Smoking and risk of negative outcomes among COVID-19 patients: A systematic review and meta-analysis

The Impact of Tobacco Use on COVID-19 Outcomes: A Systematic Review

Introduction

Tobacco use increases risks for numerous diseases, including respiratory illnesses. We examined the literature to determine whether a history of tobacco use increases risks for adverse outcomes among COVID-19 patients.

Methods

We conducted a systematic search of PubMed, LitCovid, Scopus, and Europe PMC (for preprints) using COVID-19 and tobacco-related terms. We included studies of human subjects with lab-confirmed COVID-19 infections that examined tobacco use history as an exposure and used multivariable analyses. The data was collected between March 31^st, 2020, and February 20^th, 2021. Outcomes included mortality, hospitalization, ICU admission, mechanical ventilation, and illness severity.

Results

Among the 39 studies (33 peer-reviewed, 6 preprints) included, the most common outcome assessed was mortality (n = 32). The majority of these studies (17/32) found that tobacco use increased risk, one found decreased risk, and 14 found no association. Tobacco use was associated with increased risk of hospitalization in 7 of 10 studies, ICU admission in 6 of 9 studies, mechanical ventilation in 2 of 6 studies, and illness severity in 3 of 9 studies. One study found that tobacco use history increased risk of pulmonary embolism in COVID-19 patients. Tobacco use was found to compound risks associated with diabetes (n = 1), cancer (n = 2), and chronic liver disease (n = 1).

Conclusion

There is strong evidence that tobacco use increases risks of mortality and disease severity/progression among COVID-19 patients. Public health efforts during the pandemic should encourage tobacco users to quit use and seek care early and promote vaccination and other preventive behaviors among those with a history of tobacco use.

The Impact of the COVID-19 Pandemic on Smoking Consumption: A Systematic Review of Longitudinal Studies

The COVID-19 pandemic has generated a global health crisis that has negatively impacted the mental health and wellbeing of the population. A large amount of scientific literature has emerged since 2019, but none of these studies have focused on assessing the impact of COVID-19 on smoking consumption. We aimed to analyse the changes in smoking consumption during the COVID-19 pandemic through longitudinal studies. This systematic review follows the PRISMA Statement. This study was registered on PROSPERO (CRD42021282235). MEDLINE, ERIC, PsycARTICLES, Scopus, Web of Science and PsycINFO databases were searched from inception to 24 October 2021. We completed an extensive assessment of all prospective cohort studies that aimed to explore the effect of the COVID-19 pandemic on tobacco consumption habits. According to the PICOS's acronym, we included all population (P) types and studies developed before and during the COVID-19 pandemic (I) with a change in nicotine consumption as the outcome (O), as well as prospective cohort studies. The risk of bias was assessed using the Newcastle-Ottawa Scale for observational studies. The results showed that 14 cohorts reported in 11 articles fulfilled the inclusion criteria. A total of 58,052 participants were included in the review. Most of the studies pointed out a reduction in the number of cigarettes and e-cigarettes consumed from baseline (before the pandemic) to follow-up (during the pandemic). Only two studies reported an increase in cigarette or e-cigarette consumption from baseline to follow-up. The majority of studies presented a low risk of bias. In conclusion, the impact of the COVID-19 pandemic on smoking behavior is complex and uncertain. The decrease in smoking consumption during the pandemic could be related to the fear of becoming infected by COVID-19, the advancement of COVID-19, and the reduction in social gatherings. In several cases, the increases in nicotine consumption can be explained by psychological distress. These findings can be used to create strategies to prevent relapses during the post-vaccination phases of the pandemic. Systematic Review Registration: PROSPERO, identifier: CRD42021282235.

A cross sectional study found differential risks for COVID-19 seropositivity amongst health care professionals in Chile

Objective

Health care workers (HCWs) are at increased risk for SARS-CoV-2 infection, however not all face the same risk. We aimed to determine IgG/IgM prevalence and risk factors associated with seropositivity in Chilean HCWs.

Study Design and Setting

This was a nationwide, cross-sectional study including a questionnaire and COVID-19 lateral flow IgG/IgM antibody testing. All HCWs in the Chilean public health care system were invited to participate following the country's first wave.

Results

IgG/IgM positivity in 85,529 HCWs was 7.2%, ranging from 1.6% to 12.4% between regions. Additionally, 9.7% HCWs reported a positive PCR of which 47% were seropositive. Overall, 10,863 (12.7%) HCWs were PCR and/or IgG/IgM positive. Factors independently associated with increased odds ratios (ORs) for seropositivity were: working in a hospital, night shifts, contact with Covid-19, using public transport, male gender, age>45, BMI ≥30, and reporting ≥2 symptoms. Stress and/or mental health disorder and smoking were associated with decreased ORs. These factors remained significant when including PCR positive cases in the model.

Conclusions

HCWs in the hospital were at highest risk for COVID-19, and several independent risk factors for seropositivity and/or PCR positivity were identified.

