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</form>Text Content
YOUR PRIVACY CHOICES We and our partners store and access non-sensitive information from your device, like cookies, and process personal data, like IP addresses and unique identifiers to personalize content and ads, measure performance, and analyze audiences. By clicking Accept, you consent to this data collection and processing by us and our 200 partners. You can select Reject to continue with only strictly necessary cookies or Customize to manage your preferences. Some processing of your personal data may not require your consent, but you have a right to object to such processing. You can withdraw your consent at any time from the consent preferences link in the footer of any ResearchGate page. For more information, see our Privacy Policy. We and our partners process data for the following purposesPersonalised advertising and content, advertising and content measurement, audience research and services development , Precise geolocation data, and identification through device scanning, Store and/or access information on a device CustomizeRejectAccept * Home * Medicine * Addiction Medicine * Tobacco Cessation ArticlePDF Available COVID-19 AND TOBACCO CESSATION: LESSONS FROM INDIA * November 2021 * Public Health 202(6) DOI:10.1016/j.puhe.2021.11.010 * License * CC BY-NC-ND 4.0 Authors: Monika Arora * Public Health Foundation of India & HRIDAY Gaurang Nazar * Evidinno Outcomes Research Inc Nitika Sharma Nitika Sharma * This person is not on ResearchGate, or hasn't claimed this research yet. Neha Jain * Public Health Foundation of India Show all 14 authorsHide Download full-text PDFRead full-text Download full-text PDF Read full-text Download citation Copy link Link copied -------------------------------------------------------------------------------- Read full-text Download citation Copy link Link copied Citations (14) References (30) Figures (2) ABSTRACT AND FIGURES Objectives The Government of India prohibited the sale of tobacco products during the COVID-19 lockdown to prevent spread of the SARS-CoV-2 virus. This study assessed the tobacco cessation behaviour and its predictors among adult tobacco users during the initial COVID-19 lockdown period in India. Study design : Cross-sectional study. Methods A cross-sectional study was conducted with 801 adult tobacco users (both smoking and smokeless tobacco) in two urban metropolitan cities of India over a 2-month period (July–August 2020). The study assessed complete tobacco cessation and quit attempts during the lockdown period. Logistic and negative binomial regression models were used to study correlates of tobacco cessation and quit attempts, respectively. Results In total, 90 (11.3%) tobacco users reported that they had quit using tobacco after the COVID-19 lockdown period. Overall, a median of two quit attempts (interquartile range [IQR] 0–6) were made by tobacco users. Participants with good knowledge on the harmful effects of tobacco use and COVID-19 were significantly more likely to quit tobacco use (odds ratio [OR] 2.2; 95% confidence interval [CI] 1.2–4.0) and reported more quit attempts (incidence risk ratio [IRR] 5.7; 95% CI 2.8-11.8] compared with those with poor knowledge. Participants who had access to tobacco products were less likely to quit tobacco use compared with those who had no access (OR 0.3; 95% CI 0.2–0.5]. Conclusions Access restrictions and correct knowledge on the harmful effects of tobacco use and COVID-19 can play an important role in creating a conducive environment for tobacco cessation among users. Sociodemographic characteristics of the study population (N ¼ 801). … Univariate association of cessation and quit attempts with sociodemographic characteristics. … Figures - available via license: Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International Content may be subject to copyright. Discover the world's research * 25+ million members * 160+ million publication pages * 2.3+ billion citations Join for free Public Full-text 1 Available via license: CC BY-NC-ND 4.0 Content may be subject to copyright. Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID- 19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. Original Research COVID-19 and tobacco cessation: lessons from India M. Arora a , b , * , G.P. Nazar a , b , N. Sharma a , N. Jain b , F. Davidson c , S. Mohan b , d , D. Mohan e , M.K. Ali f , V. Mohan e , N. Tandon g , K.M. Venkat Narayan f , D. Prabhakaran b , d , L. Bauld c , K. Srinath Reddy b a HRIDAY, New Delhi, India b Public Health Foundation of India, Haryana, New Delhi, India c Usher Institute and SPECTRUM Consortium, University of Edinburgh, Edinburgh, United Kingdom d Centre for Chronic Disease Control, New Delhi, India e Madras Diabetes Research Foundation, Chennai, India f Rollins School of Public Health, Emory University, Atlanta, USA g All India Institute of Medical Sciences, New Delhi, India article info Article history: Received 12 August 2021 Received in revised form 20 October 2021 Accepted 11 November 2021 Available online 16 November 2021 Keywords: COVID-19 Cessation Tobacco Smoking India abstract Objectives: The Government of India prohibited the sale of tobacco products during the COVID-19 lockdown to prevent the spread of the SARS-CoV-2 virus. This study assessed the tobacco cessation behaviour and its predictors among adult tobacco users during the initial COVID-19 lockdown period in India. Methods: A cross-sectional study was conducted with 801 adult tobacco users (both smoking and smokeless tobacco) in two urban metropolitan cities of India over a 2-month period (July to August 2020). The study assessed complete tobacco cessation and quit attempts during the lockdown period. Logistic and negative binomial regression models were used to study the correlates of tobacco cessation and quit attempts, respectively. Results: In total, 90 (11.3%) tobacco users reported that they had quit using tobacco after the COVID-19 lockdown period. Overall, a median of two quit attempts (interquartile range 0e6) was made by to- bacco users. Participants with good knowledge on the harmful effects of tobacco use and COVID-19 were significantly more likely to quit tobacco use (odds ratio [OR] 2.2; 95% confidence interval [CI] 1.2e4.0) and reported more quit attempts (incidence risk ratio 5.7; 95% CI 2.8e11.8) compared to those with poor knowledge. Participants who had access to tobacco products were less likely to quit tobacco use compared to those who had no access (OR 0.3; 95% CI 0.2e0.5]. Conclusions: Access restrictions and correct knowledge on the harmful effects of tobacco use and COVID- 19 can play an important role in creating a conducive environment for tobacco cessation among users. ©2021 The Authors. Published by Elsevier Ltd on behalf of The Royal Society for Public Health. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Introduction The COVID-19 pandemic has presented the world with un- precedented challenges for the 21st century, in addition to excess mortalities. 1 Although there remains a lack of evidence to define the risk of COVID-19 infection among tobacco users, 2 these in- dividuals are at an increased risk of adverse outcomes (i.e. death and severity of COVID-19). 3 Recent evidence suggests that smokers have a higher likelihood of COVID-19 complications, including mortality (odds ratio [OR] 1.91; 95% confidence interval [CI] 1.4 e2.6). 4 The act of tobacco smoking involves frequent contact between the fingers and mouth and hence can potentially increase the risk of COVID-19 infection. 5 The use of smokeless tobacco (SLT) products, such as gutkha, khaini, zarda, and paan (betel quid with tobacco), induces salivation and hence increased spitting, which may also increase the spread of the SARS-CoV-2 virus. 6 Stringent tobacco control measures have been enforced by some countries to help prevent the spread of COVID-19. Several countries from the Eastern Mediterranean Region banned the use of water- pipe in indoor and outdoor public places. 7 Bangladesh suspended the production, supply, marketing and sale of all kinds of tobacco *Corresponding author. HRIDAY, B-5/94, Safdarjung Enclave, First Floor, New Delhi, 110029, India. Tel.: þ919810056631. E-mail address: monika@hriday-shan.org (M. Arora). Contents lists available at ScienceDirect Public Health journal homepage: www.elsevier.com/locate/puhe https://doi.org/10.1016/j.puhe.2021.11.010 0033-3506/©2021 The Authors. Published by Elsevier Ltd on behalf of The Royal Society for Public Health. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Public Health 202 (2022) 93e99 products; 8 Botswana banned the import and sale of cigarettes and other related products; 9 South Africa restricted the sale of ciga- rettes, snuff, hookah pipes and e-cigarettes to combat the risks posed by the use of tobacco products during the pandemic. 10 The COVID-19 pandemic has provided an opportunity to study the impact of policy environment on tobacco consumption habits of users. A web-based survey in the United States, conducted during the pandemic, showed that 22.9% of respondents attempted to quit smoking cigarettes to reduce their risk of harm from COVID-19 and one-third of respondents reported an increase in motivation to quit tobacco during the pandemic period. 11 India enforced a nationwide lockdown on 24 March 2020 to prevent the spread of COVID-19. 12 At the beginning of the lock- down, different state governments issued warnings and advisories against tobacco use and about its interwoven relationship with COVID-19. Subsequently, the Indian Council of Medical Research 13 and the Ministry of Health and Family Welfare, Government of India, each issued advisories to prohibit the use and spitting of tobacco. 14,15 Many states in India also announced bans on tobacco use under the troupe of the Indian Penal Code 1890, Cigarettes and Other Tobacco Products Act 2003 and the Epidemic Diseases Act 1897. 