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      Public Health Perspectives of Smokeless Tobacco and Areca Nut Use in the COVID-19 Era

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      , MD 1 , , MD 2
      Nicotine & Tobacco Research
      Oxford University Press

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          Abstract

          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. 1 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. The Problem 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. 2 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. 3 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, 4 respiratory diseases, 5,6 metabolic disorders including diabetes, 7 and a number of cancers, to name a few. Nicotine contained in tobacco is a known immunosuppressant through central as well as peripheral mechanisms. 8 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 weak immunity. The Response 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. 9 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 10 and can be suitably scaled up to provide continuous necessary cessation support to all those trying to quit. Supplementary Material A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at https://academic.oup.com/ntr. ntaa081_suppl_Supplementary_Taxonomy_Form Click here for additional data file. Funding The authors received no specific funding for this work. The opinions or views expressed in this article are solely those of the authors and do not necessarily express the views or opinions of the organizations to which the authors are affiliated. Declaration of Interests None declared.

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          COVID-19 and smoking: A systematic review of the evidence

          COVID-19 is a coronavirus outbreak that initially appeared in Wuhan, Hubei Province, China, in December 2019, but it has already evolved into a pandemic spreading rapidly worldwide 1,2 . As of 18 March 2020, a total number of 194909 cases of COVID-19 have been reported, including 7876 deaths, the majority of which have been reported in China (3242) and Italy (2505) 3 . However, as the pandemic is still unfortunately under progression, there are limited data with regard to the clinical characteristics of the patients as well as to their prognostic factors 4 . Smoking, to date, has been assumed to be possibly associated with adverse disease prognosis, as extensive evidence has highlighted the negative impact of tobacco use on lung health and its causal association with a plethora of respiratory diseases 5 . Smoking is also detrimental to the immune system and its responsiveness to infections, making smokers more vulnerable to infectious diseases 6 . Previous studies have shown that smokers are twice more likely than non-smokers to contract influenza and have more severe symptoms, while smokers were also noted to have higher mortality in the previous MERS-CoV outbreak 7,8 . Given the gap in the evidence, we conducted a systematic review of studies on COVID-19 that included information on patients’ smoking status to evaluate the association between smoking and COVID-19 outcomes including the severity of the disease, the need for mechanical ventilation, the need for intensive care unit (ICU) hospitalization and death. The literature search was conducted on 17 March 2020, using two databases (PubMed, ScienceDirect), with the search terms: [‘smoking’ OR ‘tobacco’ OR ‘risk factors’ OR ‘smoker*’] AND [‘COVID-19’ OR ‘COVID 19’ OR ‘novel coronavirus’ OR ‘sars cov-2’ OR ‘sars cov 2’] and included studies published in 2019 and 2020. Further inclusion criteria were that the studies were in English and referred to humans. We also searched the reference lists of the studies included. A total of 71 studies were retrieved through the search, of which 66 were excluded after full-text screening, leaving five studies that were included. All of the studies were conducted in China, four in Wuhan and one across provinces in mainland China. The populations in all studies were patients with COVID-19, and the sample size ranged from 41 to 1099 patients. With regard to the study design, retrospective and prospective methods were used, and the timeframe of all five studies covered the first two months of the COVID-19 pandemic (December 2019, January 2020). Specifically, Zhou et al. 9 studied the epidemiological characteristics of 191 individuals infected with COVID-19, without, however, reporting in more detail the mortality risk factors and the clinical outcomes of the disease. Among the 191 patients, there were 54 deaths, while 137 survived. Among those that died, 9% were current smokers compared to 4% among those that survived, with no statistically significant difference between the smoking rates of survivors and non-survivors (p=0.21) with regard to mortality from COVID-19. Similarly, Zhang et al. 10 presented clinical characteristics of 140 patients with COVID-19. The results showed that among severe patients (n=58), 3.4% were current smokers and 6.9% were former smokers, in contrast to non-severe patients (n=82) among which 0% were current smokers and 3.7% were former smokers , leading to an OR of 2.23; (95% CI: 0.65–7.63; p=0.2). Huang et al. 11 studied the epidemiological characteristics of COVID-19 among 41 patients. In this study, none of those who needed to be admitted to an ICU (n=13) was a current smoker. In contrast, three patients from the non-ICU group were current smokers, with no statistically significant difference between the two groups of patients (p=0.31), albeit the small sample size of the study. The largest study population of 1099 patients with COVID-19 was provided by Guan