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India is amongst the world’s largest consumers of tobacco in widely varied smoked and smokeless forms. Results from two rounds of the nationally-representative Global Adult Tobacco Surveys (GATS, 2009-10 and 2016-17), have shown that smokeless tobacco (ST) products constitute the dominant form of tobacco consumption in the country. ST refers to types of tobacco that are not smoked or burned at the time of use, and some of the popular products in India include khaini, gutkha, zarda, betel quid with tobacco, tobacco tooth powder, tobacco toothpaste, etc. It has been estimated that ST use resulted in over 350,000 deaths in India in 2010, and nearly three‑fifth of these deaths occurred among women. Unlike smoking, which is generally considered a taboo, ST use is more socially acceptable, especially for women in the country. Many ST use practices are also imbibed within the region’s culture and tradition and tend to be passed down from one generation to another. In some slum dwellings in New Delhi, children as young as six years of age have been found to be regular users of ST products. Although well over 100 countries across the world report the use of different ST products among adults, a recent study has estimated that 85 percent of the ST-related disease burden from conditions such as oral cancer and cardiovascular disease are faced by populations in South and Southeast Asia. India alone accounts for 70 percent of the global ST-related burden from these serious and often life-threatening diseases.
Relevance of ST use practices during the COVID-19 pandemic
Traditionally, global tobacco research and control efforts tend to have a strong focus on cigarettes. This is also largely true during the current pandemic, with pooled evidence from studies conducted till date suggesting that cigarette smoking may be an independent risk factor for hospitalisation and death from COVID-19. In contrast, there is hardly any research on the association between ST use and the novel coronavirus. However, indirect evidence of certain ST-related changes found in the oral mucosa of users (e.g. higher expression angiotensin-converting enzyme 2 receptors, presence of furin, etc.), as well as altered immune response mechanisms, suggest that ST users may have increased susceptibility to contract and disseminate SARS-CoV-2 infections. In addition, ST consumption can involve the sharing of products and packets between users, frequent hand-to-mouth contacts, as well as increased salivation and compulsive spitting—all of which can greatly increase the risk for virus transmission. These practices are particularly relevant for wider community transmission of COVID-19 within Indian contexts, given the high population density, large gatherings often seen around ST retail outlets, and widespread spitting in open public places.
Policy responses in India
Recognising these risks, several policy responses relevant to ST control have been put forth in India since March 2020 to mitigate the spread of COVID-19. These started with subnational orders in some states and districts to prohibit the regional manufacture and sale of ST products. In April 2020, the Indian Council of Medical Research (ICMR) issued a nation-wide appeal, asking the general public to refrain from consuming ST and spitting in public places. In the same month, the Indian government issued a national directive for COVID-19 management, which specified public spitting as a punishable offence that would incur fines. Since spitting usually accompanies ST consumption, this applied directly to ST use practices. States and union territories (UTs) were also given additional authority under the Epidemic Disease Act 1897, the Disaster Management Act 2005, and under various provisions of the Indian Penal Code (IPC) 1860, to prohibit use of ST and spitting in public places during the pandemic.
Against this background, it was reported in May 2020 that up to 28 states and UTs had implemented various restrictions relating to ST products, specifically with the view to control the spread of COVID-19. However, tracking of these different policies at the state level against the pandemic timeline has not been carried out till date. We felt this would be useful, as it would provide greater clarity regarding any variations in approaches between states.
Differences across states
Beginning in 2012, all states in India banned the manufacture, sale and distribution of the ST product, gutkha, under an Act issued by the Food Safety and Standards Authority of India (FSSAI). According to this Act, gutkha was defined as a food product, and should therefore not contain any tobacco. In some states, this ban also extended to other oral products containing tobacco. In the wake of the pandemic, there seem to be provisions for stricter implementation of these existing measures. For example, the Maharashtra government has allowed the state police to register a non-bailable offence against the sale and purchase of gutkha and flavoured tobacco, which has been made possible under provisions of the IPC and other additional Acts mentioned in the last section. In Uttar Pradesh, the ban was briefly extended to paan masala without tobacco but lifted in May 2020. While the central government had also issued nation-wide prohibitions on all ST sales in public places during the second phase of the national lockdown, states were able to reopen ST vends during the third phase. In Rajasthan, the rationale provided for this change was that the prohibition was leading to an increase in the black market for tobacco and that livelihoods of the poor were getting affected.
