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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 5  |  Issue : 3  |  Page : 138-142

A “Bottom-up approach” to introduce ban on tobacco products to prevent spitting during COVID-19: An early review of progress made and challenges


1 International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
2 Socio Economic and Educational Development Society, New Delhi, India

Date of Submission14-May-2020
Date of Decision16-Jun-2020
Date of Acceptance20-Jul-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Mr. Pranay Lal
International Union Against Tuberculosis and Lung Disease (The Union), C-6, Qutub Institutional Area, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jncd.jncd_17_20

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  Abstract 


On March 11, 2020, WHO announced that a novel coronavirus disease 2019 (COVID-19) had transformed into pandemic. Since then, it has challenged health systems and tested the governance of every country. In India, national and sub-national governments have responded by proposing new policies to stop the advance COVID-19 through a slew of measures. Among these was prohibiting smoking and spitting, especially that induced by the use of smokeless tobacco in public places, which could potentially spread the infection further. States and districts were first to propose strict orders, which was followed by advisories and orders at the national level, which supported sub-national implementation. It is premature to estimate the impact of restricting tobacco trade, sale, and use on COVID-19 transmission; however, this early review assesses efforts made which national and sub-national commitment (or lack of it) towards tobacco control.

Keywords: Coronavirus disease 2019, health policy, public health, sustainable development goals, tobacco control


How to cite this article:
Lal P, Mishra D, Singh RJ. A “Bottom-up approach” to introduce ban on tobacco products to prevent spitting during COVID-19: An early review of progress made and challenges. Int J Non-Commun Dis 2020;5:138-42

How to cite this URL:
Lal P, Mishra D, Singh RJ. A “Bottom-up approach” to introduce ban on tobacco products to prevent spitting during COVID-19: An early review of progress made and challenges. Int J Non-Commun Dis [serial online] 2020 [cited 2020 Oct 22];5:138-42. Available from: https://www.ijncd.org/text.asp?2020/5/3/138/296790




  Introduction Top


The first cases of coronavirus disease 2019 (COVID-19) were imported by expatriates who had returned to India on January 30, 2020. Keeping a cautious watch on the global spread, a Group of Ministers and senior bureaucrats from key ministries met on February 3, 2020 to discuss and prepare for the eminent pandemic.[1] There was no significant rise in numbers of cases until March 4, when 22 new cases came to light, which included a tourist group with 14 infected members.[2] Until this time, the only proactive effort to stop COVID-19 was through screening passengers at airports arriving from countries which had reporting cases. On March 12, an inter-ministerial meeting formally announced a containment plan. Comprehensive national legislations invoked stringent social distancing measures, which commenced on the midnight of March 24, 2020, when a nation-wide lockdown was announced.[3] The lockdown was made under the provisions of the National Disaster Management Act 2005, whose powers were used to announce a nation-wide lockdown, the government sought to institutionalize physical distancing and other measures to reduce general contact between individuals.[4]

According to the WHO, tobacco use is a major risk factor for major noncommunicable diseases like cardiovascular diseases, while also contributing to the persistence of major communicable diseases like tuberculosis. Tobacco control deemed as critical to achieving sustainable development goals and reducing the burden of disease from both non-cuunicable and communicable disease. Although not traditional, tobacco use has over the last century become deeply ingrained in India's daily life. According to the second Global Adult Tobacco Survey (2017) nearly 267 million adults in India (or roughly the population of Indonesia, the fourth largest country in the world) use tobacco in any form; one-fifth of these adults (or 199 million, or about the population of Nigeria, the 7th largest country in the world) use smokeless tobacco (SLT) and 32 million adults are dual users of tobacco.

Thus, tobacco use causes in excess of 1.2 million diseases in India annually.[5] Tobacco use, especially SLT, pan masala, and the like products which induce spitting in a public place can further spread of COVID-19 and other persistent infectious diseases.

