Smokeless tobacco use and the COVID-19 pandemic


The use of tobacco products is of particular concern during the COVID-19 pandemic. Head and neck surgeons Dr Arjun  Singh and Dr Pankaj Chaturvedi argue that smokeless tobacco use requires attention to help stop the spread of the disease.

Since late 2019, the world has witnessed the spread of a pandemic affecting the respiratory system in the form of the novel coronavirus, officially known as COVID-19. The pandemic has affected people across all socioeconomic demographics and cultures in high-, middle- and low- income countries. On December 31, 2019, the Government of Wuhan, China, confirmed that it was treating dozens of cases of pneumonia of unknown origin. Within a month, the WHO declared a global health emergency with 9,800 people being infected (17 times more than the previous week) and 213 deaths. As of the 29th of March 2020, 202 countries have witnessed more than 575,000 incident cases with over 26,000 deaths.

A recently published Chinese study analyzing 78 COVID-19 infected patients found that those with a history of smoking were 14 times more likely than nonsmokers to have progression to pneumonia-like symptoms. Evidence also shows that the ACE2 gene expression, which COVID-19 uses to infect cells, is significantly higher in smokers than non-smokers, therefore suggesting greater susceptibility to COVID-19 among smokers. Another study has shown that almost a third of the population affected in China had at least one coexisting illness such as chronic obstructive pulmonary disease, not surprising given the large number of smokers in the country.

Tobacco use and smoking have been shown to cause immunosuppression affecting the adaptive (helper T cells, CD4+CD25+ regulatory T cells, CD8+ T cells, B cells and memory T/B lymphocytes) and innate (DCs, macrophages and NK cells) immune cells. Once affected, these cells disrupt pathways that make us susceptible to numerous diseases, including cardiovascular, respiratory and autoimmune diseases, allergies, cancers and transplant rejection etc. In fact all studies on COVID-19 to date have shown that the worst affected cohort had at least one of these comorbid conditions. Although there have been no specific studies investigating a link between vaping and COVID-19, scientists have raised concerns that vaping, like smoking, may contribute to increased risk from the virus.

Another product that could be aiding the spread of viral and bacterial diseases, along with making people more susceptible to COVID-19, is chewing tobacco. The WHO has advised that COVID-19 can spread through small droplets from the nose or mouth, which are dispersed when an infected person coughs or exhales. These droplets settle on objects and can survive for few hours or up to several days. Others can be infected by touching these objects or surfaces followed by touching their eyes, nose or mouth.

90% of smokeless tobacco chewers live in Asia, with China and India being significant consumers of smokeless tobacco, paan and areca nut. Most hold the quid in the mouth for a period of time and then spit out the tobacco juice along with their saliva. With lax laws and enforcement coupled with poor infrastructure, “spitting” is most often done in open public places, rendering the rest of the community at risk of a range of communicable diseases. This concern isn’t limited to low- and middle-income countries. According to the American Lung Association, an estimated 9.6% of high school and 3.1% of middle school students used two or more tobacco products within the past 30 days, including smokeless tobacco, with its attendant spitting.

The range of tobacco use forms can facilitate exposure to COVID-19 within or even between communities. This is of particular concern in countries with high population densities. In the early part of the 20thcentury many governments imposed laws to stop spitting in public areas, due to concerns about the spread of diphtheria, tuberculosis, pneumonia and influenza.Today, the spread of these diseases has been successfully controlled with widespread education campaigns. We now have a similar opportunity with COVID-19 and tobacco chewers. Restricting the use of these substances in public places would likely contribute to a corresponding reduction in the transmission of COVID-19.

Waking to the crisis, India’s largest state Uttar Pradesh (population 200 million) has banned manufacture, storage and sale of smokeless tobacco and pan masala (flavored areca nut). Thane, one of the neighboring districts of Mumbai in Maharashtra, banned the sale of all forms of tobacco to mitigate COVID 19 spread.  Public health advocates in India are now pushing other states to ban smokeless tobacco to stop the spread of COVID-19.

Arjun Singh is a Research Fellow, and Prof Pankaj Chaturvedi  the Deputy Director, at Tata Memorial Center, Mumbai, India. Email:

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