United Kingdom

Coronavirus warning for smokers: Public Health England says addicts face greater risk of coronavirus

Smokers face a greater risk of coronavirus and put their loved ones at risk, according to a stark warning from Public Health England.

Health chiefs said there has 'never been a more important time' to quit the habit than now because of the ever-worsening outbreak in Britain. 

PHE also claimed family, including children, will also be at a higher risk of serious COVID-19 complications, as a result of inhaling secondhand smoke.

They based their advice on a 'small but impactful' study in China, which suggests smokers are more likely to see their disease progress. 

But one team of experts from Wuhan - where the pandemic began - were mystified after finding smokers were less likely to catch the deadly virus in the first place.

However, leading experts who have scoured all of the available evidence collated so far say the proof is scarce and warnings are based solely on assumptions.  

Scientists have called for further trials to clarify if smoking poses a real threat, but admit, in general, smokers are more susceptible to infection.

The tiny hairs inside the airways and lungs, which help move pathogens and mucus away, are often damaged by the toxic chemicals in cigarette smoke. 

Smokers face a greater risk of coronavirus and put their loved ones at risk, according to a stark warning from Public Health England.

The new stance from Public Health England (PHE) comes as the death toll reaches new record highs. Of the 3,605 Britons who have died, 684 were reported in a single day

The largest study which analyses health profiles of patients is published in the New England Journal of Medicine. Of the 173 patients who had severe symptoms, 16.9 per cent of them were current smokers and 5.2 per cent had previously smoked. In comparison, of the patients with less-severe symptoms, 11.8 per cent were current smokers and 1.3 per cent were former smokers

Researchers at the Zhongnan Hospital of Wuhan University made the conclusion that only 1.4 per cent of 140 hospitalised patients were smokers

A study of 41 patients found that none of the 13 patients who needed to be admitted to ICU were current smokers. In contrast, 11 per cent (three) of those who did not need intensive care were smokers 

One study of 140 coronavirus patients found that among the 58 patients who severely ill, 3.4 per cent (two people) were current smokers and 6.9 per cent (four) were former smokers. In comparison, of the 82 with milder symptoms, none were current smokers and 3.7 per cent (three) were former smokers

WHAT DO THE FIVE STUDIES LOOKING AT SMOKERS SHOW? 

Leading experts who have scoured all of the available evidence collated so far say the proof smoking raises the risk of coronavirus is limited.

The group of experts even admitted warnings made by health chiefs were based mainly on assumptions, given the known infection risks of smoking. 

The team, based at the Harvard School of Dental Medicine and the University of Crete in Greece, reviewed five of the first studies on smoking and COVID-19.

Research showed smokers do face a greater risk of suffering complications but others suggested they were less likely to be infected in the first place.

Study 1:  Wei Liu and colleagues at three tertiary hospitals in Wuhan, China.

How many people were involved?

78

How many of them were smokers?

Unclear

Where were the results published?

Chinese Medical Journal 

What did it find?

The patients who progressed had a 'significantly' higher number smokers compared to the patients who got better – 27 per cent compared three per cent.

Study 2: Guan et al at 552 hospitals in 30 provinces or regions of China.

How many people were involved?

1,099

How many of them were smokers?

A total of 12.6 per cent (137) were current smokers and 1.9 per cent (21) were former smokers.

Where were the results published?

The New England Medical Journal  

What did it find?

Among the 173 patients with severe symptoms, 16.9 per cent (29) were current smokers and 5.2 per cent (nine) were former smokers.

In comparison, 11.8 per cent (108) of the 926 with milder symptoms were current smokers, and 1.3 per cent (12) were former smokers.

In the group of patients that either needed mechanical ventilation, admission to an ICU or died, 25.5 per cent were current smokers and 7.6 per cent were former smokers.

But in the group of patients that did not have these adverse outcomes, only 11.8 per cent were current smokers and 1.6 per cent were former smokers.