16 In addition, the Ministry of Home Affairs, Government of India, prohibited the sale and use of gutkha and other tobacco products in the country, 17 which created a nationwide conducive environment for tobacco control. Previous evidence suggests that tobacco control policies, such as restricting the availability or access to tobacco products, limit to- bacco use. 18,19 A study by Narotam et al., 20 with 650 participants enrolled in a tobacco cessation counselling programme before the lockdown, reported the positive impact of public health measures on tobacco use behaviour. However, the study only included par- ticipants who were already motivated and enrolled in a cessation programme and did not assess the predictors of cessation and quit attempts among other tobacco users. In this study, we aimed to assess tobacco cessation behaviours and identify predictors of to- bacco cessation and quit attempts among adult tobacco users during the late COVID-19 lockdown period in India. Methods Study design, setting and participants A cross-sectional study was conducted in two urban metropol- itan cities of India (Delhi and Chennai) over a 2-month study period (JulyeAugust 2020). Assuming a large (>1 million) target popula- tion, a 50% outcome factor in the population, a 5% margin of error and 95% CI, the minimum required sample size was estimated to be 384e400 in the general population. Therefore, a total sample size of 800 participants (approximately 400 from each city) was estimated using open-source epidemiological statistics (OpenEpi). 21 A list of participants from an existing cohort (Centre for cArdiometabolic Risk Reduction in South Asia), 22 with a history of any form of to- bacco use was prepared and individuals were invited to participate in the present study. Participants aged 25 years or more (irre- spective of their sex), using any form of tobacco, who spoke English, Hindi or Tamil, and those who provided consent were enrolled in the study. Tobacco users who had recently quit using tobacco (i.e. in the previous 3 months from the date of survey [i.e. after the initial lockdown]) or who had used tobacco in any form during the pre- vious month were also included in the study. Participants who were suffering from any severe illness, institutionalised, unable to respond to the survey or not willing to provide or record verbal consent were excluded from the study. The objectives of the study were explained to the study partic- ipants, and after obtaining informed consent, a telephone questionnaire was administered. Prior ethical approval for research involving human subjects for this study was obtained from the Centre for Chronic Disease Control's Institutional Ethics Committee (Reference #CCDC_IEC_04_2018). Study tool The questionnaire was translated, adapted and modified from the STOP survey 23 for the context of smoking and SLT use in India. The survey tool has previously been used in a longitudinal study in Pakistan to capture and compare tobacco use behaviour among users before and during COVID-19. 23 The survey was translated into regional languages (i.e. Hindi [for participants in Delhi] and Tamil [for participants in Chennai]). The survey included questions on sociodemographic variables, knowledge of the adverse effects of tobacco use during COVID-19, intentions to quit tobacco, number of quit attempts and knowledge of tobacco control policies imple- mented in India during the lockdown period. The questionnaire was piloted on a subgroup of 20 respondents (from each city) and was subsequently adapted before administering it to the study population. A brief description of the study variables is provided in the supplementary file (Table S1). Data collection and management Following the rules of social distancing, the questionnaire was administered by telephone, and a standardised protocol was used for data collection. Informed consent was sought from eligible participants. Verbal consent was audio recorded following the recent Indian Council of Medical Research's revised guidelines for obtaining consent for biomedical and health research during the COVID-19 pandemic. 24 The questionnaire was then administered in the language preferred by the participant (i.e. English, Hindi or Tamil). Data analyses Descriptive statistics are presented as frequencies and per- centages. The primary outcomes of the study were ‘cessation’and ‘quit attempts’. Participants were asked the question, ‘What best describes you?’and those selecting the option e‘I have stopped using tobacco’were categorised as 1 for cessation (otherwise, 0). Partic- ipants were then asked the question, ‘How many attempts to stop tobacco use have you made in the last 6 months?’, and the answers were recorded as an integer. The ‘Quit attempts’was treated as discrete (count) data. Univariate associations were analysed using Fisher's exact/Chi- squared test as appropriate for categorical variables, whereas the count variables were analysed using ManneWhitney/Wilcoxon test and KruskaleWallis test as appropriate. A Pvalue of <0.05 was considered significant. Cross-tabulations between various socio- demographic characteristics (e.g. gender, city, age, education, employment status), knowledge on the harmful effects of tobacco use and COVID-19, knowledge on legislative decisions (taken by government on tobacco sales and consumption during the national lockdown) and access to tobacco products during the lockdown were studied. Responses to all questions assessing the knowledge of participants were aggregated and thereafter scored anony- mously. The correct responses were marked as 1 and incorrect as 0. The maximum score for knowledge on the harmful effects and knowledge on legislative decisions was 5, and the minimum score was 0. The aggregate scores were further categorised as poor (mean 1 standard deviation [SD]), average (mean 1SDto mean þ1 SD) and good (mean þ1 SD). 25 M. Arora, G.P. Nazar, N. Sharma et al. Public Health 202 (2022) 93e99 94 Because of the overdispersion in the number of quit attempts, its associations with various independent variables were studied us- ing the negative binomial regression model, 26 whereas the logistic regression model was used to study the association of independent variables with cessation. The results of the negative binomial regression models and the logistic regression models are given in incidence risk ratio (IRR) and OR with 95% CI, respectively. Variables with a Pvalue <0.15 in the univariate analysis were retained in the multivariate models. 27 Data were analysed using STATA v.13.1 (StataCorp, LP, TX). Results Study participant characteristics A total of 801 tobacco users participated in the survey, including 444 (55.4%) from Delhi and 357 (44.6%) from Chennai (Table 1). As the survey was conducted via telephone, a disposition table 28 is used to explain the response rates. The gross response rate for the study was 48.4%, the basic response rate was 85.3% and the response rate calculated using the CASRO estimator was 60.9%. The detailed disposition table and response rate calculations are pro- vided in supplementary file (Tables S2 and S3). In total, 305 (38.1%) participants were current cigarette smokers, 195 (24.3%) were bidi smokers and 324 (40.4%) were SLT users. There were 90 (11.3%) tobacco users who reported that they had stopped using tobacco at the time of the survey after the lockdown measures were intro- duced. Overall, a median of two quit attempts (interquartile range [IQR] 0e6) was made by the tobacco users over the past 6 months. The mean scores for knowledge on the harmful effects and knowledge about legislative decisions in the study population were 2.1 (SD 1.9) and 2.7 (SD 2.1), respectively. Most participants (90.1%) were men. In total, 56.3% of partici- pants were in the 45e64 years age group, followed by 31.6% in the 25e44 years age group and 12.1% in the 65 years age group. More than half of the participants were educated either up to high school (39.4%) and intermediary school (31.1%). Most participants were employed (81.1%), whereas the remaining were students (10.9%), housewives (3.6%), retired (2.0%) or unemployed (2.2%; Table 1). Univariate association of cessation and quit attempts with sociodemographic variables Cessation and quit attempts were significantly higher in females (cessation 21.5%; number of quit attempts 6.5 [IQR 2e20]) than males (cessation 10.2%; number of quit attempts 2 [IQR 0e5]). The percentage of participants who quit was higher in Chennai (15.4%) than Delhi (7.9%); however, the median number of quit attempts in the past 6 months was higher in Delhi (2 [IQR 0e7]) than in Chennai (1 [IQR 0e4]). Cessation and quit attempts were pre- dominantly higher in housewives (cessation 27.6%; number of quit attempts 12.5 [IQR 7.5e30]) compared with students, employed or retired participants (Table 2). Univariate association of cessation and quit attempts with knowledge and access In the univariate analysis, cessation was greater in participants who had no access to tobacco products during the COVID-19 lock- down (19.0%) compared with those who had access (7.8%). Quit attempts were higher in daily bidi smokers (2 [IQR 0e7]) compared with occasional smokers (0 [IQR 0e3]). Whereas in the case of SLT users, quit attempts were higher in occasional SLT users (2 [IQR 0e10]) than in daily users (1 [IQR 0e4]). Quit attempts were pre- dominantly higher in people with good knowledge of the harmful effects of tobacco use during COVID-19 (4 [IQR 0e16]) than par- ticipants with average (1 [IQR 0e4]) or poor knowledge (0 [IQR 0e3]). Similarly, quit attempts were also higher in participants with good knowledge on legislative decisions (2 [IQR 0e7]) compared with participants with either average (1 [IQR 0e5]) or poor knowledge (0 [IQR 0e3]; Table 3). Correlates of cessation and quit attempts To further determine the correlates that are significantly asso- ciated with cessation and quit attempts, logistic regression and negative binomial regression models were used, respectively. Table 4 shows the adjusted OR, IRR and 95% CI for cessation and quit attempts. The final regression models included 797 and 328 par- ticipants for cessation and quit attempts, respectively, with com- plete cases across all variables. Participants with good knowledge on the harmful effects of tobacco use and COVID-19 were significantly more likely to cease tobacco use than participants with poor knowledge (OR 2.2; 95% CI 1.2 e4.0), whereas participants with average knowledge were 50% less likely to cease tobacco use (OR 0.5; 95% CI 0.3e0.9). Participants with good (OR 0.4; 95% CI 0.2e0.9) and average (OR 0.5; 95% CI 0.3e0.9) knowledge on legislative decisions were 60% and 50%, respectively, more likely to cease tobacco use than those with poor knowledge on legislative decisions. Participants who had access to tobacco products were 70% less likely to cease tobacco use (OR 0.3; 95% CI 0.2e0.5) compared with those who had access to tobacco. Quit attempts were significantly more likely to occur in partic- ipants with average (IRR 1.9; 95% CI 1.0e3.4) and good (IRR 5.7; 95% CI 2.8e11.8) knowledge on the harmful effects of tobacco use and COVID-19 compared with participants with poor knowledge. However, no significant associations for quit attempts were observed among participants with average or good knowledge on legislative decisions. Table 1 Sociodemographic characteristics of the study population (N¼801). Sociodemographic characteristics n(%) City (n¼801) Delhi 444 (55.4) Chennai 357 (44.6) Sex (n¼801) Male 722 (90.1) Female 79 (9.9) Age group (n¼801) 25e44 years 253 (31.6) 45e64 years 451 (56.3) 65 years 97 (12.1) Education (n¼801) Illiterate 80 (9.9) Professional degree/postgraduate 17 (2.1) Graduate (BA/BSc/BCom/Diploma) 75 (9.4) Secondary school intermediary 249 (31.1) High school (class V to IX) 316 (39.4) Primary school (up to Class IV) 64 (7.9) Employment status (n¼801) Employed 650 (81.1) Student 88 (10.9) Housewife 29 (3.6) Retired 16 (2.0) Unemployed 18 (2.2) Current cigarette smokers (n¼801) 305 (38.1) Current bidi smokers (n¼798) a 195 (24.3) Current SLT users (n¼800) b 324 (40.4) SLT, smokeless tobacco. a Three missing responses for current bidi smokers. b One missing response for current SLT users. M. Arora, G.P. Nazar, N. Sharma et al. Public Health 202 (2022) 93e99 95 Discussion The COVID-19 pandemic provided a unique opportunity for the promotion of tobacco control strategies, nationally as well as globally. 