Smokers

[Crunchymum]

Any stats available on smokers and CV19 mortality / infection rates?

I'm an ex smoker (a decade now) but I haven't seen much mentioned?

The stats that are available are very interesting:

This meta-analysis of retrospective observational case series found an unexpectedly low prevalence of current smoking among hospitalized patients with COVID-19. Hospitalized current smokers had higher odds compared with non-current smokers but lower odds compared with former smokers for an adverse outcome. Smoking cannot be considered a protective measure for COVID-19. However, the hypothesis that nicotine may have a protective effect in COVID-19 that is partially masked by smoking-related toxicity and by the abrupt cessation of nicotine intake when smokers are hospitalized should be explored in laboratory studies and clinical trials using pharmaceutical nicotine products.

journals.sagepub.com/doi/10.1177/2040622320935765#

This study was looking at the effects of ACE inhibitors on the risk of requiring hospitalisation and requiring ICU admission, but they analysed a lot of different risk factors and found similar 'counterintuitive' results with smoking status:

There was a small increased risk of both adverse outcomes among ex-smokers compared with never-smokers. We observed a markedly decreased risk of both COVID-19 disease and ICU admission in smokers. The apparent protective association was greatest for heavy and moderate smokers and most markedly on the risk of ICU admission which was 88% lower in heavy smokers compared with non-smokers

heart.bmj.com/content/106/19/1503

This has been around since the very beginning- the surprising apparent protective factor of smoking. I hypothesised that maybe it’s because smokers are less likely to spend hours in a small unventilated space with others and wash hands more regularly, and maybe are more hydrated I got laughed out of court

I remember when this data started coming out in March and April. Then everything went quiet and I just assumed that further studies had failed to confirm the findings, or had identified the flaw (inaccurate recording of smoking status would be the obvious candidate). Prompted by this thread I went looking for more recent data - it hasn't gone away, there are now loads more studies with similar results:

But it's all still very quiet.

I can't imagine a bigger hot potato for public health than 'smoking protects against covid19' but they can't just ignore these findings. Obviously smoking ruins health and hastens death in many other ways that are far more likely than dying from the virus. Obviously it would be a very bad idea to suggest that people should take up smoking or not try to quit.

This is the 21st century though and we are capable of working out what it is about smoking that apparently provides protection, and whether we can use that to improve outcomes without introducing all of the other harms that come with smoking.

Several of these papers recommend further study on the role of nicotine. Konstantinos Farsalinos has identified two potential mechanisms for a protective effect from nicotine and these urgently need further study:

What if smokers are much less likely to die of covid if they are not abruptly withdrawn from nicotine when they go into hospital?

What if ex-smokers have much better outcomes if they start using nicotine patches as soon as they test positive?

What if pharmaceutical nicotine turns out to be a powerful therapeutic, even for people who have never smoked?

The only reason this research isn't happening is because it's too politically awkward.

@LangClegsInSpace thanks
Is there evidence that it’s the nicotine not for eg the tar?

No there's no evidence because nobody is doing the research because it's too much of a hot potato.

But we don't have to test all the deadly substances in tobacco smoke first before we look at nicotine. That would be extremely unethical, and where would you start on 'the tar' anyway? You'd need to separate out over 4000 chemicals, several hundred of which are carcinogenic.

Likewise it would be a bad idea to do RCTs to find out if carbon monoxide is the useful ingredient. We know how that goes.

Why would you start there?

Pharmaceutical nicotine has a very good safety profile. In the UK we prescribe it to pregnant women. This might surprise you but it's also not particularly addictive - smoking is extremely addictive but nicotine on its own is not. Nobody gets hooked on patches or gum unless they're already a smoker. And it's cheap and plentiful. If it proved to be effective we could improve outcomes for a huge number of people very easily and cheaply.

We could easily do the research by recruiting vapers and people who use NRT for longitudinal studies. Also people using snus and heat-not-burn tobacco products.

We could do proper RCTs of giving some smokers a patch on hospital admission and leaving others to go through abrupt withdrawal.

We could do RCTs of ex smokers using nicotine from when they test positive.

We could include pharmaceutical nicotine in the Recovery trials. It's far lower risk than the other drugs being trialed, even dexamethasone.

The reason we won't do this research is because it's just too awkward. Nobody's brave enough and if they were they couldn't get funding.

Even in the complete absence of evidence there is no excuse for making smokers abruptly withdraw from nicotine.

Every smoker should be offered NRT on hospital admission. Either it will improve their chances or it won't, but it'll be a more bearable experience without abrupt nicotine withdrawal on top of everything else and there are no down sides.

I read ages ago with SARS one of the biggest cause of death was an over-reaction immune response, which basically flooded the lungs with mucus, in smokers the immune system is weaker, particularly in the lungs and so less likely to be as strong.

Covid literally is SARS 2, so I had assumed that now is probably not the best time to give up.

Ex-smokers seem to be at particular risk and we need to work out why.

There's never a bad time to quit smoking.

I think now is probably not the best time to go cold turkey - use NRT or a vape and don't be in any hurry to cut down or quit the nicotine.

I’m a smoker and no I’m not giving up at the moment. I’ve read a lot of the research but as has been said by pp’s, it’s a hot potato. But if you think about it, there’s been no big push to encourage people to quit during this time. If the outcomes were worse for smokers the anti smoking lobby would be all over it. That’s why there is mainly silence on the matter. Smoking does decrease risk of some things, for example Parkinson’s disease. But obviously there are greater risks of other illnesses. Definitely more research is needed.

@LangClegsInSpace

Ex-smokers seem to be at particular risk and we need to work out why.

That is really interesting.

From a purely selfish point of view, I wonder how long you have to be an ex smoker to have the same "risk" as a non smoker!