Study 3: Jin-jin Zhang and colleagues at No. 7 Hospital of Wuhan, China.

How many people were involved?

140

How many of them were smokers?

Some 6.4 per cent were either current smokers (two) or past smokers (seven).

Where were the results published?

Allergy

What did it find?

Among the 58 patients who severely ill, 3.4 per cent (two people) were current smokers and 6.9 per cent (four) were former smokers.

In comparison, of the 82 with milder symptoms, none were current smokers and 3.7 per cent (three) were former smokers. 

Study 4: Fei Zhou and colleagues at Jinyintan Hospital and Wuhan Pulmonary Hospital, Wuhan, China.

How many people were involved?

191

How many of them were smokers?

Six per cent (11 people) were current smokers

Where were the results published?

The Lancet

What did it find?

Among those that died (54), nine per cent (five people) were current smokers. Of those who survived, four per cent (six people) were smokers.

Study 5: Chaolin Huang, of Jin Yin-tan Hospital, Wuhan, China, and colleagues.

How many people were involved?

41

How many of them were smokers?

Seven per cent (three people) were current smokers

Where were the results published?

The Lancet 

What did it find?

None of the 13 patients who needed to be admitted to ICU were current smokers. In contrast, 11 per cent (three) of those who did not need intensive care were smokers.

ARE THE STUDIES REPRESENTATIVE OF THE REAL SMOKING POPULATION? 

In all of the studies, fewer than 15 per cent of the patients were smokers - a figure that clashes with China's smoking rate. 

The WHO says 300million people in China smoke - roughly a fifth of the country's total population and a third of the world's total.

Data from a national survey conducted by China in 2015 found up to 60 per cent of men between the ages of 45 and 64 smoke.

British researchers were clueless as to why the NEJM study, the largest studies on this topic, had such low rates of smokers (12.6 per cent), especially given 28 per cent of patients were between 50 and 64. 

The new stance from Public Health England (PHE) comes as the death toll reached 3,605 with a record 684 deaths announced.

In a statement, the government body said: 'If you smoke, you are not only putting yourself at greater risk of developing severe disease from the COVID-19 virus, but those around you exposed to second hand smoke, including children, are also put at increased risk.

'The repetitive hand to mouth movement provides an easy route of entry for the virus, putting smokers at greater risk of contracting COVID-19.' 

PHE said COVID-19 - the disease caused by the SARS-CoV-2 virus - attacks the respiratory system, 'which explains why smokers are at greater risk'.

It pointed to one 'small but highly impactful survey' which took place at The Central Hospital of Wuhan, China. Wuhan is the city where the pandemic began in December.

The patients whose conditions worsened had a 'significantly' higher number smokers compared to the patients who got better – 27 per cent compared three per cent.

Researchers who led the study also concluded that a history of smoking was a risk factor for disease progression, increasing the odds by 14 times. 

The study was one of five evaluated by a team of experts led by the Harvard School of Dental Medicine, who aimed to settle whether the debate over whether smokers should be concerned.

All of the five studies reviewed looked at either the risk of infection, disease progression or death among smokers in Chinese patients.

Of the 173 patients who had severe symptoms, 16.9 per cent of them were current smokers and 5.2 per cent had previously smoked.

In comparison, of the patients with less-severe symptoms, 11.8 per cent were current smokers and 1.3 per cent were former smokers.

In a group of patients that either needed mechanical ventilation, admission to an intensive care unit, or ultimately died, a quarter were current smokers – more than twice the rate than in patients who did not have such adverse outcomes. 

It confirmed the findings of a smaller study in Wuhan which showed more than ten per cent of COVID-19 patients who were severely ill were either smokers or former smokers.

In comparison, of those with milder symptoms, none we current smokers. Just under four per cent had smoked previously, the findings in Allergy show.  

