Since the outbreak of COVID-19 pandemic, new literature has been continuously emerging
on the probable association of tobacco use with the novel coronavirus disease.
However, most of this research is solely focused on cigarette smoking. The likely
risks associated with smokeless tobacco (ST) and areca nut (AN) use in the context
of COVID-19 have apparently not caught much attention of the researchers, although
the use of these products is widely prevalent in many countries of the South-East
Asia Region and some countries of the Western Pacific Region. With the pandemic gaining
momentum in these countries, it is imperative to prioritize research aimed at exploring
the potential association of ST and AN use with COVID-19, and thus to come out with
evidence-informed policy options.
There are around 248 million adult and 8 million adolescent ST users in the South-East
Asia Region. While ST products are extensively consumed in Bangladesh, India, Myanmar,
and Nepal, these are becoming increasingly popular in Bhutan, Maldives, Sri Lanka,
and Timor-Leste. Also, India, Bangladesh, Myanmar, and other countries of the Region
are major global consumers of AN products. Unlike tobacco smokers, more than 91% of
the global ST users reside in lower middle income and low-income group countries.
As such, these countries mostly have fragile health systems, have negligible capacity
for tobacco cessation and are ill-equipped to handle a major COVID-19 outbreak. Irrespective
of how the COVID-19 epidemic curve evolves over time in the countries of the Region,
our past experiences with comparable zoonotic pathogens with epidemic potential clearly
suggest that extreme and effective measures would be required on various fronts in
these countries over a sustained period to contain the spread of the disease.
ST and AN chewing is culturally acceptable in many countries of the South-East Asia
Region. Thus, public spitting induced by ST and AN use is widespread and an acceptable
norm at many places. This is a humongous public health menace, apparently more so
in the light of ongoing COVID-19 pandemic. Moreover, the actual act of ST and AN chewing
involves placing these products inside the mouth or oral cavity using fingers. Thus,
ST and AN users may be more vulnerable to COVID-19 owing to possibility of transmission
from hand to mouth. Also, there is evidence to suggest that ST and AN use contribute
to various morbidities such as cardiovascular disorders,
metabolic disorders including diabetes,
and a number of cancers, to name a few. Nicotine contained in tobacco is a known immunosuppressant
through central as well as peripheral mechanisms.
Thus, if infected, ST and AN users are likely to have more severe COVID-19 disease
and greater mortality owing to increased chances of having serious comorbidities and
Despite the unprecedented scale of the problem and high-stakes at play, it is unfortunate
that the appropriate response is lacking at the country level across the Region. Restrictions
on using these products and bans on spitting are not in place in most countries. With
the exception of India, none of the countries have taken any special proactive measures
to discourage the use of these products in the light of the ongoing pandemic.
In view of the COVID-19 pandemic, India adopted a piecemeal approach in restricting
the use of ST and AN products. Initially, subnational orders were passed in certain
jurisdictions of the country. These were mostly in response to the advisories issued
by the central government and were notified under relevant provisions of the law.
Barring few, most of these orders only “selectively” prohibit consumption of these
products and spitting in “public places.” Even in cases where the orders comprehensively
prohibit manufacturing and sales of these products, it is unclear how the same is
going to be enforced. It may be of relevance to underscore here that despite a complete
ban on “gutka” since many years, the ST product is freely available across India as
the industry has found new ways to easily circumvent the ban.
Spitting after consuming ST and AN products is a common sight at all public places
including roads, offices, parks, buildings, markets, etc. Very recently, on April
15, 2020, the central government passed orders completely prohibiting sales of ST
products and spitting in “public places” across the country during the second phase
of the lockdown. However, the order was amended for the third phase of the lockdown,
due to end on May 17, 2020, in which the sales of these products would be allowed
in public places, but spitting would remain prohibited. This further demeans the ban
and causes a lot of confusion owing to the contradictory nature of the prohibition.
Charting the Road Ahead
The fact remains that there is hardly any research, as of now, establishing the association
of ST and AN use with COVID-19. Thus, there is a pressing need to undertake prospective
studies to explore the potential association of use of these products with COVID-19
and related aspects. Such an approach would eventually ensure availability of evidence-informed
policy options that can be deliberated by the countries of the Region. However, time
is of essence and quality evidence needs to be generated on priority to influence
policy makers in the Region.
In the interim, several policy actions may be evaluated. Phasing out manufacturing
and sales of ST and AN products across the Region may be considered. As the use of
ST and AN products induces salivation and spitting, there seems to be no way to prevent
users of these products from spitting in public places until and unless the access
and easy availability of these products are drastically curtailed. Also, in light
of the ongoing pandemic, the enhanced receptivity of the community to the messages
encouraging quitting can possibly be translated into successful quitting of ST and
AN use by providing appropriate cessation support. Health sector along with support
from the pharmaceutical sector, the civil society and other like-minded partners needs
to prioritize development and strengthening of tobacco cessation support systems.
Nicotine replacement therapy can be made available through the public health systems.
Existing quitlines can be expanded and strengthened. Population-based cost-effective
cessation support such as mTobaccoCessation programs have proven to be successful
in the Region
and can be suitably scaled up to provide continuous necessary cessation support to
all those trying to quit.
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Declaration of Interests