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01-12-2021 | Coronavirus | Research article

Smoking is associated with worse outcomes of COVID-19 particularly among younger adults: a systematic review and meta-analysis

Authors: Roengrudee Patanavanich, Stanton A. Glantz

Published in: BMC Public Health | Issue 1/2021

Abstract

Background

Smoking impairs lung immune function and damages upper airways, increasing risks of contracting and severity of infectious diseases. This paper quantifies the association between smoking and COVID-19 disease progression.

Methods

We searched PubMed and Embase for studies published from January 1–May 25, 2020. We included studies reporting smoking behavior of COVID-19 patients and progression of disease, including death. We used random effects meta-analysis, meta-regression and locally weighted regression and smoothing to examine relationships in the data.

Results

We identified 46 peer-reviewed papers with a total of 22,939 COVID-19 patients, 5421 (23.6%) experienced disease progression and 2914 (12.7%) with a history of smoking (current and former smokers). Among those with a history of smoking, 33.5% experienced disease progression, compared with 21.9% of non-smokers. The meta-analysis confirmed an association between ever smoking and COVID-19 progression (OR 1.59, 95% CI 1.33–1.89, p = 0.001). Ever smoking was associated with increased risk of death from COVID-19 (OR 1.19, 95% CI 1.02–1.39, p = 0.003). We found no significant difference (p = 0.864) between the effects of ever smoking on COVID-19 disease progression between adjusted and unadjusted analyses, suggesting that smoking is an independent risk factor for COVID-19 disease progression. We also found the risk of having COVID-19 progression higher among younger adults (p = 0.001), with the effect most pronounced among younger adults under about 45 years old.

Conclusions

Smoking is an independent risk for having progression of COVID-19, including mortality. The effects seem to be higher among young people. Smoking prevention and cessation should remain a priority for the public, physicians, and public health professionals during the COVID-19 pandemic.

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Coronavirus disease (COVID-19) Weekly Epidemiological Update and Weekly Operational Update. 2021. https://www.who.int/emergencies/diseases/novelcoronavirus-2019/situation-reports. Accessed 21 May 2021.

Coronavirus Disease 2019 (COVID-19): People Who Are at Higher Risk for Severe Illness. 2020. https://www.cdc.gov/coronavirus/2019-ncov/need-extraprecautions/people-at-higher-risk.html. Accessed 28 May 2020.

Arcavi L, Benowitz NL. Cigarette smoking and infection. Arch Intern Med. 2004;164(20):2206–16.PubMedCrossRef

Q&A: Tobacco and COVID-19. 2020. https://www.who.int/news-room/q-a-detail/q-a-on-tobacco-and-covid-19. Accessed 28 May 2020.

Patanavanich R, Glantz SA. Smoking Is Associated With COVID-19 Progression: A Meta-analysis. Nicotine Tob Res. 2020;22(9):1653–6.PubMedPubMedCentralCrossRef

Jordan RE, Adab P, Cheng KK. Covid-19: risk factors for severe disease and death. BMJ. 2020;368:m1198.PubMedCrossRef

A Cochrane Risk Of Bias Assessment Tool: for Non-Randomized Studies of Interventions (ACROBAT-NRSI), Version 1.0.0. 2014. https://www.bristol.ac.uk/population-health-sciences/centres/cresyda/barr/riskofbias/robins-i/acrobat-nrsi/. Accessed 29 May 2020.

Beyrouti R, Adams ME, Benjamin L, Cohen H, Farmer SF, Goh YY, et al. Characteristics of ischaemic stroke associated with COVID-19. J Neurol Neurosurg Psychiatry. 2020;jnnp-2020-323:586.

Buckner FS, McCulloch DJ, Atluri V, Blain M, McGuffin SA, Nalla AK, et al. Clinical Features and Outcomes of 105 Hospitalized patients with COVID-19 in Seattle, Washington. Clin Infect Dis. 2020;71(16):2167–73.PubMedPubMedCentralCrossRef

10.

CDC COVID-19 Response Team. Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019 - United States, February 12–March 28, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(13):382–6. https://doi.org/10.15585/mmwr.mm16913e15582.CrossRefPubMedCentral

11.

Chen Q, Zheng Z, Zhang C, Zhang X, Wu H, Wang J, et al. Clinical characteristics of 145 patients with corona virus disease 2019 (COVID-19) in Taizhou, Zhejiang, China. Infection. 2020:48(4):543–551. https://doi.org/10.1007/s15010-020-01432-5. Epub 28 Apr 2020.

