+1 Recommend
1 collections
      • Record: found
      • Abstract: found
      • Article: not found

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

      , MD 1 , , MD 2

      Nicotine & Tobacco Research

      Oxford University Press

      Read this article at

          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.


          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 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.

          Related collections

          Most cited references 8

          • Record: found
          • Abstract: not found
          • Article: not found

          Impact of smokeless tobacco products on cardiovascular disease: implications for policy, prevention, and treatment: a policy statement from the American Heart Association.

            • Record: found
            • Abstract: found
            • Article: not found

            Taking forward a ‘One Health’ approach for turning the tide against the Middle East respiratory syndrome coronavirus and other zoonotic pathogens with epidemic potential

            Highlights • The appearance, disappearance, and re-emergence of pathogens of humans with epidemic potential and high mortality rates have threatened global health security for centuries. • Global public health authorities should have been better prepared for the recent Ebola virus disease (EVD) epidemic in West Africa. • The current Zika virus outbreak is diverting the attention of public authorities and governments from other important infectious diseases that continue to threaten global public health security; one such disease lurking in the background is the Middle East respiratory syndrome (MERS). • The emergence of the MERS coronavirus (MERS-CoV) in 2012 was the second time (after severe acute respiratory syndrome coronavirus (SARS-CoV)) that a new coronavirus, highly pathogenic for humans, emerged in the 21st century. Whilst most MERS cases have been reported from the Middle East, MERS cases have been reported from 27 countries in all continents. • MERS-CoV has been found in camel populations of Eastern Africa and the Middle East, and with millions of pilgrims visiting Saudi Arabia and returning home every year, the movement of MERS-CoV to new locations presents a real threat to global health security. • With animal, human, and environmental factors playing a critical role in its evolution, MERS-CoV represents a classical zoonosis. • A serious and more collaborative and coordinated MERS-CoV response plan is required to better define MERS-CoV epidemiology, transmission dynamics, molecular evolution, optimal treatment and prevention measures, and development of vaccines for humans and camels. • The ‘One Health’ concept focuses on the relationship and interconnectedness between humans, animals, and the environment, and recognizes that the health and wellbeing of humans is intimately connected to the health of animals and their environment (and vice versa). • A ‘One Health’ approach is ideally suited to the MERS-CoV situation and requires close cooperation between those who provide human health, animal health, and promote environmental and ecosystems health. • Critical to the establishment of a ‘One Health’ platform is the creation of a multidisciplinary team with a range of expertise to learn more about zoonotic spread between animals, humans, and the environment, and to monitor, respond to, and prevent major outbreaks conductive sociopolitical and economic framework for action. • The persistence of MERS-CoV 4 years since its first discovery has created major opportunities for Saudi Arabia or one of the other Middle Eastern countries to take leadership of the ‘One Health’ approach to tackling new emerging and re-emerging infectious diseases with epidemic potential in their region. • Parallel initiatives across Africa and the tropics could be harmonized to create regional networks that can serve as a repository for expert ‘One Health’ advice on safe and sustainable agricultural systems, especially for livestock, in support of human development.
              • Record: found
              • Abstract: found
              • Article: found
              Is Open Access

              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.

                Author and article information

                Nicotine Tob Res
                Nicotine Tob. Res
                Nicotine & Tobacco Research
                Oxford University Press (US )
                08 May 2020
                [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@
                © 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:

                This article is published and distributed under the terms of the Oxford University Press, Standard Journals 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.

                Page count
                Pages: 2
                Custom metadata



                Comment on this article