Smoking and COVID: The Primacy of Prevention

John Maa, MD

On February 22, the United States crossed the tragic milestone of

500,000 Covid-19 deaths, just one year and 16 days after the first US fatality was recorded in California. Our nation paused to honor this enormous loss of life, over twice the number seen in the nation that ranks second in global Covid mortality. At the peak, 5,427 daily US deaths were reported on Feb 12, 2021, exceeding the 4,414 confirmed Allied deaths at Normandy on D-Day. Over the span of three years and eight months during World War II, 407,316 US military servicemen and women were killed. The 407,000th US Covid-19 death came around January 22 - 11 months into the pandemic. Covid-19 claimed American lives at a rate nearly four times faster than World War II.

However, there is one other cause of preventable death in the US that for years consistently surpassed the death rate witnessed in the first year of the Covid-19 pandemic. An estimated 480,000 US lives are lost from tobacco use each year, including more than 41,000 deaths annually from secondhand smoke exposure. Perhaps another important date to reflect upon was February 13, 2021 (nine days before the 500,000 death milestone), when the US crossed 480,000 Covid-19 deaths. Covid-19 claimed US lives at a pace slightly behind Big Tobacco, having taken one week longer to match Big Tobacco’s yearly toll. We have never shut down the economy, closed our schools, or sheltered in place to protect the public from the health hazards created by Big Tobacco. Social distancing from cigarette smoke remains an excellent idea, given the risks of secondhand smoke exposure (and possible spread of the virus).

Perhaps the most extreme example of the power of nicotine addiction is witnessed when a current smoker picks up a discarded cigarette butt from the sidewalk and places it into their mouth. This action ignores the warnings not to touch one’s mouth, or to share items with others who might have Covid, and is of special concern as the virus falls to the ground after being sneezed and coughed. This particularly high-risk activity illustrates that tobacco use and Covid-19 present twin threats to public health. A question that will be answered over time is the number of Covid deaths in 2020 that came in patients already suffering from serious tobacco related illnesses like coronary arterial disease, asthma or chronic obstructive pulmonary disease. A lifetime of health problems related to smoking may have predisposed some to have more severe Covid disease, resulting in death. An early premature conclusion based on incomplete data suggested that smoking somehow protected one from acquiring Covid-19, which has not been substantiated by further research. Instead, most studies demonstrate the opposite, that smoking is linked to transmission of Covid-19, and lead to worse outcomes including the need for intubation and death. It is for this reason that some states have chosen to vaccinate current smokers ahead of schoolteachers and others, which may create a perverse incentive for non-smokers to begin smoking. An early silver lining from the pandemic is that up to 300,000 UK smokers may have quit smoking due to COVID-19 fears. Unfortunately, the Wall Street Journal recently reported that current smoking rates in the US are on the rise (after decades of decline) in part due to the anxiety and stress induced by the pandemic. Encouraging more Americans to follow the lead of their UK counterparts may help slow the tragic arc of COVID-19 deaths in America.

Tough action was taken against the vaping industry during the pandemic to limit their harm to society. Many vape shops across America closed, having been defined as non-essential services. The Federal Trade Commission filed litigation in the Spring of 2020 to end the Juul-Altria partnership as a violation of the Sherman Act, and class action lawsuits went further to allege the Altria-Juul deal was a conspiracy to create an illegal monopoly. In April of 2020, Juul laid off one-third of their remaining workforce, and later exited five European markets including France and Spain (Austria, Belgium and Portugal), as well as South Korea. Similar direct action against Big Tobacco now could help curb the annual death toll from smoking.

The one-year anniversary of the COVID-19 pandemic presents an opportunity to reflect upon what we have witnessed over the past year. We should ask ourselves as a nation why do we continue to financially support the planting and harvesting of tobacco crops? Why are there not graphic warning labels on cigarette packs, as in other nations? We turned the country upside down to fight COVID-19 — if just half of our assets and energy were focused on reducing smoking’s deadly toll maybe we can finally defeat Big Tobacco? We can hope that someday a vaccine will arrive to prevent nicotine addiction, and end the health burden associated with tobacco use. It is essential for policymakers to take every effort to reduce the deadly toll of of tobacco use, and its role in worsening the COVID-19 pandemic.