12.

Chen T, Wu D, Chen H, Yan W, Yang D, Chen G, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ. 2020;368:m1091.PubMedPubMedCentralCrossRef

13.

Dong X, Cao YY, Lu XX, Zhang JJ, Du H, Yan YQ, et al. Eleven Faces of Coronavirus Disease 2019. Allergy. 2020;5(7):1699–709. https://doi.org/10.1111/all.14289. Epub 6 Apr 2020.

14.

Feng Y, Ling Y, Bai T, Xie Y, Huang J, Li J, et al. COVID-19 with Different Severity: A Multi-center Study of Clinical Features. Am J Respir Crit Care Med. 2020;201(11):1380–88. https://doi.org/10.1164/rccm.202002-0445OC.

15.

Gayam V, Konala VM, Naramala S, Garlapati PR, Merghani MA, Regmi N, et al. Presenting characteristics, comorbidities, and outcomes of patients coinfected with COVID-19 and M. pneumoniae in the USA. J Med Virol. 2020;92(10):2181–7.PubMedCrossRef

16.

Giacomelli A, Ridolfo AL, Milazzo L, Oreni L, Bernacchia D, Siano M, et al. 30-day mortality in patients hospitalized with COVID-19 during the first wave of the Italian epidemic: a prospective cohort study. Pharmacol Res. 2020;158:104931. https://doi.org/10.1016/j.phrs.2020.104931. Epub 22 May 2020.

17.

Goyal P, Choi JJ, Pinheiro LC, Schenck EJ, Chen R, Jabri A, et al. Clinical Characteristics of Covid-19 in New York City. N Engl J Med. 2020;11;382(24):2372-4. https://doi.org/10.1056/NEJMc2010419. Epub 2020 Apr 17.

18.

Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med.2020;382(18):1708–20. https://doi.org/10.1056/NEJMoa2002032.

19.

Guo T, Fan Y, Chen M, Wu X, Zhang L, He T, et al. Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020;5(7):811–8. https://doi.org/10.1001/jamacardio.2020.1017.

20.

Hu L, Chen S, Fu Y, Gao Z, Long H, Wang JM, et al. Risk Factors Associated with Clinical Outcomes in 323 COVID-19 Hospitalized Patients in Wuhan, China. Clin Infect Dis. 2020;71(16):2089–98.PubMedCrossRef

21.

Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497–506.PubMedPubMedCentralCrossRef

22.

Huang R, Zhu L, Xue L, Liu L, Yan X, Wang J, et al. Clinical findings of patients with coronavirus disease 2019 in Jiangsu province, China: A retrospective, multi-center study. PLoS Negl Trop Dis. 2020;14(5):e0008280.PubMedPubMedCentralCrossRef

23.

Hur K, Price CPE, Gray EL, Gulati RK, Maksimoski M, Racette SD, et al. Factors Associated With Intubation and Prolonged Intubation in Hospitalized Patients with COVID-19. Otolaryngol Head Neck Surg. 2020;163(1):170–8.PubMedPubMedCentralCrossRef

24.

Ji D, Zhang D, Xu J, Chen Z, Yang T, Zhao P, et al. Prediction for Progression Risk in Patients with COVID-19 Pneumonia: the CALL Score. Clin Infect Dis. 2020.

25.

Kim ES, Chin BS, Kang CK, Kim NJ, Kang YM, Choi JP, et al. Clinical Course and Outcomes of Patients with Severe Acute Respiratory Syndrome Coronavirus 2 Infection: a Preliminary Report of the First 28 Patients from the Korean Cohort Study on COVID-19. J Korean Med Sci. 2020;35(13):e142.PubMedPubMedCentralCrossRef

26.

Klang E, Kassim G, Soffer S, Freeman R, Levin MA, Reich DL. Morbid Obesity as an Independent Risk Factor for COVID-19 Mortality in Hospitalized Patients Younger than 50. Obesity. 2020;28(9):1595–9.PubMedCrossRef

27.

Li X, Xu S, Yu M, Wang K, Tao Y, Zhou Y, et al. Risk factors for severity and mortality in adult COVID-19 inpatients in Wuhan. J Allergy Clin Immunol. 2020;146(1):110–8. https://doi.org/10.1016/j.jaci.2020.04.006.

28.

