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Smoking cessation during COVID-19: the top to-do list

Smoking cessation during COVID-19: the top to-do list www.nature.com/npjpcrm COMMENT OPEN 1,2✉ 1,3 4 5,6 5,7 Jaber S. Alqahtani , Abdulelah M. Aldhahir , Tope Oyelade , Saeed M. Alghamdi and Ahmad S. Almamary As evidence continues to emerge, our understanding of the relationship between smoking and COVID-19 prognosis is steadily growing. An early outlook from World Health Organisation (WHO) indicates that smokers are more vulnerable to severe COVID-19 disease and are also more likely to be infected, as frequent motions from hand to mouth and sharing of tobacco products such as waterpipes increased the possibility of being infected. In this commentary, we discuss some of the latest evidence on smoking and COVID-19 and emphasise the need to promote the personal and public advantages of smoking cessation during the COVID-19 pandemic. npj Primary Care Respiratory Medicine (2021) 31:22 ; https://doi.org/10.1038/s41533-021-00238-8 SMOKING AND COVID-19 RISK what we know already is that older age groups are the ones more likely to develop severe COVID-19, and according to survey studies Every year, smoking kills >8 million people worldwide. Of such on e-cigarette use in China and the USA, vaping is not prevalent in deaths, over 7 million are directly related to cigarettes, and ~1.2 those of 65 years and older, but popular in younger groups 15–44 million are attributed to second-hand smoke by non-smokers .No 12,13 year age range . Indeed, like smoking, it is likely, if it is not a risk doubt, that smoking is a major risk factor for most respiratory- factor for contracting COVID-19, that vaping may also lead to bad related infections, which raises the severity of respiratory diseases. outcomes. The early evidence in this area found that compared with non- smokers, smokers are more likely to develop serious COVID-19 2,3 4 disease . In a study carried out by Mehra et al. of over 8910 COVID-19 patients across three continents namely Asia, Europe, WHY SMOKING CAUSES MORE SEVERE COVID-19 CASES and North America, current smoking when compared to former or Several hypotheses exist regarding smokers tend to have worse never smoke was an independent risk factor for death at hospital outcomes after contracting COVID-19. Angiotensin-converting with odds ratio of 1.79 (95% confidence interval: 1.29–2.47). enzyme 2 (ACE-2)—the only confirmed SARS-CoV-2 receptor, is a Indeed, smoking is heavily contributing to the progression of such 5 vasodilatory protein expressed on the surface of the lung cells and long-term diseases, including cardiovascular and respiratory . serves as the cell-entry receptor for SARS viruses . Recent Recently, accumulated evidence from the largest meta‐analysis evidence showed that compared with former and never smokers, among peer‐reviewed literature that included 32,849 hospitalised smokers were associated with higher ACE-2 expression in a patients with COVID‐19 found that current smokers had an 15–17 various cohort of lung tissue and airway epithelium cells . Such increased risk of severe COVID‐19 (risk ratios: 1.80; 95% confidence an observation was further supported by other studies linking interval: 1.14–2.85) . Even though smoking might not generally 18,19 nicotine exposure, with increased ACE-2 expression . Thus, it raise the risk of contracting COVID-19, it may be particularly could be speculated that the increased ACE-2 expression in debilitating for a smoker if there is a biological and inflammatory current smokers may perhaps predispose to increased risk of cascade, following a SARS-CoV-2 infection. Recent evidence SARS-CoV-2 infection. However, it is important to note that to date suggests a low prevalence of active smokers among those there is no direct evidence linking increased expression of ACE-2 COVID-19 patients who need hospital admission in many 7,8 to increased susceptibility or severity to COVID-19. countries severely affected by COVID-19 pandemic . Such Despite the high prevalence of smokers in Italy (25.7%), Rossato underrepresentation of smokers among those patients supported et al. reported a very low prevalence of smokers in COVID-19 claims that smoking could be protective from COVID-19 infection. patients, with no significant association between smokers and Possible mechanisms can support this claim: nicotine anti- severe disease in COVID-19 patients. According to Leung et al. , inflammatory effect, a blunted immune response in current the potential explanation for this low prevalence could be smokers and potential high nitric oxide in the upper respiratory smoking status misclassification due to underreporting of smoking airway, which may prevent