29,30 The tobacco control policies implemented to address the spread of COVID-19, including restricting access to tobacco products, led to favourable circumstances for tobacco cessation among users. 31 In the present study, 11.3% of tobacco users stopped using tobacco during the lockdown. On average, two quit attempts were made by tobacco users during the past six months. The per- centage of people who ceased tobacco use was much lower than reported in a previous study (51%) by Gupte et al. 20 However, this may be attributed to the fact that the population in the study by Gupte et al. comprised of individuals who were already enrolled in a tobacco cessation programme, thus were already motivated to quit tobacco use. On the contrary, some studies from other coun- tries have reported an increase in smoking during the pandemic because of high levels of stress and boredom. 32,33 Existing evidence suggests that there are low levels of knowl- edge on the harmful effects of tobacco use and COVID-19. 34,35 The results of the present study also show low levels of knowledge on the harmful effects of tobacco use and COVID-19 among study participants during the lockdown period. Despite this, the results suggest that participants with good knowledge on the harmful effects of tobacco use and COVID-19 were more likely to cease to- bacco use and make attempts to quit compared with those with poor knowledge. These findings are consistent with those of a previous study conducted in India 20 and indicate that good knowledge on the harmful effects of tobacco use and COVID-19 could discourage tobacco use among existing users. Moreover, good knowledge on the legislative decisions also seemed to moti- vate tobacco cessation among users. Technology has played a vital role in enabling routine and pro- fessional activities to continue during the pandemic. 36 Hence, cessation efforts (e.g. creating awareness of tobacco use during COVID-19 and cessation services) via digital media (e.g. television, internet and social media) can be useful. 37,38 Information Communication and Technology can help in propelling and strengthening tobacco control policies. 39 Informative advertising (e.g. harmful effects of tobacco use during COVID-19, knowledge about the National Quitline and m-cessation services) in local languages and dialects can further motivate the cessation of to- bacco use. 29 These advertisements should be comprehensively in- tegrated with other commonly used digital applications or social media websites to create awareness among tobacco users. 29 In the present study, cessation was more prevalent in tobacco users who had no access to tobacco products (19.0%). In fact, cessation was 70% less likely among participants reporting access to tobacco products. The national lockdown during the early months of the COVID-19 pandemic curbed access to tobacco products and may have encouraged abstinence from tobacco among existing users. However, quitting tobacco is often associated with a high relapse rate, 40,41 and there is a high likelihood that users who re- ported having ceased tobacco use during this period might subse- quently relapse after the end of lockdown restrictions. Implementing non-price-based tobacco control policies (e.g. to- bacco use restrictions in working places, restriction on access to tobacco products) is considered to be a highly cost-effective mea- sure. 42 Therefore, the ban on the sale of tobacco products and spitting in public places, in addition to designating these acts as an Table 2 Univariate association of cessation and quit attempts with sociodemographic characteristics. Variables Cessation a Quit attempts b n(%) Pvalue Median (IQR) Pvalue Overall 90 (11.3) 2 (0e6) Gender 0.002*0.001 $ Male (n¼718) 73 (10.2) 2 (0e5) Female (n¼79) 17 (21.5) 6.5 (2e20) City 0.001*0.024 $ Chennai (n¼357) 55 (15.4) 1 (0e4) Delhi (n¼440) 35 (7.9) 2 (0e7) Age group 0.818 0.107 25e44 years (n¼253) 26 (10.3) 2 (0e7) 45e64 years (n¼447) 53 (11.9) 1 (0e5) 65 years (n¼97) 11 (11.3) 5 (0e4) Education 0.162 0.531 Illiterate (n¼80) 7 (8.7) 1 (0e10) Professional degree/postgraduate (n¼16) 5 (31.2) 4 (2e10) Graduate (n¼74) 7 (9.5) 2 (0e7) Secondary/intermediary schools (n¼248) 26 (10.5) High school (n¼315) 39 (12.4) 2 (0e5) Primary schools (n¼64) 6 (9.4) 0 (0e2) Employment status 0.102 0.020 & Employed (n¼648) 68 (10.5) 2 (0e5.5) Student (n¼86) 10 (11.6) 2 (0e6.5) Housewife (n¼29) 8 (27.6) 12.5 (7.5e30) Retired (n¼16) 2 (12.5) 1 (0e2) Unemployed (n¼18) 2 (11.3) 1 (0e3) Bold P-values indicate significant association. IQR, interquartile range. *Pvalue <0.05 using Chi-squared test. $ Pvalue <0.05 using ManneWhitney Wilcoxon test. & Pvalue <0.05 using KruskaleWallis H test. a 4 missing responses for cessation. b Total 329 responses for quit attempts. M. Arora, G.P. Nazar, N. Sharma et al. Public Health 202 (2022) 93e99 96 offence with huge penalties for violations, should be considered a public health strategy, both to overcome the COVID-19 pandemic and for tobacco control in India. 43,44 Continuation of the tobacco ban can be justified, as the COVID-19 pandemic is far from over; however, the restrictions laid down by the government (i.e. limiting access to tobacco products) should be monitored closely. Restrict- ing access to tobacco products requires multisectoral regulatory policies and a whole-society approach so that users can be sup- ported to quit and initial uptake can be prevented. The COVID-19 pandemic provides a conducive policy environ- ment to implement tobacco control strategies to reduce the pro- duction as well as consumption of tobacco products. Implementing demand-reduction strategies, 45 such as the ban on tobacco use and spitting in public places, and raising awareness of the harmful ef- fects of tobacco use during COVID-19 can further strengthen to- bacco control policies. Similarly, curtailing tobacco supply, 45 by limiting the access to products, can further help address both the COVID-19 pandemic and tobacco epidemic. The results from this study can be used to align population- and individual-level in- terventions, including drawing on national-level change to encourage greater participation in tobacco cessation programmes. Sustained efforts may help substantially reduce tobacco use, with the possibility of eliminating tobacco use in the future. Strengths and limitations The present study enrolled participants from an existing cohort. 22 Respondents were followed up during the COVID-19 pandemic to assess the impact of COVID-19 restrictions on to- bacco use cessation and quit attempts. A previous study investi- gated tobacco cessation behaviour during COVID-19 lockdown in participants enrolled in a tobacco-cessation programme; thus, this study population was already motivated to cease tobacco use. 20 Participants in the present study were not premotivated to cease tobacco use, and hence, their behaviour can be attributed to the pandemic alone. This study attempted to investigate cessation and quit attempts among tobacco users during the COVID-19 crisis, but there are limitations to this study. Cessation is generally defined as the abstinence from tobacco use for a minimum period of 6e12 months. However, as this was a rapid study conducted over a 2- month period (during the COVID lockdown period in India), pa- tients who reported that they had stopped using tobacco completely since the start of the lockdown were considered to have ceased tobacco use. The number of quit attempts was reported over 6 months; the survey was conducted in the months of July and August, but the number of quit attempts could also include at- tempts made before the study period. This study presents estimates based on a single study conducted in two large Indian cities (Delhi and Chennai). Furthermore, the cohort was limited to urban areas of the country and does not include tobacco users aged <25 years. Therefore, the findings of the study cannot be generalised to all tobacco users in India. Thus, we recommend that large population- based interstate studies are used to further evaluate the effects of restrictions in access to tobacco products on tobacco use cessation. Conclusion Measures enforced by the Government of India to reduce access to tobacco products during the nationwide COVID-19 lockdown led to a favourable environment for existing tobacco users to quit. This highlights an opportunity to align communicable and non- communicable disease responses during a public health crisis and could provide lessons for future tobacco control efforts. The m- Table 3 Univariate association of cessation and quit attempts with knowledge and accessibility of tobacco products. Variables Cessation a Quit attempts b n(%) Pvalue Median (IQR) Pvalue Overall 90 (11.3) 2 (0e6) Cigarette smoking Current daily cigarette smokers (n¼220) NA 1 (0e5) 0.107 Current occasional smokers (n¼85) NA 1 (0e5) Non-smokers (n¼496) NA 2 (0e7) Bidi smokers 0.002 ** Current daily bidi smokers (n¼167) NA 2 (0e7) Current occasional bidi smokers (n¼28) NA 0 (0e3) Non-smokers (n¼603) 0(0e10) SLT users 0.000 ^ Current daily SLT users (n¼266) NA 1 (0e4) Current occasional SLT users (n¼58) NA 2 (0e10) Non-users (n¼476) 5(1e60) Knowledge on the harmful effects Poor (n¼267) 41 (15.4) 0.000*0(0e3) 0.000 ^ Average (n¼298) 16 (5.4) 1 (0e4) Good (n¼232) 33 (14.2) 4 (0e16) Knowledge on legislative decisions Poor (n¼231) 45 (19.5) 0.000*0(0e3) 0.018 ^ Average (n¼280) 25 (8.9) 1 (0e5) Good (n¼286) 20 (6.9) 2 (0e7) Accessibility of tobacco products Yes (n¼550) 43 (7.8) 0.000*2(0e6) 0.649 No (n¼47) 47 (19.0) 1 (0e4) Bold P-values indicate significant association. IQR, interquartile