The Exposome and Immune Health in Times of the COVID-19 Pandemic

Growing evidence supports the importance of lifestyle and environmental exposures-collectively referred to as the 'exposome'-for ensuring immune health. In this narrative review, we summarize and discuss the effects of the different exposome components (physical activity, body weight management, diet, sun exposure, stress, sleep and circadian rhythms, pollution, smoking, and gut microbiome) on immune function and inflammation, particularly in the context of the current coronavirus disease 2019 (COVID-19) pandemic. We highlight the potential role of 'exposome improvements' in the prevention-or amelioration, once established-of this disease as well as their effect on the response to vaccination. In light of the existing evidence, the promotion of a healthy exposome should be a cornerstone in the prevention and management of the COVID-19 pandemic and other eventual pandemics.

Predictors of Mortality Among Hospitalized COVID-19 Patients at a Tertiary Care Hospital in Ethiopia

BACKGROUND

The very unprecedented virus causing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has continued causing catastrophes in economy and loss of human lives. Despite countries' urgent and resilient public health actions against the COVID-19 pandemic, the disease is causing a large number of deaths. However, predictors of mortality among hospitalized COVID-19 patients have not been well investigated in Ethiopia. Therefore, this study aimed to identify the predictors of mortality among hospitalized COVID-19 patients at a tertiary care hospital in Ethiopia.

METHODS

A hospital-based retrospective cohort design study was implemented among hospitalized COVID-19 patients at a tertiary care hospital in Harar, Ethiopia from March 20 to August 20, 2021. Data of 531 admitted patients were entered using Epi-data 3.1 and exported to STATA 14.2 for analysis. Binary logistic regression was used to identify significant predictors of outcome variables with an adjusted odds ratio (AOR) with a 95% confidence interval.

RESULTS

Of the total 531 study participants, 101 deaths occurred. The mortality rate was 16.2 per 1000 person-days of observation with median survival time of 44 days with IQR [28, 74]. Smoking history [AOR=2.55, 95% CI (1.15, 5.65)], alcohol history [AOR=2.3, 95% CI (1.06, 4.97)], comorbidities [AOR=2.95, 95% CI (1.26, 6.91)], and increasing oxygen saturation [AOR=0.92, 95% CI (0.89, 0.95)], and lymphocyte count [AOR=0.90, 95% CI (0.88, 0.97)] were independent significant predictors of death from Covid-19.

CONCLUSION

The incidence of mortality among hospitalized COVID-19 patients was found to be high. Devising individual, tailored management for patients with "risk" behaviors, comorbid conditions, and poor prognostic markers such as lymphopenia and low oxygen saturation, may reduce the incidence of death among hospitalized COVID-19 patients.

Assessment of Exclusive, Dual, and Polytobacco E-Cigarette Use and COVID-19 Outcomes Among College Students

Purpose

This study examined current (past 30-day) dual- and polytobacco use patterns and COVID-19 symptomatology, testing, and diagnosis status among college student electronic cigarette (e-cigarette) users.

Design

Cross-sectional online questionnaire administered during October–December 2020.

Setting

Four large, U.S. public universities in geographically diverse locations.

Sample

College students (N=756) ages 18–24 who reported current e-cigarette use.

Measures

Current use of e-cigarettes, combustible cigarettes, and cigars, and self-reported COVID-19 symptomatology, testing, and diagnosis status were measured.

Analysis

Multivariable logistic regression models accounting for students’ demographics, university site, fraternity/sorority membership, and current residence.

Results

Over half (53.6%) of students were exclusive e-cigarette users, 20.4% were dual e-cigarette and combustible cigarette users, 4.6% were dual e-cigarette and cigar users, and 21.4% were poly users of e-cigarettes, combustible cigarettes, and cigars. Compared to exclusive e-cigarette users, dual users of e-cigarettes and combustible cigarettes (AOR=2.12, 95%CI=1.05–4.27) and poly users of e-cigarettes, combustible cigarettes, and cigars (AOR=3.70, 95%CI=1.78–7.70) had increased odds of COVID-19 symptomatology, even when accounting for covariates. While current tobacco use groups did not differ based on COVID-19 testing, polytobacco users had significantly increased odds (AOR=2.16, 95%CI=1.11–4.20) of having received a positive COVID-19 diagnosis.

Conclusion

Given use of two or more tobacco products increased COVID-19-related risks, results underscore the need to prevent dual- and polytobacco use behaviors in college student e-cigarette users.

COVID-19 Vaccine Hesitancy and Its Determinants Among Adults with a History of Tobacco or Marijuana Use

Decreasing COVID-19 vaccine hesitancy is an urgent challenge in the US. This study aimed to examine COVID-19 vaccine hesitancy among U.S. adults with a history of using tobacco products or marijuana. Data were collected online in 2020-2021 including respondents' willingness to accept a COVID-19 vaccine, factors that may promote vaccine acceptance, and prior history of influenza vaccination. Logistic regression models were conducted to estimate the associations between vaccine hesitancy and demographic characteristics, substance use, the impact of the COVID-19 pandemic, and prior influenza vaccination. Among 387 respondents, 49.1% were willing to receive a COVID-19 vaccine, 26.0% were unwilling, and 24.9% were "not sure." Blacks, suburban or rural residents, those who lived by themselves or with a family with five members or above, those who were not stressed because of the COVID-19 pandemic were more likely to say "no" to a COVID-19 vaccine. Respondents who never, only once, or during some years received an influenza vaccine were 7.0, 6.2, and 5.2 times more likely to say "no" to a COVID-19 vaccine than respondents who received an influenza vaccination every year or almost every year. The use of cigarettes, e-cigarettes, and marijuana, as well as heavy drinking of alcohol, were not associated with COVID-19 hesitancy. The associations between demographic factors and vaccine hesitancy were roughly similar for COVID-19 and influenza vaccines. Although various demographic groups have different levels of vaccine hesitancy and also have different factors to increase their acceptance, addressing misinformation related to COVID-19 vaccines, particularly concern about the safety of the vaccines is crucial in general.

