The global outbreak of the COVID-19 pandemic, a fast spreading, primarily respiratory disease, has brought to the fore the importance of lung health, and with this, the dangers of tobacco use.

It is commonly accepted that tobacco use has a range of negative health effects including, amongst others, lung and heart disease, cancers and strokes.

With particular reference to COVID-19, smokers are at greater risk due to their already compromised lung health. It is well known that tobacco use affects the cardiovascular and respiratory systems.

Since COVID-19 can affect cardiovascular and respiratory systems, the damage caused to the lungs by smoking makes patients more susceptible to both viral and bacterial pulmonary infections. People who use tobacco products are more likely to experience severe COVID-19 outcomes. Smokers are more likely to be admitted to intensive care, to need mechanical ventilation, or die, compared to non-smokers. South Africa therefore needs to implement measures to protect smokers and non-smokers from potential COVID-19 infections and its consequences.

The current ban on the purchase of tobacco products during the lock down is therefore a crucial element of trying to reduce the impact of the virus on patients and the healthcare system.  At current capacity levels, the South African healthcare system does not have sufficient ventilators hence the emphasis of government to flatten the curve and limit the spread of the disease.  At current conservative estimations, if even 1% of South Africa’s 8 million smokers were infected and 5% of these required ICU or high care facilities, the healthcare system would not be able to cope

HSRC Surveys on the impact of COVID-19 on South Africans and their behavioural patterns during the lockdown

The Human Sciences Research Council conducted two behavioural online surveys to investigate South Africans’ knowledge, attitudes, perceptions and practises related to COVID-19 infection. The first was conducted among over 50 000 people between 27 March and 2 April and the second was conducted among 19 330 people from 8-24 April. Data was benchmarked to the South African national adult population.

Key Findings in relation to smoking behaviours

Cigarette buying behaviour

The majority of smokers (88%) were not able to buy cigarettes during the lockdown suggesting that the ban was efficient in reducing cigarette access and therefore use. Overall 11.8% of smokers were able to buy cigarettes during the lockdown.

Almost a quarter (23.5%) of smokers in informal settlements and 16% of those in townships were able to buy cigarettes. This was significantly higher than the corresponding rates for smokers in city (9.9%), suburb (8.2%) and farm (7.3%) communities.

Cigarette buying was higher in people who had lower confidence in protecting themselves and their families from COVID-19 infection.

Cigarettes and alcohol use behaviours

Cigarette buying was more prevalent among those who were able to buy alcohol than those who were not able to buy alcohol: 72% of people who bought alcohol also bought cigarettes.

Cigarette buying was also more prevalent among those who were able to drink alcohol with friends: 26% of people who drank alcohol with friends during the lock down also bought cigarettes.

Social distancing behaviours among cigarette users

The percentage of participants who came into close contact with someone outside their home, by shaking hands, hugging or kissing, was significantly higher for those who were able to buy cigarettes during lockdown (26.2%) than those who were not (9.8%).

Over 40% of those who were able to buy cigarettes came into close contact (within 2 metre distance) with more than 10 people when away from their homes compared to 26.4% of smokers who did not buy cigarettes during lock down.

Therefore, during the lock down, cigarette buyers  were in close physical contact with people outside their homes more often than non-purchasers. The data indicates therefore that they were not practicing appropriate social distancing. Social distancing is vital to reduce the spread of COVID-19. Sharing tobacco products like cigarettes or hookah pipes can also increase the risk of COVID-19 transmission in communal and social settings.

Structural living conditions of smokers

During lockdown, non-smokers, including children, the elderly, and women who do not smoke are also at increased risk of exposure to second-hand smoke (SHS) because of higher numbers of people being in small spaces.

Over half of current smokers reported that they live in a household with school going children. A third of current smokers reported that if self isolation became necessary their homes did not have a sufficient space to separate family members, such as the children and elderly from the rest of the family. These represent a significant proportion of people and households for whom COVID-19 infection would be difficult to contain should one of them become infected. 

Estimated number of smokers and potential need for ICU

South Africa had an estimated population of approximately 41 million people aged 15 years and older in 2019. The 2016 South African Demographic and Health Survey found that about 20% of South Africa’s population aged 15 years and older smoked tobacco. The survey showed that the prevalence of daily or occasional smoking increased with age, peaking at 11% among women aged 45-54 years and 45% among men age 45-54 years.

Overall this translates to about 8 million people who smoke countrywide. If only 1% of the 8 million smokers were to contract COVID-19, this means that 80 000 smokers would be infected countrywide. If an estimated 5% were to need ICU, this would translate to about 4 000 people needing ICU hospital beds and ventilators in the whole country. Under current calculations this would exceed the availability of ventilators and place health workers at risk.

Scenarios for contracting COVID-19 of out of 8 million youth and adult smokers (15 years and older), and estimated ICU admissions and ventilators that would be needed

Percentage that will need ICU and ventilators

Number of people needing ICU and ventilators (assuming that  1% were to contract COVID-19) (n=80 000)

Number of people needing ICU and ventilators (assuming that 0.5% were to contract COVID-19) (n=40 000)

10%

8 000

4 000

5%

4 000

2 000

Issued by The Human Sciences Research Council