The first policy response by states has been varied and has invoked various types of legislation. Some states (Kerala and Karnataka) issued state-level ordinances which cover all current and future epidemics, which empower to come up with new regulations to “prohibit any usage or act which the Government considers sufficient to spread or transmit epidemic diseases.” Government of India's The Epidemic Disease (Amendment) Ordinance of April 22, 2020, also empower states and official that 'any person empowered under the Act to take measures to prevent the outbreak of the disease or spread thereof.[6] The power to define “epidemic” lies with the State (Epidemics Act 1897).[7] Most other states released orders and notifications using powers from the Epidemics Act 1897 and provisions of other legislation to addressing the rapidly emerging challenges of managing COVID-19.


  Tobacco Control Efforts to Break Coronavirus Disease 2019 Transmission Top


By mid-March, early evidence of links between smoking and tobacco use and COVID-19 infection emerged,[8] following which international public health organizations issued advisories, and WHO shared a factsheet with stakeholders and governments advising them to promote cessation services and support reduction of tobacco use especially smoking.[9] Tobacco industry, both as individual companies and its various front groups, launched a series of misinformation campaigns on harm reduction[10],[11] and relative protection from COVID-19 among smokers.[12]

Starting in the last week of March 2020, districts and states began to issue orders and advisories to deter tobacco use, which can spread COVID-19. On March 13, 2020, the state of Maharashtra became the first to notify a ban spitting in public places but did not specify use and sale of tobacco using a mix of national legislations (The Epidemics Act, 1897, National Disaster Management Act 2005) and state act (Maharashtra Police Act of 1951). To get more stringent orders that covered a wide variety of SLT and pan masala products, two districts in the northern state of Bihar (Supaul[13] and Arwal) on March 27, 2020 using provisions of the Indian Penal Code together the Clean India-Healthy India campaign banned spitting in public places.[14] Over the next 2 weeks, all districts of Bihar enacted similar bans. The Bihar government followed using an ensemble of laws – the Indian Penal Code 1890, the Cigarette and Other Products Act 2003, the Epidemic Diseases Act 1897, and Bihar Epidemic Diseases COVID-19 Regulation 2020 – a comprehensive state-wide ban order on the ban on the use of SLT and spitting was issued, which became the example for issuing orders.[15] Eleven states have issue state-specific legislation based on Epidemics Act to strengthen their response to COVID-19.

In the light of these containment measures for COVID-19, India's apex medical research body, Indian Council of Medical Research in early April issued an “Appeal to the General Public: Not to consume and spit SLT in public” as “Chewing Smokeless Tobacco products (Gutkha, Paan masala with tobacco, Paan and other chewing tobacco products) and areca nut (supari) increases the production of saliva followed by a very strong urge to spit.”[16] On April 10, 2020, the Ministry of Health and Family Welfare issued an advisory to states urging them to prohibit the use and spitting of SLT in public spaces. With greater impetus and support from the Ministry of Health and Family Welfare's National Tobacco Control Programme (NTCP), more districts and states began to enact bans. Within the next fortnight districts in Bihar, Uttar Pradesh, and Jharkhand and the state of Nagaland also issued follow-up orders. Some districts additionally used the food safety law to include the prohibition of manufacture and sale of paan masala (an arecanut, catechu, and lime preparation occasionally mixed or sold alongside with processed flaked tobacco) within their jurisdictions. This district-led bottoms-up approach has been critical in institutionalizing tobacco control in India in the grassroots. Other ministries like rural development also strictly prohibited tobacco use in worksites.[17]

On April 15, 2020, the start of the second phase of the lockdown was announced, and with it, the Ministry of Home Affairs. Under the National Directives for Management of COVID-19, it prohibited the sale and use of gutka, tobacco, etc., and spitting in public spaces in public places.[18] As of May 14, 23 states and at least 187 districts from 11 states [Table 1] have used a combination of laws to prohibit the sale and use of SLT; and have begun enforcement against sale of tobacco products and spitting in public places. As a result, there are widespread seizures reported from across India. District orders have additionally ensured that strict enforcement and frequent seizures of illicitly traded tobacco products take place, and district and local administration are directly responsible for restricting its trade, sale and use.
Table 1: Chronology of national, sub-national and district-level orders to ban smokeless tobacco and pan masala use, and spitting (updated as of May 13, 2020)