Impacts of COVID-19 on cigarette use, smoking behaviors, and tobacco purchasing behaviors

BACKGROUND

The COVID-19 pandemic has had a significant global impact. As a respiratory illness, COVID-19 may pose unique risks to cigarette smokers. This study used concept mapping, a mixed-method participatory approach, to identify impacts of COVID-19 on cigarette smokers.

METHODS

Cigarette smokers across the United States (U.S.) were recruited to complete this online, multi-step study. Of the 126 participants who were invited to participate in this study, 91 participants (mean age = 40.9; SD = 11.3) completed at least one of the three study tasks (i.e., brainstorming, sorting, and rating). Participants completed a brief demographic survey and brainstormed statements that completed a focus prompt: "A specific way that Coronavirus/COVID-19 has impacted/affected my cigarette use, smoking behaviors, tobacco purchasing behaviors, and/or other tobacco-related behaviors is." After duplicate statements were removed, participants sorted the final list of 87 statements by similarity of content and rated how true statements were from them (1-Definitely NOT true to 7-Definitely true).

RESULTS

Nine thematic clusters were identified: Smoking More, Smoking to Cope/Reduce Stress, Change in Smoking Behaviors Due to COVID-19, Concerns about Smoking and COVID-19 Risk, Social Impacts, Maintaining and Rationing Cigarette Supply, Impacts on Obtaining Cigarettes, Use of Other Tobacco Products/Drugs, and Minimal/No Impacts/Concerns of COVID-19. The highest rated cluster (i.e., most true) was the Smoking More cluster followed by the Concerns about Smoking and COVID-19 Risk cluster. The highest rated statement in the study was the statement "Smoking keeps me calm".

CONCLUSIONS

Cigarette smokers may endure additional impacts of COVID-19, such as increased COVID-19 health burdens, stressors related to risk of exposure, social stigma and isolation, financial burdens, and increased toxicant exposure from increased smoking frequency.

Negative Association Between Smoking and Positive SARS-CoV-2 Testing: Results From a Swiss Outpatient Sample Population

To date, most of the evidence suggests that smoking is negatively associated with testing positive for SARS-CoV-2. However, evidence has several methodological limitations. Using an outpatient sample population, we analyzed the association of testing positive for SARS-CoV-2 and smoking considering comorbidities, socioeconomic and demographic factors. Baseline data were obtained from a cohort during the first wave of the pandemic in Geneva, Switzerland (March-April 2020). RT-PCR tests were carried out on individuals suspected of having SARS-CoV-2 according to the testing strategy at that time. Logistic regressions were performed to test the association of smoking and testing positive for SARS-CoV-2 and further adjusted for comorbidities, socioeconomic and demographic factors. The sample included 5,169 participants; 60% were women and the mean age was 41 years. The unadjusted OR for testing positive for SARS-CoV-2 was 0.46 (CI: 0.38–0.54). After adjustment for comorbidities, socioeconomic and demographic factors, smoking was still negatively associated with testing positive for SARS-CoV-2 (OR: 0.44; CI: 0.35–0.77). Women (OR: 0.79; CI: 0.69–0.91), higher postal income (OR: 0.97; CI: 0.95–0.99), having respiratory (OR: 0.68; CI: 0.55–0.84) and immunosuppressive disorders (OR: 0.63; CI: 0.44–0.88) also showed independent negative associations with a positive test for SARS-CoV-2. Smoking was negatively associated with a positive test for SARS-CoV-2 independently of comorbidities, socioeconomic and demographic factors. Since having respiratory or immunosuppressive conditions and being females and healthcare workers were similarly negatively associated with SARS-CoV-2 positive testing, we hypothesize that risk factor-related protective or testing behaviors could have induced a negative association with SARS-CoV-2.

Mental Well-Being during COVID-19: A Cross-Sectional Study of Fly-In Fly-Out Workers in the Mining Industry in Australia

Coronavirus disease 2019 (COVID-19) has devastated the world, and its mental health impact has been recognized in the general population. However, little is known about the mental health impact of COVID-19 on fly-in fly-out (FIFO) workers, who are flown to temporarily stay and work in remote areas, during this pandemic. This study examined the mental well-being of FIFO workers in the mining industry during COVID-19 restrictions in Western Australia. An online survey was conducted between May to November 2020 among (N = 842) FIFO workers who underwent COVID-19 screening at a large mining company in Western Australia. The mental well-being score among workers was higher than population norms. One-way ANOVA with Bonferroni post-hoc tests showed significant differences in mental well-being by age, being placed under travel quarantine, undertaking self-isolation, impact of social distance guidelines, and experience of COVID-19 related symptoms. Multiple linear regression analysis showed workers who were younger, placed under travel quarantine and experienced two or more COVID-19 related symptoms were more likely to have worse mental well-being. Acknowledging the negative emotions and distress experiences among the vulnerable groups could help in providing suitable support to help lessen these negative experiences in FIFO workers.