range; SLT, smokeless tobacco. * P value <0.05 using Fisher's chi exact test. ** Pvalue <0.05 using KruskaleWallis H test. a Four missing responses for cessation. b Total 329 responses for quit attempts. M. Arora, G.P. Nazar, N. Sharma et al. Public Health 202 (2022) 93e99 97 cessation, Quitline and in-person cessation services should be provided proactively during this opportune time to encompass more tobacco users and help encourage cessation and quit attempts. Author statements Acknowledgements The authors would like to acknowledge the data collection teams from HRIDAY, New Delhi and Chennai for participating in the study. The authors would also like to acknowledge the CARRS team for providing the list of participants and relevant information from the last follow-up. Ethical approval Ethical approval for this study was obtained from the Centre for Chronic Disease Control's Institutional Ethics Committee (Refer- ence #CCDC_IEC_04_2018). Funding The activities and results presented in this article were sup- ported by the following grants: the COVID-19 and Tobacco Project, funded from the University of Edinburgh's Scottish Funding Council Global Challenges Research Fund (GCRF) to the Tobacco Control Capacity Programme (MR/P027946/2), supported by UK Research and Innovation (UKRI) with funding from the Global Challenges Research Fund. Competing interests None declared. Authors’contributions M.A. and G.P.N. conceptualised the study. L.B. and M.A. secured funding for the study. M.A., G.P.N. and N.J. adapted the study tool. G.P.N., N.S. and N.J. facilitated the data collection and imple- mentation of the study. N.S. and G.P.N. analysed the results, and all the authors contributed to the interpretation of the findings. M.A., G.P.N., N.S. and N.J. drafted the article. S.M., D.P., D.M., L.B., K.S.R., M.K.A., V.M., N.T., K.M.V.N. and F.D. revised the article. All authors approved the final article. Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.puhe.2021.11.010. Table 4 Correlates of cessation and quit attempts. Variables Cessation [OR (95% CI)] a n¼797 Quit attempts [IRR (95% CI)] b n¼328 Gender Male Ref Ref Female 1.3 (0.5e3.1) 1.9 (0.5e6.7) City Chennai Ref Ref Delhi 0.6 (0.3e1.1) 0.6 (0.3e1.1) Age group 25e44 years NA Ref 45e64 years NA 0.9 (0.6e1.5) 65 years NA 0.7 (0.2e2.1) Employment status Employed Ref Ref Student 1.0 (0.4e2.4) 1.1 (0.3e3.5) Housewife 1.9 (0.6e6.1) 0.9 (0.2e5.4) Retired 1.5 (0.3e7.0) 0.2 (0.0e1.0) Unemployed 0.8 (0.1e3.9) 0.3 (0.1e2.0) Cigarette smokers Non-users NA Ref Current daily cigarette smokers NA 0.7 (0.3e1.8) Current occasional smokers NA 0.7 (0.3e1.6) Bidi smokers Non-users NA Ref Current daily bidi smokers NA 0.2 (0.1e0.6) Current occasional bidi smokers NA 0.7 (0.2e2.2) SLT users Non-users NA Ref Current daily SLT users NA 0.7 (0.2e1.7) Current occasional SLT users NA 1.4 (0.4e4.5) Knowledge on the harmful effects of tobacco use and COVID-19 Poor Ref Ref Average 0.5 (0.3e1.0) 1.9 (1.0e3.4) Good 2.2 (1.2e4.0) 5.7 (2.8e11.8) Knowledge on legislative decisions Poor Ref Ref Average 0.5 (0.3e0.9) 1.5 (0.8e2.9) Good 0.4 (0.2e0.9) 1.6 (0.7e3.6) Overall access No Ref NA Yes 0.3 (0.2e0.5) NA CI, confidence interval; IRR, incidence risk ratio; OR, odds ratio; Ref, reference; SLT, smokeless tobacco. 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The effect of the COVID-19 pandemic on smoking cessation success. J Community Health 2020:1. https://doi.org/ 10.1007/s10900-020-00880-2. Published online. 31. Ahluwalia IB, Myers M, Cohen JE. COVID-19 pandemic: an opportunity for tobacco use cessation. Lancet Public Health 2020;5(11):e577. https://doi.org/ 10.1016/S2468-2667(20)30236-X. 32. Bommele J, Hopman P, Walters BH, et al. The double-edged relationship be- tween COVID-19 stress and smoking: implications for smoking cessation. Tob Induc Dis 2020:18. 33. Sidor A, Rzymski P. Dietary choices and habits during COVID-19 lockdown: experience from Poland. Nutrients 2020;12(6):1657. 34. Yach D. Tobacco use patterns in five countries during the COVID-19 lockdown. Nicotine Tob Res 2020;22(9):1671e2. https://doi.org/10.1093/ntr/ntaa097. 35. Kalan ME, Ghobadi H, Taleb Z Ben, et al. COVID-19 and beliefs about tobacco use: an online cross-sectional study in Iran. Environ Sci Pollut Res 2020:1e9. https://doi.org/10.1007/s11356-020-11038-x. 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Probability and predictors of relapse to smoking: results of the Na- tional Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug Alcohol Depend 2013;132(3):479e85. 41. Edwards KC, Kasza KA, Tang Z, et al. Correlates of tobacco product reuptake and relapse among youth and adults in the USA: findings from the PATH Study Waves 1e3 (2013e2016). Tobac Control 2020;29(Suppl 3):s216e26. 42. Ekpu VU, Brown AK. The economic impact of smoking and of reducing smoking prevalence: review of evidence. Tob Use Insights 2015;8. TUI-S15628. 43. Policy responses to smokeless tobacco (ST) in India during the COVID19 pandemic jORF. Accessed March 18, 2021. https://www.orfonline.org/expert- speak/policy-responses-to-smokeless-tobacco-st-in-india-during-the- covid19-pandemic/. 44. India's regulatory struggle to rein in smokeless tobacco use: is Covid-19 a game changer? jBlog - Tobacco Control. Accessed March 18, 2021. https://blogs.bmj. com/tc/2020/06/28/indias-regulatory-struggle-to-rein-in-smokeless-tobacco- use-is-covid-19-a-game-changer/. 45. Warner KE. An endgame for tobacco?. 2013. Published online. M. Arora, G.P. Nazar, N. Sharma et al. Public Health 202 (2022) 93e99 99 CITATIONS (14) REFERENCES (30) ... Our earlier published study suggested that tobacco users overall made two quit attempts during the COVID-19 lockdown in 2020. We identified that the reduced availability of tobacco products in India during the first lockdown seems to have provided a conducive environment for tobacco users to quit this addiction 7 . With that background, we examined data from the same study to assess the effect of the sales ban during lockdown on the frequency of smoked (cigarettes, bidis) and smokeless tobacco use among tobacco users as well as any differences based on sociodemographic characteristics. ... ... A sample of tobacco users participating in the ongoing CARRS (Centre for cArdiometabolic Risk Reduction in South Asia) longitudinal study were surveyed for changes in tobacco use during the pandemic. The CARRS cohort consists of representative samples in two urban cities, Delhi and Chennai, and the detailed methodology is published elsewhere 7,8 . ... ... The survey questionnaire was based on the STOP (Studying Tobacco users Of Pakistan) 9 survey and adapted to the context of smoking and smokeless tobacco use in India. The questionnaire was translated into English and regional languages, Hindi (for Delhi participants) and Tamil (for Chennai participants) 7 . At the time of the survey, the participants were asked about the frequency of their tobacco use (cigarettes, bidis, and smokeless tobacco like zarda, khaini, paan masala etc.) before and during the COVID-19 lockdown in the survey 7 . ... Impact of a tobacco sales ban on the frequency of tobacco consumption in India during the COVID-19 pandemic Article Full-text available * Apr 2023 * Nitika Sharma * Mansi Chopra * Linda Bauld * Monika Arora Introduction: Measures to address the COVID-19 pandemic in India included a ban on the sale and use of tobacco products during 2020 when stay at home guidance (lockdown) was in place. In this study we examined the extent of reduction in frequency of tobacco consumption across all products. Methods: Telephone survey was conducted between July and August 2020 across an existing cohort of tobacco users (n=801) residing in Delhi (55.4%) and Chennai (44.6%), India. The participants were recruited irrespective of their gender and use of any kind of tobacco product(s). The survey questionnaire was based on the STOP (Studying Tobacco users Of Pakistan) survey and adapted to the context of smoking and smokeless tobacco use in India. Results: Cigarette consumption declined from a median value of 5.0 (IQR: 2-10) sticks in the pre-lockdown period to 2.0 (IQR: 0.4-5) sticks during the lockdown period. Reductions were reported in the daily use of bidis, from 8 (IQR: 4-12) sticks to 5 (IQR: 2-10) sticks and for smokeless tobacco users from 3.5 (IQR: 2-5) packs to 2 (IQR: 1-4) packs during the lockdown. Furthermore, the number of daily cigarette smokers in our cohort decreased from 32.6% (n=261) in the pre-lockdown period to 27.5% (n=220) during lockdown and smokeless tobacco users decreased from 35.8% (n=287) in pre-lockdown period to 30.3% (n=243) during the lockdown period. Conclusions: The decrease in tobacco use can be attributed to various societal and environmental factors. However, the pandemic-linked lockdown provided an opportune condition to reduce the use of tobacco products, which could be due to restricted access and increase in health awareness during the COVID-19 lockdown. View Show abstract ... 35 A survey conducted from July to August 2020 found that tobacco users in India who were aware of the effects of tobacco on COVID-19 were more likely to either quit use or attempt quitting more frequently during the lockdown. 36 This may explain why older populations had higher decreases in tobacco consumption, as they were at more risk to suffer from more severe COVID-19 outcomes if infected. Lastly, a telephone survey conducted in May 2020 found that 51% of participants in a tobacco cessation programme that quit reported the pandemic impacted their decision to quit, while 27% and 45% of all participants indicated that price increases and lack of tobacco availability were responsible for their decision. ... ... The COVID-19 pandemic presented a unique opportunity to target consumption by highlighting the adverse effects of tobacco and alcohol consumption for COVID-19 outcomes, which showed to have an effect on consumption. 