et al. 12 from multiple regions of mainland China. Descriptive results on the smoking status of patients were provided for the 1099 patients, of which 173 had severe symptoms, and 926 had non-severe symptoms. Among the patients with severe symptoms, 16.9% were current smokers and 5.2% were former smokers, in contrast to patients with non-severe symptoms where 11.8% were current smokers and 1.3% were former smokers. Additionally, in the group of patients that either needed mechanical ventilation, admission to an ICU or died, 25.5% were current smokers and 7.6% were former smokers. In contrast, in the group of patients that did not have these adverse outcomes, only 11.8% were current smokers and 1.6% were former smokers. No statistical analysis for evaluating the association between the severity of the disease outcome and smoking status was conducted in that study. Finally, Liu et al. 13 found among their population of 78 patients with COVID-19 that the adverse outcome group had a significantly higher proportion of patients with a history of smoking (27.3%) than the group that showed improvement or stabilization (3.0%), with this difference statistically significant at the p=0.018 level. In their multivariate logistic regression analysis, the history of smoking was a risk factor of disease progression (OR=14.28; 95% CI: 1.58–25.00; p= 0.018). We identified five studies that reported data on the smoking status of patients infected with COVID-19. Notably, in the largest study that assessed severity, there were higher percentages of current and former smokers among patients that needed ICU support, mechanical ventilation or who had died, and a higher percentage of smokers among the severe cases 12 . However, from their published data we can calculate that the smokers were 1.4 times more likely (RR=1.4, 95% CI: 0.98–2.00) to have severe symptoms of COVID-19 and approximately 2.4 times more likely to be admitted to an ICU, need mechanical ventilation or die compared to non-smokers (RR=2.4, 95% CI: 1.43–4.04). In conclusion, although further research is warranted as the weight of the evidence increases, with the limited available data, and although the above results are unadjusted for other factors that may impact disease progression, smoking is most likely associated with the negative progression and adverse outcomes of COVID-19. Table 1 Overview of the five studies included in the systematic review Title Setting Population Study design and time horizon Outcomes Smoking rates by outcome Zhou et al. 9 (2020)Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study Jinyintan Hospital and Wuhan Pulmonary Hospital, Wuhan, China All adult inpatients (aged ≥18 years) with laboratory confirmed COVID-19 (191 patients) Retrospective multicenter cohort study until 31 January 2020 Mortality 54 patients died during hospitalisation and 137 were discharged Current smokers: n=11 (6%)Non-survivors: n=5 (9%)Survivors: n=6 (4%)(p=0.20) Current smoker vs non-smokerUnivariate logistic regression(OR=2.23; 95% CI: 0.65–7.63; p=0.2) Zhang et al. 10 (2020)Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China No. 7 Hospital of Wuhan, China All hospitalised patients clinically diagnosed as ‘viral pneumonia’ based on their clinical symptoms with typical changes in chest radiology (140 patients) Retrospective 16 January to 3 February 2020 Disease Severity Non-severepatients: n=82Severe patients:n=58 Disease Severity Former smokers: n=7Severe: n=4 (6.9%)Non-severe: n=3 (3.7%) (p= 0.448) Current smokers: n=2Severe: n=2 (3.4%)Non-severe: n=0 (0%) Guan et al. 12 (2019)Clinical Characteristics of Coronavirus Disease 2019 in China 552 hospitals in 30 provinces, autonomous regions, and municipalities in mainland China Patients with laboratory-confirmed COVID-19 (1099 patients) Retrospective until 29 January 2020 Severity and admission to an ICU, the use of mechanical ventilation, or death Non-severe patients: n=926 Severe patients: n=173 By severity Severe cases16.9% current smokers5.2% former smokers77.9% never smokers Non-severe cases11.8% current smokers1.3% former smokers86.9% never smokers By mechanical ventilation, ICU or death Needed mechanical ventilation, ICU or died25.8% current smokers7.6% former smokers66.7% non-smokers No mechanical ventilation, ICU or death11.8% current smokers1.6% former smokers86.7% never smokers Huang et al. 11 (2020)Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China A hospital in Wuhan, China Laboratory-confirmed 2019-nCoV patients in Wuhan (41 patients) Prospective from 16 December 2019 to 2 January 2020 Mortality As of 22 January 2020, 28 (68%) of 41 patients were discharged and 6 (15%) patients died Current smokers: n=3ICU care: n=0Non-ICU care: n=3 (11%) Current smokers in ICU care vs non-ICU care patients (p=0.31) Liu et al. 13 (2019)Analysis of factors associated with disease outcomes in hospitalised patients with 2019 novel coronavirus disease Three tertiary hospitals in Wuhan, China Patients tested positive for COVID-19 (78 patients) Retrospective multicentre cohort study from 30 December 2019 to 15 January 2020 Disease progression 11 patients (14.1%) in the progression group 67 patients (85.9%) in the improvement/stabilization group 2 deaths Negative progression group: 27.3% smokersIn the improvement group: 3% smokers The negative progression group had a significantly higher proportion of patients with a history of smoking than the improvement/stabilisation group (27.3% vs 3.0%)Multivariate logistic regression analysis indicated that the history of smoking was a risk factor of disease progression (OR=14.28; 95% CI: 1.58–25.00; p= 0.018)
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            Harmful effects of nicotine