Smoking status related to Covid-19 mortality and disease severity in a veteran population

INTRODUCTION

Cigarette smoking is associated with development of significant comorbidities. Patients with underlying comorbidities have been found to have worse outcomes associated with Coronavirus Disease 2019 (Covid-19). This study evaluated 30-day mortality in Covid-19 positive patients based on smoking status.

METHODS

This retrospective study of veterans nationwide examined Covid-19 positive inpatients between March 2020 and January 2021. Bivariate analysis compared patients based on smoking history. Propensity score matching adjusted for age, gender, race, ethnicity, Charlson comorbidity index (0-5 and 6-19) and dexamethasone use was performed. A multivariable logistic regression with backwards elimination and Cox Proportional Hazards Ratio was utilized to determine odds of 30-day mortality.

RESULTS

The study cohort consisted of 25,958 unique Covid-19 positive inpatients. There was a total of 2,995 current smokers, 12,169 former smokers, and 8,392 non-smokers. Death was experienced by 13.5% (n = 3503) of the cohort within 30 days. Former smokers (OR 1.15; 95% CI, 1.05-1.27) (HR 1.13; 95% CI, 1.03-1.23) had higher risk of 30-day mortality compared with non-smokers. Former smokers had a higher risk of death compared to current smokers (HR 1.16 95% CI 1.02-1.33). The odds of death for current vs. non-smokers did not significantly differ.

CONCLUSION

Compared to veteran non-smokers with Covid-19, former, but not current smokers with Covid-19 had a significantly higher risk of 30-day mortality.

The relationship between COVID-19-specific health risk beliefs and the motivation to quit smoking: A UK-based survey

BACKGROUND

In some individuals who smoke, the COVID-19 pandemic has triggered an increase in the motivation to quit smoking due to the potential higher risk of severe COVID-19 infection. However, this change is not universal, and the motivation to quit appears dependent upon factors such as fear of COVID-19 and perceived risk from COVID-19. In the current investigation both COVID-19 severity and infection probability beliefs were measured to isolate which beliefs correlated with the motivation to quit smoking.

METHODS

UK-based smokers (N = 243) completed an online survey between September and October 2020, in which they reported their current motivation to quit smoking, fear of COVID-19, and their beliefs about how severe COVID-19 infection would be and how probable COVID-19 infection was.

RESULTS

The only significant predictor of the motivation to quit smoking was the perceived probability of COVID-19 infection, β = .22, p < .001, 95CI[.10, .34]. This relationship remained when controlling for the general perceived probability and severity of other smoking-related health risks, β = .20, p = .002, 95CI[.08,.32], suggesting a COVID-19-specific effect. Further, perceived probability of COVID-19 infection mediated the positive impact of fear of COVID-19 on motivation, β = .07, p = .006, 95CI[.03,.13].

CONCLUSIONS

The result places the perceived probability of COVID-19 infection as a central predictor of the motivation to quit during the pandemic. Based on this evidence, messaging aiming to facilitate smoking cessation during the pandemic should focus on the highly contagious nature of the virus to increase the motivation to quit.

Risk Factors of In-Hospital Mortality in Non-Specialized Tertiary Center Repurposed for Medical Care to COVID-19 Patients in Russia

The purpose of our study is to investigate the risk factors of in-hospital mortality among patients who were admitted in an emergency setting to a non-specialized tertiary center during the first peak of coronavirus disease in Moscow in 2020. The Federal Center of Brain and Neurotechnologies of the Federal Medical and Biological Agency of Russia was repurposed for medical care for COVID-19 patients from 6th of April to 16th of June 2020 and admitted the patients who were transported by an ambulance with severe disease. In our study, we analyzed the data of 635 hospitalized patients aged 59.1 ± 15.1 years. The data included epidemiologic and demographic characteristics, laboratory, echocardiographic and radiographic findings, comorbidities, and complications of the COVID-19, developed during the hospital stay. Results of our study support previous reports that risk factors of mortality among hospitalized patients are older age, male gender (OR 1.91, 95% CI 1.03–3.52), previous myocardial infarction (OR 3.15, 95% CI 1.47–6.73), previous acute cerebrovascular event (stroke, OR = 3.78, 95% CI 1.44–9.92), known oncological disease (OR = 3.39, 95% CI 1.39–8.26), and alcohol abuse (OR 6.98, 95% CI 1.62–30.13). According to the data collected, high body mass index and smoking did not influence the clinical outcome. Arterial hypertension was found to be protective against in-hospital mortality in patients with coronavirus pneumonia in the older age group. The neutrophil-to-lymphocyte ratio showed a significant increase in those patients who died during the hospitalization, and the borderline was found to be 2.5. CT pattern of “crazy paving” was more prevalent in those patients who died since their first CT scan, and it was a 4-fold increase in the risk of death in case of aortic and coronal calcinosis (4.22, 95% CI 2.13–8.40). Results largely support data from other studies and emphasize that some factors play a major role in patients’ stratification and medical care provided to them.

