What is VBA?

Sources of help for delivering Very Brief Advice

What resources are available to help HCPs give Very Brief Advice? In addition to the patient case-based video scenarios in this Learning Zone, explore the IPCRG Very Brief Advice desktop helper, the NCSCT Very Brief Advice training module and the PCRS tobacco dependency pragmatic guide (links will take you to the external sites).

Medthority/IPCRG VBA for tobacco dependence Learning Zone

Visit the How to deliver VBA section of this Learning Zone to view physician-patient scenarios demonstrating how VBA can be used in different patient types.

WHO 2020 literature review on COVID-19 and smoking

In June 2020, an extensive literature review on the WHO Framework Convention on Tobacco Control (FCTC) concluded that smoking was associated with an increased severity of disease and death in hospitalised COVID-19 patients and called for more research, especially population-based studies, to quantify the actual risk to smokers of hospitalisation with COVID-19 or of infection with SARS-CoV-2^3,4.

Does smoking increase the risk of developing symptomatic COVID-19?

From 24 March to 23 April 2020, guided self-reported data was logged daily by UK users of the Zoe COVID-19 Symptom Study app and subsequently analysed in a large UK prospective cohort study (N = 2,401,982)⁶. A major strength of this study was its ability to capture smoking status more accurately than studies using routine historical administrative records or with significant level of missing data⁶.

Compared with non-smokers who reported testing positive for SARS-CoV-2 infection, smokers have a greater symptom burden and were more likely to require hospitalisation⁶.

The main findings were that smokers were more likely to report the classic symptoms associated with COVID-19: fever, new persistent cough, breathlessness. Smokers also had a higher chance of reporting more symptoms, a surrogate of disease severity, and indicating an impact of smoking on disease severity.

This study suggests that efforts that address tobacco dependency should be included in strategies for the COVID-19 pandemic in an effort to decrease the burden on individual smokers and the healthcare system⁶.

Does smoking increase severe or critical outcomes?

In a systematic literature search of online databases (N = 517,020) from several countries, smoking was also associated with severe or critical outcomes, an increased risk of admission to ICU, and mortality in COVID-19 patients⁷.

Specifically, the meta-analysis found a statistically significant association between smoking history and COVID-19 severity, (OR 1.55, 95% CI: 1.41–1.71, P<0.001). Smoking was also significantly associated with the risk of admission to intensive care unit (OR 1.73, 95%CI: 1.36–2.19, P = 0.006), increased mortality (OR 1.58, 95%CI: 1.38–1.81, P<0.001), and critical diseases composite endpoints (OR 1.61, 95%CI: 1.35–1.93). Age (P  = 0.004), hypertension (P = 0.007), diabetes (P = 0.029), and chronic obstructive pulmonary disease (P = 0.001) were found to be covariates that affect this association⁷.

Finding factors associated with COVID-19 related death using OpenSAFELY

OpenSAFELY is a secure health analytics platform that has aggregated detailed longitudinal patient data from 40% of patients in England using existing primary care electronic health records. By pseudonymously linking 17 million records to COVID-19 related deaths, the collected data could be used to examine the factors associated with COVID-19 related death⁸.

Grouping patients by smoking status into current-, former- and never-smokers, the results showed that there was a higher risk of death in current smokers 1.14 (95% CI, 1.05–1.23) compared with never-smokers of 1.00 (reference group), adjusted for age and sex.

The risk of death in current smokers decreased to 0.89 (95% CI, 0.82–0.97) when fully adjusted to covariates, including age, sex, and BMI⁸. This change in hazard ratio largely resulted from an adjustment for chronic respiratory disease. However, as chronic respiratory disease and other comorbidities can be caused by smoking, the fully adjusted smoking hazard ratio could not be interpreted causally. A model adjusted for demographic factors was instead used to highlight a small increased risk in current smokers of a non-significant hazard ratio of 1.07 (95% CI, 0.98–1.18). This small difference does not however support the proposed protective effect of nicotine. As the COVID-19 pandemic progresses, more data will be accumulated to further elucidate the risk of smoking⁸.

The impact of early COVID-19 studies

Publication pressure, and the urgency to provide answers, led to the rapid dissemination of studies designed to find correlations between smoking and COVID-19, without establishing causality or receiving appropriate peer review⁹.

To date, there is little causal evidence to suggest that smokers are protected against SARS-CoV-2 infection⁹.

Subsequently shared through various media, the implied causal relationship resulted in confusion among the public, scientists, and medical community⁹. This was further compounded by the tobacco industry downplaying the risks of smoking⁹.

A notable example was the reporting of studies proposing an inverse relationship between smoking and COVID-19, resulting in increased tobacco consumption in China and France⁹. These methodologically flawed cross-sectional studies, containing incomplete data, selection bias, and misclassification bias, were not suitable for assessing the risks smoking^6,9.

Could nicotine have a protective effect against COVID-19?

As SARS-CoV-2 virus is known to primarily enter human cells by binding to ACE2 receptors¹⁰, an increased expression in smokers could lead to a greater number of viral receptors through which SARS-CoV-2 virus can enter the body and an amplification of disease severity or adverse outcomes¹¹.

However, while it has been proposed that smoking may modulate the expression of ACE2 receptors, there have been contrasting findings on relation between angiotensin converting enzyme 2 (ACE2) receptors and cigarette exposure¹¹.

Studies prior to the pandemic found evidence that cigarette smoke exposure led to a down regulation of ACE2 receptor expression¹¹. However more recent studies have found a consistent and dose-dependent correlation between smoking history and upregulated ACE2 expression in the respiratory tract¹². Additionally, refraining from smoking for at least twelve months is associated with an ~40% decrease in ACE2 expression¹².

