• advertising and promotion
• global health
• health services

The COVID-19 pandemic which originated in China in late 2019 has spread rapidly and taken much of the world by surprise, creating a health and economic emergency likely to have significant impacts for many years. The magnitude of the threat has forced both governments and businesses to urgently elevate public health above economic principles, adapt and reinvent in an attempt to contain the spread of the disease. Business closures have created sudden and widespread unemployment.1 2 Nationalisation of industries such as private healthcare3 and airlines4 has happened, or is being considered. Governments are pumping money into their economies through stimulus packages and income support, where previously austerity was the order of the day.5 6 In the private sector, car makers are pivoting to making medical equipment,7 alcohol companies are manufacturing hand sanitiser8 and digital transformation across many sectors is being fast-tracked,9 among other examples of business adaptation.10

The COVID-19 pandemic is an extraordinary event requiring extreme measures due to the potential for healthcare systems to be overwhelmed. However, the tobacco epidemic exerts a greater, sustained strain. At the time of writing, the global death toll from COVID-19 stood at just over 53 000,11 compared with over 8 million from tobacco use annually (including deaths attributed to secondhand smoke exposure).12 The cumulative death toll from tobacco use was 100 million during the 20th century and estimates indicate this could reach 1 billion this century.13 The number of COVID-19 deaths will likely continue to rise for many months, with the final toll dependent on how aggressively individual countries implement mitigation measures. In China, there have been just over 3300 COVID-19 deaths11 compared with approximately 1 million each year from tobacco.14 In Italy, which currently has the highest deaths per million of the population, there have been nearly 14 000 deaths from COVID-19,11 compared with 93 300 each year from tobacco.15 Both countries appear to be near the peak of COVID-19 infections, although there is the danger of a second wave. Nonetheless, the COVID-19 pandemic is likely to be short term, as a vaccine and effective treatments become available. COVID-19 is unlikely to ever match the relentless and growing annual toll from tobacco smoking.

Although limited, emerging evidence (unsurprisingly) suggests that smokers who are hospitalised for COVID-19 are at risk of more severe outcomes than non-smokers.16 Despite this, the tobacco industry appears unperturbed. According to British American Tobacco (BAT), consumers continue to purchase tobacco products, even in the hardest hit areas. BAT Chief Executive Officer Jack Bowles stated: ‘We don’t see any change in patterns of consumption of cigarettes because of Covid-19…It is a daily purchase, so consumers continue to go to shop, even in Italy and France where tobacco shops are still open.’17 (In some European countries, tobacconists were treated as essential retailers and excluded from general shutdowns.) His sentiment is backed by some investment analysts, who recommend tobacco stocks as a good buy during the COVID-19 market turmoil.18 19

The industry has not been completely immune to negative impacts of the virus: in March, Philip Morris USA suspended production at its Richmond manufacturing centre after two employees tested positive for COVID-19. Altria’s Vice Chairman and Chief Financial Officer Billy Gifford stated that the company is ‘committed to protecting the safety and well-being of our employees, contractors, their families and the communities where we operate’, and that the company has ‘been actively implementing plans to minimize business disruptions and their potential impact to our employees, consumers and customers’.20 The contradiction between shutting down to protect the community from a deadly virus, while minimising disruption to continue to produce the most lethal consumer product in history, is farcical. However, it raises a serious question: why should the tobacco industry continue during a pandemic which is fundamentally changing the world?

The case for phasing out cigarette sales has been clearly and persuasively argued.21 It takes on added urgency during this pandemic. The increased risk of severe outcomes for smokers hospitalised with COVID-19,16 and the reductions in hospitalisations generally that result from quitting smoking,22 23 may provide the impetus for restricting cigarette sales while health services are strained to the breaking point, as has been called for by the New York State Academy of Family Physicians.24 In one Australian state, alcohol sales have already been limited because the health service cannot spare the resources to address alcohol-related issues during this pandemic.25 COVID-19 shutdowns have enforced numerous constraints on people that restrict liberty and fulfilment of basic human needs. Strict physical distancing deprives people of physical, and in some cases meaningful social, contact. Exclusion from school impinges on one of the most basic rights of children, to receive an education. Panic buying has forced shops to limit purchases of staple foods. Many businesses that make positive contributions to society will not survive the economic consequences of these important public health measures. In contrast, tobacco retailing, which negatively impacts the health, social and economic well-being of communities, has no social licence.

For smokers, the changed social circumstances could provide an opportunity to quit smoking. Research shows that easy retail availability of tobacco products increases relapse among those trying to quit.26 Reduced or no availability of cigarettes would enhance these quit efforts. Given the role of social cues in relapse during quit attempts,27 self-isolation may make quitting easier for some, although there is a need to provide support for people to manage stress and mitigate mental health risks. Both mental health support and smoking cessation assistance should be treated as essential services and prioritised at this time of heightened stress, particularly for the most vulnerable who are at highest risk. Some quit support services are using this opportunity to promote quitting and support people to do so.28 In this context, now is an opportune time to move towards removing cigarettes from general retail sale. While there are major limitations on transport and movement of people, tobacco supply chains could be redeployed for more essential purposes. The increased control and scrutiny of movement of goods and people at this time would also likely make controlling illicit markets easier.

The tobacco cigarette pandemic is like COVID-19 in slow motion. The need to ‘flatten the curve’ is urgent. The fact that the tobacco epidemic curve is only partially flattened (in some countries) is widely accepted because the cigarette pandemic has been with us for so long, and the tobacco industry has been extraordinarily successful at conditioning the public and policymakers to accept it as a given. If governments had acted to protect the public from tobacco with a fraction of the effort (and financial investment) they have exerted to control this coronavirus, many millions of lives could have been saved, and underlying demand on health services significantly reduced.29 The world will emerge from the COVID-19 pandemic changed. Phasing out cigarette sales would be an enormous long-term gain for public health. However, it is essential to act quickly, because—like containing COVID-19—delaying decisive action will cost many lives.