Systematic review with meta-analysis of the epidemiological evidence in Europe, Israel, America and Australasia on smoking and COVID-19

BACKGROUND

Previous meta-analyses related smoking to death or severe infection from coronavirus disease 2019 (COVID-19) in hospitalized patients, but considered only a few studies, did not adjust for demographics and comorbidities, and inadequately defined smoking.

AIM

To review and meta-analyse epidemiological evidence on smoking and COVID-19, considering a range of endpoints, populations and smoking definitions and the effect of adjustment.

METHODS

Studies were identified from publications in English up to 30 September, 2020 involving at least 100 individuals, carried out in Europe, Israel, America or Australasia, not restricted to those with specific other diseases, and providing information relating smoking to various COVID-related endpoints. Meta-analyses were carried out for combinations of population and endpoint, with variation studied by smoking definition, adjustment level and other factors.

RESULTS

From 96 publications, 74 studies were identified, 37 in the United States, 10 in the United Kingdom, with up to four in the other countries. Three involved over a million individuals, and 37 involved less than a thousand. Adjusted results for smoking were available in 42 studies, with adjustment not considered in 20 studies. Results were considered by endpoint. No significant effect of smoking on COVID-19 positivity was seen in the general population, but there was a reduced risk in those tested. Best-adjusted estimates for current (vs never) smoking were 0.87 (95% confidence interval: 0.52-1.47) in the general population and 0.52 (0.43-0.64) in those tested. For those hospitalized due to COVID-19, unadjusted rates were significantly increased in current smokers (1.20, 1.01-1.42) and ever smokers (1.64, 1.41-1.91), but those adjusted for comorbidities showed no increase for current (0.82, 0.52-1.30) or ever smokers (1.00, 0.76-1.32). There was little evidence to suggest that smoking was associated with intensive care admission. For those hospitalized with COVID-19, best-adjusted estimates were 0.88 (0.72-1.08) for current smokers and 1.10 (0.99-1.22) for ever smokers. In those hospitalized with COVID-19, smoking was not significantly related to subsequent mechanical ventilation, with best-adjusted estimates of 1.12 (0.60-2.09) for current smokers and 1.05 (0.88-1.25) for ever smokers. For those hospitalized with severe COVID-19, best-adjusted estimates were 0.74 (0.49-1.12) for current smokers and 1.15 (0.87-1.51) for ever smokers; few estimates were adjusted for comorbidities. While smoking was associated with increased mortality in unadjusted analyses, the association disappeared after adjustment for comorbidities. For example, in those hospitalized with COVID-19, the unadjusted estimate for ever smokers of 1.59 (1.37-1.83) reduced to 1.07 (0.82-1.38) when adjusted for comorbidities. Studies on those with severe COVID-19 showed that smoking tended to be associated with worsening of the disease. However, no estimate was adjusted, even for demographics. Estimates did not clearly vary by location or study size, and there was too little evidence to usefully study variations by age, amount smoked or years quit.

CONCLUSION

The increased COVID-19 death rate in smokers seen in unadjusted analyses disappears following adjustment for demographics and comorbidities. Among those tested, smoking is associated with lower COVID-19 infection rates.

Assessment of Severe COVID-19 Outcomes Using Measures of Smoking Status and Smoking Intensity

Objective: Smoking status does not indicate the amount or length of tobacco use, and thus, it is an imperfect measure to assess the association between cigarette smoking and severe coronavirus disease 2019 (COVID-19) outcomes. This investigation assessed whether cigarette smoking status, intensity of smoking (i.e., average daily packs of cigarettes smoked), duration of smoking, and pack-years of smoking are associated with severe outcomes among adults diagnosed with COVID-19. Methods: We conducted a retrospective, cross-sectional study in which we identified consecutive patients diagnosed with COVID-19 at the University of Cincinnati healthcare system between 13 March 2020 and 30 September 2020 who had complete information on smoking status, severe COVID-19 outcomes, and covariates (i.e., demographics and comorbidities). We used logistic regression to evaluate the associations of smoking status and intensity of smoking with COVID-19 severity, defined as hospitalization, admission to intensive care unit (ICU), or death, adjusting for sociodemographics and comorbidities. Results: Among the 4611 COVID-19 patients included in the analysis, 18.2% were current smokers and 20.7% were former smokers. The prevalence of COVID-19 outcomes was 28.9% for hospitalization, 9.8% for ICU admission, and 1.4% for death. In the adjusted analysis, current smoking (AOR: 1.23, 95% CI: 1.02–1.49), former smoking (AOR: 1.28, 95% CI: 1.07–1.54), and pack-years of smoking (AOR: 1.09, 95% CI: 1.02–1.17) were associated with a higher prevalence of hospitalization. Average daily packs of cigarettes smoked was associated with a higher prevalence of hospitalization (AOR: 1.30, 95% CI: 1.10–1.53) and ICU admission (AOR: 1.23, 95% CI: 1.04–1.44). Conclusions: Smoking status, pack-years, and intensity of smoking were associated with hospitalizations in patients with COVID-19 and intensity of smoking was associated with ICU admission. The findings underscore the need for detailed information beyond smoking status when evaluating smokers with COVID-19 so that the potential for adverse sequelae may be optimally managed in at-risk patients.