replication of SARS-CoV-2 and its entry in such cohorts or perhaps because of using some medications into cells . that may offer some protection against COVID-19. Thus far, there As scientists get more evidence in this area, more concerns arise about other smoking products, such as vaping. Considering the is no evidence that smoking protects against COVID-19. Indeed, risks of significant pulmonary injury with vaping , McAlinden the speed of events during COVID-19 makes it quite challenging et al. hypothesise that similar risks may happen to COVID-19 to verify the truth from false evidence. Therefore, it is crucial to be extremely careful about the messages about smoking and COVID- patients who are vaping . The potential risk of vaping to prime 19 in these fragile times. Figure 1 shows the burden of smoking in the lung for SARS-CoV-2 is speculative, given that vaping prevalence in COVID-19 patients has not been reported. However, COVID-19 patients. 1 2 UCL Respiratory, University College London, London, UK. Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dammam, Saudi Arabia. 3 4 5 Respiratory Care Department, Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia. UCL Institute for Liver and Digestive Health, London, UK. National 6 7 Heart and Lung Institute, Imperial College London, London, UK. Faculty of Applied Medical Sciences, Umm Al-Qura University, Makkah, Saudi Arabia. Respiratory Therapy Department, King Saud Bin Abdulaziz University for Health Sciences, Ahsa, Saudi Arabia. email: Alqahtani-Jaber@hotmail.com Published in partnership with Primary Care Respiratory Society UK 1234567890():,; JS Alqahtani et al. which COVID-19 provided us an unexpected opportunity to help more people quit smoking . Put together, the COVID-19 pandemic and the relative risk of severity linked with smoking furthermore justifies the need for a unified and global public health campaign targeted at discouraging direct or indirect tobacco exposure around the world. Health and financial benefits We highly advocate providing country-specific, evidence-driven smoking cessation recommendations in public health commu- nications focusing on how to curb the spread of SARS-CoV-2. Such cessation attempts can provide a variety of advantages within and after the present pandemic, including a reduction in the incidence of smoking-related conditions, such as myocardial infarction and chronic respiratory conditions, and ultimately reduce the clinical 26–28 challenge faced by frontline clinicians . On top of that, there are personal and healthcare system financial savings because of smoking cessation. Smoking has many detrimental consequences on cardiovascular and respiratory functions, which high-quality research shows that preoperative reduction of smoking by using smoking cessation interventions can lead to substantial health benefits . Smoking cessation is a significant public health gain at any moment. A prospective study included 1.3 million partici- pants, which resurveyed postally ~3 and 8 years later found that two-thirds of all deaths of smokers in their 50s, 60s, and 70s are caused by smoking; smokers lose at least 10 years of lifespan . They also demonstrated that ceasing before age 40 years prevents >90% of the additional mortality triggered by continuing smoking; quitting before age 30 years avoids >97% of it. Policy and practice At this time during COVID-19 pandemic, it is the right time that Fig. 1 Burden of smoking in COVID-19 patients and role of the ongoing concern about the COVID-19 outbreak undoubtedly smoking cessation. Smoking is associated with increased risk of offers a ‘learnable window’, when smokers will be exclusively open severe COVID-19 and mortality that are linked with ACE 2 to smoking consultation for smoking cessation. This has been seen overexpression and frequent hand to mouth movement. The health in a recent study that found the rate of smoking cessation cost of COVD-19-associated morbidity can be reduced via the promotion of smoking cessation through apps, public health increased from 23% before COVID-19 to 31% during COVID-19 campaigns, telehealth models and the hospital quality measures. pandemic . Such health and financial benefits are maximised by psychological and pharmacological interventions that delivered HOW CAN WE SUPPORT SMOKING CESSATION DURING THE from specialist smoking cessation services . However, smoking COVID-19 PANDEMIC? cessation services should be more resilient and change their traditional delivery models in response to COVID-19 by using Why smokers should quit? telehealth tools, such as expanding telecommunications and With over 8,000,000 deaths per year due to direct or indirect interactive assistance capabilities, and allow remote access to exposure, smoking