36 Second, as the pandemic may have spurred increased tobacco quit attempts, there should be expanded coverage of cessation aid services for individuals such as toll-free quit lines and m-cessation. An article, largely referencing news media, suggested the consequences of alcohol unavailability included withdrawal, increased black market activity and suicides from withdrawal symptoms. ... Changes in tobacco and alcohol consumption during the COVID-19 pandemic in India: a propensity score matching approach Article Full-text available * Nov 2024 * Amit Summan * Ramanan Laxminarayan Objectives The COVID-19 pandemic may have influenced alcohol and tobacco consumption in low-income and middle-income countries, yet the effects are relatively unknown. In this study, we estimated the medium-term effects of the pandemic on tobacco and alcohol consumption in India. Methods We used data from the fifth round of the National Family Health Survey 2019–2021, a nationally representative survey conducted between June 2019 and April 2021. We employed propensity score matching to evaluate the change in tobacco and alcohol consumption patterns by exploiting the gap in survey activities due to the pandemic lockdown—no data collection took place from April to October 2020. Individuals surveyed after the lockdown were considered COVID-19-affected, while those surveyed before were considered as unaffected. Results The tobacco use rate was 1.4% lower and alcohol consumption was 0.3% lower for COVID-19-affected individuals relative to non-affected individuals. By tobacco product, there was a 0.9%, 0.6% and 0.4% decrease in the use of smokeless tobacco, cigarettes and bidi, respectively. Recent initiation decreased by 2.3%, 1.6% and 1.4%, for cigarettes, smokeless tobacco and alcohol, respectively. Tobacco use declined to a greater extent in low-wealth and rural populations, and in male and older subsamples. Alcohol use decreased in urban households, and among male and young subsamples, relative to their counterparts. Secondhand smoke exposure decreased by 4.6%. Conclusion Tobacco and alcohol consumption, including recent initiation, decreased during the pandemic in India. Varying effects by subgroups suggest the need for targeted future control policies that support cessation and limit consumption. View Show abstract ... We found two studies that assessed the impact of the tobacco sales ban in India 23,24 but none in Botswana. Based on a sample of 801 respondents in two cities (Delhi and Chennai), one of the Indian studies found that 11.3% of tobacco users stopped using tobacco during India's lockdown 23 . At first sight, this is a somewhat higher quitting percentage than in South Africa, but the study does not indicate whether the quitters used smoked and smokeless tobacco, so it is not directly comparable to the current study. ... ... The second Indian study, based on a sample of 650 participants enrolled in a tobacco cessation program before the lockdown, found that 38% of tobacco users abstained from using tobacco after the start of the lockdown 24 . While the proportion of quitters is substantially higher than that found in the other India study 23 and the present study, the results are not comparable because it only included participants who were already motivated to quit because they were enrolled in a cessation program. However, as is the case in South Africa, the analysis indicates that tobacco products were mostly available, despite the sales ban 24 . ... Quitting behavior during the tobacco sales ban in South Africa: Results from a broadly nationally representative survey Article Full-text available * Aug 2023 * Corné van Walbeek * Robert Hill * Samantha Filby Introduction: In response to COVID-19, the South African government banned the sale of tobacco products for 20 weeks. Before the ban, the illicit cigarette market was well-entrenched and smoking cessation services were not widely available. Several surveys conducted to ascertain cigarette smokers' responses to the ban reported substantial differences in the proportion of smokers who quit. This study provides a broadly nationally representative ex-post investigation into cigarette smokers' quitting behavior related to the sales ban. Methods: We used data from wave three of NIDS-CRAM (the National Income Dynamics Study-Coronavirus Rapid Mobile Survey) conducted in November-December 2020. We first investigated the proportion of people who quit and who continued smoking during and after the sales ban. We subsequently linked the NIDS-CRAM survey to the fifth wave of NIDS (2017) to identify a subset of established smokers, and considered whether their quitting behavior differed from that of all smokers who smoked at the start of the sales ban. Results: The cross-sectional analysis showed that 7.8% of cigarette smokers quit during the sales ban, but that 55% of these quitters relapsed after it was lifted. Of the pre-ban smokers, 3.5% indicated that they did not smoke both during and after the sales ban, and 3.7% quit after the ban was lifted. The longitudinal analysis showed that 7% of people who were smoking in 2017, quit smoking cigarettes during the tobacco sales ban, but that >70% of quitters relapsed after it was lifted. Only 2% of pre-ban established smokers indicated that they did not smoke during or after the ban. Conclusions: The sales ban did not have the intended objective of encouraging large-scale smoking cessation. This reflects policy failures to provide smokers with appropriate cessation support and to effectively control the illicit market both prior to and during the sales ban. View Show abstract ... [4][5][6] Lockdowns during COVID, with no sale of tobacco showed an increase in cessation among tobacco users. 7 One of the major roadblocks in policy development and effective implementation of tobacco control measures has been the tobacco industry interference. 8 The tobacco industry, during all times, aims to hook a new generation of tobacco users, especially adolescents and youth through continuing marketing of tobacco products. ... Trends in Level of Implementation of the WHO FCTC Article 5.3 in India Article Full-text available * Sep 2024 * Shalini Bassi * Mansi Chopra * Aastha Chugh * Monika Arora Introduction The tobacco industry intends to ensure continuing marketing of tobacco products by influencing and interfering in tobacco control policies. This paper assessed trends of tobacco industry interference (TII), the level of implementation, and the government’s response to enforcing Article 5.3 guidelines in India to safeguard tobacco control efforts from commercial and other vested interests of the tobacco industry. Methods We conducted a descriptive comparative analysis of four consecutive India TII Indexes (January 2018-December 2021) based on the seven key 5.3 recommendations and twenty indicators to capture (i) the Level of Industry Participation, (ii) Corporate Social Responsibility (CSR) Activities, (iii) Benefits to the Tobacco Industry, (iv) Forms of Unnecessary Interactions, (v) Transparency, (vi) Conflict of Interest, and (vii) Preventive Measures. The Southeast Asia Tobacco Control Alliance’s (SEATCA) TII Index was used to undertake this assessment. Results The comparative analysis showed that the overall score of the India TII Indexes over the years decreased from 72 (2018) to 57 (2021). Improvements were shown over the years in adherence to Article 5.3 for limiting unnecessary interactions with the tobacco industry, avoiding conflicts of interest, and having preventive measures. However, major gaps were observed in restricting industry participation, regulating their so-called CSR, providing benefits to the industry in the form of incentives, exemptions, and maintaining transparency. Conclusion The study provides the status of implementing Article 5.3 and its guidelines in India. Given the gaps in the existing measures, India needs to comprehensively adopt Article 5.3 guidelinesin all states and union territories adopting whole-of-government approach. There is an urgent need to establish an observatory for periodic compilation of the TII indexes to monitor the tobacco industry and report violations at the national and sub-national levels. View Show abstract ... It was also reported that users who had access to tobacco products were less likely to quit use compared to those who had no access. The study concluded that the access restriction measures introduced by the Government of India, coupled with accurate knowledge about the harmful effects of tobacco use and COVID-19, created a conducive environment to quit tobacco [106]. ... A Complex Interplay: Navigating the Crossroads of Tobacco Use, Cardiovascular Disease, and the COVID-19 Pandemic: A WHF Policy Brief Article Full-text available * Jul 2024 * Regina Dalmau * Abdullah M. Alanazi * Monika Arora * Yunshu Wang The Coronavirus Disease 2019, commonly referred to as COVID-19, is responsible for one of the deadliest pandemics in human history. The direct, indirect and lasting repercussions of the COVID-19 pandemic on individuals and public health, as well as health systems can still be observed, even today. In the midst of the initial chaos, the role of tobacco as a prognostic factor for unfavourable COVID-19 outcomes was largely neglected. As of 2023, numerous studies have confirmed that use of tobacco, a leading risk factor for cardiovascular and other diseases, is strongly associated with increased risks of severe COVID-19 complications (e.g., hospitalisation, ICU admission, need for mechanical ventilation, long COVID, etc.) and deaths from COVID-19. In addition, evidence suggests that COVID-19 directly affects multiple organs beyond the respiratory system, disproportionately impacting individuals with comorbidities. Notably, people living with cardiovascular disease are more prone to experiencing worse outcomes, as COVID-19 often inherently manifests as thrombotic cardiovascular complications. As such, the triad of tobacco, COVID-19 and cardiovascular disease constitutes a dangerous cocktail. The lockdowns and social distancing measures imposed by governments have also had adverse effects on our lifestyles (e.g., shifts in diets, physical activity, tobacco consumption patterns, etc.) and mental well-being, all of which affect cardiovascular health. In particular, vulnerable populations are especially susceptible to tobacco use, cardiovascular disease and the psychological fallout from the pandemic. Therefore, national pandemic responses need to consider health equity as well as the social determinants of health. The pandemic has also had catastrophic impacts on many health systems, bringing some to the brink of collapse. As a result, many health services, such as services for cardiovascular disease or tobacco cessation, were severely disrupted due to fears of transmission and redirection of resources for COVID-19 care. Unfortunately, the return to pre-pandemic levels of cardiovascular disease care activity has stagnated. Nevertheless, digital solutions, such as telemedicine and apps, have flourished, and may help reduce the gaps. Advancing tobacco control was especially challenging due to interference from the tobacco industry. The industry exploited lingering uncertainties to propagate misleading information on tobacco and COVID-19 in order to promote its products. Regrettably, the links between tobacco use and risk of SARS-CoV-2 infection remain inconclusive. However, a robust body of evidence has, since then, demonstrated that tobacco use is associated with more severe COVID-19 illness and complications. Additionally, the tobacco industry also repeatedly attempted to forge partnerships with governments under the guise of corporate social responsibility. The implementation of the WHO Framework Convention on Tobacco Control could address many of the aforementioned challenges and alleviate the burden of tobacco, COVID-19, and cardiovascular disease. In particular, the implementation of Article 5.3 could protect public health policies from the vested interests of the industry. The world can learn from the COVID-19 pandemic to better prepare for future health emergencies of international concern. In light of the impact of tobacco on the COVID-19 pandemic, it is imperative that tobacco control remains a central component in pandemic preparedness and response plans. View Show abstract ... [4][5][6] Lockdowns during COVID, with no sale of tobacco showed an increase in cessation among tobacco users. 