‘Policy responses to smokeless tobacco (ST) in India during the COVID19 pandemic’

Smokeless tobacco products use is increasingly becoming a serious health issue in India.

• India is amongst the world’s largest consumers of tobacco in widely varied smoked and smokeless forms.
• India has the second largest number of tobacco users (268 million) in the world.
• Nearly 1.2 million Indians die every year from tobacco-related diseases, of which 1 million deaths are due to smoking, over 200,000 due to second hand smoke exposure, and over 35,000 due to smokeless tobacco use. 
• Nearly 27% of all cancers in India are due to tobacco usage. The total direct and indirect cost of diseases attributable to tobacco use was a staggering Rs 1,82,000 crore which is nearly 1.8% of India's GDP.

What is smokeless tobacco?

• Smokeless tobacco (SLT) is defined as a product that contains tobacco, is not smoked or burned at the time of use, and commonly consumed orally or nasally.
  • Some of the popular products in India include khaini, gutkha, zarda, betel quid with tobacco, tobacco tooth powder, tobacco toothpaste, etc.
• These products can be placed in the mouth, cheek or the lip and are sucked or chewed.

Harmful Chemicals

• Smokeless tobacco contains nicotine, which is highly addictive.
• Smokeless tobacco is also known to contain 28 carcinogens, including very high levels of tobacco-specific nitrosamines (TSNAs).
  • TSNAs are known to be some of the most potent carcinogens present in chewing tobacco, snuff and tobacco smoke.
• Other cancer-causing substances in smokeless tobacco are known to include:
  • Formaldehyde
  • Arsenic
  • Cadmium
  • Radioactive polonium-210

• Early initiationto smoking: At present, 18 is the minimum age of purchasing tobacco products, which leads to early initiation to smoking.
• Easy availability and affordability: Easy availability and affordability of ST products compared to smoking products and restrictions on smoking in public places have intensified the ST consumption.
• Socially acceptable: Unlike smoking, which is generally considered a taboo, ST use is more socially acceptable, especially for women in the country.
• Cultural issue: Many ST use practices are also imbibed within the region’s culture and tradition and tend to be passed down from one generation to another.
  • In some slum dwellings in New Delhi, children as young as six years of age have been found to be regular users of ST products

Smokeless tobacco is associated with many health problems. Using smokeless tobacco:

• Addiction: It can lead to nicotine addiction. It can cause nicotine poisoning in children
• Cancer: It can cause cancer of the mouth, esophagus, and pancreas
• Mouth disease: It is also associated with diseases of the mouth
• Pregnancy issues: It can increase risks for early delivery and stillbirth when used during pregnancy
• Risk for death: It may increase the risk for death from heart disease and stroke

Recognising the harmful risks, several policy responses relevant to ST control have been put forth in India since March 2020 to mitigate the spread of COVID-19. These started with sub-national orders in some states and districts to prohibit the regional manufacture and sale of ST products.

• Nation-wide appeal: In April 2020, the Indian Council of Medical Research (ICMR) issued a nation-wide appeal, asking the general public to refrain from consuming ST and spitting in public places.
• Making spitting, a punishable offence: In the same month, the Indian government issued a national directive for COVID-19 management, which specified public spitting as a punishable offence that would incur fines. Since spitting usually accompanies ST consumption, this applied directly to ST use practices.
• Prohibiting the use: States and union territories (UTs) were also given additional authority under the Epidemic Disease Act 1897, the Disaster Management Act 2005, and under various provisions of the Indian Penal Code (IPC) 1860, to prohibit use of ST and spitting in public places during the pandemic.

However, tracking of these different policies at the state level against the pandemic timeline has not been carried out till date.

• Pan-India ban: Beginning in 2012, all states in India banned the manufacture, sale and distribution of the ST product, gutkha, under an Act issued by the Food Safety and Standards Authority of India (FSSAI).
  • According to this Act, gutkhawas defined as a food product, and should therefore not contain any tobacco.
  • In some states, this ban also extended to other oral products containing tobacco.
• Stricter implementation: In the wake of the pandemic, there seem to be provisions for stricter implementation of these existing measures. For example-
  • Maharashtrahas allowed the state police to register a non-bailable offence against the sale and purchase of gutkha and flavoured tobacco, which has been made possible under provisions of the IPC and other additional Acts mentioned in the last section.
  • In Uttar Pradesh, the ban was briefly extended to paan masalawithout tobacco but lifted in May 2020.
  • While the central government had also issued nation-wide prohibitions on all ST sales in public places during the second phase of the national lockdown, states were able to reopen ST vends during the third phase.
  • In Rajasthan, the rationale provided for this change was that the prohibition was leading to an increase in the black market for tobacco and that livelihoods of the poor were getting affected.
• Unlike an existing ban on smoking in public places, public use of ST was not banned in India, with the exception of some states – Maharashtra became the first state in India to ban the use of ST in public places in 2014; in some states like UP, the ban was for certain public places such as government offices, etc.
• However, in dealing with the pandemic, there now seems to be a uniform ban on all public use of ST across all states since April 2020.
• While policies against public spitting (including ST) existed pre-COVID in many local jurisdictions, these now seem to uniformly extend to all states, keeping in line with the advisory issued by the Ministry of Health and Family Welfare in April 2020.
• Recently, the Jharkhand government has made it mandatory for its employees to file affidavits stating that they will not consume tobacco in any form.

• The WHO Framework Convention on Tobacco Control (WHO FCTC) is the first international treaty negotiated under the auspices of WHO.
• It entered into force on 27 February 2005. It has since become one of the most rapidly and widely embraced treaties in United Nations history.
• The WHO FCTC was developed in response to the globalization of the tobacco epidemic and is an evidence-based treaty that reaffirms the right of all people to the highest standard of health.
• The Convention represents a milestone for the promotion of public health and provides new legal dimensions for international health cooperation.
• India has been a Party to the WHO Framework Convention on Tobacco Control (WHO FCTC) since 2005.

The current pandemic has changed peoples’ attitudes towards the use of ST and people are now more receptive to ST control measures. A greater understanding of these aspects would be useful for informing the future direction of ST control policies in the country. The time may be right for focusing the efforts on how best to apply policy measures for effective ST control in India.