As cigarette smoke contains many individual compounds and the factors that mediate the overall susceptibility to SARS-CoV-2 infections are still poorly understood, larger, peer-reviewed, epidemiological and characterisation studies will be needed to definitively understand the effect of nicotine and ACE2 expression on COVID-19 severity.

Role of HCPs in reducing smoking dependency during the COVID-19 pandemic

Substantial interest from respondents to an online survey on the best methods of providing smoking cessation advice and support during the pandemic suggests that there may be an increased receptiveness to quitting smoking¹³.

In the online survey of adults in Australia (N = 604) and the UK (N = 600), approximately half of the respondents shared an interest in receiving personal counselling and/or participating in a text support programme during the month following the survey; the most popular form being by email. Three-quarters also expressed an interest in receiving free, home-delivered nicotine replacement therapy (NRT) suggesting that this may be a useful method for assisting quit attempts during the pandemic¹³.

The survey also identified that individuals’ doctors/GPs and the Government were the most popular sources of information about smokers’ COVID-related risks¹³. This highlights the essential need for healthcare physicians (HCPs) to share the growing evidence that current smokers are more likely to become infected and have worse outcomes, ^6,9.

It is important that healthcare physicians help to dispel any lingering misbeliefs among the general public about the protective nature of smoking against COVID-19⁹.

While HCPs have always been important in providing smoking cessation advice, their role has a renewed urgency during the COVID-19 pandemic⁹. Effective and evidence-based VBA interventions mean this can be done seamlessly at the end of a consultation.

Although face-to-face cessation support may continue to be limited, primary HCPs can point patients to the availability of support at a distance, including telephone quit lines or eHealth interventions. Prominently displayed material in the waiting room can inform patients about the harmful relationship between smoking, COVID-19 and other serious illness. Primary healthcare providers are also in a good position to bring up the topic of COVID-19 and smoking in consultations with youth and young adults⁹.

To find out more about tobacco dependency during the COVID-19 pandemic, click here to watch GP Dr Noel Baxter and pharmacist Darush Attar-Zadeh host ‘The impact of nicotine and smoking in COVID-19 and respiratory diseases (asthma and COPD)’ webinar.

Click here to learn more about pharmacotherapies for treating tobacco dependency.

References

1. The International Primary Care Respiratory Group (IPCRG). Desktop Helper No. 4 - Helping patients quit tobacco - 3rd edition. https://www.ipcrg.org/desktophelpers/desktop-helper-no-4-helping-patients-quit-tobacco-3rd-edition. Accessed 29 April 2021.
2. Primary Care Respiratory Society (PCRS). Tobacco dependency pragmatic guide. 2020. https://www.pcrs-uk.org/resource/tobacco-dependency-pragmatic-guide. Accessed 29 April 2021.
3. WHO. Smoking and COVID-19. 2020. https://www.who.int/news-room/commentaries/detail/smoking-and-covid-19. Accessed 16 April 2021.
4. Huber L, Cuadrado U, Fernandez-Megina R, Raw M, Marquizo AB, Romeo-Stuppy K. The impact of COVID-19 on the WHO FCTC, cessation, and tobacco policy. Tobacco Induced Diseases. 2021;18(December). doi:10.18332/TID/130779.
5. WHO. WHO | Advancing in tobacco control amidst the COVID-19 pandemic. WHO. 2020. http://www.who.int/fctc/mediacentre/news/2020/advancing-in-tobacco-control-amidst-the-covid-19-pandemic/en/. Accessed 16 April 2021.
6. Hopkinson NS, Rossi N, El-Sayed-moustafa J, Laverty AA, Quint JK, Freidin M, et al. Current smoking and COVID-19 risk: Results from a population symptom app in over 2.4 million people. Thorax. 2020. doi:10.1136/thoraxjnl-2020-216422.
7. 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.
8. Williamson EJ, Walker AJ, Bhaskaran K, Bacon S, Bates C, Morton CE, et al. Factors associated with COVID-19-related death using OpenSAFELY. Nature. 2020;584(7821):430–436.
9. van Westen-Lagerweij NA, Meijer E, Meeuwsen EG, Chavannes NH, Willemsen MC, Croes EA. Are smokers protected against SARS-CoV-2 infection (COVID-19)? The origins of the myth. npj Primary Care Respiratory Medicine. 2021;31(1):1–3.
10. Wrapp D, Wang N, Corbett KS, Goldsmith JA, Hsieh CL, Abiona O, et al. Cryo-EM structure of the 2019-nCoV spike in the prefusion conformation. Science (80- ). 2020;367(6483):1260–1263.
11. Usman MS, Siddiqi TJ, Khan MS, Patel UK, Shahid I, Ahmed J, et al. Is there a smoker’s paradox in COVID-19? BMJ Evidence-Based Med. 2020;0. doi:10.1136/bmjebm-2020-111492.
12. Smith JC, Sausville EL, Girish V, Yuan M Lou, Vasudevan A, John KM, et al. Cigarette Smoke Exposure and Inflammatory Signaling Increase the Expression of the SARS-CoV-2 Receptor ACE2 in the Respiratory Tract. Dev Cell. 2020;53(5):514-529.e3.
13. Pettigrew S, Jun M, Roberts I, Bullen C, Nallaiah K, Rodgers A. Preferences for tobacco cessation information and support during Covid-19. J Addict Med. 2020;14(6):E362–E365.