As we reflect on COVID-19’s toll, the US must also act on the tobacco pandemic

John Maa and Jeff Wigand

On February 22, 2021, the United States paused to honor the tragic milestone of 500,000 COVID-19 deaths, just one year and 16 days after the first fatality was recorded in California.  The peak of 5,427 new US deaths reported on Feb 12, 2021 exceeded the 4,414 Allied deaths at Normandy on D-Day. Over the 3 years and 8 months of US involvement in World War II, 407,316 US military servicemen and women were killed. The 407,000th US COVID-19 death came after just 11 months, as COVID-19 claimed American lives at a rate nearly 4 times faster than World War II.

However, there is one cause of preventable US death that surpassed the death rate of COVID-19. An estimated 480,000 Americans die annually from tobacco use, including more than 41,000 deaths from secondhand smoke exposure. COVID-19 claimed US lives at a pace slightly behind Big Tobacco, taking 53 weeks to match smoking’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 of Big Tobacco. A commonly witnessed sight during the pandemic is a smoker pulling their mask aside during a cigarette break outdoors. A more extreme example of nicotine addiction is a smoker who picks up a discarded cigarette butt from the street, and places it into their mouth. This particularly high-risk activity disregards the warnings to not touch one’s face or mouth, not to share items with others who might have Covid, and to avoid contact with items on the ground where the virus falls after someone has sneezed or coughed.

These activities highlight the twin threats that smoking and Covid present to public health. The estimated deaths in America from smoking in 2020 have yet to be announced, and it is likely that the final number of 1) direct smoking-related US deaths and 2) Covid deaths in US patients with underlying smoking related illnesses will be far in excess of 480,000.

Worldwide, tobacco use causes more than 7 million deaths per year, whereas the death toll from Covid-19 only crossed 3 million as of mid-April 2021.

Most studies have demonstrated that smoking is linked to transmission and developing symptoms of COVID-19, and leads to worse outcomes, including intubation and death. It is for this reason that some states chose to vaccinate current smokers ahead of schoolteachers and others, perhaps 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 decades long decline in US cigarette sales ended in 2020, in part due to the anxiety and stress induced in smokers by the pandemic.

A major setback worldwide in the fight against Covid-19 may have resulted from the early and premature conclusions in spring 2020 based upon incomplete data suggesting nicotine and smoking protect one from acquiring COVID-19. Researchers in China and France amplified this incorrect belief about a potential benefit from smoking, which led to a temporary shortage of nicotine patches in France as non-smokers rushed to try this ineffective strategy to prevent Covid transmission.  The World Health Organization invested in educational programs to debunk this myth. The original researchers in Paris who perpetuated this misinformation have not published any prospective clinical data to support their theory, and likely should now issue a retraction, as has been done with a similarly confusing article.

The truth is that a lifetime of health problems resulting from smoking likely predisposed many patients to develop more severe COVID disease and die sooner than would have been otherwise expected. Encouraging more American smokers to follow the lead of their UK counterparts and stop smoking immediately may help slow the tragic arc of COVID-19 deaths in America.

Tough action was taken against the vaping industry during the pandemic in the aftermath of the E-cigarette or vaping product use-associated lung injury (EVALI) epidemic that hospitalized thousands across America in 2019. The Federal Trade Commission filed litigation in Spring 2020 to end a key partnership between the vaping industry and Big Tobacco as a violation of the Sherman Act. In January 2021, the FDA issued warning letters to 10 firms who manufacture and operate websites selling e-cigarettes that doing so without FDA pre-market approval is illegal. Similar pro-active action against Big Tobacco now could help curb both the US COVID-19 mortality and the annual death toll from smoking, which are interlinked.

The one-year anniversary of the COVID-19 pandemic presents an opportunity for US and international policymakers to consider future actions to reduce both the deadly toll of tobacco use, and its role in worsening the pandemic. Today the US Food and Drug Administration announced the intent to ban menthol flavored cigarettes and all flavored cigars (including menthol flavor) within the next year. This action can counteract the disproportionate impact of Covid-19 on communities of color, which have been targeted by Big Tobacco for decades particularly through relationships with African American leadership organizations and community social connections to promote menthol sales. The Biden Administration should now follow the lead of other nations and also 1) finalize the long-awaited graphic warning levels on cigarette packs, and 2) ban menthol flavored e-cigarettes, as has been done in California.

Earlier actions undertaken in other countries years before may have helped reduce their national COVID mortality. Valuable lessons were learned from South Africa’s ban on the sale of all tobacco and vaping products between March and August 2020. New Zealand recently proposed making sales of cigarettes to anyone born after 2004 illegal, along with a slate of proposals to make the nation’s goal to be smoke-free by 2025 a reality. New Zealand’s efforts to reach the Tobacco Endgame (often defined as national smoking prevalence under 5%) join that of several other countries, including Canada, Finland, Britain, Ireland and Sweden.

Raising the price of cigarettes remains the most powerful incentive for smokers to quit, and both states and the federal government should consider raising tobacco taxes further.  It may also be time to implement retailer reduction policies and end the subsidies to tobacco growers for the planting and harvesting of tobacco crops that cost America around $60 million each year.

We turned the country upside down to fight COVID-19. If just half of our assets and energy were focused on simultaneously reducing smoking’s deadly toll, maybe we can also finally end Big Tobacco’s societal harm and reach the Tobacco Endgame.

John Maa, MD, is a surgeon in San Francisco and Past President, San Francisco-Marin Medical Society. He has been involved for many years in health care reform and tobacco control policy. He tweets at @JohnMaaMD. Jeffrey Wigand, PhD, is the founder of Smoke-Free Kids Inc., a non-profit organization dedicated to helping kids of all ages make better decisions and healthy choices about tobacco use. He rose to prominence in 1995 when he became the highest ranking former tobacco executive to turn whistleblower on the industry. His story was told in the 1999 film The Insider. He tweets at @Jeffrey_Wigand. Both authors declare no conflicts of interest.

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