India’s regulatory struggle to rein in smokeless tobacco use: is Covid-19 a game changer?

Deepak Mishra, Riddhi D’souza, Adhip Amin, Pranay Lal and Dr. Kaushal Kishore

India has introduced laws for some of the most stringent physical distancing measures in the world. In addition to these measures, which started on 25 March 2020, there have been a range of restrictions introduced to contain the potential for smokeless tobacco use to spread Covid-19.

On 27 March, Supaul and Arwal — two districts in the eastern state of Bihar – drew on India’s penal law to ban spitting in publicly occupied spaces, including government offices, educational institutes and health establishments. Within two weeks, more than half the districts in Bihar had bans in place. On 13 April the state government, using the punitive provisions of India’s penal law, in tandem with the national tobacco control law which prohibits smoking in public, the Epidemic Diseases Acts 1897, and the Bihar Epidemic Diseases Covid-19 Regulation 2020 to ensure restrictions for containment. Through these actions, Bihar has spearheaded local efforts to use tobacco control efforts to contain Covid-19, building on its existing leadership in this area. Previously, the state government has withstood strong pushback from the tobacco industry in its protracted battle to regulate chewing tobacco. Giving effect to the national food safety regulation 2.3.4, the state government  has issued an order comprehensively banning the sale and manufacture of gutka and paan masala.

The intervention on smokeless tobacco is crucial in the light of Covid-19. The Global Adult Tobacco Survey 2017 estimated that 23.5% of the state’s population (17 million adults) currently use smokeless tobacco in Bihar. This is approximately 40% more than the population of Mumbai, India’s largest city. Spitting induced by smokeless tobacco use can exacerbate the spread of Covid-19, among other infections. Arwal and Supaul’s, and later the state government’s order, specifically highlight how spitting increases the chance of infection not only for Covid-19, but also tuberculosis, encephalitis, swine flu and other serious infectious diseases. Tuberculosis alone kills more than a thousand people in India per day.

Bihar’s district-initiated bottom-up approach has been critical for encouraging similar actions by other states. Shortly after Bihar’s action, the neighboring states of Jharkhand and Uttar Pradesh came out with similar orders. By the 15 May, 23 states and more than 190 districts had employed a combination of laws to either prohibit the sale and use of smokeless tobacco and/or started enforcement against sale of tobacco products and spitting in public places. Evidence of this can be found in the widespread seizures reported from across India.

The actions by states took place against a backdrop of national warnings by medical and government bodies. In early April, India’s apex medical research body the Indian Council of Medical Research issued an appeal to the general public to not consume and spit smokeless tobacco in public, noting that: “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.” This appeal was followed by similar clear directions by the Central Government. On 10th April 2020, a few days before the second phase of the lockdown the Ministry of Health and Family Welfare highlighted spitting as a public health issue, and issued an advisory to its federal units urging them to prevent the consumption and spitting of smokeless tobacco in public spaces.

Recognising the health impacts of smokeless tobacco, Indian states have previously enacted bans, under the national food safety law, which prohibited the manufacture and sale of these products in their jurisdictions. However, amidst the pressure to contain the spread of Covid-19, a new regulatory process has been conceived. Giving effect to the central government’s advisory, the states are now authorised to use provisions of the Epidemic Diseases Act 1897 and the Disaster Management Act 2005 in addition to India’s (procedural and substantive) criminal code to combat the spread of Covid-19. This fresh wave of orders operationalises a combination of laws allowing states – like Bihar – to leverage additional powers to ban both the smokeless tobacco trade itself, as well its use and the act of spitting. States and districts are now equipped with additional (tobacco control) powers. This network of laws encompasses many more smokeless tobacco products, in contrast to the prior framework which had a narrower regulatory focus, primarily paan masala and gutka; and thereby excluded the many other local varieties of tobacco in India. The extension of the aforementioned (new) legal mechanism will eliminate the usage of all forms of smokeless tobacco by prohibiting spitting. Several orders unequivocally recognise that spitting remains a formidable challenge with grave public health implications.

On 26 April, the Prime Minister, in a nationally broadcast radio appeal, reiterated that spitting is harmful to public health, and during the Covid-19 pandemic the responsibility of all to minimise the spread of disease.

Deepak Mishra is executive director of Socio Economic and Educational Development Society (SEEDS). Riddhi D’souza and Adhip Amin are researchers at the Institute of Public Health, India (IPH), and are supported through the DBT/Wellcome trust India Alliance fellowship awarded to Upendra Bhojani (IA/CPHI/17/1/503346) Pranay Lal works with The International Union Against Tuberculosis and Lung Disease (The Union). Dr Kaushal Kishore is medical doctor and Indian Administrative Service Officer, and currently serves as Additional Secretary, Department of Health, Government of Bihar.

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