Li YK, Peng S, Li LQ, Wang Q, Ping W, Zhang N, et al. Clinical and Transmission Characteristics of Covid-19 - A Retrospective Study of 25 Cases from a Single Thoracic Surgery Department. Curr Med Sci. 2020;40(2):295–300.PubMedCrossRef

29.

Liang W, Liang H, Ou L, Chen B, Chen A, Li C, et al. Development and Validation of a Clinical Risk Score to Predict the Occurrence of Critical Illness in Hospitalized Patients With COVID-19. JAMA Intern Med. 2020;180(8):1081–9. https://doi.org/10.1001/jamainternmed.2020.2033.

30.

Liu W, Tao ZW, Lei W, Ming-Li Y, Kui L, Ling Z, et al. Analysis of factors associated with disease outcomes in hospitalized patients with 2019 novel coronavirus disease. Chin Med J. 2020;133(9):1032–8.PubMedPubMedCentralCrossRef

31.

Mehra MR, Desai SS, Kuy S, Henry TD, Patel AN. Cardiovascular Disease, Drug Therapy, and Mortality in Covid-19. N Engl J Med. 2020;382(25):e102. https://doi.org/10.1056/NEJMoa2007621.

32.

Mo P, Xing Y, Xiao Y, Deng L, Zhao Q, Wang H, et al. Clinical characteristics of refractory COVID-19 pneumonia in Wuhan, China. Clin Infect Dis. 2020. https://doi.org/10.1093/cid/ciaa270. Epub 2020 Mar 16.

33.

Morassi M, Bagatto D, Cobelli M, D’Agostini S, Gigli GL, Bnà C, et al. Stroke in patients with SARS-CoV-2 infection: case series. J Neurol. 2020;267(8):2185–92. https://doi.org/10.1007/s00415-020-09885-2.

34.

Palaiodimos L, Kokkinidis DG, Li W, Karamanis D, Ognibene J, Arora S, et al. Severe obesity, increasing age and male sex are independently associated with worse in-hospital outcomes, and higher in-hospital mortality, in a cohort of patients with COVID-19 in the Bronx, New York. Metabolism. 2020;108:154262.PubMedPubMedCentralCrossRef

35.

Petrilli CM, Jones SA, Yang J, Rajagopalan H, O’Donnell L, Chernyak Y, et al. Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in New York City: prospective cohort study. Bmj. 2020;369:m1966.PubMedPubMedCentralCrossRef

36.

Qin C, Zhou L, Hu Z, Zhang S, Yang S, Tao Y, et al. Dysregulation of immune response in patients with COVID-19 in Wuhan, China. Clin Infect Dis. 2020;71(15):762–8.PubMedCrossRef

37.

Rastrelli G, Di Stasi V, Inglese F, Beccaria M, Garuti M, Di Costanzo D, et al. Low testosterone levels predict clinical adverse outcomes in SARS-CoV-2 pneumonia patients. Andrology. 2021;9(1):88–9.PubMedCrossRef

38.

Ren D, Ren C, Yao RQ, Feng YW, Yao YM. Clinical features and development of sepsis in patients infected with SARS-CoV-2: a retrospective analysis of 150 cases outside Wuhan, China. Intensive Care Med. 2020;46(8):1630–3. https://doi.org/10.1007/s00134-020-06084-5.

39.

Shi Y, Yu X, Zhao H, Wang H, Zhao R, Sheng J. Host susceptibility to severe COVID-19 and establishment of a host risk score: findings of 487 cases outside Wuhan. Crit Care. 2020;24(1):108.PubMedPubMedCentralCrossRef

40.

Wan S, Xiang Y, Fang W, Zheng Y, Li B, Hu Y, et al. Clinical Features and Treatment of COVID-19 Patients in Northeast Chongqing. J Med Virol. 2020;92(7):797–806. https://doi.org/10.1002/jmv.25783.

41.

Wang R, Pan M, Zhang X, Fan X, Han M, Zhao F, et al. Epidemiological and clinical features of 125 Hospitalized Patients with COVID-19 in Fuyang, Anhui, China. Int J Infect Dis. 2020;95:421–8.PubMedPubMedCentralCrossRef

42.

Xiong F, Tang H, Liu L, Tu C, Tian JB, Lei CT, et al. Clinical Characteristics of and Medical Interventions for COVID-19 in Hemodialysis Patients in Wuhan, China. J Am Soc Nephrol. 2020;31(7):1387–97. https://doi.org/10.1681/ASN.2020030354.