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  Challenges to Tobacco Control Despite High-Level Support Top


On April 26, 2020, India's Prime Minister, Narendra Modi in a nationwide broadcast[19] appealed to the public that spitting is harmful to public health – and is, during the COVID 19 pandemic – a reasonable responsibility for all to be mindful of how the environment which can engender diseases, is treated. However, on May 1, 2020, the Ministry of Home Affairs issued a new directive to resume a few economic activities under which sale of tobacco products is also permitted, provided social distancing norms are maintained. The Ministry of Home Affairs, issued National Directives for Management of COVID-19, which prescribed a total ban on spitting and consumption of paan, gutka, tobacco, etc., in public places and allows the sale of tobacco products subject to minimum six feet distance between customers and at one time not > 5 persons shall remain present in the shops.[20] This is potentially a setback for arresting tobacco use and therefore spread of infection locally. With the removal of lockdown restrictions, India is expected to witness a rapid increase in numbers of cases.[21]

While most states have retained their restrictions, Uttar Pradesh, the largest tobacco consuming state, has resumed manufacture, trade, and use provided social distancing and other restrictions are maintained. Public health associations like the state chapters of the Indian Medical Association and Indian Dental Association have written to policymakers in Uttar Pradesh to reverse the order, and to other states not to open tobacco vends. A public interest litigation seeking a ban on production, distribution and sale of pan masala and SLT has been filed by a journalist on May 9, 2020, in the state High Court.[22] In addition to state and district level bans, Jharkhand following on the footsteps of Bihar,[23] has banned 11 leading pan masala brands for containing additives and adulterants under the food legislation.[24] Several states like Maharashtra, Goa, Telangana, among others, have already banned sale and use of SLT and pan masala, and any measures to reduce the use of these noxious products will help reduce the burden of diseases. States in India remain committed to supporting the ban spitting and through it continuing the prohibition on the sale of SLT and related products. As a result, there is strict enforcement across states with seizures being highest in Bihar, Karnataka, Uttar Pradesh, Rajasthan, followed by other states. At least 28 seizures of more than Rs. one crore (or USD 1,32,500) have been made in the first 50 days of the lockdown (March 24 to May 14, 2020).[25]


  Conclusion Top


There has been significant progress in advancing national, sub-national and district-level policies to arrest tobacco use during the early stages of the COVID-19 pandemic. There is good awareness among health and non-health actors who support tobacco control, whether in the context of the disease or without (as seen in the case of Jharkhand pan masala ban). COVID-19 provides an opportunity for governments to arrest the spread of tobacco products. However, the current infrastructure to support current tobacco users to quit tobacco at national and sub-national efforts is far from adequate. This is also an opportunity for the Ministry of Health and Family Welfare, the NTCP, and state health departments to strengthen cessation support and make the National Tobacco Quit Line, tobacco cessation centers, mCessation and communit-based cessation efforts and truly integrate tobacco cessation within disease control programs. The benefit of spitting bans and arresting (smokeless) tobacco use in India can potentially help reduce transmission of COVID-19 and other diseases, and in particular, help realizes Prime Minister Modi's mission to eradicate TB by 2025 well ahead of the global target of 2030.[26] Sustaining the ban on tobacco products and paan masala beyond the current COVID-19 crisis will have wider collateral benefits for public health and help current users to quit, and avert possible new initiations.

Acknowledgment

The authors are gratefully acknowledge the support of the Bloomberg Initiative to Reduce Tobacco Use for supporting their work at the national and sub-national level, which has enabled this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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23.
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24.
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25.
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26.
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