26 October 2020
John P A Ioannidis and Prabhat Jha, The Lancet Global Health:
Tobacco use is the top modifiable global health problem, but the global tobacco market grows 3% annually. Most anti-tobacco measures to date target demand (eg, higher excise taxes). However, the endgame might require reducing supply. 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.Furthermore, key conditions that predispose to poor COVID-19 outcomes (eg, vascular, neoplastic, and respiratory diseases) 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. 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.
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). 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. Most growers and home workforce are underpaid and openly exploited by tobacco manufacturers.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 diseases
is similar to the number becoming impoverished from the COVID-19 response this year.
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.
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. More than $50 billion dollars a year of profit ($10 000 per tobacco death) 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). 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.