Compelling Evidence that Smoking Protects Against Covid-19 & Reduces the Likelihood of ICU Admission

Long-term cigarette smoking is associated with a number of serious diseases, but not COVID-19. In fact, numerous studies demonstrate that smokers are far less likely to be diagnosed with coronavirus than are non-smokers. In June, Konstantinos Farsalinos and colleagues reviewed 18 published reports, finding “an unexpectedly low prevalence of current smoking among hospitalized patients with COVID-19.” (here). 

It is, however, an understatement to say that the quality of COVID-19 information and data is poor. That partly explains why the protective effect of smoking has not generated significant mainstream interest. That is likely to change. 

Last week, researchers from the Universities of Oxford and Nottingham published a prospective cohort study of 19,500 coronavirus patients in the UK, 1,300 of whom ended up in intensive care units (ICUs) (here).  Their analysis, published in the British Medical Journal, found that smokers are far less likely to be diagnosed with COVID-19 and less likely to be admitted to an ICU.

 

The magnitude of the protection is not marginal. The above chart from the article shows that smokers are less than half as likely as non-smokers to be diagnosed with COVID-19.  Even more impressive, light smokers are 74% less likely to be in an ICU, and heavy smokers are 93% less likely. 

The BMJ study confirmed the elevated risks for other factors. For example, people over 60 years old were about twice as likely to be diagnosed and 6-7 times more likely to be in an ICU.  People with Type I diabetes were nearly three times more likely to be both diagnosed and end up in an ICU.  A body mass index of 30+ increased diagnoses by 24-60% and ICU admissions by 3- to 4-fold.  

Although smokers are clearly protected from COVID-19, it is not known how this is achieved. Farsalinos and colleagues believe that nicotine plays a role (here), however, fully understanding the mechanism will require a lot more research.

This is not an invitation to start smoking, but if the mechanism of protection involves nicotine, this finding might lead to a better understanding of how to avoid and treat this devastating pandemic.

 

New WHO/NCI Report Falsely Conflates Smoking & Tobacco

The World Health Organization and the U.S. National Cancer Institute recently published a 700-page report on the economic consequences of smoking, tobacco use, or both (here).  The dozens of tobacco experts who contributed failed to distinguish between tobacco and smoke.  This is especially disappointing, since one of the two editors, University of Illinois at Chicago professor Frank Chaloupka, previously acknowledged the difference (here).

The report’s summary conclusions, which are mainly about smoking and not tobacco, follow, with smoke highlighted in red and tobacco highlighted in green.

1.  There are about 1.1 billion smokers in the world, and about 4 in 5 smokers live in low- and middle-income countries. Nearly two-thirds of the world’s smokers live in 13 countries.

2.  Substantial progress has been made in reducing tobacco smoking in most regions, especially in high-income countries. Overall smoking prevalence is decreasing at the global level, but the total number of smokers worldwide is still not declining, largely due to population growth. Unless stronger action is taken, it is unlikely the world will reach the WHO Member States’ 30% global reduction target by 2025.

3.  Globally, more than 80% of the world’s smokers are men.  Differences in prevalence between male and female smokers are particularly high in the South-East Asia and Western Pacific Regions and in low- and middle-income countries.

4.  Globalization and population migration are contributing to a changing tobacco landscape, and non-traditional products are beginning to emerge within regions and populations where their use had not previously been a concern.

5.  An estimated 25 million youth currently smoke cigarettes.  Although cigarette smoking rates are higher among boys than girls, the difference in smoking rates between boys and girls is narrower than that between men and women. Smoking rates among girls approach or even surpass rates among women in all world regions.

6.  Worldwide, an estimated 13 million youth and 346 million adults use smokeless tobacco products.  The large majority of smokeless tobacco users live in the WHO South-East Asia Region.  Smokeless tobacco use may be undercounted globally due to scarcity of data.

