Does the COVID-19 pandemic provide an opportunity to eliminate the tobacco industry?
Authors: John P A Ioannidis, Prabhat Jha
Journal: The Lancet Global Health (2020)

Tobacco use is the top modifiable global health problem,1Jha P The hazards of smoking and the benefits of cessation: a critical summation of the epidemiological evidence in high-income countries.Elife. 2020; 9e49979Crossref PubMed Scopus (64) Google Scholar, 2Jha P Peto R Global effects of smoking, of quitting, and of taxing tobacco.N Engl J Med. 2014; 370: 60-68Crossref PubMed Scopus (523) Google Scholar but the global tobacco market grows 3% annually.3Grand View ResearchTobacco market size worth $1.08 trillion by 2027.https://www.grandviewresearch.com/press-release/global-tobacco-marketDate: May, 2020Date accessed: October 14, 2020Google Scholar Most anti-tobacco measures to date target demand (eg, higher excise taxes). However, the endgame might require reducing supply.4Ioannidis JP Henriksen L Prochaska JJ Endgame: engaging the tobacco industry in its own elimination.Eur J Clin Invest. 2013; 43: 1366-1370Crossref PubMed Scopus (10) Google Scholar, 5Hefler M Gartner CA The tobacco industry in the time of COVID-19: time to shut it down?.Tob Control. 2020; 29: 245-246PubMed Google Scholar The main counterarguments are financial (eg, economic damage or lost jobs) and defences of personal choice. Most importantly, public health has little experience in enforcing major changes that disrupt markets. The ongoing societal response to COVID-19 offers a precedent for drastic action taken to eliminate the tobacco industry. COVID-19 is a natural experiment: expedient public health considerations have led to decisions being made that have important socioeconomic repercussions. The cumulative disease burden of COVID-19 is large but uncertain. However, if COVID-19 actions were deemed defensible, the risk–benefit ratio for actions to eliminate tobacco is far more favourable. Even under the most pessimistic projections, COVID-19 fatalities are well below the perpetuated burden of tobacco deaths. Moreover, COVID-19 kills mostly older people with multiple underlying diseases, whereas half of tobacco deaths occur in people aged 30–69 years.1Jha P The hazards of smoking and the benefits of cessation: a critical summation of the epidemiological evidence in high-income countries.Elife. 2020; 9e49979Crossref PubMed Scopus (64) Google Scholar, 2Jha P Peto R Global effects of smoking, of quitting, and of taxing tobacco.N Engl J Med. 2014; 370: 60-68Crossref PubMed Scopus (523) Google Scholar Furthermore, key conditions that predispose to poor COVID-19 outcomes (eg, vascular, neoplastic, and respiratory diseases)6Williamson EJ Walker AJ Bhaskaran K et al.Factors associated with COVID-19-related death using OpenSAFELY.Nature. 2020; 584: 430-436Crossref PubMed Scopus (3634) Google Scholar are largely related to smoking. Measures taken to prevent the spread of COVID-19 have disrupted multiple sectors of the economy quickly and deeply, including travel, tourism, restaurants, entertainment, and retail. The cumulative share of these markets before COVID-19 far exceeded the US$1 trillion tobacco market.3Grand View ResearchTobacco market size worth $1.08 trillion by 2027.https://www.grandviewresearch.com/press-release/global-tobacco-marketDate: May, 2020Date accessed: October 14, 2020Google Scholar In the second quarter of 2020, the US gross domestic product declined by 33%, according to the US Bureau of Economic Analysis. Concurrently, a 12% year-to-year decrease in the eurozone (ie, countries that have adopted the Euro as primary currency) was recorded. Rebound is uncertain. Any further lockdown measures could compound this damage. Moreover, COVID-19 will probably be time-limited, whereas tobacco causes at least 5–6 million deaths (and increasing) every year.2Jha P Peto R Global effects of smoking, of quitting, and of taxing tobacco.N Engl J Med. 2014; 370: 60-68Crossref PubMed Scopus (523) Google Scholar Even if all 100 million tobacco-related jobs were lost, this number is still much lower than the number of jobs lost by lockdown measures for COVID-19 worldwide (400 million full-job equivalents in the second quarter of 2020 alone).7McKeever V The coronavirus is expected to have cost 400 million jobs in the second quarter, UN labor agency estimates.https://www.cnbc.com/2020/06/30/coronavirus-expected-to-cost-400-million-jobs-in-the-second-quarter.htmlDate: June 30, 2020Date accessed: October 19, 2020Google Scholar Moreover, of 100 million people among the tobacco workforce, manufacturing accounts for only 1·2% of jobs. 40 million people work in tobacco-growing and leaf-processing, 20 million work in home industries, and the remaining people work on distribution, sales, and promotion.8International Labour OrganizationUp in smoke: what future for tobacco jobs?.http://www.oit.org/global/about-the-ilo/newsroom/features/WCMS_071230/lang--en/index.htm#:~:text=Some%20100%20million%20people%20are,prospects%20for%20tobacco%20workers%20worldwideDate: Sept 18, 2003Date accessed: October 14, 2020Google Scholar Most growers and home workforce are underpaid and openly exploited by tobacco manufacturers.8International Labour OrganizationUp in smoke: what future for tobacco