Among 41 patients, none of the 13 who needed to be admitted to intensive care were current smokers, the team in Wuhan said. But there were smokers in the group who fared better. 

Similarly, researchers at Zhongnan Hospital of Wuhan University - whose work was not included in the meta-analysis - were mystified after finding smokers were less likely to catch the deadly virus in the first place.

They made the conclusion that only 1.4 per cent of 140 hospitalised patients were smokers.

Writing in the journal The Lancet,  the researchers added: 'The exact underlying causes of the lower incidence of COVID‐19 in current smokers are still unknown.' 

But they admitted: 'The outcome of SARS‐CoV‐2 infection in smokers may be more severe.'

Although further research is warranted, smoking is 'most likely associated with the negative progression and adverse outcomes of COVID-19', the Harvard team concluded in the journal Tobacco Induced Diseases. 

Doctors across the world have echoed the concern and called for further trials, aware that smokers generally are in danger of picking up more infections. 

Dr James Gill, a locum GP and honorary clinical lecturer, Warwick Medical School, said: 'Possibly one of the biggest reasons smokers are at increased risk of respiratory infections is the impairment and death of the cilia in the airways and lungs.

'In simple terms, the airways are lined with cilia - small brush-like hairs - these structures provide an absolutely vital function in moving mucous, inhaled debris and potentially infectious agents out of the airways and lungs before an infection can take hold.' 

Dr Tom Wingfield, a senior clinical lecturer and honorary consultant physician, Liverpool School of Tropical Medicine (LSTM), highlighted the tendency of smokers to have a health condition.

They have higher rates of high blood pressure, high disease and chronic lung, 'all of which themselves are risk factors for severe COVID-19'.

But Professor Gordon Dougan, department of medicine, University of Cambridge, said it's 'too early' to make a call on whether smoking impacts COVID-19 infection.

'However, we do know that smoking does impair normal lung function in many ways,' he said.  

Professor John Newton, director of health improvement at PHE said: 'In light of this unprecedented COVID-19 pandemic, there has never been a more important time to stop smoking. Not only for your own health but to protect those around you. It will also help alleviate the huge pressures on the NHS.' 

WHY MAY SMOKERS BE MORE AT RISK OF SEVERE CORONAVIRUS? 

Dr James Gill, a locum GP and honorary clinical lecturer, Warwick Medical School, said: 'Smoking is a significant risk factor for coronavirus infections and, in fact, infections generally. 

'There are many interlocking factors as to why smoking reduces the body’s ability to fight an infection.

'Possibly one of the biggest reasons smokers are at increased risk of respiratory infections is the impairment and death of the cilia in the airways and lungs.

'In simple terms, the airways are lined with cilia - small brush-like hairs - these structures provide an absolutely vital function in moving mucous, inhaled debris and potentially infectious agents out of the airways and lungs before an infection can take hold.'

Increased levels of carbon monoxide in the blood, a by-product of smoking, blocks the blood's ability to carry oxygen to cells in the body.

It puts smokers at a pre-disposed disadvantage if they catch coronavirus, considering the disease leaves patients unable to get enough oxygen into the bloodstream due to lung inflammation.

Dr Tom Wingfield, a senior clinical lecturer and honorary consultant physician, Liverpool School of Tropical Medicine (LSTM), said: 'Smoking both increases someone’s vulnerability to infection (repetitive touching of hand-to-face and hand-to-mouth) and reduces their ability to fight against it resulting in more severe disease.'

He highlighted the tendency of smokers to have a health condition, such as high blood pressure, high disease and chronic lung, 'all of which themselves are risk factors for severe COVID-19'.

Professor Gordon Dougan, department of medicine, University of Cambridge, said: 'The real danger lies in the lung and systems damage COVID causes. It will make people more vulnerable to secondary bacterial and viral infections. It is known that lung damage per say does that.

'I would recommend that people stop smoking but, having lost my own sister to lung cancer, know it is not easy.'

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