Smoking and COVID-19 Scientific brief
This is an update to the Scientific Brief entitled ‘Smoking and COVID-19,’ originally published on 26 May 2020. Since its publication, a study entitled ‘Cardiovascular Disease, Drug Therapy, and Mortality in Covid-19’ by Mehra et al. has been retracted by the New England Journal of Medicine. This version of the Scientific Brief has removed the study from the review. The removal of this study from the review does not change the conclusions of the analysis.
Background The harms of tobacco use are well-established. Tobacco causes 8 million deaths every year from cardiovascularhttps://www.who.int/publications/i/item/WHO-2019-nCoV-Sci_Brief-Smoking-2020.2 diseases, lung
disorders, cancers, diabetes, and hypertension.1 Smoking tobacco is also a known risk factor for severe disease and death from many
respiratory infections.2-4 In the COVID-19 pandemic, questions have been asked about clinical outcomes for smokers, and whether
they are equally susceptible to infection, and if nicotine has any biological effect on the SAR-CoV-2 virus (the virus that causes
COVID-19).
5-7 At the time of writing, one clinical trial to test the effects of nicotine has been announced, but no trial registration
record was found as of 12 May 2020.
This review therefore assesses the available peer-reviewed literature on the association between smoking and COVID-19, including
1) risk of infection by SARS-CoV-2; 2) hospitalization with COVID-19; and 3) severity of COVID-19 outcomes amongst
hospitalized patients such as admission into intensive care units (ICU), use of ventilators and death.
Methods
A review was conducted on 12 May 2020 on smoking and COVID-19, using MEDLINE, EMBASE, Cochrane Library, and WHO
Global Database. Quantitative primary research on adults or secondary analyses of such studies were included. Individual studies
included in meta-analyses that were not otherwise identified in the search were sought.
Due to the preliminary nature of the many non-peer-reviewed reports issued during the COVID-19 pandemic, preprint repositories
were deliberately excluded from this review.
Review of the evidence
Thirty-four peer-reviewed studies met the inclusion criteria. All included studies were in English. None examined tobacco use and
the risk of infection or the risk of hospitalization. A total of 26 observational studies and eight meta-analyses were identified. All
observational studies reported the prevalence of smoking amongst hospitalized COVID-19 patients. Two meta-analyses reported
pooled prevalence of smoking in hospitalized patients using a subset of these studies (between 6 and 13 studies).
Eighteen of the 26 observational studies containing data on smoking status by severity of COVID-19 outcomes. Six meta-analyses
were identified that examined the association between smoking and severity of COVID-19. Nine of the 18 studies were included in
the six meta-analyses of smoking and severity (five to seven studies in each analysis), resulting in 1,604 sets of patient data being
reported more than once. All data in the six meta-analyses come from patients in China.
What is the risk of smokers being infected by SARS-CoV-2?
There are currently no peer-reviewed studies that have evaluated the risk of SARS-CoV-2 infection among smokers. This research
question requires well-designed population-based studies that control for age and relevant underlying risk factors.
What is the risk of smokers being hospitalized for COVID-19?
There are currently no peer-reviewed studies that directly estimate the risk of hospitalization with COVID-19 among smokers.
However, 27 observational studies found that smokers constituted 1.4-18.5% of hospitalized adults.
8-32 Two meta-analyses have
been published which pooled the prevalence of smokers in hospitalized patients across studies based in China. The meta-analysis
by Emami et al.
33 analysed data for 2986 patients and found a pooled prevalence of smoking of 7.6% (3.8% -12.4%) while Farsalinos
et al.
34 analysed data for 5960 hospitalized patients and found a pooled prevalence of 6.5% (1.4% - 12.6%).
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