A call for a moratorium on the sale of inhalable products

The work of our lungs is absolutely essential for the health of our bodies. While the whole world is focusing on protecting our lungs from failing us during the COVID-19 pandemic, we urge a moratorium on the sale of all inhalable products, like cigarettes, cigars, e-cigarettes, vape pens, and respectfully request current smokers to try to quit. We are physicians in the San Francisco Bay Area, concerned for patients who could have walked away with an asymptomatic or mild case of this novel coronavirus infection, but instead require hospitalization, intensive care, or die prematurely because they have or had underlying lung damage caused by inhaling smoke or vapors, something for which lungs are not designed.

For responsible stewardship of our hospital-based resources, and for the health of the people we care for, our society needs to proactively minimize preventable lung diseases such as those caused by inhaling tobacco, marijuana, and other substances. At a time when medical resources may be maximally strained due to the COVID-19 pandemic, we encourage individuals to choose not to inhale anything other than air, and communities to choose not to sell inhalable products.

We also take note of previous commentaries suggesting nicotine use may have a protective effect in COVID-19 disease. However, this effect hasn’t been seen yet in any other studies.

In fact, a peer-reviewed systematic review of the evidence on smoking and COVID-19 published in Tobacco Induced Diseases in March 2020 by researchers from Harvard and the University of Crete strongly suggests smoking is a significant risk factor for developing severe COVID-19 disease needing intensive care, mechanical ventilation, and dying.

A collaborative viewpoint by researchers in Rome and at Stanford published in JAMA Internal Medicine hypothesizes that the high proportion of people with a history of smoking and high rates of chronic obstructive pulmonary disease, otherwise known as emphysema, were contributing factors to the severity of the epidemic in Italy.

On the other hand, California has been lucky to have a flatter curve than most states in the USA. Some scientists suggest this could be due to a lower prevalence of smoking, and improved air quality from early adoption of shelter-in-place policies, among other factors.

While rigorous research is underway to investigate the COVID-19-nicotine connection, we do know your lungs are designed to inhale only clean air.

Lung tissue is delicate and fragile. Oxygen and carbon dioxide are exchanged over a two-cell layer of tissue that is only one micrometer thick. What’s in the air enters our lungs, whether that’s SARS-CoV-2 (the virus that causes COVID-19 disease), influenza, tuberculosis, styrene, coal dust, silica, asbestos, fuel exhaust, wood smoke, tobacco smoke, marijuana smoke, fumes from vaping, or any number of living organisms or toxic substances. Right now, we must protect our lungs from any unnecessary exposures to injurious agents.

You may be anxious or have experienced devastating losses and might be overwhelmed. We want to support you in ways that support your overall wellbeing and that of your loved ones and of society at large. As clinicians, we understand you may be tired of this COVID-19 conundrum. Tired of sheltering in place. Tired of wearing a mask. Tired of the seeming whiplash of recommendations from the CDC. Tired of the snafus around testing, or the confusion about the accuracy of those tests. Tired of waiting for the research studies to pan out. Tired of the conflicting information you see in the news and on social media. Worried about a crashing economy. Anxious about the uncertainty. Depressed by the loneliness of shelter-in-place, the loss of a livelihood, or a loved one. In grief about the losses; exhausted by the grief. Afraid of feeling afraid. We get it.

We also recognize that many inhalable products offer relief from the anxiety, tension, or depression you may be experiencing in our current situation. Yet, there are many ways to help you cope with all the stress. We won’t belabor the list of modalities here, but will encourage you to seek support. If you need help to quit smoking or vaping, assistance is available for that too. Nicotine replacement therapy with gum or patches could actually save someone’s life, including yours, by avoiding preventable lung injury. Drive-thru acupuncture could also help relieve nicotine withdrawal symptoms. Please consult your treating clinician or call a warmline/hotline, like the Center for Disease Control’s free Quitline: 1-800-QUIT-NOW (1-800-784-8669).

Personal freedom is a value we hold dear and sacred, as we should. The personal freedom to roam freely, to gather with others, to work, and to smoke. This crisis has bared the truth that what each of us chooses to do as individuals impacts everyone across the globe. We are currently sacrificing significant personal freedoms, livelihoods, social engagements, creative, intellectual, athletic, artistic, and spiritual pursuits in order to protect the lungs of the vulnerable among us. This is a noble act of courage and love.

Over the years, we have come to recognize secondhand smoke, and, more recently, third-hand smoke, to be as harmful to non-smokers as smoking is to smokers. As a society, we have agreed to curtail the personal freedom of smokers by prohibiting smoking in public places to protect the lungs of non-smokers.

We recognize the immense effort required to quit smoking or vaping with a salute of gratitude for the potential rewards of extending the lives, or delaying the deaths, of those whose lung function may become severely compromised at this time.

In summary, the inflammatory response elicited by the novel coronavirus can do great damage to the essential function of lungs. People with underlying lung disease are more vulnerable to this coronavirus, including people with asthma, emphysema, lung fibrosis, and even people with high exposure to air pollution. Smoking and vaping are perfectly preventable forms of high-intensity air pollution. We strongly urge city, county, and state governments across the planet to place a temporary moratorium on the sale of all inhalable products to protect our lungs and our freedom.

Jayshree Chander is an occupational medicine physician. John Balmes and Jagat Satia are pulmonary physicians.

Image credit: Shutterstock.com

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