jobs?.http://www.oit.org/global/about-the-ilo/newsroom/features/WCMS_071230/lang--en/index.htm#:~:text=Some%20100%20million%20people%20are,prospects%20for%20tobacco%20workers%20worldwideDate: Sept 18, 2003Date accessed: October 14, 2020Google Scholar A safety net could be provided during a transition period to reduce poverty, similar to those activated for COVID-19-related unemployment. Tobacco use contributes to poverty. The number of people worldwide who fall below the poverty line annually because of catastrophic health expenses from tobacco-attributable diseases9Global Tobacco Economics ConsortiumThe health, poverty, and financial consequences of a cigarette price increase among 500 million male smokers in 13 middle income countries: compartmental model study.BMJ. 2018; 361k1162Crossref PubMed Scopus (6) Google Scholar is similar to the number becoming impoverished from the COVID-19 response this year.10Mahler DG Lakner C Castaneda Aguilar RA Wu H Updated estimates of the impact of COVID-19 on global poverty.https://blogs.worldbank.org/opendata/updated-estimates-impact-covid-19-global-povertyDate: June 8, 2020Date accessed: October 14, 2020Google Scholar Elimination of the tobacco industry would require huge efforts for counselling, cessation support, and dealing with short-term nicotine withdrawal among addicted smokers, which presents an opportunity for serious efforts to scale up cessation.11Gollust SE Schroeder SA Warner KE Helping smokers quit: understanding the barriers to utilization of smoking cessation services.Milbank Q. 2008; 86: 601-627Crossref PubMed Scopus (74) Google Scholar A transition period over a few years might allow gradual but decisive decline and eventual elimination of smoking, and could address smuggling. The net number of jobs lost would be few. Money spent on tobacco is spent on other goods and services that generate employment. Previous other technological disruptions (eg, ice blocks or typewriters) ended whole subsectors reasonably quickly. The biggest beneficiaries would be the poorest populations: elimination of smoking would sharply decrease social inequalities in mortality.9Global Tobacco Economics ConsortiumThe health, poverty, and financial consequences of a cigarette price increase among 500 million male smokers in 13 middle income countries: compartmental model study.BMJ. 2018; 361k1162Crossref PubMed Scopus (6) Google Scholar During the COVID-19 pandemic, sectors of the economy that have few adverse effects on health—eg, airlines, restaurants, tourism, and entertainment (excepting their effect on climate change)—have been sharply curtailed. The demise of these industries would lead to a more impoverished world. Conversely, the tobacco industry has done quite well reputationally during the pandemic and is even utilising the COVID-19 crisis to its advantage.5Hefler M Gartner CA The tobacco industry in the time of COVID-19: time to shut it down?.Tob Control. 2020; 29: 245-246PubMed Google Scholar More than $50 billion dollars a year of profit ($10 000 per tobacco death)2Jha P Peto R Global effects of smoking, of quitting, and of taxing tobacco.N Engl J Med. 2014; 370: 60-68Crossref PubMed Scopus (523) Google Scholar enable the tobacco industry's powerful public relations, marketing, and scientific arms to present themselves in a bright light, including donations of cash, protective equipment, ventilators, and other health support to governments and health-care systems, and aggressive marketing of new products. Until now, only Bhutan has tried banning cigarettes, with mixed effects (eg, oral tobacco use remains high).12World Health OrganizationFactsheet: Bhutan.https://apps.who.int/iris/bitstream/handle/10665/272671/wntd_2018_bhutan_fs.pdf?sequence=1Date: 2018Date accessed: October 19, 2020Google Scholar This situation might radically change in the COVID-19 era. We acknowledge that bans on tobacco products overnight might meet public resistance (reducing the currently high support for tobacco control, even among smokers). In litigation-heavy societies (eg, the USA), there might be court challenges. A realistic strategy would be to set a clear future date when sales would be banned, with a transition period of heavily taxed sales only through prescribed government shops. Another helpful strategy might be to buy out tobacco cultivators in producing countries and to impose growing restrictions on imports for other countries. Concerns about smuggling would naturally arise. However, large-scale smuggling can be effectively countered. The exact sequence and details on measures might vary across different countries, aiming to maximise their acceptability. The WHO Framework Convention on Tobacco Control and the Paris Agreement offer models to build the necessary global cooperation to eliminate the tobacco industry. The COVID-19 pandemic and response could shape a new world, with losers and winners, as have past epidemics. It will be devastating if the tobacco industry emerges as a winner from this global event, ameliorating its reputation and increasing sales. Conversely, now that major decisions and actions for health are acceptable under exigency, an unique opportunity exists to eliminate the tobacco industry. We declare no competing interests. The Meta-Research Innovation Center at Stanford has been funded by the Laura and John Arnold Foundation.