43.

Xu K, Chen Y, Yuan J, Yi P, Ding C, Wu W, et al. Factors associated with prolonged viral RNA shedding in patients with COVID-19. Clin Infect Dis. 2020;71(28):799–806.PubMedCrossRef

44.

Yan D, Liu XY, Zhu YN, Huang L, Dan BT, Zhang GJ, et al. Factors associated with prolonged viral shedding and impact of Lopinavir/Ritonavir treatment in hospitalised non-critically ill patients with SARS-CoV-2 infection. Eur Respir J. 2020;56(1):2000799. https://doi.org/10.1183/13993003.00799-2020.

45.

Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020;8(5):475–81. https://doi.org/10.1016/S2213-2600(20)30079-5.

46.

Yao Q, Wang P, Wang X, Qie G, Meng M, Tong X, et al. Retrospective study of risk factors for severe SARS-Cov-2 infections in hospitalized adult patients. Pol Arch Intern Med. 2020;103(5):390–9.

47.

Yu Q, Wang Y, Huang S, Liu S, Zhou Z, Zhang S, et al. Multicenter cohort study demonstrates more consolidation in upper lungs on initial CT increases the risk of adverse clinical outcome in COVID-19 patients. Theranostics. 2020;10(12):5641–8.PubMedPubMedCentralCrossRef

48.

Yu T, Cai S, Zheng Z, Cai X, Liu Y, Yin S, et al. Association Between Clinical Manifestations and Prognosis in Patients with COVID-19. Clin Ther. 2020;42(6):964–72. https://doi.org/10.1016/j.clinthera.2020.04.009.

49.

Yu X, Sun X, Cui P, Pan H, Lin S, Han R, et al. Epidemiological and clinical characteristics of 333 confirmed cases with coronavirus disease 2019 in Shanghai, China. Transbound Emerg Dis. 2020;67(4):1697–707.PubMedCrossRef

50.

Zhang JJ, Dong X, Cao YY, Yuan YD, Yang YB, Yan YQ, et al. Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China. Allergy. 2020;75(7):1730–41.PubMedCrossRef

51.

Zhang R, Ouyang H, Fu L, Wang S, Han J, Huang K, et al. CT features of SARS-CoV-2 pneumonia according to clinical presentation: a retrospective analysis of 120 consecutive patients from Wuhan city. Eur Radiol. 2020;30(8):4417–26. https://doi.org/10.1007/s00330-020-06854-1.

52.

Zhang X, Cai H, Hu J, Lian J, Gu J, Zhang S, et al. Epidemiological, clinical characteristics of cases of SARS-CoV-2 infection with abnormal imaging findings. Int J Infect Dis. 2020;94:81–7.PubMedPubMedCentralCrossRef

53.

Zheng Y, Xiong C, Liu Y, Qian X, Tang Y, Liu L, et al. Epidemiological and clinical characteristics analysis of COVID-19 in the surrounding areas of Wuhan, Hubei Province in 2020. Pharmacol Res. 2020;157:104821.PubMedPubMedCentralCrossRef

54.

Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054–62. https://doi.org/10.1016/S0140-6736(20)30566-3.

55.

Diagnosis and Treatment Protocol for COVID-19. 2020. [http://en.nhc.gov.cn/2020-03/29/c_78469.htm]. Accessed 31 May 2020.

56.

Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45–67.PubMedPubMedCentralCrossRef

57.

Park JE, Jung S, Kim A, Park JE. MERS transmission and risk factors: a systematic review. BMC Public Health. 2018;18(1):574.PubMedPubMedCentralCrossRef

58.

Simons D, Shahab L, Brown J, Perski O. The association of smoking status with SARS-CoV-2 infection, hospitalization and mortality from COVID-19: a living rapid evidence review with Bayesian meta-analyses (version 7). Addiction. 2021;116(6):1319–68.PubMedCrossRef

59.

Zhang H, Ma S, Han T, Qu G, Cheng C, Uy JP, et al. Association of smoking history with severe and critical outcomes in COVID-19 patients: A systemic review and meta-analysis. Eur J Integr Med. 2021;43:101313.PubMedPubMedCentralCrossRef

60.

Adams SH, Park MJ, Schaub JP, Brindis CD, Irwin CE. Medical Vulnerability of Young Adults to Severe COVID-19 Illness—Data From the National Health Interview Survey. J Adolesc Health. 2020;67(3):362–8. https://doi.org/10.1016/j.jadohealth.2020.06.025.

