American Univesity of Beirut

Double trouble: Smoking and COVID-19

​​Commentary | Dr. Rima Nakkash 

There is no doubt that COVID-19 poses new challenges for governments and humanity as a whole. We are all grappling with this new reality in our personal and working lives. In Lebanon, where smoking is highly prevalent and where waterpipe tobacco smoking, especially among the young, is common, we must ask whether COVID-19 should change the way smokers think about the risks? And what role governments have to play in tobacco control once the pandemic passes?

Tobacco smoking – of cigarettes, waterpipe and other products – leads to death and disease. In fact, in one year alone, tobacco use kills 8 million people. All these deaths are preventable by simply not consuming any tobacco.

In Lebanon, cigarette smoking rates are high and there are surprisingly high rates of waterpipe tobacco smoking particularly among the younger age groups. A recent national household survey conducted in Lebanon (data unpublished yet) documented among adults 18 years or older, a current cigarette smoking prevalence rate of 48.6 percent among males and 21.5 percent among females and a prevalence rate of current waterpipe smoking of 32.7 percent among males and 46.2 percent among females.

Cigarettes and waterpipe tobacco contain nicotine and can lead to addiction. Decades of research – much of it coming from Lebanon and our Arab region – have confirmed that waterpipe tobacco smokers face many of the same health risks as cigarette smokers. Waterpipe tobacco smoking contains heavy metal emissions such as lead, chromium, nickel, and arsenic as well as high levels of carbon monoxide (CO). These cause harm to many organs in the body mainly the respiratory and cardiovascular systems, and leads to cancers (such as in the lungs and stomach).

Harm from cigarette and waterpipe tobacco smoking are not only limited to the smoker. Secondhand smoke from cigarettes and waterpipe tobacco smoking are known to cause cancer. A pregnant mother can harm her unborn child if she continues to smoke. Cigarette and waterpipe tobacco smoking have been linked to low birthweight, pulmonary complications, and infant mortality. For waterpipe tobacco smoking, the spread of communicable/infectious diseases is also possible. Bacterial contamination found in the various parts of the waterpipe (e.g. mouthpiece, hose, etc) include staphylococci, Streptococcus spp, and Escherichia coli. The risk for transmission of infections through waterpipe tobacco use is real.

With the advent of the pandemic, one key question is: What is the impact of tobacco use on COVID-19 morbidity and mortality? Research has shown that tobacco use increases the risk of dangerous outcomes of COVID-19. Smoking leads to a more severe illness and greater mortality related to COVID-19, especially in those with heart and lung disease. Because of the damage that smoking has on the lungs, this renders the lungs less able to cope with additional injury. In addition, smoking affects the immune system making smokers more vulnerable to a variety of infectious diseases, possibly including COVID-19.

In light of such evidence, the World Health Organization has issued a warning that “smoking damages the lungs and other parts of the body and increases risks of getting a severe case of COVID-19." For that reason alone, it may be an opportune time to consider quitting smoking given the double trouble of tobacco use with COVID-19. Quitting smoking has individual, social and economic impact and can alleviate stresses on the health care system in the short and long run.

However, in addition making COVID-19 outcomes worse, tobacco use also can increase the risk of acquiring the COVID-19 infection. How? For waterpipe, if the device is shared, the virus can be lurking in the hose or on the mouthpiece or in various other places on the device. Waterpipe preparation also entails a lot of human hand contact, which can transmit the disease, and the virus is known to remain on surfaces for hours or days. Cigarette smoking involves repetitive hand-to-mouth movements, a known conduit to infection. When people smoke both waterpipe and cigarette, the risk of transferring the virus in the ways described above is largely increased. Specifically, for waterpipe smoking, smokers should consider that:

  • Changing the mouthpiece and the hose or use of disposable parts does not eliminate potential risk from infection because the virus can stick to the other various parts of the waterpipe made of a mix of different material, or in the water bowl. Risk of transmission will persist.

