The effect of smoking on COVID-19 severity: A systematic review and meta-analysis

Rohin K Reddy, Walton N Charles, Alexandros Sklavounos, Atul Dutt, Paul T Seed, Ankur Khajuria, Rohin K Reddy, Walton N Charles, Alexandros Sklavounos, Atul Dutt, Paul T Seed, Ankur Khajuria

Abstract

Various comorbidities represent risk factors for severe coronavirus disease 2019 (COVID-19). The impact of smoking on COVID-19 severity has been previously reported in several meta-analyses limited by small sample sizes and poor methodology. We aimed to rigorously and definitively quantify the effects of smoking on COVID-19 severity. MEDLINE, Embase, CENTRAL, and Web of Science were searched between 1 December 2019 and 2 June 2020. Studies reporting smoking status of hospitalized patients with different severities of disease and/or at least one clinical endpoint of interest (disease progression, intensive care unit admission, need for mechanical ventilation, and mortality) were included. Data were pooled using a random-effects model. This study was registered on PROSPERO: CRD42020180920. We analyzed 47 eligible studies reporting on 32 849 hospitalized COVID-19 patients, with 8417 (25.6%) reporting a smoking history, comprising 1501 current smokers, 5676 former smokers, and 1240 unspecified smokers. Current smokers had an increased risk of severe COVID-19 (risk ratios [RR]: 1.80; 95% confidence interval [CI]: 1.14-2.85; P = .012), and severe or critical COVID-19 (RR: 1.98; CI: 1.16-3.38; P = .012). Patients with a smoking history had a significantly increased risk of severe COVID-19 (RR: 1.31; CI: 1.12-1.54; P = .001), severe or critical COVID-19 (RR: 1.35; CI: 1.19-1.53; P < .0001), in-hospital mortality (RR: 1.26; CI: 1.20-1.32; P < .0001), disease progression (RR: 2.18; CI: 1.06-4.49; P = .035), and need for mechanical ventilation (RR: 1.20; CI: 1.01-1.42; P = .043). Patients with any smoking history are vulnerable to severe COVID-19 and worse in-hospital outcomes. In the absence of current targeted therapies, preventative, and supportive strategies to reduce morbidity and mortality in current and former smokers are crucial.

Keywords: coronavirus; epidemiology; pandemics; pathogenesis; respiratory tract; virus classification; zoonoses.

Conflict of interest statement

The authors declare that there are no conflict of interests.

© 2020 The Authors. Journal of Medical Virology published by Wiley Periodicals LLC.

Figures

Figure 1
Figure 1
Flow diagram of selection of included studies
Figure 2
Figure 2
A, Forest plot showing the effect of current smoking on severe COVID‐19. B, Forest plot showing the effect of current smoking on severe or critical COVID‐19. C, Forest plot showing the effect of current smoking on mortality. COVID‐19, coronavirus disease 2019
Figure 3
Figure 3
A, Forest plot showing the effect of a smoking history on severe COVID‐19. B, Forest plot showing the effect of a smoking history on severe or critical COVID‐19. C, Forest plot showing the effect of a smoking history on mortality. COVID‐19, coronavirus disease 2019

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