7 One of the major roadblocks in policy development and effective implementation of tobacco control measures has been the tobacco industry interference. 8 The tobacco industry, during all times, aims to hook a new generation of tobacco users, especially adolescents and youth through continuing marketing of tobacco products. ... Bridging the gap in the implementation of the World Health Organization’s Framework Convention on Tobacco Control Article 5.3 in India: Insights from an opinion poll and stakeholder consultation Article * Mar 2024 * Shalini Bassi * Rupesh Mahajan * Prakash C Gupta * Monika Arora Background Article 5.3 of the World Health Organization Framework Convention on Tobacco Control (FCTC) outlines a roadmap for the parties to safeguard public health policies in compliance with the national law from the influence of commercial and other vested interests of the tobacco industry. Aim The study was conducted with the aim to identify gaps and bring existing Indian policies in compliance with Article 5.3 of FCTC. Materials and Methods A nationwide cross-sectional opinion poll involving respondents aged >18 years ( n = 164) and a panel discussion ( n = 31) were conducted. Results The majority of stakeholders expressed (strongly agree = 65% and agree = 22.6%) the need for a nationwide policy to regulate interactions between public officials and the tobacco industry. About 56.7% felt the need to expand existing protocols and codes of conduct for public officials across India. Over 84% of the participants supported incorporating specific sections to implement Article 5.3 into the Cigarettes and Other Tobacco Products Act Amendment Bill 2020. The majority of participants supported the need for guidelines for medical bodies and prohibiting tobacco companies from participating in corporate social responsibility activities. Conclusion The Government of India should comprehensively adopt Article 5.3, in all states and union territories, adopting a whole-of-government approach in partnership with the community and civil society under the “whole-of-society” approach for effective tobacco control measures. View Show abstract ... Even though the proportion is smaller further studies may explore regional factors contributing to this (7). Some studies like study by Arora M et al 2021 in two cities Delhi and Chennai, India shows 11.3% tobacco users reported that they had quit using tobacco after the COVID-19 lockdown period and concluded that the measures enforced by the Government of India to reduce access to tobacco products during the nationwide COVID-19 lockdown led to a favorable environment for existing tobacco users to quit (8). ... COVID SPIKES ON TOBACCO STICKS -TOBACCO HABIT CHANGES DURING COVID-19 PANDEMIC Article Full-text available * Mar 2024 * Nivetha Rajaraman * Arunagirinathan Keerthana * Sree T. Sucharitha Introduction: Tobacco is the foremost preventable cause of death and disease in the world today, killing half of the people who use it. The use of tobacco is a risk factor for many respiratory infections and increases the severity of respiratory diseases. Experts have confirmed that tobacco users are more likely to develop severe symptoms or die from COVID-19, as it primarily attacks the lungs. Hence the present study assessed the tobacco habit changes during COVID-19 pandemic and to determine the factors associated with tobacco habits during pandemic. A mixed method study was conducted from December 20 Methodology: 21 – January 2022 among 200 tobacco users attending outpatient services in a tertiary care hospital, Tamil Nadu, South India with informed consent using an interview administered structured questionnaire by convenient sampling method. Result: Out of 200 study participants, around 59% participants have experienced decrease in tobacco consumption during COVID-19 pandemic because of lockdown (24%), lack of accessibility (19%) and 5.5% individuals was afraid of acquiring COVID-19 infection and similar percentage of individuals due to unavailability of products. But around 41% participants increased their tobacco usage in COVID -19 pandemic. Tobacco habits during COVID19 pandemic shows signifcant association with socio-economic status of consumer, current tobacco habits and plan to quit tobacco use. Conclusion: The COVID-19 pandemic offered a singular chance to minimize and discontinue tobacco use among tobacco users, and lockdown-experiences might strengthen control behaviors among users on a national and international level. During the COVID-19 pandemic, there may have been a decline in tobacco use due to several factors, including fear of contracting the virus and product scarcity as a result of lockdown. KEYWORDS : COVID-19, Tobacco, Pandemic, Lockdown View Show abstract ... Studies from India as well as abroad suggested complex drivers and mechanisms associated with COVID-19 lockdown that impacted SLT consumption (Gupte et al., 2020;Singh et al., 2021;Anderson, 2022). The lockdown more specifically resulted to decreasing use of SLT due to the closure of tobacco sales and/or isolation from social circles (Grover et al., 2020;Arora et al., 2022). Gupte et al, 2020 suggested that the lockdown provided an opportunity for reducing or quitting SLT among those currently under treatment for cessation. ... Smokeless Tobacco Use and Cessation Attempts during COVID-19 Lockdown: A Qualitative Study Article Full-text available * Jun 2023 * Senthanro Ovung * Saritha Nair * Meena Hijam * Vishnu Vardhana Rao Mendu Background: Smokeless tobacco (SLT) use among women is widely prevalent in Manipur state accounting for 45% users as per Global Adult Tobacco Survey (GATS)-2 India. Studies from India and elsewhere indicate changes in the way people used SLT during COVID-19 lockdown. This study explores individual and economic influences on SLT consumption and cessation attempts by tribal women in Manipur during the first COVID-19 lockdown (March-June, 2020) in India. Methods: Twenty in-depth interviews, both in-person and telephonically, were conducted among tribal women from Imphal west, Manipur, India, who used any SLT, from April to September 2020. Objective of the study was to understand the use, factors associated with consumption, purchasing behaviors, and cessation attempts of SLT during the lockdown. Thematic content analysis was used to identify core themes and codes. Results: Study participants reported of changes in current SLT use during restrictions imposed to contain COVID-19 pandemic in India. Majority reported of reduction or quit attempts in SLT use. Reasons included inaccessibility due to travel restrictions, limited availability and price rise of SLT products, fear of COVID-19, and disposable income for purchase of SLT products. However, a few women reported of increased consumption due to bulk purchasing, or switching to other SLT products as a result of unavailability or price rise of preferred products or to cope up with social isolation caused by the lockdown. Conclusion: Study findings on factors influencing quit attempts and strategies used for reducing SLT use by tribal women in Imphal, Manipur provide valuable insights for development of appropriate intervention for prevention of SLT use among women. View Show abstract ... Being a female smoker, residing in a rural area, and having a shorter smoking history were associated with a higher ability to reduce the smoking habit [14]. Another study assessed the COVID-19 situation with quitting smoking and found having knowledge about the harmful relationship and effect of tobacco use with COVID-19 significantly affected smokers' attempts to smoke cessation [15]. However, growing misinformation that smoking protects against COVID-19 infection could influence smokers' smoking habits. ... Beliefs about the smoking effect on COVID-19 as significant factors in smoking cessation efforts Article Full-text available * Mar 2023 * Mochamad Iqbal Nurmansyah * Yustiyani Yustiyani * Narila Mutia Nasir * Deni Wahyudi Kurniawan Owing to the various scientific evidence linking smoking to the increased risk of developing severe disease and death from the COVID-19 pandemic, now is a critical time for smokers to cut back or quit. This study aimed to analyze the influence of beliefs about smoking effects in relation to COVID-19 and attempts to quit smoking among university student smokers in Jakarta, Indonesia. This study was conducted in three different universities. As many as 198 respondents who were conveniently selected participated in this study. The health belief model (HBM) was adopted to determine the independent variables in this study. Having had a previous infection of COVID-19 influenced the smoking quitting attempts (AOR: 3.87, 1.49–10.0). Moreover, the belief that smoking increased COVID-19 severity, having a friend who reminded the respondents to not smoke during the pandemic, and having the ability to terminate smoking also increased the possibility for respondents to have a quit smoking attempt. However, perceived barriers such as feeling uncomfortable without smoking (AOR: 0.31, 0.15-0.6) were a protective factor against the attempt to quit smoking. Increasing smokers’ confidence to quit smoking and education about the risk of smoking during the pandemic should be intensified to support smokers in successfully quitting the smoking habit. View Show abstract ... Recent studies have revealed that there is a significant improvement in smoking cessation during this pandemic compared to before. [9] Authors have also suggested that fear of the pandemic and lockdown measures could be the possible reason for such outcomes. [10] An