Covid-19 Smoking Ban: The good, the bad and the very ugly

South Africa is now entering the third week since President Cyril Ramaphosa declared a State of National Disaster and the country was put on lockdown due to Covid-19. The lockdown signalled that life as we knew it could not continue as normal and it was not “business as usual”. The global pandemic had reached our shores, and one of the best-known ways to reduce transmission was to practice physical distancing of between one and two metres between people and to limit the size of public gatherings.

The lockdown regulations introduced a number of restrictions on daily life including restricting all workers – except essential workers – to their homes and limiting the items that could be purchased to essentials such as food, medicines, some baby essentials and toiletries. Cigarettes, e-cigarettes, snuff and hookah pipes were not included as either “essential” or “basic” items, and are not on sale during the lockdown.

The ban on the sale of cigarettes, snuff, hookah pipes and e-cigarettes or vapes protects workers in the entire supply chain of these industries, from production, packing, driving and delivery to shelf packers at retail stores. This reduces the risk of contracting Covid-19, not only for the worker, but it reduces the risk of exposure for their families as well, because these workers can also stay at home. In this way, the lockdown has protected workers from many industries across the country because it has minimised movement and therefore, physical contact.

A second reason to support the ban on the sale of tobacco products is related to the health impact of Covid-19 and the disease progression and impact on treatment seen in smokers in other countries. A recent review of studies on smoking status and Covid-19 cases in China (Vardavas, 2020), found that in all of the studies available, the need for ICU support and ventilation or death as a result of the progression of the disease was higher among current and former smokers than in non-smokers.

Smokers also made up a higher percentage of severe cases of Covid-19. These preliminary studies indicate that those who smoke had worse health outcomes if they contracted Covid-19.

The researchers calculated that smokers were 1.4 times more likely to have severe symptoms of Covid-19 and approximately 2.4 times more likely to be admitted to an ICU, or need mechanical ventilation, or die, compared to non-smokers.

Another study in China (Liu et al, March 2020), found that smokers with Covid-19 were 14 times more likely to progress to pneumonia than non-smokers.

It is not ideal for smokers to have to suddenly stop smoking without having had the time to make that decision themselves. Nor is it ideal for smokers to have been forced into the decision because of not having the opportunity to buy sufficient tobacco products before the lockdown. But these are not ideal times for anyone and it has been a common experience for the entire population to suddenly be without something they considered essential in their lives.

There are many sources of support and counselling for smokers who want help to cope with withdrawal symptoms because they have run out of cigarettes or those who want to use the smoking ban and the lockdown to stop smoking. Many organisations are providing online or telephonic counselling – here’s a list. The National Council against Smoking provides telephone counselling for smokers who want to stop smoking on 011 720-3145, while CANSA has an online stop smoking support programme. Pharmacies, clinics and doctors are also available and nicotine replacement therapy is being sold to assist smokers who are experiencing withdrawal symptoms.

The lockdown measures are intended to reduce the spread of Covid-19. Minister of Health Zweli Mkhize said on 1 April 2020: “Internal transmission has started and it may have a tendency to spread silently as people with less means and slight symptoms may be slow to seek medical help as they are few and far apart, initially. Our testing criteria of patients with symptoms is currently reactive and restrictive. This means we don’t yet have a true picture of the size of the problem. There will not be time to prepare what we will not have put in place in the next seven days.”

The minister’s statement hints at the challenges that will be faced by our healthcare system in its’ response to Covid-19. The healthcare system is already strained by the existing disease burden, even without Covid-19.

Clinics and public hospitals already have long queues, with a limited number of health facilities in townships and informal settlements having to treat increasing numbers of patients each day. Even with the best intentions to do so, health workers will be unable to deal with an exponential increase in the number of Covid-19 patients without more human resource support, along with the personal protective equipment (PPE) that they require.

The small living spaces in townships, the shared use of toilets and basins, and the high number of informal settlements across the country without access to running water, sanitation and access to soap and sanitisers mean that Covid-19 will disproportionately affect poorer South Africans. A reduction in the overall number of Covid-19 cases will reduce demand on the health system and protect those of our compatriots with limited access to the essential services that they require to stay healthy.

Covid-19 has been reduced in both China and in South Korea by the introduction of a lockdown and mass testing. This is the phase we are currently in, with the lockdown in place for almost two weeks, and with testing being implemented in townships and informal settlements to reduce community transfer. We still do not know the true extent of Covid-19 because testing has until now focused only on those that were symptomatic and had travel history or contact with someone who had contracted Covid-19.  

Given the scale of the Covid-19 pandemic in other countries, and the many unknowns we face here, including the extent of the demand that will be placed on our health system, we urge smokers to try their best to use this opportunity to stop smoking. This is a good decision not only for your own health, but for that of your family and community – and for our country too. Remember that there are many organisations that are able to assist you during this transition – reach out so that they can give you the support and help you need to make it easier for you to stay tobacco-free. DM

Savera Kalideen and Sharon Nyatsanza are with the National Council against Smoking; Pamela Naidoo is with the Heart and Stroke Foundation South Africa; Lorraine Govender is with CANSA; and Catherine Egbe is with the South African Medical Research Council.