World No Tobacco Day is observed around the globe every year on May 31. This year it holds unparalleled significance in light of the extraordinary global health circumstances we find ourselves in. There is an emerging correlation between tobacco and COVID-19 that reinforces the need to further strengthen tobacco control laws. In response to COVID-19, the Indian Government recently banned the use of smokeless tobacco products and prohibited spitting in public places. The Union Ministry of Health notified a newly enhanced set of specified health warnings on all tobacco products.
THE COVID LINK
Unsurprisingly, there is a mounting concern among health experts that smokers may be at a higher risk of severe COVID-19 complications compared to non-smokers. As early as February 14, 2020, the head of the World Health Organization (WHO) Health Emergencies Programme posited that smoking is a risk factor for the severity of any lower respiratory tract infection, and that the same may be expected in COVID-19. A review of studies by public health experts convened by the WHO on April 29, 2020 found that smokers are more likely to develop severe diseases with COVID-19, compared to non-smokers. The underlying logic of the link between smoking and COVID-19 is that smoking compromises the immune system and its responsiveness to infections, making smokers more vulnerable to infectious diseases such as COVID-19. Furthermore, tobacco use is the main risk factor to most non-communicable diseases (NCDs) such as cardiovascular diseases and chronic respiratory conditions, cancer, and diabetes, that have emerged as risk factors for COVID-19 severity and death.
Addressing the recent hypothesis that tobacco or nicotine may prevent or treat COVID-19, the WHO clarified that there is currently insufficient information to confirm such a link and urged scientists to be cautious about amplifying ‘unproven claims that tobacco or nicotine could reduce the risk of COVID-19’.
It is not only the inhalation of toxic chemicals in cigarettes that put smokers at risk. The WHO has advised that the physical hand-to-mouth movements associated with smoking increases the possibility of transmission of the virus (possibly from contaminated cigarettes/bidis). This should be a major concern for India where the sale of loose cigarettes/bidis is rampant. Spitting associated with smokeless tobacco products is another cause of concern during any communicable disease pandemic. Water pipes (including shisha, hukkah, chillum), which often involve sharing of mouthpieces, have also been implicated in outbreaks of respiratory diseases. WHO now recommends a ban on water pipes in public places and some countries in the Eastern Mediterranean region, including Iran, Kuwait, Pakistan, Qatar and Saudi Arabia, have banned their use to avoid COVID-19 transmission. Not good at the best of times, tobacco use could be fatal now.
The COVID-19 pandemic is an extraordinary event requiring extreme measures due to the potential for the healthcare systems to be overwhelmed and for the economy to crash. However, the tobacco epidemic exerts a greater, sustained strain. To put things into perspective, tobacco-related diseases cost the India INR 1,04,500 crore (over $15 billion) in 2011 alone. Bidi smoking cost India INR 805.5 crore (US$ 12.4 billion) in terms of ill health and early deaths in the year 2017, and yet the tax revenue derived from bidi smoking came to just INR 4.17 billion in 2016-17. The Global Adult Tobacco Survey (2016-17) reported that 28.6% of adults in India and 42.4% of Indian men use some form of tobacco. At the time of writing, the death toll in India from COVID-19 stood at just over 4500, compared with over 1 million from tobacco use annually. The number of deaths due to COVID-19 will likely continue to rise for the months to come, but it is unlikely to ever match the persistent and rising annual toll from tobacco use.
THE PARADOX: INDUSTRY INTERFERENCE
The tobacco industry which has an irreconcilable conflict of interest with public health is capitalizing on the crisis to improve its public relations by taking advantage of this vulnerable situation. The industry is spreading misinformation, creating controversies and confusion on risks through blog posts, social media and articles, and continues to aggressively market their products using COVID-19 references [example: promotion in Czech Republic and Lebanon]; offers “philanthropic help” through donations of money, personal protective equipment’s (PPEs), ventilators [example: donations in India, Germany, and Bangladesh]; attracts media attention for their vaccine research; and is trying to manipulate policymaking to get tobacco shops and products listed as ‘essential’ [example: campaign in Russia]. The paradox is striking – the tobacco industry offering to help and support governments during this pandemic.