            With the advent of nicotine replacement therapy, the consumption of the nicotine is on the rise. Nicotine is considered to be a safer alternative of tobacco. The IARC monograph has not included nicotine as a carcinogen. However there are various studies which show otherwise. We undertook this review to specifically evaluate the effects of nicotine on the various organ systems. A computer aided search of the Medline and PubMed database was done using a combination of the keywords. All the animal and human studies investigating only the role of nicotine were included. Nicotine poses several health hazards. There is an increased risk of cardiovascular, respiratory, gastrointestinal disorders. There is decreased immune response and it also poses ill impacts on the reproductive health. It affects the cell proliferation, oxidative stress, apoptosis, DNA mutation by various mechanisms which leads to cancer. It also affects the tumor proliferation and metastasis and causes resistance to chemo and radio therapeutic agents. The use of nicotine needs regulation. The sale of nicotine should be under supervision of trained medical personnel.
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              Impact of smokeless tobacco products on cardiovascular disease: implications for policy, prevention, and treatment: a policy statement from the American Heart Association.

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                Author and article information

                Journal
                Nicotine Tob Res
                Nicotine Tob. Res
                nictob
                Nicotine & Tobacco Research
                Oxford University Press (US )
                1462-2203
                1469-994X
                08 May 2020
                : ntaa081
                Affiliations
                [1 ] Tobacco Free Initiative, South-East Asia Regional Office, World Health Organization , New Delhi, India
                [2 ] Public Health Consultant , Haryana, India
                Author notes
                Corresponding Author: Arvind Vashishta Rinkoo, MD, House Number 15, Sector 8, Faridabad, Haryana 121006, India. Telephone: 919540318991, 911292245135, 911292243774; E-mail: docavr@ 123456gmail.com
                Author information
                http://orcid.org/0000-0001-5920-4110
                Article
                ntaa081
                10.1093/ntr/ntaa081
                7239101
                32382754
                7e601c9d-ca86-4c3b-b481-36263d998ccb
                © The Author(s) 2020. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved.For permissions, please e-mail: journals.permissions@oup.com.

                This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model ( https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

                This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.

                History
                : 26 April 2020
                : 04 May 2020
                : 06 May 2020
                : 13 May 2020
                Page count
                Pages: 2
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                AcademicSubjects/SOC02541
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                Agriculture
                Agriculture

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