Unlike an existing ban on smoking in public places, public use of ST was not banned in India, with the exception of some states – Maharashtra became the first state in India to ban the use of ST in public places in 2014; in some states like UP, the ban was for certain public places such as government offices, etc. However, in dealing with the pandemic, there now seems to be a uniform ban on all public use of ST across all states since April 2020. In states with existing policies, the pandemic-related measures seem to have broadened the scope of the ban to more public places, reinforced provisions and allowed stricter implementation. While policies against public spitting (including ST) existed pre-COVID in many local jurisdictions (e.g. Bihar Municipal Act 2007, Tamil Nadu Prohibition of Smoking and Spitting Ban 2002, Bombay Police Act, 1951), these now seem to uniformly extend to all states, keeping in line with the advisory issued by the Ministry of Health and Family Welfare in April 2020.
Critique of policies in context
Policies relating to ST control have rightly come into prominence during the COVID-19 pandemic in India, given the scale of ST consumption in the country and the potential for increased risk of virus transmission associated with ST use in these contexts. India is already a signatory to the WHO Framework Convention on Tobacco Control (FCTC), an international treaty to regulate the supply and demand of all tobacco products including ST, although many of the central policies and legislations (e.g., pictorial health warnings on product packages and advertising bans) tend to be circumvented by ST. While efforts related to FCTC remain ongoing in the country, the focus of ST control policies during the pandemic has been on reinforcing existing product bans (e.g., gutkha ban), and prohibiting public use of ST and spitting, all of which are outside the policy areas covered by FCTC. These policy measures seem to have been more uniformly rolled out across the country during the pandemic and provided states with additional powers for implementing effective ST control. However, the amendment of some policies within a short span of time (e.g., banning the sale of ST in public places) is likely to have caused confusion, and given past experiences, difficulties with policy implementation and compliance may be considered likely.
Future directions
To better understand the effectiveness of these policy interventions, they should be evaluated in the coming months. It may be that the pandemic has changed peoples’ attitudes towards the use of ST and spitting in public places, and a greater understanding of these aspects would be useful for informing the future direction of ST control policies in the country. It may also be that people are now more receptive to ST control measures, and the time may be right for focusing our efforts on how best to apply both FCTC and non-FCTC policy measures for effective ST control in India.
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The Department of Health (DOH) and the Philippine Pediatric Society (PPS) have pushed for tobacco cessation as they reminded the public about the risks of both cigarette and vape smoking, and the possible spread of the Covid-19 virus.
Health Undersecretary Maria Rosario Vergeire, however, admitted that pushing for total tobacco cessation is never easy.
“It has been challenging to push for total tobacco cessation among the public, but we are not giving up. This is why it is part of the department’s health priorities that are being championed by the Health Promotion Bureau,” said Vergeire.
Vergeire said that ceasing tobacco use has always been part of the campaigns of the DOH and has been one of its health priorities due to the long-term adverse effects of smoking, not only to smokers, but on the people around them and the environment.
Critical hospitalization
For her part, Dr. Rizalina Racquel H. Gonzalez, chair of the PPS Tobacco Control Advocacy Group, revealed a startling connection between cigarette or vape smoking and Covid-19, which can cause critical hospitalization or even death.
“Smoking is associated with increased severity of disease and death in hospitalized Covid-19 patients,” Dr. Gonzalez emphasized.
She added, “Given the well-established harms associated with tobacco use and second-hand smoke exposure, the WHO [World Health Organization] recommends that tobacco users stop using tobacco.”
