The continued ban on cigarette sales during lockdown appears to be a bone of considerable contention. From a general health perspective, the message is pretty clear – smoking is bad for you, and at Health24, we agree – the studies are clear, and we have a section dedicated to stopping smoking – here.
This stance won’t change, but, in relation to this unprecedented period in our history, we are still not clear on the relevance of this ban to the lockdown.
From a business perspective, the Fair-Trade Independent Tobacco Association (FITA) – a body representing cigarette manufacturers – recently said it would be pursuing court action to have the ban during lockdown lifted.
"Our mere request is that government authorise, at a minimum, the distribution and sale of cigarettes at retail stores, spaza shops and filling stations where citizens are currently permitted to purchase what has been classified as essential goods, FITA chairperson Sinenhlanhla Mnguni said.
Earlier this month Fin24 reported that SA tobacco manufacturer British American Tobacco South Africa (BATSA) warned that as many as 11 million smokers could decide to defy the ban. Since then, many people have been arrested and cigarettes worth hundreds of thousands of rands have been confiscated by the police.
In a column on News24 on 21 April, Mandy Wiener also raised some very relevant points, foremost of which was, “… while Trade and Industry Minister Ebrahim Patel, Health Minister Zweli Mkhize and Police Minister Bheki Cele have all made public comments on the ban of cigarettes, none have explicitly given an explanation as to why this is happening.”
And that’s what we also want to know - what’s the reasoning behind the continued ban?
The word draconian crops up regularly, to describe the ban – frankly, warnings regarding smoking have been around for years, it’s front and centre on packaging, yet people still choose to smoke.
So, why has this choice been taken away? We reached out to a few medical experts to find out more.
The health minister’s take on smoking amid the coronavirus crisis
But first, we looked at the health minister’s most recent comments – and also reached out to the health department.
On 18 April, Health Minister Zweli Mkhize, during a briefing, was asked about smoking and the coronavirus.
According to a News24 report, the minister said "It is something we discourage. Once you have Covid-19 as an added infection, we believe that those who smoke are vulnerable because Covid-19 affects the capacity of the lung to be able to process the normal day-to-day exchange of gasses in the lungs.
“I still have to find a good beneficial action that the tobacco has in an individual. In general terms, we discourage people from smoking and more so with this Covid-19," said Mkhize, further stating: "We have been talking about active smoking and passive smoking. It induces so many conditions and other conditions which are related to pulmonary diseases, or chest-related symptoms.
"The problem with smoking is that it tends to affect the lining where people breathe and creates some reactions. In some instances, it can provoke a reaction where someone's lining is irritated and becomes easy to get infected," he said.
More and more studies are showing that Covid-19 does seem to be worse in smokers who are infected with the virus – and the minister is certainly correct in referring to the general stance on smoking.
But we wanted to know more about the specific relevance to lockdown.
What the department of health says about smoking and lockdown
According to the National Department of Health, one of the main reasons behind the maintenance of these strict measures was decided after considering the culture of sharing cigarettes with others and consequently increasing the risk of the Covid-19 virus spreading.
"In many poor communities, the practice of smoking is highly prevalent. In doing so, the risk of spreading Covid-19 through the sharing of cigarette smoking is very high,” Spokesperson for the Department of Health (DoH), Popo Maja told Health24, adding: “Similarly, people share a bottle of beer or wine. There was a careful consideration from a public health perspective when these measures were taken."
So, what do the medical experts think?
Covid-19, smoking and the lockdown: what the experts say
Health24 reached out to to five top experts for their take on smoking, Covid-19 and the sales ban during lockdown.
For Professor Keertan Dheda, Head of Division of Pulmonology at the University of Cape Town, preliminary studies serve as sufficient evidence to curtail smoking during the pandemic:
“Preliminary studies indicate that smoking is associated with upregulation of the ACE-2 receptor, which is the human binding site for the SARS-CoV-2 virus in the respiratory tract. Smoking, through subversion of protective immunity, increases the susceptibility to many respiratory tract infections including influenza, bacterial pneumonia, and tuberculosis (TB), and clinical outcomes in smokers with respiratory tract infections, including TB, are worse.