  • Sharing the waterpipe at home also does not eliminate risk since the persons you might share with at home can be asymptomatic but still transmit the virus.

  • As noted above, use of any tobacco product makes impact of COVID-19 worse.

  • To reduce your risk, you should consider quitting and ask your physician for advice.

In addition to individual level action to decrease tobacco use, the government has a responsibility to create a supportive and enabling tobacco free environment.

Though Lebanon in 2011 passed comprehensive tobacco control legislation (Law 174) that has the potential to decrease loss, illness and death from tobacco use, political commitment to implement the law has been very weak. Ironically, this month the Regie donated to the government $1 million to purchase ventilators for COVID-19 victims. For years, the government has prioritized profits of the Regie, the hospitality sector, and the tobacco industry over the health of the Lebanese people. In light of the huge loss of life from tobacco use generally, and the increased consequences of tobacco use resulting from COVID-19, stronger implementation and enforcement of tobacco control policy is essential. Now more than ever there is a need to reinforce existing national polices and put new ones in place.

Prevention and mitigation strategies for COVID-19 have been suggested by the Lebanese government in line with recommendations of the World Health Organization. The government has appropriately given COVID-19 a high priority and commitment. However, everyone is eagerly waiting to get back to "normal" and to regular habits.

For many people in Lebanon, this means returning to social gatherings that include the waterpipe. But, smoking kills more people in Lebanon annually than the COVID-19 is projected in its worst-case scenario. With that in mind, the government should renew its commitment and give the same amount of attention to tobacco control as it currently is giving to COVID-19. The Health Ministry should take full ownership of this issue without interference from the Tourism Ministry and its allies, who shamelessly influenced the implementation of the ban of smoking in the hospitality sector in 2011. Waterpipe sales should not persist, as a way to raise profit at the expense of health.

The government, spearheaded by the Health Ministry, should:

  • Ban the serving of waterpipes in all public places altogether even after the lockdown is over. This is critical. Affected stakeholders such as the Regie and the hospitality sector are politically influential, but if the government uses the same firm hand of policy implementation as it has to combat COVID-19, this ban is possible. In turn, after lockdown is over, the government should support the revival of the Lebanese hospitality sector as a waterpipe-free sector.

  • If a complete ban does not take place, then the government must introduce and enforce strict regulations to effectively disinfect all waterpipe parts and ban sharing of waterpipes all together. This measure should include policies that require complete shutdown of establishments where contact tracing reveals hotspots of virus (COVD-19 and other) transmission. With COVID-19, municipalities and the Internal Security Forces have been diligent in fining individuals who flouted the social distancing requirements and raiding businesses that didn’t abide by the government lockdown requirements. The same level of enforcement should be put to ensuring the safety of people in Lebanon from the risks of infection through waterpipes.

  • In waterpipe serving establishments, there are individuals who go around to "light up" the charcoal of the waterpipe before serving it. This process puts these individuals at risk of acquiring the infection, and also risks transmitting infection from these individual to others. This tradition of "lighting up" should be discontinued. The government should put social policies in place that ensure that those who currently perform this work have alternative sources of income.​

  • Conducting public safety campaigns to address the issue of risk of infection as a result of waterpipe smoking. Many countries in the region, for example, the Egyptian Health Ministry has issued excellent public health campaigns in this regard.

COVID-19 has shown us that our government can take decisive action for health and well-being of people living in Lebanon when it chooses to. Let’s use the events of this pandemic as a window of opportunity to take tobacco control measures more seriously in Lebanon. It is very likely that COVID-19 will not be the last infectious disease we will face in this decade and beyond. Stronger measures such as the ones described here will save lives in the short and long-term run​​.

Rima Nakkash is associate professor of health promotion and community health at the Faculty of Health Sciences at the American University of Beirut; associate director of the WHO FCTC waterpipe tobacco smoking Knowledge Hub; associate director of the K2P Center and coordinator of the AUB Tobacco control research group.

​This article was originally publis​hed in The Daily Star 

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