operational research study conducted in India to assess the impact of the pandemic and the lockdown on the behaviour of tobacco users has highlighted that awareness activities about the harmful effects of tobacco during the coronavirus pandemic have to be strengthened. ... Dental Public Health and COVID 19 Article Full-text available * Feb 2023 * Sri Priya Narayanan * Utkal K Mohanty View Show more COVID-19 pandemic: an opportunity for tobacco use cessation Article Full-text available * Nov 2020 * Indu B. Ahluwalia * Matthew L. Myers * Joanna Cohen View “YES it’s the Perfect Time to Quit”: Fueling Tobacco Cessation in India during COVID-19 Pandemic Article Full-text available * Sep 2020 * Shekhar Grover * Vikrant Mohanty * Swati Jain * Mira B Aghi Entire world is battling the Novel Coronavirus Disease (COVID-19) pandemic. India too, has undertaken stringent containment measures to combat this disease. The country is in a state of national lockdown, which has inadvertently led more than a quarter of the Indian population to not use tobacco. This paper discusses the opportunity that surfaces with unavailability of tobacco products, and advocates the need for escalation of tobacco cessation services as well as strategic management of stress to stay tobacco-free. View Show abstract COVID-19 and beliefs about tobacco use: an online cross-sectional study in Iran Article Full-text available * Oct 2020 * Ebbie Kalan * Hassan Ghobadi * Ziyad Ben Taleb * Mehdi Fazlzadehdavilb View COVID-19 and beliefs about tobacco use: an online cross-sectional study in Iran Article Full-text available * Aug 2021 * ENVIRON SCI POLLUT R * Davoud Adham * Hassan Ghobadi * Mehdi Fazlzadehdavilb * Raed Behaleh There is mixed evidence surrounding the relationship between tobacco use and COVID-19 infection/progression. The current study investigates beliefs and tobacco use behaviors and COVID-19 infection among a sample of smokers and never-smokers. Data were collected using an online survey distributed through Telegram, a cloud-based socialmedia networking application in Iran fromApril 1 to May 31, 2020. The study participants included never-smokers (n = 511), current (past-month) waterpipe smokers (n = 89), current cigarette smokers (n = 158), and ex-smokers (n = 172). Multinomial logistic regression was used to compare tobacco use groups with never- smokers on beliefs, controlling for potential confounders. The study participants (n = 944) was mostly male (64%), had > high school education (76%), and lived in an urban area (91%), with mean ± SD age of 35.3 ± 10.8. Key findings of this study are that compared with never-smokers: (1) cigarette smokers were less likely to believe that smoking cigarette can lead to spreading COVID-19; (2) waterpipe smokers were more likely to believe that smoking waterpipe at home was a safe practice, that waterpipe protects against COVID-19, and smoking waterpipe may lead to a more rapid recovery from COVID-19; (3) both waterpipe and cigarette smokers believed that using e-cigarettes in public places was a safe practice during the COVID-19 pandemic; and (4) more than half of the ex-smokers stopped smoking due to COVID-19 and most of them planned to continue abstaining from smoking after the pandemic. Our findings underscore the need to raise awareness about the unsupported claims of a lower hazard of using tobacco products or possible protective effects against COVID-19 and to promote cessation programs. View Show abstract How has the COVID-19 pandemic affected tobacco users in India: Lessons from an ongoing tobacco cessation program Article Full-text available * Sep 2020 * Himanshu A. Gupte * Gauri Mandal * Dinesh Jagiasi Introduction: Tobacco use is detrimental at any time. However, it is proving to be more dangerous during the COVID-19 pandemic. Tobacco use may increase the risk of being infected, increases the chances of complications, and also increases the probability of its spread. We assessed the awareness about this association and the impact of the lockdown on tobacco use among tobacco users registered before the lockdown for LifeFirst, a tobacco dependence treatment program. Methods: 1016 tobacco users were under active follow-up in their course of the 6-month counselling program. From 14 to 28 May 2020, 650 (64%) of these registered users were contacted by counsellors for follow-up sessions over the telephone. Semi-structured questionnaires were filled in during the calls. Results: Two-thirds (67%) of tobacco users were unaware of the association between tobacco and COVID-19. Only 30% of the users felt that the current situation had affected their tobacco use, the commonest impacts being unavailability and increased prices of tobacco products. While this was seen as an opportunity to quit by some users, some reported increased tobacco use due to increased stress. Of the 219 (34%) tobacco users who quit tobacco during the lockdown, 51% quit because of the lockdown and their concern over COVID-19. Abstinence among those who were aware of the association between the coronavirus and tobacco was twice that among those who were not aware. Conclusions: Awareness activities about the harmful effects of tobacco during the coronavirus pandemic have to be strengthened. Measures to motivate and support tobacco users to quit have to be provided through cessation services. View Show abstract The double-edged relationship between COVID-19 stress and smoking: Implications for smoking cessation Article Full-text available * Jul 2020 * Jeroen Bommelé * Petra Hopman * Bethany Hipple Walters * Marc C. Willemsen Introduction: Although recent research shows that smokers respond differently to the COVID-19 pandemic, it offers little explanation of why some have increased their smoking, while others decreased it. In this study, we examined a possible explanation for these different responses: pandemic-related stress. Methods: We conducted an online survey among a representative sample of Dutch current smokers from 11-18 May 2020 (n=957). During that period, COVID-19 was six weeks past the (initial) peak of cases and deaths in the Netherlands. Included in the survey were measures of how the COVID-19 pandemic had changed their smoking, if at all (no change, increased smoking, decreased smoking), and a measure of stress due to COVID-19. Results: Overall, while 14.1% of smokers reported smoking less due to the COVID-19 pandemic, 18.9% of smokers reported smoking more. A multinomial logistic regression analysis revealed that there was a dose-response effect of stress: smokers who were somewhat stressed were more likely to have either increased (OR=2.37; 95% CI: 1.49-3.78) or reduced (OR=1.80; 95% CI: 1.07-3.05) their smoking. Severely stressed smokers were even more likely to have either increased (OR=3.75; 95% CI: 1.84-7.64) or reduced (OR=3.97; 95% CI: 1.70-9.28) their smoking. Thus, stress was associated with both increased and reduced smoking, independently from perceived difficulty of quitting and level of motivation to quit. Conclusions: Stress related to the COVID-19 pandemic appears to affect smokers in different ways, some smokers increase their smoking while others decrease it. While boredom and restrictions in movement might have stimulated smoking, the threat of contracting COVID-19 and becoming severely ill might have motivated others to improve their health by quitting smoking. These data highlight the importance of providing greater resources for cessation services and the importance of creating public campaigns to enhance cessation in this dramatic time. View Show abstract The Effect of the COVID-19 Pandemic on Smoking Cessation Success Article Full-text available * Jun 2021 * J COMMUN HEALTH * Burcu Kayhan Tetik * Işılay Gedik Tekinemre * Servet Taş The coronavirus pandemic first started in Wuhan, China, in December 2019 and affected the whole world. In our country, new measures to be taken were announced after the first case was seen on March 11, 2020. In this study, patients who admitted to the smoking cessation clinic in 2018 and followed up by phone, regarding smoking cessation status in 2019 were questioned for their smoking cessation status after the coronavirus pandemic in 2020. In this descriptive study, the patients who applied to the smoking cessation outpatient clinic in 2018 were questioned regarding their smoking cessation status after 1 year and after the pandemic. It was investigated whether coronapandemia had an effect on smoking cessation. The data were evaluated by using SPSS 22 software. A value of p < 0.05 was considered significant. A total of 357 individuals with a median of Fagerström score of 7.0 were included in the study. Seventy-one (19.9%) of the subjects used nicotine tape, 268 (75.1%) used varenicline, and 18 (5.0%) used both. When the success of those who quit smoking before pandemic and those who quit smoking after pandemic were compared, a statistically significant relationship was found (p < 0.001). In our study, the rate of smoking cessation after 1 year was 23.7%, and the most common side effects were psychiatric complaints, whereas the rate of smoking cessation during the pandemic period was 31.1%. In order to increase the rate of smoking cessation, which is an important public health problem, more counseling should be provided, during the pandemic period. View Show abstract Applications of digital technology in COVID-19 pandemic planning and response Article Full-text available * Jun 2020 * Sera Whitelaw * Mamas A. Mamas * Eric Topol * Harriette G C Van Spall With high transmissibility and no effective vaccine or therapy, COVID-19 is now a global pandemic. Government-coordinated efforts across the globe have focused on containment and mitigation, with varying degrees of success. Countries that have maintained low COVID-19 per-capita mortality rates appear to share strategies that include early surveillance, testing, contact tracing, and strict quarantine. The scale of coordination and data management required for effective implementation of these strategies has—in most successful countries—relied on adopting digital technology and integrating it into policy and health care. This Viewpoint provides a framework for the application of digital technologies in pandemic management and response, highlighting ways in which successful countries have adopted these technologies for pandemic planning, surveillance, testing, contact tracing, quarantine, and health care. View Show abstract A “Bottom-up approach” to introduce ban on tobacco products to prevent spitting during COVID-19: An early review of progress made and challenges Article * Jan 2020 * Pranay Lal * Deepak Mishra * RanaJugdeep Singh View Applications