After more than 100 days of a ban on the sale of cigarettes in South Africa, several significant uncertainties still surround the issue. These include, on the one hand, the impact of the ban on the health of smokers, the number of people who continue to access cigarettes, when the ban will be lifted, how much it is costing the fiscus and job losses, and, on the other hand, the prevalence of smokers among those who have been hospitalised and died from the coronavirus in the country.

In particular, there appears to be uncertainty about the relationship between smoking and the risk of infection, hospitalisation and death due to Covid-19.

A recent World Health Organisation (WHO) scientific brief on this issue has not helped. The brief, released on 30 June 2020, draws on a review of relevant scientific literature on hospitalisations and deaths from the disease published before 12 May. It concludes that “the available evidence suggests that smoking is associated with increased severity of disease and death in hospitalised Covid-19 patients”. Smokers are deemed high risk.

One of the studies reviewed by the WHO for the brief, titled “Prevalence of Underlying Diseases in Hospitalised Patients with COVID-19: a Systematic Review and Meta-Analysis”, illustrates the type of data and conclusions reached in the studies reviewed. The authors conducted a review of journal articles on the coronavirus in China published before 15 February. They selected 10 papers that utilised the data of 2,986 patients to determine the pooled prevalence of hypertension, cardiovascular disease and diabetes in people infected with the virus, as well as their smoking history.

The main findings were that patients with a history of smoking made up 7.63% of hospitalised Covid-19 patients; 16% of the Covid-19 patients who were hospitalised suffered from hypertension, 12.11% suffered from cardiovascular disease and 7.87%  from diabetes. There were lower percentages of patients suffering from other ailments.

The paper concludes that smoking is among the most prevalent underlying factors among patients hospitalised with Covid-19. What is not said is that smokers, who make up 24.7% of China’s population, made up 7.63% of hospitalised patients, while non-smokers, who make up 75.3% of the population, made up 92.37% of Covid-19 patients, which would logically indicate that the latter are more vulnerable to infection.

However, such logic does not apply in determining who is at high risk of infection by a virus. It is the prevalence of a particular disease in comparison with the prevalence of other diseases that is taken into account, and not in relation to those who do not suffer from the disease.

Where such a study becomes problematic, however, is if – as the WHO admits – it falls into the same category as most of the studies reviewed in the WHO brief, namely studies that are hampered by poor data quality and “did not make statistical adjustments to account for age and other compounding factors”.

The study does not indicate if any statistical adjustment was made for the age of smokers who were infected by the virus and hospitalised, or the prevalence of other relevant comorbidities (such as cardiovascular disease) among them. The conclusions reached in the study about smoking would not have much relevance if all the smokers in the various studies reviewed were also in a high-risk age group, for instance.

… it does not appear that employees in any of the recently reopened sectors – as well as learners – who are smokers, are considered so high risk that they are prevented from returning to work or school.

Relying on such studies leads to more uncertainty, and even more so when the WHO states that “population-based studies” are still needed “to quantify the risk to smokers of hospitalisation with Covid-19”.

It is disturbing to note that no protocols exist, either nationally or internationally, to gather data that would unequivocally indicate the high-risk groups that would inform the approach to prevention, treatment and the roll-out of vaccines needed to prevent infection in the global population of more than seven billion people.

Why is it that, after South Africa’s 100 days of lockdown and just more than 3,000 deaths, we have no data on the number of smokers among the country’s Covid-19 fatalities, the age group of smokers who died, and any comorbidities among them?

Is this data impossible or difficult to obtain?

Despite this lack of data, the Covid-19 National Command Council has deemed smokers to be a vulnerable group, at high risk, and has prohibited the sale of cigarettes so as to limit smoking for health reasons. It has argued that smokers are among those most likely to be hospitalised if infected, which would add strain onto the health system. This view has been upheld by the High Court in a recent judgment.

But what are the implications of smoking being deemed a high-risk activity in the time of a pandemic?

It would follow, one assumes, that smokers would fall into the category of people to be treated differently because they are vulnerable to infection. A concession to their vulnerability would be to allow them to work from home.

However, it does not appear that employees in any of the recently reopened sectors – as well as learners – who are smokers, are considered so high risk that they are prevented from returning to work or school. The Department of Basic Education, for instance, does not include smoking as a risk factor for severe Covid-19 infection. Teachers who wish to work from home have to be older than 60; suffer from a cardiovascular, respiratory or kidney disease; be pregnant; have a suppressed immune system, and/or be severely obese. They are not allowed to do so simply because they are smokers.

Finally, if smoking carries a high risk, one would also assume that smokers will be given preferential access to the Covid-19 vaccine when it arrives in South Africa. It remains to be seen how the National Command Council will treat smokers when it develops its plan to roll out the distribution of the vaccine. DM/MC

Professor Narnia Bohler-Muller is divisional executive of the Developmental, Capable and Ethical State research programme of the Human Sciences Research Council and an adjunct professor of law at the University of Fort Hare. She writes in her personal capacity.