Dr. Gonzalez also pointed out that another way that tobacco use increases the risk and spread of Covid-19 is through the hand-to-mouth gesture of puffing a cigarette or vape, which is counterintuitive to public medical advice to people not to touch their faces.
Counterintuitive
As tobacco use is often a social activity, according to Dr. Gonzalez, it also opens an opportunity for crowding which is also counterintuitive to another anti-Covid-19 preventive measure—physical distancing. Using waterpipe or shisha also entails sharing the same pipe, which can spread viruses from person to person.
Moreover, as the PPS chair elaborated, the effects of coronavirus can be worse for people who use tobacco as it leads to disease and disability, harming nearly every body organ including the lungs.
As the lungs are damaged by tobacco use, the effects of coronavirus can be worse, said Dr. Gonzalez.
She also added that tobacco use affects the immune system, hence making smokers less able to fight off infections.
Stronger policy support
Considering these risks, Dr. Gonzalez also asked for stronger support for policies against tobacco use.
“So, we urge this call, we have been using this call, pre-Covid to let’s help push our tobacco-free laws to have a smoke-free Philippines,” she said.
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Data from the Global Adult Tobacco Survey from 31 countries between 2008–18 show that more than 176 million smokers attempted to quit in the past 12 months, and most reported little to no assistance when quitting.1 During the COVID-19 pandemic, researchers have highlighted the association between tobacco smoking and adverse COVID-19 disease outcomes, and the need for smokers to quit.2 Evidence from the US Surgeon General's report shows that cigarette smoking can suppress the immune system, increase the risk of respiratory infections, increase the risk of respiratory illnesses such as chronic obstructive pulmonary disease and asthma, and cause heart and lung diseases. Cigarette smoking is associated with severe clinical outcomes for people with other types of coronaviruses, including Middle East respiratory syndrome.3
There is robust scientific evidence showing that comprehensive smoking cessation interventions are essential to reducing tobacco use.4 Articles 12 and 14 of the WHO Framework Convention on Tobacco Control call for parties to increase awareness and cessation services for tobacco users. WHO's MPOWER policy package and the 2019 Global Tobacco Control report5 promote the provision of access to comprehensive cessation interventions to help quit tobacco use as an essential component of tobacco control programmes.
In response to COVID-19 and the role of cigarette smoking in increased severity of illness, some countries have banned tobacco product sales or taken measures to reduce tobacco use, given its potential to increase the likelihood of virus transmission (eg, exhaling respiratory droplets while exhaling tobacco smoke, spitting, sharing of mouth pieces for water pipe use). For example, in India, sales of tobacco products were banned when the country went into lockdown in April, 2020, and the country required people to refrain from consuming smokeless tobacco products in public to prevent the spread of COVID-19.6 South Africa also banned sales of tobacco products.7 17 countries in the WHO-Mediterranean region banned waterpipe use in public places to reduce practices that might lend themselves to potential virus transmission, such as sharing of waterpipe equipment and social proximity.8 All these actions, although temporary, present an opportunity for reducing the global burden of tobacco use by strengthening tobacco control programmes and policies to protect millions of people worldwide from tobacco use and second-hand smoke.
This is an opportune time to encourage and support quitting tobacco use by offering cessation services. Interventions might include leveraging new technology to reach tobacco users with evidence-based information and resources (eg, apps, mobile phones, Quitlines, social media), providing brief advice to quit in health-care settings, providing telehealth services or apps that allow the end user to opt in for cessation advice, increasing access to free or low-cost pharmacotherapy (eg, cessation medications and nicotine replacement therapies), and offering behavioural counselling. Currently the COVID-19 pandemic presents an unprecedented opportunity to provide evidence-based, comprehensive tobacco cessation services to tobacco users and strengthen tobacco control policies. During this pandemic, it is crucial to assist the world's more than one billion tobacco users, who might also be at increased risk of severe illness from COVID-19, to get the services that can increase the likelihood of successfully quitting tobacco use and accelerate the progress towards a tobacco-free world.
