Opportunities and Strategies for Tobacco Prevention During the COVID-19 Pandemic

June 10, 2021

COVID-19 has drastically shifted the focus of public health, but tobacco prevention and control remains a priority for many states. Recent trends demonstrate a strong link between tobacco use and heightened risk for severe COVID-19 illness. Public health professionals must consider how best to integrate tobacco control efforts into the new landscape that COVID-19 has created. This brief spotlights new findings on tobacco use and COVID-19, opportunities for tobacco prevention during the pandemic, guidance for communicating risk, and recommendations for engaging state health officials.

Relationship Between Tobacco Use and COVID-19

Researchers have examined the effects of smoking on the immune system and respiratory defense mechanisms for decades. There is sufficient evidence that smoking cigarettes compromises the immune system, which puts individuals at greater risk for pulmonary infections such as SARS-CoV-2. Smoking is also associated with general pulmonary changes such as airway inflammation, impaired mucociliary clearance, and increased permeability of the epithelial lining of the airways, which further increase the risk for infection and for more severe COVID-19.

Opportunities for Tobacco Prevention in the COVID-19 Response

While the COVID-19 response has challenged tobacco prevention and control resources, the pandemic has also afforded health officials unique opportunities to retool their tobacco prevention response.

Smoke-Free Policies: One opportunity for tobacco prevention that has emerged during the pandemic is the option to re-open businesses such as restaurants, bars, and casinos with smoke-free policies in place. Casinos and other gaming establishments remain one of the few public spaces where employees and patrons are likely to be exposed to secondhand smoke indoors. Some businesses, such as tribal casinos, have transitioned to smoke-free to reduce the risk of COVID-19 transmission. Similarly, airports are closing smoking rooms to prevent the transmission of COVID-19. It is important to continue advocating for policies that close gaps in smoke-free protections for all workspaces, public places, and multi-unit homes. The American Nonsmokers’ Rights Foundation has published a running list of tribal casinos that have reopened as smoke-free, as well as a resource guide for businesses looking to reopen as smoke-free.

Increased Opportunities to Promote Cessation: The COVID-19 response has helped form new points of contact to promote smoking cessation to the public. A significant contact tracing workforce has been hired to gather information related to individuals’ potential exposure to COVID-19 in order to stop chains of transmission. During this process, tracers gather information about individuals’ underlying health factors and risk conditions, which includes discussing smoking. This provides an opportunity to discuss the increased risk for more severe COVID-19 illness, as well as provide cessation guidance and resources. Similarly, vaccination sites can serve as valuable points of contact to promote cessation, connecting individuals who smoke with resources when they register for the vaccine. There is evidence that this trusted and newly bolstered workforce improves health outcomes, bringing greater diversity and community reach to public health agencies.

Expand Cessation Support Programs: Established cessation support programs should ensure that counseling and pharmacotherapy supports continue to be accessible both during and after the pandemic. Uptake of cessation support can be enhanced by integrating the opportunity for smoking cessation support into the care routines of all healthcare settings. The Harvard School of Dental Medicine produced a guide for dental providers, which outlines strategies to promote cessation during the pandemic. Other providers can integrate similar questions and support into their care plans as a standard of patient care. Cessation support and messages on the intersect of COVID-19 and smoking should also be incorporated into virtual and home care.

Pair COVID-19 and Tobacco Communications: In a recent study published by the University of North Carolina Chapel Hill, researches found that messages that combine information on smoking and COVID- 19 are effective in reaching their intended audience. In an expert-led webinar, ASTHO Chief Medical Officer Marcus Plescia highlighted the importance of sticking to the science when communicating the risks of tobacco use, and stressed the importance of avoiding areas where science is not yet conclusive so as to maintain credibility.

Engaging State Health Officials and Other Potential Partners

Throughout the COVID-19 response, state health officials have stayed engaged in tobacco control efforts. Public health leaders want to protect the progress that tobacco control has been made in recent years and are concerned about the threats of vaping and youth tobacco initiation.

Amanda Mortensen, a Tobacco Free Nebraska program manager at the Nebraska Department of Health and Human Services and chair of the Tobacco Control Network, has taken several approaches to engage Nebraska health officials around tobacco control issues. Her team used ASTHO’s blog to share policy change information with state health officials and leveraged data from CDC and the Surgeon General’s Report on Smoking Cessation to generate smoking cessation talking points that later appeared in a COVID-19 response update press conference by Nebraska Governor Pete Ricketts.

As pharmacies continue to engage more in public health activities such as the COVID-19 vaccination campaign, there are growing opportunities to engage them in tobacco free policies. For example, Rite Aid ceased e-cigarette and vaping sales following the 2019 EVALI outbreak, while CVS stopped selling tobacco altogether in 2014. Pharmacies could become valuable partners to help strengthen tobacco product sale restrictions during the pandemic.

Looking Ahead

As COVID-19 continues to capture the attention of public health leaders, it is important for public health professionals to seek out opportunities to align COVID-19 work and other public health efforts. In summary, state and territorial health officials can consider the following practices when thinking through opportunities for tobacco prevention during the pandemic.

• Re-open businesses such as restaurants, bars, and casinos with smoke-free policies in place.
• Advocate for policies that emphasize the need for 100% smoke-free air.
• Utilize vaccination sites as points of contact to promote cessation.
• Support established cessation support programs in ensuring that counseling and pharmacotherapy supports remain accessible both during and after the pandemic.
• Stick to the science when communicating the risks of tobacco use and avoid areas where science is not yet conclusive.
• Engage community partners in strengthening tobacco product sale restrictions.