Piasecki, Thomas M; Smith, Stevens S; Baker, Timothy B; Slutske, Wendy S; Adsit, Robert T; Bolt, Daniel M; Conner, Karen L; Bernstein, Steven L; Eng, Oliver D; Lazuk, David; Gonzalez, Alec; Jorenby, Douglas E; D’Angelo, Heather; Kirsch, Julie A; Williams, Brian S; Nolan, Margaret B; Hayes-Birchler, Todd; Kent, Sean; Kim, Hanna; Lubanski, Stan; Yu, Menggang; Suk, Youmi; Cai, Yuxin; Kashyap, Nitu; Mathew, Jomol P; McMahan, Gabriel; Rolland, Betsy; Tindle, Hilary A; Warren, Graham W; An, Lawrence C; Boyd, Andrew D; Brunzell, Darlene H; Carrillo, Victor; Chen, Li-Shiun; Davis, James M; Deshmukh, Vikrant G; Dilip, Deepika; Ellerbeck, Edward F; Goldstein, Adam O; Iturrate, Eduardo; Jose, Thulasee; Khanna, Niharika; King, Andrea; Klass, Elizabeth; Mermelstein, Robin J; Tong, Elisa; Tsoh, Janice Y; Wilson, Karen M; Theobald, Wendy E; Fiore, Michael C

doi:10.1093/ntr/ntac201

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Smoking Status, Nicotine Medication, Vaccination, and COVID-19 Hospital Outcomes: Findings from the COVID EHR Cohort at the University of Wisconsin (CEC-UW) Study

2023

Published Web Location

https://doi.org/10.1093/ntr/ntac201

Abstract

Introduction

Available evidence is mixed concerning associations between smoking status and COVID-19 clinical outcomes. Effects of nicotine replacement therapy (NRT) and vaccination status on COVID-19 outcomes in smokers are unknown.

Methods

Electronic health record data from 104 590 COVID-19 patients hospitalized February 1, 2020 to September 30, 2021 in 21 U.S. health systems were analyzed to assess associations of smoking status, in-hospital NRT prescription, and vaccination status with in-hospital death and ICU admission.

Results

Current (n = 7764) and never smokers (n = 57 454) did not differ on outcomes after adjustment for age, sex, race, ethnicity, insurance, body mass index, and comorbidities. Former (vs never) smokers (n = 33 101) had higher adjusted odds of death (aOR, 1.11; 95% CI, 1.06-1.17) and ICU admission (aOR, 1.07; 95% CI, 1.04-1.11). Among current smokers, NRT prescription was associated with reduced mortality (aOR, 0.64; 95% CI, 0.50-0.82). Vaccination effects were significantly moderated by smoking status; vaccination was more strongly associated with reduced mortality among current (aOR, 0.29; 95% CI, 0.16-0.66) and former smokers (aOR, 0.47; 95% CI, 0.39-0.57) than for never smokers (aOR, 0.67; 95% CI, 0.57, 0.79). Vaccination was associated with reduced ICU admission more strongly among former (aOR, 0.74; 95% CI, 0.66-0.83) than never smokers (aOR, 0.87; 95% CI, 0.79-0.97).

Conclusions

Former but not current smokers hospitalized with COVID-19 are at higher risk for severe outcomes. SARS-CoV-2 vaccination is associated with better hospital outcomes in COVID-19 patients, especially current and former smokers. NRT during COVID-19 hospitalization may reduce mortality for current smokers.

Implications

Prior findings regarding associations between smoking and severe COVID-19 disease outcomes have been inconsistent. This large cohort study suggests potential beneficial effects of nicotine replacement therapy on COVID-19 outcomes in current smokers and outsized benefits of SARS-CoV-2 vaccination in current and former smokers. Such findings may influence clinical practice and prevention efforts and motivate additional research that explores mechanisms for these effects.

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