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Smokers should quit their habit as it may weaken their immune system, making them vulnerable to COVID-19, an official of the Philippine Pediatric Society said.
“Smoking is associated with increased severity of disease and death in hospitalized COVID-19 patients. Given the well-established harms associated with tobacco use and second-hand smoke exposure, the WHO (World Health Organization) recommends that tobacco users stop using tobacco,” said PPS Tobacco Control Advocacy Group Chair Dr. Rizalina Racquel Gonzalez.
Gonzalez noted that the effects of COVID-19 can be “worse for people who use tobacco as it leads to disease and disability, harming nearly every body organ, including the lungs.”
“As the lungs are damaged by tobacco use, the effects of coronavirus can be worse. Tobacco use affects the immune system, hence, making smokers less able to fight off infections,” she said.
The use of vapes can make the SARS-CoV-2, which is the virus that causes COVID-19, transmissible through aerosolization.
“That aerosol that is produced by that device is being inhaled by the user, inhaled by the second-hand bystander, and even the third-hand, and can carry that COVID-19 virus,” said Gonzales.
The Department of Health also encouraged the public to avoid smoking, including the use of vape products.
“Ceasing tobacco use has always been part of the campaigns of the DoH and has been one of its health priorities due to the long-term adverse effects of smoking, not only to smokers, but on the people around them and the environment,” said DoH Undersecretary Maria Rosario Vergeire.
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Smoking substantially worsens health outcomes for COVID-19 patients
We all are aware that every single puff of a cigarette leads to lung damage. And with the Covid-19 pandemic, quitting smoking has become even more important than ever.If you’re intending to quit smoking, now is the best time to quit it completely. Smoking heavily, occasionally, or relapsing back to it makes people the high-risk group for Covid-19. And given their weak lung function, the chances of complications are even more if they do not quit.1
Smokers trying to quit often attribute smoking relapse to craving, and a range of other unpleasant withdrawal symptoms such as anxiety, irritability and restlessness, which they find difficult to deal with.2The need of the hour is to stay determined to your quitting goals and manage these withdrawal symptoms in a safe way.
This is the time when you should make the decision to quit smoking and do your best to control the urge. The good news is that quitting smoking is possible with Nicotine Replacement Therapy (NRT), the first pharmacological treatment for smoking cessation that was approved by the World Health Organization (WHO), and US Food and Drug Administration (FDA).3
Controlling withdrawal symptoms in these challenging times
Smoking cessation may be difficult for some smokers, especially in these challenging times. Even ex-smokers may relapse due to unexpected urges which increases their chances of contracting Covid-19.4 However, if you're ready to quit, you can succeed with proven effective method. In this tough situation, Nicotex Nicotine products can be extremely helpful for taming your urges and safely weaning you off tobacco. The products help in controlling the urge to smoke and manage the withdrawal symptoms, and thus help you quit smoking. And, while they do contain nicotine, other dangerous chemicals found in cigarettes are not present in these products.
Receiving a small, controlled dose of nicotine offers the advantage of reducing nicotine cravings in a safe and gradual manner. This way of nicotine delivery allows your body to get used to less and less of amount of nicotine till it is stopped completely. This process helps you quit smoking which helps heal your lungs gradually,
NRTs are clinically-approved, rigorously-tested for safety and can be used as an aid to quit smoking. Nicotex is the No. 1 brand in the NRT category in India. Indicated for smoking cessation, the product makes it easier for you to go through the withdrawal symptoms and helps you quit completely.
Due to increased risk of Covid-19, smokers should act quickly to start their journey towards quitting the habit. It’s also vital that ex-smokers maintain their hard-earned quit status. The lockdown has thrown up an opportunity for smoking cessation with clinically-proven methods so that you improve your lung health.
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