Q & A on tobacco use, including waterpipe use and COVID19 in EMRO

Increased risk of COVID-19 infection amongst smokers and amongst waterpipe users
March 13, 2020
What do we know about COVID-19?
March 16, 2020

Questions and answers on tobacco use, including waterpipe use and COVID19 in the Eastern Mediterranean Regioni

What are the possible relations between tobacco use and the COVID19 epidemic?

Any kind of tobacco smoking is harmful tothe bodily systems, includingthe cardiovascular and respiratory systems[1][2]. COVID-19 can also harm these systems. Information fromChina, where COVID-19 originated, shows that people who have cardiovascular and respiratory conditions caused by tobacco use, or otherwise,are at higher risk of developingsevere COVID-19 symptoms[3]. Research on 55,924 laboratory confirmed cases in China shows that the crude fatality ratiofor COVID-19 patients is much higher among those with cardiovascular disease, diabetes, hypertension, chronic respiratory disease or cancer than those with no pre-existing chronic medical conditions[4]. Thisdemonstratesthat these pre-existing conditions may contribute to increasingthe susceptibility of such individuals to Covid-19.

Tobacco has a huge impact on respiratory health. The link between tobacco use and lung cancer is well-established, with tobacco use beingthe most common cause of lung cancer[5]. It alsosubstantially increases the risk of tuberculosis infection[6]. Further, tobacco use is also the most important risk-factor for chronic obstructive pulmonary disease (COPD), causing the swelling and rupturing of the air sacs inthe lungs, which reduces the lung’s capacity to take in oxygen and expel carbon dioxide, and the build-up of mucus, which results in painful coughing and breathing difficulties[7][8][9]. This may have implications for smokers, given thatsmoking is considered to be a risk factor for any lower respiratory tract infection[10]and the virus that causes COVID-19 primarily affects the respiratory system,often causing mild to severe respiratory 2damage[4]. However, given that COVID-19 is a newly identified disease, thelink between tobacco smoking and the diseasehas yet to be established.

There isan increased risk of more serious symptoms and death among COVID-19 patients that have underlying cardiovascular diseases (CVDs)[11][12]. According to the available evidence the virus that causesCOVID-19 (SARS-CoV-2) is from the same family as MERS-CoV and SARS-CoV, both of whichhave been associated with cardiovascular damage (either acute or chronic) [13][14]. Research has shown COVID-19 patients in China with CVDs are at greater riskof more severe symptoms[15]In addition, there is evidence that COVID-19 patients that have more severe symptoms often have heart related complications[16].This relation between COVID-19 and cardiovascular health is important because tobacco use and exposure to second-hand smoke are major causes of CVDs globally[17]. The effect of COVID-19 on the cardiovascular system could thus make pre-existing cardiovascular conditions worse. In addition, a weaker cardiovascular system among COVID-19 patients witha history of tobacco use could make such patientssusceptible tosevere symptoms,therebyincreasingthe chance of death[18].

How can use of waterpipe contribute to the spread of COVID19?

Waterpipes aretobacco products [19]and their use has both acute and long-term harmful effects on the respiratory and cardiovascular systems [20], likely increasing the risk of diseases including coronary artery disease and chronic obstructive pulmonary disease[21].

The communal nature of waterpipe smoking means that a single mouthpiece and hose areoftenshared between people, especially in social and communal settings[22]. In addition, the waterpipe apparatus (including the hose and chamber) itself may contribute to this risk by providing an environment that promotes the survival of microorganisms outside the body. Most cafés tend not to clean the waterpipes after each smoking session because washing and cleaning waterpipe parts is labour intensive and time consuming[23][24].These factorsincrease the potential for the transmission of infectious diseases between users[20].Consistent with this, evidence has shown that waterpipe use is associated with an increased risk of transmission of infectious agents such as respiratory viruses, hepatitis C virus, Epstein Barrvirus, Herpes Simplex virus, tuberculosis, Heliobacter pylori, and Aspergillus[25][26][27][28][29][30]. Social gatherings provide ample opportunityfor the virus that causes COVID-19 to spread [31].

Since waterpipe smoking is typically an activity that takes place within groups in public settings[22]andwaterpipe use increasesthe risk oftransmission of diseases, it could also encourage the transmission of COVID-19 insocial gatherings. When this smoking takes place in indoor areas, as it does in many places, the risk could be higher.

Will strengthened tobacco control measures help in this context?