remains a major global health issue especially nicotine replacement products . Further, promoting tech-driven in low- and middle-income countries. Indeed, in the context of approach by using quitting smoking apps is more beneficial to COVID-19, this number is expected to go up, but the time has not increase the odds of quitting success. A randomised clinical trial gone by to quit smoking. With an average light smoker published recently compared the efficacy of two smartphone consuming 10–15 cigarette/day, including an average of up to applications for smoking cessation, and found that smokers who 22,23 13 puffs per cigarette and each puffs duration of 1.5 s (refs. ). used the iCanQuit app (teaches acceptance of smoking triggers) This shows that an average smoker has a hand to their mouth had 1.49 times higher odds of quitting smoking compared with between 130 and 195 times. This translates into 195–293 s more, those who used the QuitGuide app (depends on avoiding in which the hand is on the lip per day compared with non- 34 smoking triggers) . This elevates apps as an effective way of smokers. This is especially interesting giving that the SARS-CoV-2 quitting smoking, particularly apps that depend on accepting the can survive on surfaces for days depending on the medium of existence of cravings rather than trying to eliminate them. shedding. This provides a possible hypothesis for the increased Indeed, using such strategies would reduce the smoking burden risk of SARS-CoV-2 infection and/or re-infection in smokers on healthcare systems. A recent study synthesised that best compared to non-smokers. Therefore, both smokers and health- hospitals should be required to deliver smoking cessation, and care providers should be aware of this practice behaviour. such a service provision should be considered as a quality According to a recent study, many smokers showed substantial measure for accreditation and recognition . Furthermore, policy- levels of interest expressed in accessing various forms of cessation makers and healthcare providers should consider the information assistance, during COVID-19 compared before COVID-19 (ref. ). delivery preferences of smokers when campaigning about This shows that smokers understand how to reduce the risk of smoking cessation (see Fig. 1). A recent study reported that most COVID-19 by addressing their smoking. Action on Smoking and of the smokers preferred to receive such information through a Health (Ash) calculates that around a million smokers stopped television channel (61%), followed by online news (36%), social smoking during COVID-19, an additional 550,000 have attempted media (31%), and email (31%) . Indeed, policymakers should to quit and 2.4 million have been reduced to smoke cigarettes, establish innovative strategies to increase the uptake to the npj Primary Care Respiratory Medicine (2021) 22 Published in partnership with Primary Care Respiratory Society UK 1234567890():,; JS Alqahtani et al. smoking cessation therapies, and eventually raise the chances of 22. Fagan, P. & Rigotti, N. A. Light and intermittent smoking: the road less traveled. Nicotine Tob. Res 11, 107–110 (2009). quitting to promote greater patients and system outcomes. 23. Ross, K. C., Dempsey, D. A., St Helen, G., Delucchi, K. & Benowitz, N. L. The influence of puff characteristics, nicotine dependence, and rate of nicotine metabolism on daily nicotine exposure in African American Smokers. Cancer CONCLUSION Epidemiol. Biomark. Prev. 25, 936–943 (2016). Beyond the health and financial benefits of avoiding tobacco use 24. Pettigrew, S. et al. Preferences for tobacco cessation information and support before COVID-19 pandemic, an increase in quit rates may help to during covid-19. J. Addict. Med. 14, e362–e365 (2020). minimise public SARS-CoV-2 transmission and the associated 25. ASH. Action on Smoking and Health (Ash). https://ash.org.uk/category/media-and- severity with current smokers. Enhancing smoking cessation trials news/press-releases-media-and-news/ (2020). during this pandemic is a clinical priority and should be 26. Alqahtani, J. S. et al. Risk factors for all-cause hospital readmission following thoroughly endorsed. Smoking cessation with high-quality advice exacerbation of COPD: a systematic review and meta-analysis. Eur. Respiratory Rev. 29, 190166 (2020). using unconventional approaches during respiratory virus epi- 27. Alqahtani, J. S. et al. Global current practices of ventilatory support management demics, like COVID-19, should be part of public health efforts. in COVID-19 patients: an international survey. J. Multidiscip. Health. 13, 1635–1648 (2020). 