7.  Secondhand smoke exposure remains a major problem. In most countries, an estimated 15%–50% of the population is exposed to secondhand smoke; in some countries secondhand smoke exposure affects as much as 70% of the population.

8.  Annually, around 6 million people die from diseases caused by tobacco use, including about 600,000 from secondhand smoke exposure. The burden of disease from tobacco is increasingly concentrated in low- and middle-income countries.

In the last item, the substitution of tobacco for smoke is obvious.  In fact, most of the report is distorted by this bogus substitution.

 

The sham synonym tactic reflects the anti-tobacco posture of the report’s sponsors, NCI and WHO.  Officials at those organizations supplied two prefaces, totaling 2,700 words. “Tobacco” appears 128 times, while “smoke” is used only 14 times.

Decades of scientific studies document that tobacco is not synonymous with smoke (here and here).  The deliberate conflation of terms by anti-tobacco forces would not be tolerated in any other serious scientific or medical debate. 

The Surprising Economic Effects of Smoking & Quitting

Anti-tobacco forces often argue that smokers are a burden on the American economy.  When Congress debated FDA tobacco regulation in 2009, the White House advised that tobacco use “accounts for over a $100 billion annually in financial costs to the economy” (here).  In 2011, the CDC estimated smoking costs at $193 billion (here).

New data from a highly credible source reinforce a very different perspective on the issue.

In June, the non-partisan Congressional Budget Office (CBO) produced a financial analysis of a hypothetical federal cigarette tax increase (available here).  It reveals that quitting smoking is a money-saver for the government in some respects, and a money-loser in others.

Using standard methodology, the CBO studied the effects on the federal budget of “a hypothetical increase of 50 cents per pack in the federal excise tax on cigarettes and small cigars (adjusted each year to keep pace with inflation)…”  The analysis focuses mainly on the period 2013 to 2021, with long-term projections to 2085.

The CBO estimates that the tax increase would produce a gain of $41 billion through 2021.  Most of the gain ($38 billion) would come from increased tax revenues.  Another $3 billion would come from income tax receipts related to increased productivity among former smokers.

With respect to federal health care, “Medicaid would see the largest savings over the 2013-2021 period—about $560 million,” while “Medicare would have the next-largest savings in the near term—about $250 million.” 

But the CBO also reported some expenses related to cessation: “By contrast, Social Security’s Old-Age and Survivors Insurance program, which pays retirement benefits, would experience the largest net increase in costs because of the policy. On net, outlays for Social Security would rise by about $150 million over the 2013-2021 period.”

Medicaid/Medicare savings would exceed increased Social Security payments until 2025.  After that, Social Security increases due to increased longevity would exceed Medicaid/Medicare savings.

Not smoking is associated with increased longevity, which is associated with increased net costs for the health care system, rather than savings. 

A 2008 study from the National Institute for Public Health and the Environment, Tilburg University and Erasmus University in The Netherlands (access here) concluded that the average 20-year-old smoker would consume $270,000 in health care in their remaining lifetime, while the average “healthy-living” person would consume $345,000 (assuming the current euro/dollar conversion).  As the researchers explained, “…smoking is in particular related to lethal (and relatively inexpensive) diseases… Unfortunately, these life-years gained [by healthy living] are not lived in full health and come at a price: people suffer from other diseases, which increases health-care costs.”

Another study from The Netherlands (available here) in 1998 came to a similar conclusion: “From a humanitarian point of view, life is preferable to death and health to illness.  The aim of health care is not to save money but to save people from preventable suffering and death… There is no evidence that healthcare costs are increasing because citizens live unhealthier lives. In fact, quite the contrary would seem to be the case.”

Despite the research, the CDC refuses to consider smoking-related health care costs and savings.  This narrow perspective has been criticized by Vanderbilt economist Kip Viscusi: “It looks unpleasant or ghoulish to look at the cost savings as well as the cost increases and it's not a good thing that smoking kills people.  But if you're going to follow this health-cost train all the way, you have to take into account all the effects, not just the ones you like…” (quoted here).