Are smokers more at risk from COVID-19?

COVID-19: an update on the situation

The coronavirus pandemic is now affecting 184 countries, according to a report by the Center for Systems Science and Engineering at Johns Hopkins University in Baltimore.

In recent weeks, 3.9 billion people are expected to be confined in their homes. This is an inevitable step to reduce the fatality of the spread of COVID-19.

The coronavirus has become the unavoidable topic of our daily lives. We are now aware of the reality of the caregivers, people who are sick and the measures we have to take to limit the spread of the pandemic. The safety rules that have been taken, such as confinement, prohibition to be around fragile people, our friends, family and colleagues, are pushing us to refocus on ourselves. This situation provides us with time for reflection so that we can focus on our lives and our desires.

This new virus is impacting the whole world. Given its recent discovery, it still leaves many questions unanswered. In this blog article, we want to help people understand the connection between smoking and COVID-19.

Are smokers more at risk if they get infected by COVID-19?

Given the risk factors that a person has with the disease, we may ask ourselves how dangerous COVID-19 is for smokers.

The answer to this question may seem simple, but it is difficult to say with certainty that smokers have a greater risk of developing a severe form of the coronavirus based on established data. In fact, knowledge about the current pandemic is slowly being updated as new studies are published. According to the current literature, we do not have enough data and studies to affirm that there is a direct causal link between smoking and the risk of contracting a severe form of COVID-19.

In the absence of recent data, however, we can infer from recognized and validated information.

On the one hand, we are aware of the long-term negative effects of smoking on the immune, cardiovascular and respiratory systems. Indeed, smokers tend to have more fragile lungs than non-smokers. As we already discussed in our article «Smoking when you have the flu: bad idea!», smoking doubles the risk of contracting a respiratory infection and increases the likelihood of progression to permanent complications from the flu. In addition, smokers also experienced higher mortality during the previous MERS-CoV7.

One of the risk factors making people more vulnerable to the COVID-19 is having underlying diseases of the immune system, the cardiovascular system, or the respiratory system, particularly with chronic obstructive pulmonary disease (COPD). In fact, according to the U.S. Department of Health and Human Services, 78% of individuals admitted to intensive care units had at least one underlying health problem or risk factor. Thus, we could deduce that quitting smoking provides long-term protection from the same diseases that are a vulnerability factor for COVID-19.

We can also point out that smoking or vaping involves many small acts that can impact the propagation rate of the virus. For example, we can mention hand and mouth gestures, having to remove one's mask often or buying a pack of cigarettes. The purpose of informing you of this danger is not to create fear or panic, but to make you more aware so that you can implement protective measures even if you continue to smoke.

In fact, when you smoke a cigarette or vape, your hand/mouth gestures can increase the risk of being contaminated with COVID-19. If you touch a surface contaminated by the virus and light a cigarette a few moments later, your fingers will touch your face, mouth and/or saliva. You are more likely to introduce the virus into your body and to spread the virus by touching others. Therefore, it is crucial to wash your hands carefully before and after smoking a cigarette to protect yourself.

Transmission through saliva and the respiratory tract is one of the reasons why masks are required to be worn in public places in many countries. A mask protects you from contamination. If you take regular cigarette or vaping breaks, you should remove your mask by only touching the strings on the back of your head. If you remove your mask with your fingers and touch the upper part of the mask all the time, the protective effect of the mask becomes ineffective. A mask that is used incorrectly is of no use. You should be careful not to touch the inside of the mask with your fingers. Otherwise you can leave bacteria in the area that will come into contact with your mouth. This requires extra vigilance for smokers. If you are in an environment where you are in contact with fragile people, you must throw away your mask permanently to avoid any contamination.

In addition, when you go to the store to buy your pack of cigarettes or your vape refills and pods, you expose yourself more; moving around and touching the cigarette packages puts you in contact with the virus. According to a study published by the National Institutes of Health (NIH), COVID-19 lasts four hours on copper surfaces, 24 hours on cardboard and up to three days on plastics and stainless steel. To protect yourself from it, you must disinfect your packages/pods/refills, be careful about what you touch, and wash your hands as soon as possible.

Finally, cigarette breaks with co-workers result in people gathering together and therefore increase the likelihood of spreading the virus. However, no study has yet been able to demonstrate the transmission of micro-particles of the virus in the vapor or smoke. In any case, it has always been recommended to smoke or vape in open spaces.

What is currently known about smoking, nicotine and COVID-19

In an effort to make science more accessible to the public, we also want to share with you the current information on the connection between COVID-19, tobacco and nicotine. Our objective is to keep you updated on the scientific advances through this blog.