28. Grundy, E. J., Suddek, T., Filippidis, F. T., Majeed, A. & Coronini-Cronberg, S. DATA AVAILABILITY Smoking, SARS-CoV-2 and COVID-19: a review of reviews considering implica- No data were generated in the preparation of this manuscript. tions for public health policy and practice. Tob. Induc. Dis. 18,58–58 (2020). 29. Thomsen, T., Villebro, N. & Møller, A. M. Interventions for preoperative smoking cessation. Cochrane Database Syst. Rev. 2014, Cd002294 (2014). Received: 8 October 2020; Accepted: 7 April 2021; 30. Pirie, K., Peto, R., Reeves, G. K., Green, J. & Beral, V. The 21st century hazards of smoking and benefits of stopping: a prospective study of one million women in the UK. Lancet 381, 133–141 (2013). 31. Kayhan Tetik, B., Gedik Tekinemre, I. & Taş, S. The effect of the COVID-19 pan- demic on smoking cessation success. J. Community Health,1–5. https://doi.org/ REFERENCES 10.1007/s10900-020-00880-2 (2020). 1. Wilkinson, T. M. et al. Effect of interactions between lower airway bacterial and 32. Filby, A. & Taylor, M. Smoking cessation interventions and services. York Health rhinoviral infection in exacerbations of COPD. Chest 129, 317–324 (2006). Economics Consortium. https://www.nice.org.uk/guidance/ng92/evidence/ 2. Vardavas, C. I. & Nikitara, K. COVID-19 and smoking: a systematic review of the economic-modelling-report-pdf-4790596573 (2018). evidence. Tob. Induc. Dis. 18, 20 (2020). 33. Alghamdi, S. M., Alqahtani, J. S. & Aldhahir, A. M. Current status of telehealth in 3. Alqahtani, J. S. et al. Prevalence, severity and mortality associated with COPD and Saudi Arabia during COVID-19. J. Fam. Community Med. 27, 208 (2020). smoking in patients with COVID-19: a rapid systematic review and meta-analysis. 34. Bricker, J. B., Watson, N. L., Mull, K. E., Sullivan, B. M. & Heffner, J. L. Efficacy of PLoS ONE 15, e0233147–e0233147 (2020). smartphone applications for smoking cessation: a randomized clinical trial. JAMA 4. Mehra, M. R., Desai, S. S., Kuy, S., Henry, T. D. & Patel, A. N. Cardiovascular disease, Intern. Med. 180,1–9 (2020). drug therapy, and mortality in covid-19. N. Engl. J. Med. 382, e102 (2020). 35. Sarna, L., Fiore, M. C. & Schroeder, S. A. Tobacco dependence treatment is critical 5. Chen, Y. W., Leung, J. M. & Sin, D. D. A systematic review of diagnostic biomarkers to excellence in health care. JAMA Intern. Med. 180, 1413–1414 (2020). of COPD exacerbation. PLoS ONE 11, e0158843 (2016). 6. Reddy, R. K. et al. The effect of smoking on COVID-19 severity: a systematic review and meta-analysis. J. Med. Virol. 93, 1045–1056 (2020). AUTHOR CONTRIBUTIONS 7. Tsigaris, P. & Teixeira da Silva, J. A. Smoking prevalence and COVID-19 in Europe. J.S.A. wrote the paper with input from all other authors. A.M.A. and T.O. provided Nicotine Tob. Res. 22, 1646–1649 (2020). critical review of the manuscript, with contributions and advice from S.M.A. and A.S.A. 8. Farsalinos, K., Barbouni, A. & Niaura, R. Systematic review of the prevalence of All authors have read and approved the final draft for publication. current smoking among hospitalized COVID-19 patients in China: could nicotine be a therapeutic option? Intern. Emerg. Med. 15, 845–852 (2020). 9. Usman, M. S. et al. Is there a smoker’s paradox in COVID-19? BMJ Evid. Based Med. COMPETING INTERESTS https://doi.org/10.1136/bmjebm-2020-111492 (2020). Published online 11 Aug 2020. 10. Werner, A. K. et al. Hospitalizations and deaths associated with EVALI. N. Engl. J. The authors declare no competing interests. Med. 382, 1589–1598 (2020). 11. McAlinden, K. D. et al. COVID-19 and vaping: risk for increased susceptibility to SARS-CoV-2 infection? Eur. Respir. J. 56, 2001645 (2020). ADDITIONAL INFORMATION 12. Huang, J., Duan, Z., Wang, Y., Redmon, P. B. & Eriksen, M. P. Use of electronic Correspondence and requests for materials should be addressed to J.S.A. nicotine delivery systems (ENDS) in China: evidence from citywide representative surveys from five Chinese cities in 2018. Int. J. Environ. Res. Public Health 17, 2541 Reprints and permission information is available at http://www.nature.com/ (2020). reprints 13. Bao, W., Xu, G., Lu, J., Snetselaar, L. G. & Wallace, R. B. Changes in electronic cigarette use among adults in the United States, 2014-2016. JAMA 319, Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims 2039–2041 (2018). in published maps and institutional affiliations. 14. Walls, A. C. et al. Structure, function, and antigenicity of the SARS-CoV-2 spike glycoprotein. Cell 181, 281–292 (2020). 15. Cai, G., Boss, Y., Xiao, F., Kheradmand, F. & Amos, C. I. Tobacco smoking increases the lung gene expression of ACE2, the receptor of SARS-CoV-2. Am. J Respir. Open Access This article is licensed under a Creative Commons Critical Care Med 201, 1557–1559 (2020). Attribution 4.0 International License, which permits use, sharing, 16. Li, G. et al. Assessing ACE2 expression patterns in lung tissues in the pathogenesis adaptation, distribution and reproduction in any medium or format, as long as you give of COVID-19. J. Autoimmun. 