Dr Sudhanshu Patwardhan is a UK based licensed medical doctor, an MBA from the London Business School and the Director of Policy at the Centre for Health Research and Education.

In an article published on Wednesday 8 April in the BJGP Open, Dr Pooja, practising GP and Medical Director at the Centre for Health Research and Education (CHRE), highlighted her concerns of the unintended consequence of increased smoking incidence during covid and proposed pragmatic approaches to minimise those. Here, Dr Sudhanshu Patwardhan summarises the key points from the article and answers questions on smoking and coronavirus.

As COVID-19 rages on, how urgent is it to discuss smoking rates and relapse to smoking?

Its urgent and more important than ever!

As the world goes into lockdown, economic uncertainty, self-isolation and social distancing are bound to make society very lonely and life very stressful in the short to the medium term. This could be a key trigger for smoking relapse among ex-smokers and increased smoking among current smokers. Not only that, but the specific increased dangers that smoking brings to this covid epidemic makes the mission to reduce this habit all the more necessary. Lives could be at stake otherwise.

How do you know that with certainty?

Can we be absolutely sure. No! But as responsible experts in public health and smoking cessation, we need to flag the strong likelihood of this happening before it becomes a public health catastrophe overlaid on a nasty pandemic.

There is plenty of evidence and literature on the emotional triggers for smoking and relapse. Covid-related stress, isolation, boredom and unemployment are very likely to cause a relapse among ex-smokers worldwide, and an increase in smoking among current smokers. Our team of doctors and stop-smoking experts are working with senior economists from the University of Southampton to build a predictive model based on triggers of smoking. Our team will be working with data emerging from around the world in the coming months to test the model and better inform policymakers globally.

Why does the covid threat increase if you smoke?

Smoking will cause a billion premature deaths worldwide in this century due to smoking related cancer, heart disease and lung disease. These numbers will only rise from the added risk of covid for the following reasons:

  1. Coronavirus is known to attack the lungs which can develop into covid related pneumonia in severe cases. The government has clearly outlined those who may be at a higher risk, including the elderly and people with pre-existing medical conditions such as asthma or diabetes. Emerging data suggests that current smokers will have worst outcomes from covid due to pre-existing lung damage. Covid binds to cells in the lungs as it enters the body, which in severe cases, can eventually make it more and more difficult to breath. Additional oxygen obstructers such as smoking, reduces oxygen delivery to the lungs only adding to the breathing difficulty. Smoking is now being shown to be likely to make covid symptoms much worse.
  2. People who smoke regularly and for some years are more likely to have higher rates of hypertension, ischaemic heart disease, problems with their circulation, and chronic lung disease (lung damage and decreased lung capacity), all of which on their own are risk factors for severe covid complications.
  3. Beyond lung damage, there is also an added transmission risk. Smoking involves many finger-to-cigarette-to-mouth movements which may result in further spreading of the virus.

Can you explain how many current and ex-smokers are at risk and why?

In England alone, covid threatens to trigger a relapse to smoking among 11 million ex-smokers as well as increased smoking rates among the 6 million current smokers. Unfortunately, with the isolation policy, any local face to face stop smoking support will not be available to people who are currently in the middle of their quitting journey. Worldwide numbers are in the hundreds of millions. That’s a real public health emergency.

Stress and worsening mental health are known predisposing factors for increased smoking (quantity and frequency) as well as relapse. Covid brings health and economic uncertainties with it. The feeling of helplessness will be pronounced when the usual comfort of sharing worries and stresses of life with friends and extended family are not available anymore. Social isolation is bound to negatively impact the mental health of the population.

There may be people who have cut down smoking as they are not allowed to smoke in their workplace. There will be ex-smokers who have successfully quit smoking by going to the gym or joining a local sports group to help them. These and so many other ways that people may have used to shift towards a healthier lifestyle may just suddenly be inaccessible in their lives.

With the treasury estimation of over 3 million workers likely to be furloughed by their employers in the UK alone, a record numbers of people will be staying at home; anxious and stressed. Worldwide, the rise in unemployment due to covid and the resulting poverty and economic uncertainty could see millions more turning to smoking.

What can be done by policymakers and healthcare professionals around the world to support smokers and ex-smokers in the times of covid?

Worldwide, national agencies and the World Health Organisation need to ensure that covid-related messaging does not replace opportunities and support for reducing the smoking related burden of the society.

A clear message needs to reach all smokers, ex-smokers and their healthcare advisors: these are understandably stressful times but smoking is not a solution.

People need to know that a) they may be at risk of relapsing back into smoking b) it is natural to have these urges, but support is available for trying to reduce its influence. What I suggest should be included on all covid-related government advice to the public and on healthcare providers’ websites (e.g. hospitals, GP surgeries etc) is:

1. To warn people of this impending risk of relapse and increased smoking

2. Give a variety of evidence-based strategies on staying smokefree, like ensuring easy access to available stop-smoking aids like nicotine replacement gums, nicotine mouth sprays and e-cigarettes (for e-cigarettes: in countries where they are legal and adequately regulated for safety, quality and sales to smoking adults only).

3. signposting to the resources available on the internet, e.g. NHS Smokefree website and apps (www.nhs.uk/smokefree) in the UK or relevant national resources.

Based on our experience in smoking cessation projects globally, we believe that timely, brief and opportunistic advice by healthcare professionals and government agencies may have the potential to avert the unintended and disastrous consequence of increased smoking during this epidemic.

ABOUT CHRE:

The Centre for Health Research and Education (CHRE) is an international centre of excellence of a growing team of healthcare professionals dedicated to global cancer prevention, with smoking cessation as a primary focus area. CHRE is based at the University of Southampton Science Park, Chilworth, Hampshire.

ROLE OF FUNDING SOURCE AND CONFLICTS OF INTEREST

SP is a paid director of CHRE and provides mentoring for young researchers in smoking cessation and harm reduction.

SP or CHRE do not receive any funding from pharmaceutical, electronic cigarette or tobacco industries.