The COVID-19 pandemic has affected almost every aspect of life for a large portion of the world’s population. Although evidence on who is most vulnerable to COVID-19 is still emerging, it is clear that individuals with underlying chronic health conditions are more at risk. Many of these conditions, such as heart or respiratory diseases, cancer and diabetes, are more common among smokers (1) and tobacco users.

Smokers may also be at greater risk for poorer outcomes if they require hospitalization for COVID-19, as smoking is a significant risk factor for respiratory infections and complications during recovery (2) (3). Although 8 million deaths are attributed annually to tobacco use, the tobacco industry continues to nurture this global pandemic.

The tobacco pandemic has recently been equated with “COVID-19 in slow motion” (4). Extensive evidence has established that smoking is associated with an adverse disease prognosis. Smoking damages the upper respiratory tract, reduces the pulmonary immune system and consequently increases the vulnerability to infections. Smokers are twice as likely to catch infections and have worse symptoms. A higher risk of infection and mortality was also recorded among smokers in the previous CoV-MERS outbreak (6) (7).

Tobacco use and risk of COVID-19

The WHO announced COVID-19 in March 2020 as a global pandemic, and also stated that smokers are likely to be more vulnerable due to: (a) inhalation of toxic chemicals in cigarettes, and (b) increased hand-to-mouth -movement. Smoking aggravates conditions that reduce the body’s ability to use oxygen, which puts patients at greater risk for pneumonia. The WHO also noted that smoking products such as water pipes often involve the sharing of nozzles and hoses, which will increase the transmission of COVID-19 in communal and social environments (1). The use of smokeless tobacco (ST) is also associated with increased risk of COVID-19 due to the need to spit after chewing ST products. Some ST products require mixing ingredients with fingers, which also increases the risk of infection.

Evidence supporting increased risk of COVID progression among smokers

A recent meta-analysis revealed a significant association between smoking and the progress of COVID-19. Of 218 smoking patients, 29.8% experienced disease progression, compared with 17.6% of non-smoking patients (8). Evidence from China also highlighted that the likelihood of progressing to serious illness was 14 times higher among patients with a history of smoking, compared with those who had never smoked (2). Evidence also shows gender vulnerability – infected men in China have higher death rates from COVID-19 than women. This can be attributed to the fact that the prevalence of smoking among Chinese men is higher – 45% use tobacco daily, compared to only 2% of women. A recent review of smoking status studies and COVID-19 cases in China (9) has a greater need for ICU support and ventilation or death due to disease progression among current and former smokers than among non-smokers. brought to light (2).

New studies and misinformation by the tobacco industry

Two recent studies have argued that nicotine protects tobacco users from COVID-19 and can be used as a coronavirus treatment. These studies have been widely cited by the media, have confused people, and have even led panicked people to buy nicotine replacement products. These studies have methodological weaknesses and one article included an author with conflict of interest.

The WHO reiterated its position on tobacco use and COVID by convening a group of public health experts. A review of studies by these experts confirmed that smokers are more likely to develop severe symptoms or die from COVID-19, as it mainly attacks the lungs. Data are still insufficient to confirm any association between tobacco or nicotine in the prevention or treatment of COVID-19.

Tobacco control policies during COVID-19 pandemic

Since the COVID-19 outbreak, countries have developed tobacco control policies according to their specific contexts. Some countries, including Iran, Kuwait, Pakistan, Qatar and Saudi Arabia, have banned the use of water pipes to avoid COVID-19 transmission. South Africa has banned the sale of cigarettes, snuff, water pipes and e-cigarettes to protect workers throughout the supply chain of these industries. India has banned the sale of all tobacco products and their use in public places. ST use in public places is prohibited with fines, to avoid spitting and reduce the risk of COVID-19 transmission.

These differences are fascinating and some of them will be the focus of a new study on COVID-19 and tobacco in Africa and South Asia, led by the University of Edinburgh and involving partners in Bangladesh, Ethiopia, Ghana, India, Pakistan and Uganda involved. More details here.

The theme for this year’s No Tobacco Day is “Protecting young people from industrial manipulation and preventing tobacco and nicotine use”. Industry manipulation of data, a gross violation of India’s tobacco-free TV and movie rules in youth popular streaming programs (12), and litigation against Plain Packaging in Australia (13) reiterate that the tobacco industry will continue to pursue science, policy manipulate, government and the vulnerable youth. Now that the world has united to seek COVID-19 solutions, governments must also stand together to stop the manipulation of the tobacco industry and create a tobacco-free future generation.

Authors

Monika Arora (@DrMonikaArora), Director and Professor: Division of Health Promotion, Public Health Foundation of India and Executive Director: HRIDAY, New Delhi, India

Fiona Davidson – Research Manager, Usher Institute, University of Edinburgh

Linda Bauld (@LindaBauld) – Bruce and John Usher Professor of Public Health, Usher Institute, University of Edinburgh

References

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2. Liu W, Tao ZW, Lei W, Ming-Li Y, Kui L, Ling Z, et al. Analysis of factors related to disease outcomes in hospitalized patients with 2019 new coronavirus disease. Chin Med J (English). 5 May 2020; 133 (9).

3. Public Health England. Smokers at greater risk for serious respiratory diseases from COVID-19 – GOV.UK [Internet]. 2020 [cited 2020 May 20]. Available from: https: //www.gov.uk/government/news/smokers-at-greater-risk-of-severe-res …

4. Hefler M, Gartner CE. The tobacco industry in the time of COVID-19: Time to close it? Full. 29, Tobacco Control. BMJ Publishing Group; 2020. p. 245–6.

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6. Park JE, Jung S, Kim A. MERS transfer and risk factors: A systematic review. BMC Public Health. 2018 May 2; 18 (1): 1–15.

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11. World Health Organization. WHO statement: Tobacco use and COVID-19 [Internet]. [cited 2020 May 20]. Available from: https: //www.who.int/news-room/detail/11-05-2020-who-statement-tobacco-us …

12. Arora M, Nazar GP, Chugh A, Rawal T, Shrivastava S, Sinha P, et al. Tobacco images in streaming content on demand popular among adolescents and young adults in India: Implications for global tobacco control. Tob control. 2020;

13. WHO FCTC, McCabe Center for Rights and Cancer. Australia’s simple packaging laws at the WTO: progress so far – WTO FCTC Secretariat’s Knowledge Hub on legal challenges [Internet]. [cited 2020 May 20]. Available from: http: //untobaccocontrol.org/kh/legal-challenges/australias-plain-packagi …