Bangladesh has shown remarkable leadership in public health with a very strong focus on equity and many people in tobacco control. Over the last 50 years, the country has propelled itself to the global stage where everyone had to stop and take notice of the sustainable development and impressive socioeconomic growth.
It comes as no surprise then that when it came to address tobacco control, Bangladesh was one of the very first countries to sign the WHO Framework Convention on Tobacco Control (FCTC). What we've seen really over the last three decades is that Bangladesh has undergone what many call an economic transformation -- resulting in a dramatic decline in poverty and a shift from Bangladesh being defined as a low middle income country to middle income country.
It has basically become the envy of the developing world. One of the consequences of this rapid economic transition, has been a dramatic shift away from infectious diseases to non-communicable diseases as the leading causes of death.
Bangladesh finds itself in a situation where the UK was 40 years ago. About 45% of men and 25% of women currently use tobacco with an equal distribution of combustible and smokeless toxic products.
However, Bangladesh possesses the means to significantly reduce tobacco related deaths, if it was to follow the policies that are already in place in several countries. If the current trend continues, even if we assume there's a modest improvement in tobacco control, Bangladesh is set to witness around 4 million tobacco related deaths between 2025 and 2060.
Embracing the sensible regulation of a comprehensive range of reduced-risk products, including everything from e-cigarettes to heat not burn products to other alternatives of smoking would reduce the estimated number of deaths by 50% to 2 million over the next few decades.
There is no other public health intervention that comes close to achieving such a significant impact.
Harm reduction and the Framework Convention on Tobacco Control
The FCTC provides for an opportunity for harm reduction, to also have a regulatory place as defined in Article 1D. The principle should be that we should be regulating, proportionate to the risk of the product.
Now we know that products like e-cigarettes or nicotine pouches, uh, constitute a minimal risk to the adult population. Probably close to zero, but they help people move away from cigarettes away from the toxic product.
The regulatory environment going forward needs to make it easier for a smoker or user of toxic smokeless products to make that transition. What does that mean? It means you need a good price differential between the reduced risk products and the combustible products. It must be tougher to buy a combustible cigarette in terms of price. The advertising and marketing needs to reflect that differential too. It needs to not just talk about the dangers of vapes and make them equivalent to cigarettes, but to be very clear about the benefits of what it'll mean in terms of reduced risk to exposure and ultimately to death.
Ensuring accessibility of less harmful alternatives
Bangladesh has set an ambitious and bold goal of becoming smoke-free by 2040. Becoming smoke-free technically means an adult smoking prevalence of less than 5%. That is a massive challenge to achieve by 2040. Sweden is about to become the first country in the world to achieve it, but remember it was 40-50 years ago that they were smoking at the rates currently prevalence in Bangladesh.
If the country wants to accelerate the process and achieve the 2040 target, you have to double down and remove all regulatory barriers to access the full range of harm reduction products. Speak out about toxic tobacco products and be very careful to make sure that you don't demonize nicotine itself. Dismiss the myth that nicotine causes cancer or that nicotine has other adverse effects -- when by and large, it doesn't.
Bangladesh can become regional leaders in harm reduction alongside its steam in terms of its economic growth. They can copy the examples of the United Kingdom, Sweden, South Africa, Japan. I'm sure they could look nearby to Indonesia, Malaysia and Pakistan where e-cigarettes are legal, or to the UAE, where we're seeing a massive displacing of conventional tobacco products.
If they succeed, I have no doubt that Bangladesh will achieve its goal, like it always has had in other areas of global health and the beneficiaries in terms of smokers, the users of smokeless tobacco products and their families will be immensely grateful and the economy will benefit.
The author has been a Professor of Global Health at Yale University and is a former Executive Director for Noncommunicable Diseases and Mental Health of the World Health Organization (WHO). At WHO, he served as cabinet director under Director-General Gro Harlem Brundtland where he led the development of WHO's Framework Convention on Tobacco Control (FCTC) and the Global Strategy on Diet and Physical Activity.