of digital technology in COVID-19 pandemic planning and response Article * Jun 2020 * Sera Whitelaw * Mamas A. Mamas * Eric Topol * Harriette G C Van Spall With high transmissibility and no effective vaccine or therapy, COVID-19 is now a global pandemic. Government-coordinated efforts across the globe have focused on containment and mitigation, with varying degrees of success. Countries that have maintained low COVID-19 per-capita mortality rates appear to share strategies that include early surveillance, testing, contact tracing, and strict quarantine. The scale of coordination and data management required for effective implementation of these strategies has—in most successful countries—relied on adopting digital technology and integrating it into policy and health care. This Viewpoint provides a framework for the application of digital technologies in pandemic management and response, highlighting ways in which successful countries have adopted these technologies for pandemic planning, surveillance, testing, contact tracing, quarantine, and health care. View Show abstract Show more RECOMMENDED PUBLICATIONS Discover more about: Tobacco Cessation Article PREVALENCE, CORRELATES, AND TRENDS IN TOBACCO USE AND CESSATION AMONG CURRENT, FORMER, AND NEVER ADU... April 2017 · Addictive Behaviors * Brian A King * Gillian L. Schauer * Timothy A McAfee Background: Approximately 70% of current (past 30-day) adult marijuana users are current tobacco users, which may complicate tobacco cessation. We assessed prevalence and trends in tobacco cessation among adult ever tobacco users, by marijuana use status. Methods: Data came from the National Survey on Drug Use and Health, a cross-sectional, nationally representative, household survey of U.S. ... [Show full abstract] civilians. Analyses included current, former, and never marijuana users aged≥18 reporting ever tobacco use (cigarette, cigar, chew/snuff). We computed weighted estimates (2013-2014) of current tobacco use, recent tobacco cessation (quit 30days to 12months), and sustained tobacco cessation (quit>12months) and adjusted trends in tobacco use and cessation (2005-2014) by marijuana use status. We also assessed the association between marijuana and tobacco use status. Results: In 2013-2014, among current adult marijuana users reporting ever tobacco use, 69.1% were current tobacco users (vs. 38.5% of former marijuana users, p<0.0001, and 28.2% of never marijuana users, p<0.0001); 9.1% reported recent tobacco cessation (vs. 8.4% of former marijuana users, p<0.01, and 6.3% of never marijuana users, p<0.001), and 21.8% reported sustained tobacco cessation (vs. 53.1% of former marijuana users, p<0.01, and 65.5% of never marijuana users, p<0.0001). Between 2005 and 2014, current tobacco use declined and sustained tobacco cessation increased among all marijuana use groups. Conclusions: Current marijuana users who ever used tobacco had double the prevalence (vs. never-marijuana users) of current tobacco use, and significantly lower sustained abstinence. Interventions addressing tobacco cessation in the context of use of marijuana and other substances may be warranted. Read more Article SALES TRENDS IN PRICE-DISCOUNTED CIGARETTES, LARGE CIGARS, LITTLE CIGARS, AND CIGARILLOS-UNITED STAT... December 2017 · Nicotine & Tobacco Research * Teresa W. Wang * Kyle Falvey * Doris Gammon * [...] * Brian A King Introduction: Tobacco manufacturers continue to implement a range of pricing strategies to increase the affordability and consumption of tobacco products. To demonstrate the extent of retail- and brand-level price discounts at the point of sale, this study assessed national sales trends in price-discounted cigarettes, large cigars, little cigars, and cigarillos. Methods: Retail scanner data ... [Show full abstract] for tobacco product sales were obtained for convenience stores (C-store) and all-other-outlets-combined (AOC) from September 25, 2011, to January 9, 2016. The proportion of price-discounted sales, average nondiscounted unit price, and average discounted unit price were examined by product category and brand. JoinPoint regression was used to assess average monthly percentage change. Results: Overall, price-discounted sales accounted for 11.3% of cigarette, 3.4% of large cigar, 4.1% of little cigar, and 3.9% of cigarillo sales. The average difference between nondiscounted and discounted prices was 25.5% (C-store) and 36.7% (AOC) for cigarettes; 11.0% (C-store) and 11.2% (AOC) for large cigars; 19.2% (C-store) and 9.6% (AOC) for little cigars; and 5.3% (C-store) and 14.7% (AOC) for cigarillos. Furthermore, price-discounted sales of top-selling tobacco brands comprised up to 36% of cigarette, 7.4% of large cigar, 7.7% of little cigar, and 4.2% of cigarillo unit sales. Conclusions: These findings highlight the use of price discounts by tobacco manufacturers to reduce the cost of cigarettes, large cigars, little cigars, and cigarillos to consumers. These sales patterns underscore the importance of sustained efforts to implement evidence-based strategies to increase prices and reduce availability and consumption of combustible tobacco in the United States. Implications: This study highlights the prevalence and provides a baseline of price-discounted cigarettes, large cigars, little cigars, and cigarillos. Surveillance of tobacco sales data, including state-level trends and additional product types, is critical for informing approaches to reduce tobacco consumption. These approaches include countering tobacco product price-discounting practices and raising and maintaining a high sales price for all tobacco products. The implementation of evidence-based population-level interventions, together with local, state, and federal regulation of tobacco products, could prevent tobacco initiation, increase tobacco cessation, and reduce overall tobacco use among US youth and adults. Read more Article Full-text available TOBACCO USE AND NICOTINE DEPENDENCE AMONG PATIENTS WITH DIABETES AND HYPERTENSION IN BALLABGARH, IND... August 2021 · Monaldi Archives for Chest Disease * Rakesh Kumar * Shashi Kant * Ankit Chandra * Anand Krishnan Tobacco use is one of the most important modifiable risk factors for cardiovascular mortality and has a synergistic effect with diabetes and hypertension. This study was conducted to estimate the prevalence of tobacco use and nicotine dependence among adult diabetic and/or hypertensive patients. We conducted a cross-sectional study among 419 consecutively enrolled patients from the ... [Show full abstract] non-communicable diseases (NCDs) outpatient clinic of a secondary level hospital in Ballabgarh, India between July 2018 and January 2019. We administered a pre-tested questionnaire to assess tobacco use and Fagerstrom Test for Nicotine Dependence (FTND) to assess nicotine dependence. Current tobacco users were defined as those who smoked in the past seven days. Nicotine dependence was classified as low, moderate or high for the FTND score of 0 -3, 4-6, and 7-10, respectively. Seventy-nine patients had diabetes, 226 had hypertension, and 114 had both. The prevalence of tobacco use was 20.8% (95% CI : 17.1 - 24.9); prevalence of smoking was 15% (95% CI: 11.9 – 18.8) and smokeless tobacco use was 7.2% (95% CI: 5 - 10.1). Moderate to high nicotine dependence was found among 59.7% of tobacco users; 75.9% tobacco users attempted to quit tobacco in the past one month. One-fifth of attendees of a NCD clinic in a secondary level hospital used tobacco, most of whom had moderate-to-high nicotine dependence. High level of nicotine dependence and inability to quit despite making an attempt for it necessitates the inclusion of tobacco cessation services in the management of patients with non-communicable diseases. View full-text Article TOBACCO COUPONING: A SYSTEMATIC REVIEW OF EXPOSURES AND EFFECTS ON TOBACCO INITIATION AND CESSATION February 2022 · Nicotine & Tobacco Research * Alex Craig Liber * Luz Maria Sánchez-Romero * Christopher J. Cadham * [...] * David Theodore Levy Background Tobacco couponing continues to be part of contemporary tobacco marketing in the US. We performed a systematic review of the evidence of tobacco product coupon receipt and redemption to inform regulation. Methods We searched EMBASE OVID and Medline databases for observational (cross-sectional and longitudinal) studies that examined the prevalence of tobacco coupon receipt and coupon ... [Show full abstract] redemption across different subpopulations, as well as studies of the association between coupon receipt and redemption with tobacco initiation and cessation at follow-up. We extracted unadjusted and adjusted odds ratios for the associations between coupon exposure (receipt, redemption) and tobacco use outcomes (initiation, cessation) and assessed each studies’ potential risk of bias. Results 27 studies met the criteria for inclusion. Of 60 observations extracted, 37 measured coupon receipt, nine measured coupon redemption, eight assessed tobacco use initiation, and six assessed cessation. Tobacco product coupon receipt and redemption tended to be more prevalent among younger adults, women, lower education individuals, members of sexual and gender minorities, and more frequent tobacco users. Coupon receipt at baseline was associated with greater initiation. Coupon receipt and redemption at baseline were associated with lower cessation at follow-up among tobacco users. Results in high-quality studies did not generally differ from all studies. Conclusion Tobacco product coupon receipt and redemption are often more prevalent among price-sensitive subpopulations. Most concerning, our results suggest coupon receipt may be associated with higher tobacco initiation and lower tobacco cessation. Couponing thereby increases the toll of tobacco use and could prove to be a viable public health policy intervention point. Implications A systematic review was conducted of the scientific literature about the receipt, redemption, and effects on tobacco initiation and cessation of tobacco product couponing. This review found that tobacco coupons are more often received by price-sensitive persons and these coupons serve to increase tobacco initiation and decrease tobacco cessation. Policy efforts to address these consequences may help curb tobacco’s harms and address health inequities. Read more Last Updated: 22 Oct 2024 Interested in research on Tobacco Cessation? Join ResearchGate to discover and stay up-to-date with the latest research from leading experts in Tobacco Cessation and many other scientific topics. Join for free ResearchGate iOS App Get it from the App Store now. 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