19.The ministry of health issued this request after it had become aware that smokers among COVID-19 patients were facing significantly higher risks of dying than nonsmokers.The ministry of industries rejected this call because of the effect it could have on the livelihoods of thousands of marginal farmers and workers.In its letter responding to the call, the ministry highlighted the importance of foreign investment in the country and substantial revenues for the government, both of which were greatly affected by the pandemic (Mamun 2020).Another recent example of the lack of a whole-of-government approach is the selection of British American Tobacco Bangladesh for the President's Award for Industrial Development.However, this selection was ultimately withdrawn after widespread criticism by public health activists and a new policy was introduced to prevent tobacco manufacturers and associated companies from receiving this prestigious award (Zubair, 2021).
The lack of a whole-of-government approach also results in inadequate enforcement of tobacco control rules.Many authorized government officers are still unclear about their roles or how to enforce penalties.For instance, railway officers who were assigned to act against smoking were reported to be unclear about their roles (Saleh and Sujon 2021).Furthermore, most authorities in public transport have not yet been able to prohibit tobacco use or ensure designated smoking areas.As a result, in large passenger boats, people still smoke indiscriminately, and exposure to secondhand smoke in public transport is as high as 44.0%(Bangladesh Bureau of Statistics and National Tobacco Control Cell 2019).Although mobile courts where executive magistrates officiate are occasionally seen taking legal action against those who disobey the rules, reliance on executive magistrates and running mobile courts for enforcing tobacco control regulations is not a viable approach.The obligation not to sell to or engage minors in the marketing and distribution of tobacco products is another area where enforcement is inadequate.Minors are often involved in selling and buying tobacco products.Retailers of tobacco products are supposed to have clear and prominent displays indicating that tobacco sales to minors are prohibited, and they must show proof of age.However, most sellers and buyers are either not aware of this law and the punishment for breaking it (Amin et al. 2018) or disobey it due to inadequate monitoring.The awareness of this requirement is even less regarding smokeless tobacco.
Successful implementation of policies within a whole-of-government approach envisages and manages the messy engagement of multiple players effectively.The lack of a whole-of-government approach in Bangladesh translates into inadequate functioning of the key committees that were set up to monitor policy implementations.Most committees that are formed to foresee the enforcement of the regulations at the national and regional levels remain essentially inactive.The National Task Force for Tobacco Control, a high-power multi-sectoral committee, could not convene any meetings for a long time (Hoque 2016).Furthermore, the committees at the district and sub-district levels convene meetings only irregularly.In these committees, the chief executive officers of the administrative cadres were named as the chairpersons and the top health officials as the member-secretaries.The chairpersons and membersecretaries are officers of the same rank.As member-sectary of the committees, the health officials need to call the meetings.However, health officials are hesitant to call meetings under the supervision of administration officers who share the same ranks as they do (Hoque 2016).
On the global tobacco industry interference index, Bangladesh scored 72 out of 100 in 2021 compared to 68 in 2020 (Assunta 2021) and sits at the top among the six South Asian nations.This four-point rise from the previous year's performance suggests that the country has experienced increased interference from the tobacco industry.The report that published the index outlined several observations, including the government's partial ownership of British American Tobacco Bangladesh.This ownership conflicts with the moral ground of the tobacco control effort and violates the FCTC obligation to protect tobacco control-related public health policies from the commercial and other vested interests of the tobacco industry (Hoque 2016).
The state's shareholding in British American Tobacco Bangladesh requires the government to nominate senior officials to serve as directors.This creates institutionaland individual-level conflicts of interest (Abdullah et al. 2022).Attracting foreign investment in tobacco industries also contradicts the moral grounds of the tobacco control effort and raises questions about whether and how the government will achieve complete tobacco control by 2040.
Another example of a whole-of-government approach is its insufficient focus on cessation services.There are not enough cessation services for smokers and even fewer services for smokeless tobacco users.In addition, the scant services that are available are rarely integrated into routine healthcare at public facilities (Huque et al. 2017).According to the Global Adult Tobacco Survey 2017, almost 80% of tobacco users who tried to quit did not use any cessation treatments (Islam, 2022;Islam, 2022) and 3.3% switched to smokeless tobacco as a quitting approach to smoking (Islam, 2022).The high cost of nicotine replacement therapy and other pharmacological treatments makes them too expensive for many smokers.While numerous countries, including some LMICs, heavily subsidize such treatments, Bangladesh's efforts toward this are either absent or insignificant.
In Bangladesh, the current tobacco control initiatives revolve mainly around demand reduction, although supply reduction is equally important.The overall production of tobacco crops has been steady since 2011, except for a few sporadic spikes and falls.The country has set targets to reduce tobacco cultivation at all stages by 2040 and introduced some initiatives, including blocking tobacco cultivation on public leased-out lands (Parvez 2017) and dropping tobacco from the list of cash crops.Barring loans for tobacco farming and supporting credit flow to farmers who switch to alternative crops are two other initiatives.Although these endeavors are commendable, they are sporadic and lack a whole-of-government approach.These measures are, then, unlikely to be effective, especially because tobacco cultivation in Bangladesh is supervised through a contract growing system.Farmers get quality seeds, inputs at a cost price, loans, technical advice, and a buy-back guarantee from tobacco companies.To expedite this switchover process, some of the revenues from the existing 1% health development surcharge on tobacco retail prices could be spent or additional surcharges introduced.Similar earmarked levies exist in some other countries (Aloria, Reganon, and Chavez 2018).

