Authors: Monika Arora, Fiona Davidson, Linda Bauld Affiliations: Monika Arora: Director and Professor, Health Promotion Division, Public Health Foundation of India & Executive Director, HRIDAY, New Delhi, India Fiona Davidson: Research Manager, Usher Institute, University of Edinburgh Linda Bauld: Bruce and John Usher Professor of Public Health, Usher Institute, University of Edinburgh The COVID-19 pandemic has affected almost all aspects of life for much 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 disease, cancer and diabetes, are more common among smokers(1) and tobacco users. Smokers may also be at greater risk of poorer outcomes if they require hospital admission 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 to tobacco use annually, the tobacco industry continues to nurture this global pandemic. The tobacco pandemic has recently been equated to “COVID-19 in slow motion”(4). Extensive evidence has established that smoking is associated with an adverse disease prognosis. Smoking damages the upper airways, decreasing the pulmonary immune system and consequentially increasing vulnerability to infections. Smokers have twice the risk of contracting infections and have more severe 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 WHO announced COVID-19 to be a global pandemic in March 2020, also stating 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 exacerbates conditions that reduce the body’s ability to use oxygen, putting patients at higher risk of pneumonia. WHO also noted that smoking products such as water pipes often involve the sharing of mouthpieces and hoses, which would increase transmission of COVID-19 in communal and social settings(1). Smokeless tobacco (ST) use is also associated with increased risk of COVID-19 due to the need to spit after chewing ST products. Some ST products require mixing of ingredients with fingers, also increasing risk of infection. Evidence supporting an increased risk of COVID progression among smokers A recent meta-analysis revealed a significant association between smoking and the progression 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 probability of progression towards serious illness were 14 times higher among patients with a history of smoking, compared to those who never smoked(2). Evidence also shows vulnerability by gender – infected men in China had higher death rates due to COVID-19 than women. This may be attributed to the fact that the prevalence of smoking among Chinese men is higher – 45% use tobacco daily, compared to just 2% of women. A recent review of studies on smoking status and COVID-19 cases in China(9) revealed a higher need for ICU support and ventilation or death as a result of the disease progression among current and former smokers than in non-smokers (2). New studies and misinformation by the tobacco industry Two recent studies argued that nicotine protects tobacco users from COVID-19 and can be used as a coronavirus treatment. These studies were widely quoted by the media, confused people, and even resulted in panicked people buying nicotine replacement products. These studies have methodological weaknesses and one paper included an author with conflict of interest. Review of Controversial Study Related To Smoking and COVID-19: STOP website The WHO has 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 primarily attacks the lungs. Data is still insufficient to confirm any link between tobacco or nicotine in the prevention or treatment of COVID-19. WHO statement: Tobacco use and 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 banned the sale of cigarettes, snuff, hookahs and e-cigarettes to protect workers in the entire supply chain of these industries. India 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 danger 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 the partners in Bangladesh, Ethiopia, Ghana, India, Pakistan and Uganda. COVID-19 and Tobacco project information The theme for World No Tobacco Day this year is “Protecting youth from industry manipulation and preventing them from tobacco and nicotine use”. Industry manipulation of data, a gross violation of India’s tobacco-free TV and movie rules in streamed programmes popular among youth(12), and litigation against Plain Packaging in Australia(13) reiterates that the tobacco industry will continue to manipulate science, policies, government and the vulnerable youth. Now that the world has united to seek COVID-19 solutions, governments must also come together to stop tobacco industry manipulation and create a Tobacco-Free Future Generation. 1. World Health Organization. Q&A: Smoking and COVID-19 [Internet]. 2020 [cited 2020 May 20]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/q-a-on-smoking-and-covid-19 2. Liu W, Tao ZW, Lei W, Ming-Li Y, Kui L, Ling Z, et al. Analysis of factors associated with disease outcomes in hospitalized patients with 2019 novel coronavirus disease. Chin Med J (Engl). 2020 May 5;133(9). 3. Public Health England. Smokers at greater risk of severe respiratory disease 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-respiratory-disease-from-covid-19 4. Hefler M, Gartner CE. The tobacco industry in the time of COVID-19: Time to shut it down? Vol. 29, Tobacco Control. BMJ Publishing Group; 2020. p. 245–6. 5. Jha P. Avoidable Deaths from Smoking: A Global Perspective. Public Health Rev. 2011 Dec 3;33(2):569–600. 6. Park JE, Jung S, Kim A. MERS transmission and risk factors: A systematic review. BMC Public Health. 2018 May 2;18(1):1–15. 7. Arcavi L, Benowitz NL. Cigarette smoking and infection. Vol. 164, Archives of Internal Medicine. American Medical Association; 2004. p. 2206–16. 8. Patanavanich R, Glantz SA. Smoking Is Associated With COVID-19 Progression: A Meta-analysis. Nicotine Tob Res. 9. Vardavas CI, Nikitara K. COVID-19 and smoking: A systematic review of the evidence. Tob Induc Dis. 2020 Mar 20;18(March). 10. Simons D, Shahab L, Brown J, Perski O. The association of smoking status with SARS-CoV-2 infection, hospitalisation and mortality from COVID-19: A living rapid evidence review. Qeios [Internet]. 2020 May 7 [cited 2020 May 20]; Available from: https://www.qeios.com/read/UJR2AW.3 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-use-and-covid-19 12. Arora M, Nazar GP, Chugh A, Rawal T, Shrivastava S, Sinha P, et al. Tobacco imagery in on-demand streaming content popular among adolescents and young adults in India: Implications for global tobacco control. Tob Control. 2020; 13. WHO FCTC, McCabe Centre for Law and Cancer. Australia’s plain packaging laws at the WTO: progress to date - WHO FCTC Secretariat’s Knowledge Hub on legal challenges [Internet]. [cited 2020 May 20]. Available from: http://untobaccocontrol.org/kh/legal-challenges/australias-plain-packaging-laws-wto/ Publication date 25 May, 2020
