"Covid-19 hits old people the hardest." The oft-heard statement might have given many young Indonesians a false sense of security as they puff away on their cigarettes, often right next to children, during their self-isolation at home.
In fact smoking puts them at higher risks of contracting Covid-19 and becoming severely ill from the disease.
They're also exposing their children and other family members to secondhand smoke that may also cause passive smoking-related diseases like asthma, lung cancer and ear infection.
A growing body of evidence has shown that smoking is one of the risk factors for severe Covid-19 cases. Smokers are 14 times more likely to die from Covid-19. Severe Covid-19 cases at the time of hospital admission were more prominent among patients with a smoking history compared to never-smokers (32 percent vs. 15 percent).
At the endpoint of the Covid-19 course, 16 percent of smokers are more likely to be admitted to intensive care (ICU) and requiring mechanical ventilation, compared to 4.7 percent of never-smokers.
There have been several hypotheses for a causal link between smoking and Covid-19. First, scientists have found a ballooning number of a specific cell attribute called the angiotensin-converting enzyme-2 (ACE-2) receptor in the airways of smokers.
The ACE-2 receptor is piggybacked by the coronavirus to enter a human cell and, subsequently, to infect the human host.
Second, smoking causes a myriad of serious health conditions, such as chronic obstructive pulmonary disease (COPD), diabetes and heart diseases, that compromise the body’s capacity to fight infections, including Covid-19.
These "pre-existing conditions" have been acknowledged to be linked with smoking.
Third, the act of smoking involves frequent contact between one's fingers, and probably contaminated cigarettes, and lips.
This may increase the possibility of virus transmission to the airway via the hand-to-mouth route.
Given that Indonesia is a "smoker's heaven," with one of the highest prevalence of male smokers (63 percent) in the world and the fact that 96 million Indonesians are passively exposed to tobacco smoke, it comes as no surprise that we've seen many severe Covid-19 cases in the country.
At the time of writing (April 22), Indonesia's Covid-19 fatality rate is at a high 8.6 percent, with 469 deaths out of 5136 confirmed cases, higher than the global rate at 6.9 percent and the fatality rate in the United States – the country with the most number of coronavirus cases – of 5.5 percent.
The vulnerable population for Covid-19 in Indonesia might be younger than in other countries since smoking is very popular among young people.
In fact nine percent of Indonesians between 10 and 18 years old are smokers.
The widespread use of electronic cigarettes (e-cigarettes), or vaping, among young Indonesians might also mean more of them will succumb to serious cases of Covid-19.
Vaping damages lung and airway cells, hence vapers may be more susceptible to coronavirus infection and its serious complications.
In the US, a country where vaping is extremely popular among young people, vaping has been suspected to have caused the oddly high number of younger people who have severe cases of Covid-19.
Although one of the most influential Indonesian Muslim organizations has declared vaping as haram in January 2020, e-cigarettes are still poorly regulated in the country – predisposing the young generation to another nicotine addiction as well as coronavirus infection.
Yet, during this pandemic, smoking history is not part of the medical screening at Indonesian healthcare facilities. Let alone vaping history.
This is when smoking and vaping history may potentially help doctors predict the likely medical course for Covid-19 patients.
The World Health Organization (WHO) has actually warned Indonesia about the high risk of critical Covid-19 infection among smokers at the beginning of the outbreak in the country.
Similarly, 42 prominent national health and social organizations have recently called for more stringent Indonesian tobacco control strategies to protect smokers and, consequently, the healthcare system from an unmanageable number of serious Covid-19 cases.
The first and most important step is to encourage Indonesian smokers to quit now.
This is the best time to quit smoking not just because of the added incentive of avoiding Covid-19, but also because self-isolation minimizes exposure to social cues which might cause a relapse during quitting attempts.
On top of that, Indonesian smokers who mostly come from low-income families, or who might even have lost their jobs due to the coronavirus crisis, can spend their cigarette money on more essential expenses like food and education.
However, quitting smoking during this stressful situation would not be easy without support.
The government should not leave smokers helpless – they have been the victims of Indonesia's weak tobacco control.
It's the government's responsibility to help them quit by providing smoking cessation aids to as many people as possible and for free.
The quitline service that has been available in the country for some time should be promoted to smokers in a more appealing way.
Smoking cessation assistance, including medications like nicotine replacement therapies, should be treated as essential services and prioritized.
The government should also add information about the harms of smoking in their Covid-19 communication as part of its mitigation strategy.
Additionally, smoking status should be recorded in all medical assessments and in the country’s surveillance system for Covid-19.
The University of San Francisco has added smoking and vaping to its screening and triage protocols for Covid-19 to help assess risks in patients.
Some countries have even ramped up their tobacco control prevention measures by restricting sales of tobacco products to try to slow the pandemic.
Quezon Town in the Philippines, for example, has banned cigarette sales while Syria has prohibited shisha. There have been demands to ban sales of vaping products in New York, the city with the most Covid-19 cases and the highest death toll in the US.
Reduced availability of cigarettes would help smokers to quit and support ex-smokers to remain abstinent.
Ultimately, helping smokers to quit also means sparing resources in healthcare facilities that otherwise would have been used to treat tobacco-related health problems during this pandemic.
Lastly, the Indonesian government should aim for long-term public health gains by strengthening its tobacco control strategy for both combustible and electronic cigarettes, from producing stronger anti-smoking law to preventing interference by the tobacco lobby.
The tobacco industry has been found to take advantage of this pandemic to gain more profits and improve its image by promoting smoking alternative products and giving donations to health institutions.
Now is the time to hold the tobacco industry accountable for the harms its products have caused in Indonesia, including for health problems related to Covid-19.
That way the government can spare the healthcare system from having to treat smoking-related illnesses during the pandemic and use the budget to prepare for another pandemic in the future.
This is the perfect time for smokers, of any age, to be a real hero for themselves, their families and the communities – to help flatten the curve of the pandemic by stubbing out their smoking habit forever.
Beladenta Amalia is an Indonesian physician pursuing a PhD in Public Health at the University of Barcelona. She works as a doctoral researcher at the Tobacco Control Unit, Bellvitge Biomedical Research Institute-Catalan Institute of Oncology, Spain.