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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