“Through the same mechanisms, smoking increases the burden of pneumonia and would therefore drive increased utilisation of hospital facilities and the need for respiratory support, especially in people with pre-existing lung disease like COPD,” explains Dheda.
Dheda added that smoking is associated with chronic lung and heart disease – which are major risk factors for worse outcomes in patients with Covid-19.
“On the non-medical side of things, the need for large numbers of smokers to purchase cigarettes would likely intensify social mixing in shops and the need for public transport,” says Dheda.
“Smoking is also characterised by repetitive hand-to-mouth movements which may facilitate transmission of Covid-19.
“Finally, it needs to be borne in mind that with large numbers of smokers being at home, there will be increased exposure of children and family members to second-hand smoke. If one is thinking of doing so, this is probably a very good time to quit.”
Associate Professor Richard van Zyl-Smit, Consultant Pulmonologist at Groote Schuur Hospital, University of Cape Town, shares the same view, also pointing to the evidence: “There is no question that smoking is bad for your health – there is very strong evidence that smoking increases your risk for influenza – by impacting your lung’s defenses against viral infection.
"This, in addition to pneumococcal pneumonia and TB infection, which has been known for many years. There is emerging data that smoking is also a risk factor for SARS-CoV-2 infection and potentially severe Covid-19 respiratory disease. Not smoking at this time or stopping smoking is a very good option, always – but especially at this time,” says van Zyl-Smit.
A small study of 78 patients with Covid-19 pneumonia in Wuhan this year listed the history of smoking as one factor contributing to poorer patient outcomes, notes this Health24 article.
Another study which involved up to 1 099 Covid-19 patients and was published in March, linked smoking to a negative progression and adverse outcomes of Covid-19.
Good intentions, bad idea?
Professor Sean Wasserman, Infectious Diseases Specialist at Groote Schuur Hospital, University of Cape Town, added that enforcing strict bans on the sale and distribution of cigarettes during this time allows for social and economic activities only for essential purposes, to continue.
“The benefits of this level of enforcement are debatable. Clusters of local transmission at grocery stores is very possible, and reducing physical interaction in these environments would be an important intervention,” Wasserman says, although not ignoring the consequences of such a decision.
Wasserman added: “On the other hand, despite being effective at slowing community transmission, strict lockdowns clearly have profoundly negative impacts on society and the incremental benefit of smoking bans may not outweigh the potential harms (psychological, domestic violence, black market trading, etc.).”
Professor Wolfgang Preiser, Head of the Division of Medical Virology at the University of Stellenbosch, feels that the DoH’s arguments are fair and is clever thinking, but wonders what remains:
“Smoking is probably a risk factor for more severe Covid-19, but I do not know how soon any damage from long-term smoking would be undone. I presume that is many months, if not years – not a few weeks.
“It may be to do with general health improvements or to avoid social gathering and frequent going out to get more cigarettes. I suppose one argument would be that in contrast to food, tobacco is not essential – but where to draw the line?”
Professor Shaheen Mehtar, Infection Prevention and Control (IPC) Specialist at Tygerberg Hospital, Stellenbosch University, expressed that while smokers may have a higher risk of complications from Covid-19, banning the sale of cigarettes is not going to change that necessarily.
“Wouldn’t it be better to then ask smokers to conduct themselves in a particular manner during the outbreak, in that they should be instructed not to share? If adults understand the risk of sharing cigarettes, I am sure they will try to avoid getting infected,” Mehtar told Health24.
The South African Drug Policy Initiative (SADPI) also called for the ban on the sale of alcohol and tobacco to be reversed last month, saying that authorities "have erred" in their decision to impose the ban, News24 reported.
In a statement, the SADPI presented two reasons for their belief: that the sales ban will be harmful to those suffering from substance use disorders, in that, should they need support, already-understaffed health services won’t be available to assist them. Those trying to get their fix will also have to break the law by obtaining them through illicit means, and run the risk of being arrested – the second reason they argued in their statement.
But, despite all the expert input, and some very valid points, there still doesn't seem to be a definitive answer relating to the ban and lockdown.
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