As of April 16 2020, more than two million individuals have been infected with COVID-19 across 210 countries, resulting in over 1,33,800 deaths. India has recorded more than 12,000 cases with 405 deaths. Not all is known about the ways it may be transmitted.
Chinese researchers have reported that patients with a history of smoking were 14 times more likely than non-smokers to progress to pneumonia-like symptoms. It was also reported that almost a third of the population affected in China had at least one co-existing illness such as chronic obstructive pulmonary disease, which is not surprising given the large number of smokers in the country (52 per cent among men and 2.7 per cent among women). It was also reported that three times more smokers either died, required ICU admission or needed intubation, compared to never-smokers.
Tobacco use is also the most important risk factor for chronic obstructive pulmonary disease, which may reduce the lung’s capacity to take in oxygen, resulting in the build-up of mucus, painful coughing and breathing difficulties, which are the hallmarks of the COVID-19 infections. At times, the disease ends in Acute Respiratory Distress—not even responding to oxygen supplementation.
It has been found that the gene expression for the Angiotensin Converting Enzyme (ACE2), which the virus uses to infect cells, is significantly higher in smokers than non-smokers. In addition, cigarette, bidis and hookahs may destroy the tiny, hair-like structures that help to trap viruses in the airway passages and the lungs. Notably, smoking cigarettes or bidis involve repetitive hand-to-face movements, which provide a route of entry for virus, more so when these are shared amongst friends, a practice common amongst youngsters.
The relationship between COVID-19 and cardiovascular health is important because tobacco use, and exposure to second-hand smoke, are major causes of heart disease globally. A compromised cardiovascular system in patients with a history of tobacco use could predispose these individuals to severe symptoms and possibly fatal outcomes.
The increased risk in these individuals provides the impetus for restricting gutkha, pan and tobacco sales, especially while health services are strained to the breaking point. Chewing tobacco and areca nut, without or without pan or betel leaf, is often accompanied by spitting which is a major risk factor.
Armed with these facts. the Indian Council of Medical Research (ICMR) released an advisory asking the public to refrain from consuming smokeless tobacco products, and spitting in public places, which was, in turn, endorsed by the ministry of health. Many states including Bihar, Jharkhand, Telangana, Uttar Pradesh, Uttarakhand, Maharashtra, Haryana, Rajasthan, Gujarat, Mizoram, Nagaland, Maharashtra and Andhra Pradesh have already banned spitting after tobacco consumption.
Himachal Pradesh police even threatened to charge infected patients found spitting with an attempt to murder. While these states have come down on pan and tobacco sales, West Bengal has deemed them an essential business. The National Directives for Lockdown 2.0, released on April 15, reiterates fines for spitting in public places and banning substances like gutkha, tobacco and alcohol.
Tobacco cessation at any time represents a huge opportunity for health, with smokers tending to lose at least ten years of life. It is likely that the current concern about the pandemic may be a watershed moment in that users may be uniquely receptive to cessation advice. When the individual is not around other tobacco users due to mandatory social distancing, quitting can be easier. However, some users may need support to manage withdrawal symptoms. This is a good time to utilise the national toll-free services tobacco quitline (1800 227787) in addition to time-trusted technologies, if available.
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This will be a good time to ban chewable tobacco products in the short term, and then extend it as a long term measure. Let us aim to make the most of the tough times and turn this opportunity into a game-changer, to reduce the spread of COVID-19 and to kick the tobacco habit for good,
Dr Ravi Mehrotra is the Chief Executive Officer of the ICMR-India Cancer Research Consortium, New Delhi and was, until recently, the Director of the Global Knowledge Hub on Smokeless Tobacco of the WHO-FCTC at ICMR-NICPR, Noida.