In 2004, India ratified the WHO Framework Convention on Tobacco Control (FCTC), one of the most widely embraced treaties in United Nations history. Under the WHO FCTC and its guidelines, governments are required to implement evidence-based interventions, encourage quitting and protect their respective tobacco control measures from the commercial and vested interests of the industry. The Head of the WHO FCTC Secretariat on May 4, 2020 alerted member States of the industries’ usual game plan of initially claiming to provide significant support to governments during the pandemic, but then pressuring or interfering with the efforts of those same governments to strengthen tobacco control.
There has never been a more opportune time to enhance tobacco control regulations by prioritizing and implementing proven evidence-driven policies from the WHO FCTC. Since smoking is an avoidable risk factor for poor prognosis in COVID-19 infection, a national effort at smoking cessation, bolstering deaddiction services and supporting individuals in their efforts to quit tobacco use is an intervention that may be necessary to reduce demand for scarce resources – PPEs, ICU capacity, and ventilators. Smokers may be willing and anxious to stop smoking and are more likely to do it knowing it will help save their own and others’ lives, not just in the long term, but now.
There is an urgent need to make the Cigarettes and Other Tobacco Products Act (COTPA), a 2003 legislation, more effective and more inclined to the WHO FCTC guidelines. In 2015, the government had drafted an amendment which was later withdrawn. Recently, the ministry has re-initiated the process of amending the legislation. This is an appropriate time for the government to strengthen national tobacco control measures by protecting tobacco control policies from the commercial and vested interests of the tobacco industries and prohibiting corporate social responsibility by tobacco companies. The amendment must prohibit the sale of tobacco products in loose and single sticks, ensure stricter advertising, promotion and sponsorship (TAPS) bans including a ban on surrogate advisement, and increase penalties on violation of the law. The amendment is also an occasion to address the Youth Tobacco Epidemic by increasing the legal age of tobacco consumption to 21 years and ensuring effective enforcement measures are in place that strictly penalises retailers.
In 2018, the (Indian) Cabinet approved accession to the FCTC Protocol to eliminate illicit trade in tobacco products. The amendment should introduce a tracking mechanism to check the illicit trade of tobacco products, a major challenge in tobacco control, which holds greater significance for prohibited products such as the recently banned electronic cigarette (ENDS) and Heated Tobacco Products.
Raising tobacco taxes has proven to be the most effective individual measure to address sorely needed revenues for governments, avoid future health care costs and ease the burden on the health care system. As an urgent measure to address resource constraints and the negative health consequences of tobacco use, governments may consider imposing an additional cess on all tobacco products, a ‘sin tax’ of the sort the Delhi Government recently imposed on alcohol.
An amendment to the existing tobacco control legislation is an opportunity to bring into effect the mandate underlined in the government’s Multisectoral Action Plan for Prevention and Control of NCDs (2017), to address the challenges in tobacco control and to meet India’s international commitment of 30% relative reduction in the prevalence of tobacco use by 2025. It is the best time ever to take Indian Government’s policy on the tobacco endgame seriously and regulate all tobacco products, particularly non-virginia tobacco, with a public health objective. Unlike COVID-19, we fortunately have well-documented scientific solutions to the tobacco epidemic. It’s a burden we no longer can afford.
Kashish Aneja a practicing lawyer at New Delhi, and an international legal consultant specializing in Global Health Law. Over the past 2 years, he has worked in different capacities for the World Health Organization, the O’Neill Institute for National and Global Health Laws, Centre for Reproductive Rights, and GAVI the Vaccine Alliance.
Ravi Mehrotra leads the India Cancer Research Consortium (Indian Council of Medical Research-Department of Health Research). He is a member of the Scientific Council of the International Agency for Research on Cancer (IARC) of the World Health Organization at Lyon, France. Earlier he was the Director of the ICMR-National Institute of Cancer Prevention and Research, Noida as well as the WHO-FCTC Global Knowledge Hub on Smokeless Tobacco Products.