Electronic Cigarette Use Is Not Associated with COVID-19 Diagnosis

This analysis tested the hypothesis that current e-cigarette use was associated with an increased risk of SARS-CoV-2 infection in patients seeking medical care. E-cigarette and conventional cigarette use were ascertained using a novel electronic health record tool, and COVID-19 diagnosis was ascertained by a validated institutional registry. Logistic regression models were fit to assess whether current e-cigarette use was associated with an increased risk of COVID-19 diagnosis. A total of 69,264 patients who were over the age of 12 years, smoked cigarettes or vaped, and were sought medical care at Mayo Clinic between September 15, 2019 and November 30, 2020 were included. The average age was 51.5 years, 62.1% were females and 86.3% were white; 11.1% were currently smoking cigarettes or using e-cigarettes and 5.1% tested positive for SARS-CoV-2. Patients who used only e-cigarettes were not more likely to have a COVID-19 diagnosis (OR 0.93 [0.69-1.25], P = .628), whereas those who used only cigarettes had a decreased risk (OR 0.43 [0.35-0.53], P < .001). The OR for dual users fell between these 2 values (OR 0.67 [0.49-0.92], P = .013). Although e-cigarettes have the well-documented potential for harm, they do not appear to increase susceptibility to SARS-CoV-2 infection. This result suggests the hypothesis that any beneficial effects of conventional cigarette smoking on susceptibility are not mediated by nicotine.

The Risk of COVID-19 Related Hospitalsation, Intensive Care Unit Admission and Mortality in People With Underlying Asthma or COPD: A Systematic Review and Meta-Analysis

Background: Several underlying diseases have been associated with unfavorable COVID-19 related outcomes including asthma and Chronic Obstructive Pulmonary Disease (COPD), however few studies have reported risks that are adjusted for confounding variables. This study aimed to examine the adjusted risk of COVID-19 related hospitalsation, intensive care unit (ICU) admission, and mortality in patients with vs. without asthma or COPD. Methods: A systematic review of major databases was undertaken for studies published between 1/12/2019 and 19/4/2021. Studies reporting the adjusted (for one or more confounder) risks of either hospitalsation, ICU admission, or mortality in asthmatics or COPD patients (control group = no asthma or no COPD) were identified. Risk of bias was determined via the QUIPS tool. A random effect meta-analysis was undertaken. Findings: 37 studies were eligible for analysis, with a total of 1,678,992 participants. The pooled ORs of COVID-19 hospitalsation in subjects with asthma and COPD was 0.91 (95% CI 0.76-1.09) and 1.37 (95% CI 1.29-1.46), respectively. For ICU admission, OR in subjects with asthma and COPD was 0.89 (95% CI 0.74-1.07) and 1.22 (95% CI 1.04-1.42), respectively. For mortality, ORs were 0.88 (95% CI 0.77-1.01) and 1.25 (95% CI 1.08-1.34) for asthma and COPD, respectively. Further, the pooled risk of mortality as measured via Cox regression was 0.93 (95% CI 0.87-1.00) for asthma and 1.30 (95% CI 1.17-1.44) for COPD. All of these findings were of a moderate level of certainty. Interpretation: COPD was significantly associated with COVID-19 related hospital admission, ICU admission, and mortality. Asthma was not associated with negative COVID-19 related health outcomes. Individuals with COPD should take precautions to limit the risk of COVID-19 exposure to negate these potential outcomes. Limitations include differing population types and adjustment for differing cofounding variables. Practitioners should note these findings when dealing with patients with these comorbidities. Review Protocol Registration: https://www.crd.york.ac.uk/prospero/.

Perceived health risks associated with the use of tobacco and nicotine products during the COVID-19 pandemic

INTRODUCTION

The perceived health risks of tobacco products may change during the ongoing COVID-19 pandemic. This study aimed to examine the perceived risks of tobacco use on COVID-19 infection and severity, and possible COVID-related changes in perceptions of tobacco use and overall health.

METHODS

We conducted an online survey of adults in the United States in June 2020 (n=2097). The survey covered cigarettes, cigars, e-cigarettes, and hookah. We also assessed changes in the use of any of the four tobacco products. Multivariate logistic regression models were used to estimate the odds of agreeing with the perceived risks for each risk and each product, with the adjustment of demographic and COVID-19 related variables.

RESULTS

For all four tobacco products, the perceived risks to general health were slightly higher during the pandemic than before the pandemic (77% vs 79.5% for cigarettes) and the perceived risk of COVID-19 severity was larger than the perceived risk of COVID-19 infection (73.3% vs 56.2% for cigarettes). All risk measures varied with tobacco products consistently, with the risks highest for cigarettes, then cigars, followed by e-cigarettes and hookah. Females and people with higher income or education were more likely to endorse the risks of tobacco use than their counterparts. People who perceived higher risks of using cigarettes (OR=1.65; 95% CI: 1.20-2.27) and cigars (OR=1.63; 95% CI: 1.17-2.27) to COVID-19 severity were more likely to have decreased or quit their use.

CONCLUSIONS

Tobacco/nicotine use was perceived to increase the risk of COVID-19 severity and the perceived risk of tobacco/nicotine use to general health was high during the pandemic, particularly for cigarettes. The change of perceived risks appeared to be prompting harm-reducing changes in tobacco product use.