Most of the current studies on COVID-19 focus on the Chinese population. Only a few of them are directed at the American and Italian population. Most of these studies are "retrospective", meaning that they are looking at past conditions. Researchers describe the observed characteristics of patients severely affected by this infection. These studies never include the general population with a mild or asymptomatic form of the virus.

For information, 27.7% of the Chinese population smokes, with a very significant difference between men and women (52.1% in men and 2.7% in women) compared to France, where about 25.4% of the adult population smokes (35.3% of men and 28.9% of women). In America, the proportion of smokers is lower with only 11% of adult Americans who smoke.

Some studies highlight three main ideas regarding the effects of smoking on severe forms of coronavirus:

• Former smokers are less likely to develop a serious form of coronavirus compared to smokers and the general population.

• The current proportion of smokers with severe forms of COVID-19 would be relatively small in relation to the proportion of smokers in the general population.

• Being a smoker at the time of contracting the virus would make it more difficult to make full recovery compared to non-smokers.

People who have stopped smoking are less likely to carry the ACE2 receptor and are less likely to contract a severe form of coronavirus. In fact, a study30110-2/abstractFarsalinos%20:%20https://www.qeios.com/read/article/541) by Giusseppe Lippi and colleagues points out that the virus host receptor (ACE2), responsible for COVID-19, is not as present in former smokers. Moreover, Guan's study of 1099 people noticed the same phenomenon: only 5.2% of the patients with a severe form of coronavirus were former smokers and 7.6% of the patients in the intensive care unit were former smokers. This study raises the question if being a former smoker protects against developing a severe form of COVID-19.

The current proportion of smokers with severe forms of COVID-19 is too low to define it as a direct risk factor. The study conducted by Fei Zhou30566-3/fulltext) on March 28, 2020, on a sample of 191 hospitalized people, shows that only 6% were smokers at the time they contracted the virus. This figure was defined as low, given the number of non-smoking patients in the intensive care unit and the smoking population in China.Guan published a study on March 6, 2020, carried out on 1099 people. In the study, 16.9% of the group of patients with severe forms of coronavirus were current smokers, 5.2% were former smokers and 66.9% had never smoked. Moreover, in his letter, Hua Cai suggests that the relatively small proportion of current smokers in the two studies (Zhou and Guan) compared to the proportion of male smokers in China (50%) is unlikely to correlate with the severity of COVID-19. This assumption is supported by the meta-analysis of Ali Akbari and colleagues (a multi-study research) which suggests that 7.63% of people with severe forms of COVID-19 were smokers at the time they contracted the virus.

Being a smoker at the time of contracting the virus may make it more difficult to progress towards full recovery. The Nikitara team estimates that smokers are 1.4 more likely to be infected with the virus than non-smokers, and 2.4 times more likely than non-smokers to be admitted to an intensive care unit, require mechanical ventilation or die. This group of researchers observed that only 3% of the patients who had recovered quickly in that group were smokers. This figure increased to 27% in the group of patients who still needed medical support. In Guan's study, 25.5% of the people in intensive care who used artificial respirators were smokers and 7.6% were former smokers.

According to Konstantinos, there are two reasons that may explain this phenomenon. The first one would be the fact that smokers are more likely to suffer from other respiratory, cardiac or immune diseases, making them vulnerable. The second would be the withdrawal symptoms associated with abrupt nicotine cessation during hospitalization.

A recent study, that looked at the number of ACE2 receptors on which the virus binds suggests that COVID-19 infects the respiratory tract through different airways in smokers, ex-smokers and non-smokers. This may partially explain the different sensitivity levels, disease severity and treatment outcomes.

Unfortunately, none of these studies have collected information on the effects of the vaping. Therefore, the information presented here cannot be generalized to those who use electronic cigarettes.

Finally, a meta-analysis was recently carried out by the Konstantinos team on April 4, in which 13 studies were analysed involving 5960 patients. The team members were surprised by the low rate of smokers affected by this viral disease, while the prevalence rate of smokers in all these studies ranged from 1.4% to 12.6%. They also wondered about the role of nicotine in the evolution of the disease. Nicotine may in fact play a protective role on the immune system.

Summary

• Smokers tend to have pulmonary fragility.

• The coronavirus infects the respiratory tract.

• We cannot assert that there is a causal link between smoking and the development of a serious form of the virus.

• We are getting more and more information on the mechanism and mode of transmission of COVID-19, and safety rules are being enforced, so we must respect them and not give in to panic.

This virus has impacted the whole world and forces us to reflect on our lifestyles as a society. This reflection is also true in our personal lives. We can afford to take time to reflect, to make decisions that are more in line with the life we want to lead.

If you want to quit smoking, Kwit can support you in this process. Our goal isn't to force you to stop smoking if you don't feel ready. We would like to help you by informing you on how to prepare yourself to quit smoking!

Remember to take care of yourself and your relatives and to love each other from afar. 🖤