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


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.


Piasecki TM, Smith SS, Baker TB, Slutske WS, Adsit RT, Bolt DM, Conner KL, Bernstein SL, Eng OD, Lazuk D, Gonzalez A, Jorenby DE, D’Angelo H, Kirsch JA, Williams BS, Nolan MB, Hayes-Birchler T, Kent S, Kim H, Lubanski S, Yu M, Suk Y, Cai Y, Kashyap N, Mathew JP, McMahan G, Rolland B, Tindle HA, Warren GW, An LC, Boyd AD, Brunzell DH, Carrillo V, Chen LS, Davis JM, Deshmukh VG, Dilip D, Ellerbeck EF, Goldstein AO, Iturrate E, Jose T, Khanna N, King A, Klass E, Mermelstein RJ, Tong E, Tsoh JY, Wilson KM, Theobald WE, Fiore MC. Smoking Status, Nicotine Medication, Vaccination, and COVID-19 Hospital Outcomes: Findings from the COVID EHR Cohort at the University of Wisconsin (CEC-UW) Study. Nicotine Tob Res. 2022 Sep 7:ntac201. doi: 10.1093/ntr/ntac201. Epub ahead of print. PMID: 36069915; PMCID: PMC9494410.

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