Smokers' cognitive and behavioural reactions during the early phase of the COVID-19 pandemic: Findings from the 2020 ITC Four Country Smoking and Vaping Survey

INTRODUCTION

COVID-19 is primarily a respiratory illness, and smoking adversely impacts the respiratory and immune systems; this confluence may therefore incentivize smokers to quit. The present study, conducted in four high-income countries during the first global wave of COVID-19, examined the association between COVID-19 and: (1) thoughts about quitting smoking; (2) changes in smoking (quit attempt, reduced or increased smoking, or no change); and (3) factors related to a positive change (making a quit attempt or reducing smoking) based on an adapted framework of the Health Belief Model.

METHODS

This cross-sectional study included 6870 adult smokers participating in the Wave 3 (2020) ITC Four Country Smoking and Vaping Survey conducted in Australia, Canada, England, and United States (US). These four countries had varying responses to the pandemic by governments and public health, ranging from advising voluntary social distancing to implementing national and subnational staged lockdowns. Considering these varying responses, and the differences in the number of confirmed cases and deaths (greatest in England and the US and lowest in Australia), smoking behaviours related to COVID-19 may have differed between countries. Other factors that may be related to changes in smoking because of COVID-19 were also explored (e.g., sociodemographics, nicotine dependence, perceptions about personal and general risks of smoking on COVID-19). Regression analyses were conducted on weighted data.

RESULTS

Overall, 46.7% of smokers reported thinking about quitting because of COVID-19, which differed by country (p<0.001): England highest (50.9%) and Australia lowest (37.6%). Thinking about quitting smoking because of COVID-19 was more frequent among: females, ethnic minorities, those with financial stress, current vapers, less dependent smokers (non-daily and fewer cigarettes smoked/day), those with greater concern about personal susceptibility of infection, and those who believe COVID-19 is more severe for smokers. Smoking behaviour changes due to COVID-19 were: 1.1% attempted to quit, 14.2% reduced smoking, and 14.6% increased smoking (70.2% reported no change). Positive behaviour change (tried to quit/reduced smoking) was reported by 15.5% of smokers, which differed by country (p = 0.02), where Australia had significantly lower rates than the other three countries. A positive behavioural smoking change was more likely among smokers with: lower dependence, greater concern about personal susceptibility to infection, and believing that COVID-19 is more severe for smokers.

CONCLUSIONS

Though nearly half of smokers reported thinking about quitting because of COVID-19, the vast majority did not change their smoking behaviour. Smokers were more likely to try and quit or reduce their smoking if they had greater concern about susceptibility and severity of COVID-19 related to smoking. Smokers in Australia were least likely to reduce or try to quit smoking, which could be related to the significantly lower impact of COVID-19 during the early phase of the pandemic relative to the other countries.

Lower Gene Expression of Angiotensin Converting Enzyme 2 Receptor in Lung Tissues of Smokers with COVID-19 Pneumonia

Angiotensin-converting enzyme 2 (ACE-2) is the main cell entry receptor for severe acute respiratory syndrome-Coronavirus-2 (SARS-CoV-2), thus playing a critical role in causing Coronavirus disease 2019 (COVID-19). The role of smoking habit in the susceptibility to infection is still controversial. In this study we correlated lung ACE-2 gene expression with several clinical/pathological data to explore susceptibility to infection. This is a retrospective observational study on 29 consecutive COVID-19 autopsies. SARS-CoV-2 genome and ACE-2 mRNA expression were evaluated by real-time polymerase chain reaction in lung tissue samples and correlated with several data with focus on smoking habit. Smoking was less frequent in high than low ACE-2 expressors (p = 0.014). A Bayesian regression also including age, gender, hypertension, and virus quantity confirmed that smoking was the most probable risk factor associated with low ACE-2 expression in the model. A direct relation was found between viral quantity and ACE-2 expression (p = 0.028). Finally, high ACE-2 expressors more frequently showed a prevalent pattern of vascular injury than low expressors (p = 0.049). In conclusion, ACE-2 levels were decreased in the lung tissue of smokers with severe COVID-19 pneumonia. These results point out complex biological interactions between SARS-CoV-2 and ACE-2 particularly concerning the aspect of smoking habit and need larger prospective case series and translational studies.

[COVID-19 and Smoking - A Position Paper by the DGP Taskforce for Smoking Cessation]