Factors impeding a whole-of-government approach
The fragmented and often conflicting activities discussed in the previous sections are self-illuminating and justify the significance of a whole-of-government approach to tobacco control in Bangladesh.The main barrier to a whole-of-government approach is the conflicting mandates of the individual ministries/organizations.Individual ministries endeavor to achieve their portfolio targets and place high importance on vertical coordination.While the officials of the relevant ministries may recognize the interdependence of tobacco control measures, conflicting mandates obstruct the allout effort that the Ministry of Health may expect.The tobacco industry is a key source of revenue, which is considered critical for the country's growing fiscal budget and economic development.Thus, the Ministry of Finance, for instance, may not prefer a stern measure that may eliminate the tobacco industry altogether.This, to an extent, explains the reason for an incremental rather than a large tax being imposed on tobacco products.The current economic downturn has created additional barriers to tobacco control measures.Indeed, the incompatible roles of various organizations of the government are the primary cause of noncompliance with Article 5.3 of the FCTC, which requires the signatories to protect public health tobacco control policies from commercial and vested interests of the tobacco industry (WHO 2005).
Factors such as inadequate organizational capacity can also impede a whole-ofgovernment approach.For instance, the main responsibility for making progress with the FCTC and overall tobacco control lies with the National Tobacco Control Cell (NTCC).The NTCC runs as a Bloomberg Initiative under the Ministry of Health and Welfare.Currently, it runs with four staff and just one programme officer (Ministry of Health and Family Welfare 2023).This understaffed NTCC does not have the capacity to drive broader engagement (Abdullah et al. 2022) and lead the required horizontal coordination among the various governmental organizations.Some policymakers may be complacent about the achievements thus far, and a tobacco-free Bangladesh by 2040-almost two decades to achieve the target-may be considered a feasible target.Also, the consequences of failing to achieve the target are further out into the future than the tenure of the current policymakers.
In Bangladesh, like many other LMICs, tobacco is seen only as a health problem.Efforts to generate whole-of-government responses typically fail where tobacco is presented as a health challenge only (WHO and UNDP 2016).Apparently, the government wants to achieve the target gradually without drastically affecting the trusted and growing source of revenue from the tobacco industry.However, even for a gradual pathway, a clear roadmap and whole-of-government responses are needed, or else the tobacco industries and interest groups may make it unrealistic to achieve a tobacco-free Bangladesh by 2040.

Introducing a whole-of-government approach to tobacco control
Approaches to whole-of-government are likely to be different across countries.In Bangladesh, individual ministries' portfolio interests in the tobacco industry and conflicting interests suggest that mere coordination among the departments is unlikely to produce the desired goal.Since tobacco control is a cross-cutting issue, a whole-ofgovernment approach necessitates that it receives the same status as organisationspecific targets, followed by an integrated effort between the relevant units/sections of the key ministries.There is no doubt that balancing fragmentation, which encourages specialization, and integration, which is necessary for resolving cross-cutting issues, is a significant challenge for tackling wicked problems like tobacco control.However, once tobacco control becomes a performance target for the relevant organizations, this challenge is easy to overcome.
The NTCC needs to be strengthened.It should be a state-of-the-art unit capable of functioning toward the commitment of the government regarding tobacco control measures and with adequate authority to influence the key departments/officials of the other ministries.The current NTCC should be reconstituted by involving officials from the key ministries.Apart from multiple programme officers and civil servants from the Ministry of Health and Family Welfare and its implementing agencies, the relevant officials from other ministries such as Agriculture, Labor and Employment, Industries, Finance, Education, and Local Government should be appointed.These appointments should be made for a reasonable duration.The reconstituted NTCC can be put under the direct supervision of the cabinet secretary or the prime minister's office and let it function as an effective unit presenting the whole-of-government and working toward a single goal.The NTCC should be able to formulate a plan of action and execute the necessary activities with clear milestones and lines of accountability for the relevant ministries and their executive agencies.
The current practice of senior government officials serving as directors of British American Tobacco Bangladesh is a substantial deterrent to the whole-of-government approach to tobacco control and needs to be stopped without further delay.Some officials are simultaneously serving as board directors while working in the ministry that has obligations toward tobacco control (Abdullah et al. 2022).This practice arises mainly due to the state holding a small percentage of shares, which also needs to be ended.The government will then be able to clear up any moral ambiguities regarding its commitment to tobacco control.
Finally, the fragmentation between the key ministries and their conflicting interests is so strong that a commitment and clear directives from the highest level of political leadership may be needed to generate a whole-of-government approach.Such a commitment is also consistent from the FCTC perspective since it is a legally binding international treaty and the entire government signed it, and the directives will be consistent with the target the leadership set: a tobacco-free Bangladesh by 2040.

Concluding remarks
Controlling tobacco use is a challenging task.Regarding tobacco control measures in Bangladesh, the critical role of sectors beyond that of health has been clearly identified and acknowledged by those working in the health sector.However, this sector does not appear to be able to sensitize the other key players.Although international evidence in support of the whole-of-government approach is mixed (El-Taliawi and Van Der Wal 2019; Jackson-Morris 2019), the fact that the implementation of tobacco control measures in Bangladesh is fragmented suggests that such an approach is likely to work in this country.Substantial progress has been made in Bangladesh regarding tobacco control measures.The FCTC and the country's tobacco control-related rules and regulations and the growing awareness of the adverse outcomes of tobacco use have created an unprecedented opportunity to reduce tobacco use drastically.However, the lack of a whole-of-government approach creates barriers to making use of this opportunity and allows the tobacco industry to influence relevant policies and programmes.While the tobacco sector is a source of much-needed revenue and employment for this rapidly developing country, both the real and the opportunity costs of this sector are detrimental to sustainable development.Top policymakers may occasionally forget this because controlling tobacco use is not a tangible developmental achievement but a large infrastructure project.

Disclosure statement
No potential conflict of interest was reported by the author(s).