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

Thomas M Piasecki^{1

2}, Stevens S Smith^{1

2}, Timothy B Baker^{1

2}, Wendy S Slutske^{1

3}, Robert T Adsit¹, Daniel M Bolt^{4

1}, Karen L Conner¹, Steven L Bernstein⁵, Oliver D Eng⁶, David Lazuk⁷, Alec Gonzalez⁸, Douglas E Jorenby^{1

2}, Heather D'Angelo⁹, Julie A Kirsch^{1

3}, Brian S Williams^{1

2

10}, Margaret B Nolan¹, Todd Hayes-Birchler¹, Sean Kent¹¹, Hanna Kim⁴, Stan Lubanski¹², Menggang Yu¹³, Youmi Suk¹⁴, Yuxin Cai¹, Nitu Kashyap^{7

15}, Jomol P Mathew¹⁶, Gabriel McMahan¹¹, Betsy Rolland^{6

9}, Hilary A Tindle¹⁷, Graham W Warren¹⁸, Lawrence C An¹⁹, Andrew D Boyd²⁰, Darlene H Brunzell²¹, Victor Carrillo²², Li-Shiun Chen²³, James M Davis²⁴, Vikrant G Deshmukh²⁵, Deepika Dilip²⁶, Edward F Ellerbeck²⁷, Adam O Goldstein²⁸, Eduardo Iturrate²⁹, Thulasee Jose³⁰, Niharika Khanna³¹, Andrea King³², Elizabeth Klass³³, Robin J Mermelstein³⁴, Elisa Tong³⁵, Janice Y Tsoh³⁶, Karen M Wilson³⁷, Wendy E Theobald^{1

2}, Michael C Fiore^{1

2}

Affiliations

¹ Center for Tobacco Research and Intervention, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA.
² Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA.
³ Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA.
⁴ Department of Educational Psychology, University of Wisconsin-Madison, Madison, WI, USA.
⁵ Department of Emergency Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
⁶ Institute for Clinical and Translational Research, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA.
⁷ Yale-New Haven Health System, New Haven, CT, USA.
⁸ BlueTree Network, a Tegria Company, Madison, WI, USA.
⁹ Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, USA.
¹⁰ Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA.
¹¹ Department of Statistics, University of Wisconsin-Madison, Madison, WI, USA.
¹² United States Census Bureau, Washington, DC, USA.
¹³ Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA.
¹⁴ Department of Human Development, Teachers College Columbia University, New York, NY, USA.
¹⁵ Yale School of Medicine, New Haven, CT, USA.
¹⁶ Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA.
¹⁷ Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
¹⁸ Department of Radiation Oncology, Medical University of South Carolina, Charleston, SC, USA.
¹⁹ Division of General Medicine, Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA.
²⁰ Department of Biomedical and Health Information Sciences, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA.
²¹ Virginia Commonwealth University School of Medicine, Richmond, VA, USA.
²² Hackensack Meridian Health, Hackensack University Medical Center, Hackensack, NJ, USA.
²³ Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
²⁴ Duke Cancer Institute and Duke University Department of Medicine, Durham, NC, USA.
²⁵ University of Utah Health, Salt Lake City, UT, USA.
²⁶ Memorial Sloan Kettering Cancer Center, New York, NY, USA.
²⁷ Department of Population Health, University of Kansas Medical Center, Kansas City, MO, USA.
²⁸ Department of Family Medicine and Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
²⁹ New York University Langone Health, New York, NY, USA.
³⁰ Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA.
³¹ University of Maryland School of Medicine, Baltimore, MD, USA.
³² Department of Psychiatry and Behavioral Neuroscience, University of Chicago Comprehensive Cancer Center, Chicago, IL, USA.
³³ Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
³⁴ Department of Psychology and Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, IL, USA.
³⁵ Department of Internal Medicine, University of California Davis, Davis, CA, USA.
³⁶ Department of Psychiatry and Behavioral Sciences, Hellen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA.
³⁷ Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.

PMID: 36069915
PMCID: PMC9494410
DOI: 10.1093/ntr/ntac201

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

Thomas M Piasecki et al. Nicotine Tob Res. 2023.

. 2023 May 22;25(6):1184-1193.

doi: 10.1093/ntr/ntac201.

Authors

Affiliations

¹ Center for Tobacco Research and Intervention, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA.
² Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA.
³ Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA.
⁴ Department of Educational Psychology, University of Wisconsin-Madison, Madison, WI, USA.
⁵ Department of Emergency Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
⁶ Institute for Clinical and Translational Research, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA.
⁷ Yale-New Haven Health System, New Haven, CT, USA.
⁸ BlueTree Network, a Tegria Company, Madison, WI, USA.
⁹ Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, USA.
¹⁰ Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA.
¹¹ Department of Statistics, University of Wisconsin-Madison, Madison, WI, USA.
¹² United States Census Bureau, Washington, DC, USA.
¹³ Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA.
¹⁴ Department of Human Development, Teachers College Columbia University, New York, NY, USA.
¹⁵ Yale School of Medicine, New Haven, CT, USA.
¹⁶ Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA.
¹⁷ Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
¹⁸ Department of Radiation Oncology, Medical University of South Carolina, Charleston, SC, USA.
¹⁹ Division of General Medicine, Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA.
²⁰ Department of Biomedical and Health Information Sciences, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA.
²¹ Virginia Commonwealth University School of Medicine, Richmond, VA, USA.
²² Hackensack Meridian Health, Hackensack University Medical Center, Hackensack, NJ, USA.
²³ Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
²⁴ Duke Cancer Institute and Duke University Department of Medicine, Durham, NC, USA.
²⁵ University of Utah Health, Salt Lake City, UT, USA.
²⁶ Memorial Sloan Kettering Cancer Center, New York, NY, USA.
²⁷ Department of Population Health, University of Kansas Medical Center, Kansas City, MO, USA.
²⁸ Department of Family Medicine and Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
²⁹ New York University Langone Health, New York, NY, USA.
³⁰ Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA.
³¹ University of Maryland School of Medicine, Baltimore, MD, USA.
³² Department of Psychiatry and Behavioral Neuroscience, University of Chicago Comprehensive Cancer Center, Chicago, IL, USA.
³³ Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
³⁴ Department of Psychology and Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, IL, USA.
³⁵ Department of Internal Medicine, University of California Davis, Davis, CA, USA.
³⁶ Department of Psychiatry and Behavioral Sciences, Hellen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA.
³⁷ Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.

PMID: 36069915
PMCID: PMC9494410
DOI: 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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Conflict of interest statement

None declared.

Figures

**Figure 1.**
(A) Observed mortality rates and associated 95% confidence intervals by smoking status and vaccination status. (B) Observed ICU admission rates and associated 95% confidence intervals by smoking status and vaccination status.

See this image and copyright information in PMC

References

1. Centers for Disease Control and Prevention. CDC COVID Data Tracker. 2022. https://covid.cdc.gov/covid-data-tracker/#datatracker-home. Accessed June 29, 2022.
1. Arcavi L, Benowitz NL.. Cigarette smoking and infection. Arch Intern Med. 2004;164(20):2206–2216. - PubMed
1. U.S. Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014.
1. Samet JM. Tobacco products and the risks of SARS-COV-2 infection and COVID-19. Nicotine Tob Res. 2020;22(Suppl 1):S93–S95. - PMC - PubMed
1. World Health Organization. Smoking and COVID-19: Scientific Brief, 30 June 2020 (No. WHO/2019-nCoV/Sci_Brief/Smoking/2020.2). World Health Organization; 2020.

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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

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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

Authors

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Abstract

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