112, 102463 (2020). appropriate credit to the original author(s) and the source, provide a link to the Creative 17. Zhang, H. et al. Expression of the SARS-CoV-2 ACE2 receptor in the human airway Commons license, and indicate if changes were made. The images or other third party epithelium. Am. J. Respir. Crit. Care Med. 202, 219–229 (2020). material in this article are included in the article’s Creative Commons license, unless 18. Leung, J. M., Yang, C. X. & Sin, D. D. COVID-19 and nicotine as a mediator of ACE- indicated otherwise in a credit line to the material. If material is not included in the 2. Eur. Respir. J. 55, 2001261 (2020). article’s Creative Commons license and your intended use is not permitted by statutory 19. Russo, P. et al. COVID-19 and smoking: is nicotine the hidden link? Eur. Respir. J. regulation or exceeds the permitted use, you will need to obtain permission directly 55, 2001116 (2020). from the copyright holder. To view a copy of this license, visit http://creativecommons. 20. Rossato, M. et al. Current smoking is not associated with COVID-19. Eur. Respir. J. org/licenses/by/4.0/. 55, 2001290 (2020). 21. Leung, J. M., Yang, C. X. & Sin, D. D. Reply to: "Current smoking is not associated with COVID-19". Eur. Respir. 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Smoking cessation during COVID-19: the top to-do list

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www.nature.com/npjpcrm COMMENT OPEN 1,2✉ 1,3 4 5,6 5,7 Jaber S. Alqahtani , Abdulelah M. Aldhahir , Tope Oyelade , Saeed M. Alghamdi and Ahmad S. Almamary As evidence continues to emerge, our understanding of the relationship between smoking and COVID-19 prognosis is steadily growing. An early outlook from World Health Organisation (WHO) indicates that smokers are more vulnerable to severe COVID-19 disease and are also more likely to be infected, as frequent motions from hand to mouth and sharing of tobacco products such as waterpipes increased the possibility of being infected. In this commentary, we discuss some of the latest evidence on smoking and COVID-19 and emphasise the need to promote the personal and public advantages of smoking cessation during the COVID-19 pandemic. npj Primary Care Respiratory Medicine (2021) 31:22 ; https://doi.org/10.1038/s41533-021-00238-8 SMOKING AND COVID-19 RISK what we know already is that older age groups are the ones more likely to develop severe COVID-19, and according to survey studies Every year, smoking kills >8 million people worldwide. Of such on e-cigarette use in China and the USA, vaping is not prevalent in deaths, over 7 million are directly related to cigarettes, and ~1.2 those of 65 years and older, but popular in younger groups 15–44 million are attributed to second-hand smoke by non-smokers .No 12,13 year age range . Indeed, like smoking, it is likely, if it is not a risk doubt, that smoking is a major risk factor for most respiratory- factor for contracting COVID-19, that vaping may also lead to bad related infections, which raises the severity of respiratory diseases. outcomes. The early evidence in this area found that compared with non- smokers, smokers are more likely to develop serious COVID-19 2,3 4 disease . In a study carried out by Mehra et al. of over 8910 COVID-19 patients across three continents namely Asia, Europe, WHY SMOKING CAUSES MORE SEVERE COVID-19 CASES and North America, current smoking when compared to former or Several hypotheses exist regarding smokers tend to have worse never smoke was an independent risk factor for death at hospital outcomes after contracting COVID-19. Angiotensin-converting with odds ratio of 1.79 (95% confidence interval: 1.29–2.47). enzyme 2 (ACE-2)—the only confirmed SARS-CoV-2 receptor, is a Indeed, smoking is heavily contributing to the progression of such 5 vasodilatory protein expressed on the surface of the lung cells and long-term diseases, including cardiovascular and respiratory . serves as the cell-entry receptor for SARS viruses . Recent Recently, accumulated evidence from the largest meta‐analysis evidence showed that compared with former and never smokers, among peer‐reviewed literature that included 32,849 hospitalised smokers were associated with higher ACE-2 expression in a patients with COVID‐19 found that current smokers had an 15–17 various cohort of lung tissue and airway epithelium cells . Such increased risk of severe COVID‐19 (risk ratios: 1.80; 95% confidence an observation was further supported by other studies linking interval: 1.14–2.85) . Even though smoking might not generally 