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

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 Region¹⁰ and can be suitably scaled up to provide continuous necessary cessation support to all those trying to quit.

Supplementary Material

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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.