This commentary was jointly authored by Dr Gauden Galea, WHO Representative in China, and Dr Wang Chen, the President of Chinese Academy of Medical Sciences and Peking Union Medical College, and was originally published in Chinese media on 14 September 2020.
COVID-19 has put China and the world through a historical trying time. The impacts are profound, and the world may never return to the one we know. While China has effectively managed to keep the virus at bay, the whole society has learned to live with the virus and not let its guard down.
Health is now a consideration in every behaviour and practice, bringing a new perspective to the way we interact and operate. The government is improving the weak links for more effective prevention and proactive preparedness for new outbreaks or future public health threats. In a world living with COVID-19, we need to scrutinize not only the risks of COVID infection and transmission, but also the risks to health overall.
One risk stands out - tobacco use. In addition to putting smokers and the non-smokers around them at risk of heart disease, cancer, respiratory ailments, and a host of other health harms, smoking also puts smokers and others at an elevated risk for COVID-19. And these risks are interconnected and intensified.
First, evidence shows that people with pre-existing conditions like respiratory disease and cardiovascular disease, both of which can result from smoking, face a much greater risk of severe illness with COVID-19 and a higher mortality rate. Second, smokers are likely to be more vulnerable to COVID-19 as the act of smoking means that fingers (and possibly contaminated cigarettes) are in contact with lips which increases the possibility of transmission of virus from hand to mouth. Smokers may also already have lung disease or reduced lung capacity which would greatly increase the risk of serious illness. Third, COVID-19 spreads primarily through respiratory droplets when a person with COVID-19 coughs, sneezes, or speaks. Exhaled cigarette smoke may also carry such droplets from someone’s lungs, which could potentially spread COVID-19. When smokers take off their mask to smoke and exhale smoke from their lungs, the second-hand smoke puts other people in the same physical space at risk, not only because of the toxic particles in tobacco smoke itself, but also because that smoke may carry virus-laden droplets if the smoker is already infected. Further, if smokers gather in enclosed smoking rooms, transmission of the virus becomes even more likely.
With a high smoking prevalence at 27%, smoking and second-hand smoke is already killing over 2 million Chinese every year. COVID-19 further highlights the health impacts of tobacco use. Reducing tobacco use at the population level must be a priority at this critical time.
Let’s look at this from a different perspective. Tobacco use causes enormous amount of healthcare resources and puts burden on the health system. The total economic costs (including medical costs treating tobacco related diseases and indirect costs) of smoking in China in 2014 was ¥350 billion, about one-third of the total medical and health expenditure financed by the government that year—it is important to note that this number is likely largely underestimated. The economic costs will only grow when tobacco related illnesses continue to increase. As China is working hard to strengthen public health system and become better equipped with dealing with the looming threat of COVID-19 and other future public health challenges, treating smoking related diseases will take up incredible amount of medical resources and drain government’s investment in health, which could have been used for tackling COVID-19 and other public health priorities. Preventing these tobacco-related diseases is doubly important now.
One tobacco control measure that calls for immediate action is smoke-free laws, which simultaneously reduce tobacco-related health risks as well as COVID risks. Smoke-free laws protect non-smokers from the deadly tobacco smoke and create an environment that helps smokers break the deadly habit (both second-hand smoke exposure and smoking rates have greatly decreased in Beijing and Shanghai after implementing 100% smoke-free laws). Our experience with COVID-19 makes smoke-free laws a policy of common sense—one simply should not smoke in indoor public places to endanger the health of others. Effective smoke-free laws protect everyone and cover all indoor work places and public places. Smoking rooms, whether with separate ventilation systems or not, have repeatedly been shown to be ineffective in protecting against exposure to tobacco smoke. Smoking rooms also pose greater risks of COVID-19 transmission. Some cities in China, including Chongqing, where there are not yet comprehensive smoke-free laws, have closed smoking rooms during the pandemic due to health concerns. While we welcome such action, there shouldn't be a time-out for protecting public health and we look forward to 100% smoke-free laws protecting all residents Citizens in China.
Another measure, which is the single most effective tobacco control measure to reduce tobacco use, is increasing tobacco tax and price. This measure is particularly effective for vulnerable populations such as the poor. As China is trying to get the economy back on track and strives to fulfil the poverty elimination goal by 2020, the win-win characteristic of higher tobacco tax is even more evident. On one hand, it decreases diseases and deaths by reducing tobacco use. On the other hand, it provides the government with additional revenue. China’s major economic goal for 2020 is to secure the fundamentals of economic and social functioning by continuing the “fees and taxes reduction” policy, any additional revenue is much urgently needed now. Moreover, studies have repeatedly shown smoking disproportionally affects poor families. COVID-19 may already have put some poor families back into poverty due to job losses. Tobacco exacerbates poverty. When struck by tobacco related illness, low-income families are usually hit by medical expenses for advanced medical treatment and drugs. COVID-19 has put China and other countries at the crossroads of health and economy. China has decisively chosen health and is making remarkable progress with economy and social recovery without sacrificing lives and public health. Tobacco tax policy would give this effort the necessary mileage to win on both health and economy.
During 7 months of battling the pandemic, China has demonstrated leadership in safeguarding health and lives. President Xi has repeatedly spoken about the uttermost priority of health and that health is the prerequisite of a prosperous society. One preventable death is one too many. China has made great sacrifices to save tens of thousands of lives from COVID-19; at the same time, tobacco is causing the loss of millions of lives. Urgent and decisive actions are called for to control the tobacco epidemic as societies enter the recovery phase from COVID-19.