ASH Webinar on Tobacco Cessation, Production & Sales in Light of COVID-19
April 16, 2020
Statement from Chris Bostic, Deputy Director for Policy at ASH
I’m mostly going to focus on the responsibilities of governments in the context of tobacco and COVID-19, and I think it falls into three broad categories: cessation services, tobacco sales and production during the pandemic, and, more broadly, tobacco sales and marketing at any time.
As Linda has explained, the U.S. is open for business when it comes to cessation services. This is also true in many other countries, although we have limited information. Some medical services that are essential in the long term have been curtailed or postponed due to social distancing, like elective surgeries, routine dental and eye exams, etc. But cessation must continue in earnest, and we are fortunate that face-to-face therapy is only a small aspect of cessation therapy.
People who smoke are faced with an historic challenge – many are stuck at home for an extended period, they are at greater risk of serious complications from COVID-19 and therefore must take extra precautions, and going out to purchase tobacco increases the risk of exposure, to themselves, their families and society in general.
Even in more normal times, the vast majority of people who smoke want to quit, and the need to do so has never been greater. Society has a responsibility to help them, for two reasons. First, every government has a human rights duty to provide the highest attainable standard of physical and mental health. The U.S. is certainly capable of providing cessation assistance. It is cheap, and the return on investment – to individuals and society – is massive. Second, it was the failure of governments to protect the health of their citizens that paved the way for a billion addicted smokers in the world. As the Danish Institute for Human Rights concluded,
“there can be no doubt that the production and marketing of tobacco is irreconcilable with the human right to health.”
The tobacco industry violates human rights every day, and by allowing it governments fail in their duty to protect their citizens.
But let’s put aside what governments should have done before coronavirus and focus on what they should be doing now as we attempt to minimize disease and death during the pandemic. To reiterate, their first duty is to provide cessation services.
The second consideration is more complicated. As economies are partially shut down to increase social distancing and “flatten the curve” of the epidemic, governments are faced with deciding which activities are essential. Every business left open diminishes the impact of social distancing. Most governments have not thought about tobacco production and sales, which by default has meant that in most places it’s business as usual for the tobacco industry, since tobacco is sold in the same places that sell food and medicine and gasoline, which are unarguably essential.
Those governments that have directly faced the question of the tobacco industry have come to different conclusions. South Africa and Botswana, for example, have banned tobacco sales and production during the shut-down. France and Spain, on the other hand, have explicitly declared tobacco to be “essential.” Russia banned tobacco production but not sales, but then turned production back on to avoid a shortage. In the U.S., of course, tobacco is sold nearly everywhere, so it is still being sold nearly everywhere. Some jurisdictions, like Wisconsin, have at least forbidden home delivery of tobacco products, even from stores that can deliver other things.
The issue of whether to allow tobacco sales gets tricky, especially for people who don’t work in public health. On the one hand, tobacco is perhaps the consumer good furthest from “essential.” I’ve been unable to find a word in English that means the complete opposite of essential. “Unessential” or “unnecessary” don’t begin to describe how not essential tobacco is. On the other hand, some may perceive temporarily ending tobacco sales as somehow “mean” to smokers, and adding additional hardship, both to smokers and those employed in the tobacco commerce stream.
I think there are two other issues that come into play here. First, it is not simply that tobacco cannot be considered essential. We know that leaving it on the market exacerbates the COVID-19 pandemic, although we don’t have an exact understanding of the magnitude of the impact. As I mentioned, smokers are at much higher risk of hospitalization should they contract the virus. The data so far suggests that smokers are 14-fold more likely to be hospitalized. And while much of the damage to lungs can’t be undone immediately upon quitting, we know there are health benefits to quitting within days and even hours, and we also know that exposure to secondhand smoke can have rapid ill-effects on lungs. And of course, leaving the house to buy cigarettes undermines social distancing.
The second issue is nicotine addiction. This is one of the aspects that makes this discussion a bit different than some other “behavioral health risks.” With cigarettes, the thing that causes the addiction – nicotine – is not the thing that causes most of the harm to health – the smoke or vapor. And there are other sources of nicotine available. There are nicotine replacement products that are FDA-approved, widely available and often covered by health plans. Some are over the counter, and I doubt many doctors would object to writing a prescription over the phone. Nationwide, many pharmacies are offering free delivery during the pandemic.
No state in the U.S. has banned tobacco sales, and none have explicitly sanctioned sales. Some cigarette factories have been shut down, but to our knowledge this has been the decision of the tobacco industry, not governments. Two weeks ago, the New York State Academy of Family Physicians called on Governor Cuomo to temporarily ban tobacco sales. There is no indication the State of New York is seriously considering it.
As you may know, ASH has long espoused phasing out tobacco sales, as has been done in two cities in California. We call it Project Sunset, which plays off a tobacco industry scheme to renormalize smoking that they called Project Sunrise. This is a global effort, and it is gaining traction. We have not advocated immediate sales bans, but instead urge governments to put a plan in place that helps smokers quit and minimizes harm to small retailers. However, the pandemic is upon us, and governments have a choice to make. Ignoring the issue is a choice in itself. It seems clear that allowing tobacco sales to continue unfettered increases the damage of the pandemic while continuing the damage of the most lethal consumer product in history. Again, this is not the way we would have chosen to do it, but given the circumstances, ending sales is the far better of the two options.
One final thought, on what happens after the pandemic. In its call for a sales ban, the New York State Academy of Family Physicians made it clear that it should be only for the duration of the pandemic. We respectfully disagree. Governments have made a mistake by allowing tobacco sales for the past 70 years even as the knowledge of the disease and death it causes piled up. On the other side of the pandemic, in a place that has ended tobacco sales for weeks or months, what rationale can be given for re-allowing the sale and marketing of tobacco? If a new product came out tomorrow that was highly addictive and killed when used as intended, it would obviously be removed from shelves. Governments have been negligent in continuing to allow tobacco to be sold like any other product. To willfully re-allow tobacco sales, especially after a period of time in which many smokers would have finally succeeded in quitting, would be outrageous.