Tobacco smoking is associated with severe health risks. In 2020, the WHO estimated that 8 million people have died due to smoking. Furthermore, smoking tobacco is a well-known risk factor for various infectious pulmonary diseases. The question raised, whether smoking is facilitating SARS-CoV-2-infections and increases adverse outcomes of COVID-19. To answer these questions a narrative review was conducted, finally including 7 systematic reviews with meta-analyses published in January and February 2021. Tobacco smoking was associated with an increased COVID-19 disease severity (odds ratio range of active vs. never smokers 1.55-2.19 and former vs. never smokers 1.20-2.48) and an increased COVID-19 in-hospital mortality (odds ratio range of active vs. never smokers 1.35-1.51 and former vs. never smokers 1.26-2.58). Beside immediate pulmonary toxic effects through active smoking, the cumulative livelong tobacco exposition and subsequent tobacco-associated diseases seem to predominantly predict adverse outcomes in patients with COVID-19. Data regarding an increased risk of infection among smokers is conflicting. However, a large observational study from England with 2.4 million persons reported an association between tobacco smoking and typical symptoms of COVID-19. For e-cigarettes and vaping less data exist, but experimental and first clinical investigations also suggest an increased risk for adverse outcomes for their use and SARS-CoV-2 infections. Especially during the current SARS-CoV-2 pandemic with limited therapeutic options it is particularly important to advise smokers of their increased risks for unfavourable COVID-19 outcomes. Evidence based support for smoking cessation should be offered. In Germany, the existing and well-established methods to support tobacco cessation need to be reimbursed by statutory health insurances.

Smoking and the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection

Introduction

It is unclear whether smokers are more vulnerable to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. This study aimed to evaluate the association between smoking and the risk of SARS-CoV-2 infection.

Methods

A matched case-control study was conducted using a large nationwide database. The case group included patients with SARS-CoV-2 infection confirmed by the Korea Centers for Disease Control and Prevention, and the control group was randomly sampled from the general Korean population in the National Health Insurance Service database by matching sex, age, and region of residence. Conditional logistic regression models were used to investigate whether the risk of infection with SARS-CoV-2 was affected by smoking status.

Results

A total of 4,167 patients with SARS-CoV-2 infection and 20,937 matched controls were enrolled. The proportion of ex-smokers and current smokers was 26.6% of the total participants. In multivariate analysis, smoking was not associated with an increased risk of SARS-CoV-2 infection (odds ratio [OR] = 0.56, confidence interval [CI] = 0.50–0.62). When ex-smokers and current smokers were analysed separately, similar results were obtained (current smoker OR = 0.33, CI = 0.28–0.38; ex-smoker OR = 0.81, CI = 0.72–0.91).

Conclusions

This study showed that smoking may not be associated with an increased risk of SARS-CoV-2 infection. Smoking tends to lower the risk of SARS-CoV-2 infection; however, these findings should be interpreted with caution.

Implications

It is unclear whether smokers are more vulnerable to coronavirus disease 2019. In this large nationwide study in South Korea, smoking tended to lower the risk of infection with severe acute respiratory syndrome coronavirus 2. However, these findings should be interpreted with caution, and further confirmatory studies are required.

Current Activities Centered on Healthy Living and Recommendations for the Future: A Position Statement from the HL-PIVOT Network

We continue to increase our cognizance and recognition of the importance of healthy living (HL) behaviors and HL medicine (HLM) to prevent and treat chronic disease. The continually unfolding events precipitated by the coronavirus disease 2019 (COVID-19) pandemic have further highlighted the importance of HL behaviors, as indicated by the characteristics of those who have been hospitalized and died from this viral infection. There has already been recognition that leading a healthy lifestyle, prior to the COVID-19 pandemic, may have a substantial protective effect in those who become infected with the virus. Now more than ever, HL behaviors and HLM are essential and must be promoted with a renewed vigor across the globe. In response to the rapidly evolving world since the beginning of the COVID-19 pandemic, and the clear need to change lifestyle behaviors to promote human resilience and quality of life, the HL for Pandemic Event Protection (HL-PIVOT) network was established. The 4 major areas of focus for the network are: (1) knowledge discovery and dissemination; (2) education; (3) policy; (4) implementation. This HL-PIVOT network position statement provides a current synopsis of the major focus areas of the network, including leading research in the field of HL behaviors and HLM, examples of best practices in education, policy, and implementation, and recommendations for the future.

GIS-Based Analysis Framework to Identify the Determinants of COVID-19 Incidence and Fatality in Africa

Corona virus diseases 2019 (COVID-19) pandemic is an extraordinary threat with significant implications in all aspects of human life; therefore, it represents the most immediate challenge for the countries all over the world. This study, hence, is intended to identify the best GIS-based model that can explore, quantify, and model the determinants of COVID-19 incidence and fatality. For this purpose, geospatial models were developed to estimate COVID-19 incidence and fatality rates in Africa, up to 16th of August 2020 at the national level. The models involved Ordinary Least Squares (OLS) and Geographically Weighted Regression (GWR) analysis using ArcGIS. Spatial autocorrelation analysis recorded a positive spatial autocorrelation in COVID-19 incidence (Moran index 0.16, P = 0.1) and fatality (Moran index 0.26, P = 0.01) rates within different African countries. GWR model had higher R2 than OLS for prediction of incidence and mortality (58% vs 45% and 55% vs 53%). The main predictors of COVID-19 incidence rate were overcrowding, health expenditure, HIV infections, air pollution, and BCG vaccination (mean β = 3.10, 1.66, 0.01, 3.79, and -66.60 respectively, P < 0.05). The main determinants of COVID-19 fatality were prevalence of bronchial asthma, tobacco use, poverty, aging, and cardiovascular diseases fatality (mean β = 0.00162, 0.00004, -0.00025, -0.00144, and -0.00027 respectively, P < 0.05). Application of the suggested model can assist in guiding intervention strategies, particularly at the local and community level whenever the data on COVID-19 cases and predictors variables are available.