In 2008, WHO introduced theMPOWER technical package,which is based on key tobacco demand reduction articles of the WHO Framework Convention on Tobacco Control (WHO FCTC),as follows:

  • Monitor tobacco use and prevention policies
  • Protect people from tobacco use
  • Offer help to quit tobacco use
  • Warn about the dangers of tobacco
  • Enforce bans on tobacco advertising, promotion and sponsorship
  • Raise taxes on tobacco.

Strengthened tobacco control measures including tobacco free public places and protection of people from second hand smoke as per the WHO FCTC Article 8 and its Guidelines will reducethe risk of suffering from severesymptoms. Lower tobacco use will reduce rates of many respiratory and cardiovascular conditions that are strongly associated with more serious COVID-19 symptoms and mortality.

Reducing the demand for tobacco products, including waterpipe, could also indirectly discourage the social gatherings that contribute to the spread of the virus.ú

Good respiratory and cardiovascular health is important for a COVID-19 patient topositivelyrespond and successfully recover from the disease.

Specifically regarding waterpipe usage, since it is often overlookedin tobacco control efforts, there is a significant opportunity for positive health outcomes at this time, both with respect to COVID-19 and generally, if immediate comprehensive tobacco control measures are takenthat include the control of waterpipe.

Countries can use the WHO’s highly effective MPOWER policy package to support their formulation and implementation of tobacco control measures.

How can regional tobacco control legislation support the limitation of the virus spreading?

The same considerations thatapply to tobacco control globally as per the WHO FCTC and the MPOWER policy packagealso apply to tobacco control within the Eastern MediterraneanRegion (EMR). Countries should seek to limit the use of waterpipe and other tobacco use in order to reduce its well documented health impactand improve people’s respiratory and cardiovascular health.

Controlling tobaccouse and reducing waterpipe usemay be important for reducing the risk of the transmission of the virus that causes COVID-19.It is important that the control of waterpipe use is taken especially seriously at this timeand within a comprehensive approach to control all tobaccouse in light of WHO FCTC obligations and MPOWER policy recommendations.

In general, WHO recommends that countries fully implementthe WHO FCTC and the MPOWER policy package.This includes a comprehensive ban onall forms of tobacco use,includingwaterpipe, in all public places (incl. cafes and restaurants).Such a ban may help prevent anyincreased risk of transmission of the virus that causes COVID-19 that may be related to tobacco use. Countries should ensure that this ban is fully enforced.

Why is this a good time to try and quit tobacco use?

Tobacco use dramatically increases the risk of many serious health problems, including both respiratory problems (like lung cancer, TB and COPD) and cardiovascular diseases. While this means that it is always a good idea to quit tobacco use, quitting tobacco use may be especially important at this time to reduce the harm caused by COVID-19.Tobacco users areprobably less likely to become infected if they quit because the absence of smoking helps reduce the touching of fingers to the mouth. Also, it is possible that they would better manage the comorbid conditionsifthey become infectedbecause quitting tobacco use has an almost immediate positive impact on lung and cardiovascular function and these improvements only increase as time goes on[10]. Such improvement may increase the ability of COVID-19 patients to respond to the 5infection and reduce the risk of death. Faster recovery and milder symptoms also reduce the risk of the transmission of the disease to other people.

What are the key lessons learnt from previous experiences?

From previous experience in responding to MERS-Cov and SARS-CoV, general precautions should be taken,especially in social gatherings[31].

Waterpipes may bea catalyst for social gatherings in environments thatcould increase disease transmission.

Previous evidence showsthatsmoking has adverse effects on the survival of individuals with infectious diseases[32]and evidence from otheroutbreaks caused by viruses from the same family as COVID-19 suggeststhat tobacco smoking could, directly or indirectly, contribute to an increased risk ofinfection,poor prognosis and/or mortality for infectious respiratory diseases[33][34].

What is next??

This document is based on the most updated available evidence.

Evidence is still evolving and the document will be subject to updates in light of any new emerging evidence. Regularlywe will look into the new available evidence and update the document.

In the context of COVID19 countries are encouraged to take the needed action to protect the public from the devastating health consequences of tobacco use in light of their international commitments under the WHO FCTC and WHO recommendations.


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i Note: Many countries in the Eastern Mediterranean Region have reported cases of COVID-19. The WHO is actively involved in supporting Member States prepare and respond to the outbreak. Further regularly updated information about COVID-19 and the WHO’s work can be found here: http://www.emro.who.int/health-topics/corona-virus/index.html

For information on countries that took action to strengthen tobacco control in light of COVID19 please contactTobacco Free Initiate WHO EMRO emrgotfi@who.int


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March tobacco use and COVID 19 updated