61.

Coronavirus Disease 2019 (COVID-19): Cases in the U.S. 2020. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html. Accessed 31 May 2020.

62.

The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020. China CDC Weekly. 2020;2(8):113–22.CrossRefPubMedPubMedCentral

63.

Bruine de Bruin W. Age differences in COVID-19 risk perceptions and mental health: Evidence from a national US survey conducted in March 2020. J Gerontol Ser B. 2021;76(2):e2–e29.CrossRef

64.

Karanasos A, Aznaouridis K, Latsios G, Synetos A, Plitaria S, Tousoulis D, et al. Impact of smoking status on disease severity and mortality of hospitalized patients with COVID-19 infection: a systematic review and meta-analysis. Nicotine Tob Res. 2020;22(9):1657–9. https://doi.org/10.1093/ntr/ntaa107.

65.

Gotts JE, Jordt SE, McConnell R, Tarran R. What are the respiratory effects of e-cigarettes? BMJ. 2019;366:l5275.PubMedPubMedCentralCrossRef

66.

Fontanet A, Tondeur L, Madec Y, Grant R, Besombes C, Jolly N, et al. Cluster of COVID-19 in northern France: A retrospective closed cohort study. medRxiv. 2020;04.18.20071134. https://doi.org/10.1101/2020.04.18.20071134.

67.

Farsalinos K, Barbouni A, Niaura R. Systematic review of the prevalence of current smoking among hospitalized COVID-19 patients in China: could nicotine be a therapeutic option? Intern Emerg Med. 2020;15(5):845–52.PubMedCrossRefPubMedCentral

68.

Miyara M, Tubach F, Pourcher V, Morelot-Panzini C, Pernet J, Haroche J, et al. Low incidence of daily active tobacco smoking in patients with symptomatic COVID-19. Qeios. 2020. https://doi.org/10.32388/WPP32319W.32383.

69.

Rainer T, Smit D, Cameron P. Smoking and Severe Acute Respiratory Syndrome. Hong Kong J Emerg Med. 2004;11(3):143–5.CrossRef

70.

Parascandola M, Xiao L. Tobacco and the lung cancer epidemic in China. Transl Lung Cancer Res. 2019;8(Suppl 1):S21–S30. https://doi.org/10.21037/tlcr.2019.03.12.

71.

Current Cigarette Smoking Among Adults in the United States. 2019. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm. Accessed 6 Apr 2020.

72.

State Cancer Profile: Screening and Risk Factors Table. 2020. https://statecancerprofiles.cancer.gov/data-topics/screening-risk-factors.html. Accessed 1 June 2020.

73.

Lugo A, Zuccaro P, Pacifici R, Gorini G, Colombo P, La Vecchia C, et al. Smoking in Italy in 2015–2016: prevalence, trends, roll-your-own cigarettes, and attitudes towards incoming regulations. Tumori. 2017;103(4):353–9.PubMedCrossRef

74.

Verlato G, Accordini S, Nguyen G, Marchetti P, Cazzoletti L, Ferrari M, et al. Socioeconomic inequalities in smoking habits are still increasing in Italy. BMC Public Health. 2014;14:879.PubMedPubMedCentralCrossRef

75.

Smoking habits in the UK and its constituent countries (2018). 2019. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/datasets/smokinghabitsintheukanditsconstituentcountries. Accessed 1 June 2020.

76.

Kim Y, Cho W-K. Effects of smoking on disease risk among South Korean adults. Tob Induc Dis. 2018;16:45.PubMedPubMedCentral

77.

Norton EC, Dowd BE, Maciejewski ML. Odds Ratios-Current Best Practice and Use. JAMA. 2018;320(1):84–5.PubMedCrossRef

Title: Smoking is associated with worse outcomes of COVID-19 particularly among younger adults: a systematic review and meta-analysis
Authors: Roengrudee Patanavanich
Stanton A. Glantz
Publication date: 01-12-2021
Publisher: BioMed Central
Keywords: Coronavirus
COVID-19
Published in: BMC Public Health / Issue 1/2021
Electronic ISSN: 1471-2458
DOI: https://doi.org/10.1186/s12889-021-11579-x

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Smoking is associated with worse outcomes of COVID-19 particularly among younger adults: a systematic review and meta-analysis

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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