18,19 nicotine exposure, with increased ACE-2 expression . Thus, it raise the risk of contracting COVID-19, it may be particularly could be speculated that the increased ACE-2 expression in debilitating for a smoker if there is a biological and inflammatory current smokers may perhaps predispose to increased risk of cascade, following a SARS-CoV-2 infection. Recent evidence SARS-CoV-2 infection. However, it is important to note that to date suggests a low prevalence of active smokers among those there is no direct evidence linking increased expression of ACE-2 COVID-19 patients who need hospital admission in many 7,8 to increased susceptibility or severity to COVID-19. countries severely affected by COVID-19 pandemic . Such Despite the high prevalence of smokers in Italy (25.7%), Rossato underrepresentation of smokers among those patients supported et al. reported a very low prevalence of smokers in COVID-19 claims that smoking could be protective from COVID-19 infection. patients, with no significant association between smokers and Possible mechanisms can support this claim: nicotine anti- severe disease in COVID-19 patients. According to Leung et al. , inflammatory effect, a blunted immune response in current the potential explanation for this low prevalence could be smokers and potential high nitric oxide in the upper respiratory smoking status misclassification due to underreporting of smoking airway, which may prevent replication of SARS-CoV-2 and its entry in such cohorts or perhaps because of using some medications into cells . that may offer some protection against COVID-19. Thus far, there As scientists get more evidence in this area, more concerns arise about other smoking products, such as vaping. Considering the is no evidence that smoking protects against COVID-19. Indeed, risks of significant pulmonary injury with vaping , McAlinden the speed of events during COVID-19 makes it quite challenging et al. hypothesise that similar risks may happen to COVID-19 to verify the truth from false evidence. Therefore, it is crucial to be extremely careful about the messages about smoking and COVID- patients who are vaping . The potential risk of vaping to prime 19 in these fragile times. Figure 1 shows the burden of smoking in the lung for SARS-CoV-2 is speculative, given that vaping prevalence in COVID-19 patients has not been reported. However, COVID-19 patients. 1 2 UCL Respiratory, University College London, London, UK. Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dammam, Saudi Arabia. 3 4 5 Respiratory Care Department, Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia. UCL Institute for Liver and Digestive Health, London, UK. National 6 7 Heart and Lung Institute, Imperial College London, London, UK. Faculty of Applied Medical Sciences, Umm Al-Qura University, Makkah, Saudi Arabia. Respiratory Therapy Department, King Saud Bin Abdulaziz University for Health Sciences, Ahsa, Saudi Arabia. email: Alqahtani-Jaber@hotmail.com Published in partnership with Primary Care Respiratory Society UK 1234567890():,; JS Alqahtani et al. which COVID-19 provided us an unexpected opportunity to help more people quit smoking . Put together, the COVID-19 pandemic and the relative risk of severity linked with smoking furthermore justifies the need for a unified and global public health campaign targeted at discouraging direct or indirect tobacco exposure around the world. Health and financial benefits We highly advocate providing country-specific, evidence-driven smoking cessation recommendations in public health commu- nications focusing on how to curb the spread of SARS-CoV-2. Such cessation attempts can provide a variety of advantages within and after the present pandemic, including a reduction in the incidence of smoking-related conditions, such as myocardial infarction and chronic respiratory conditions, and ultimately reduce the clinical 26–28 challenge faced by frontline clinicians . On top of that, there are personal and healthcare system financial savings because of smoking cessation. Smoking has many detrimental consequences on cardiovascular and respiratory functions, which high-quality research shows that preoperative reduction of smoking by using smoking cessation interventions can lead to substantial health benefits . Smoking cessation is a significant public health gain at any moment. A prospective study included 1.3 million partici- pants, which resurveyed postally ~3 and 8 years later found that two-thirds of all deaths of smokers in their 50s, 60s, and 70s are caused by smoking; smokers lose at least 10 years of lifespan . They also demonstrated that ceasing before age 40 years prevents >90% of the additional mortality triggered by continuing smoking; quitting before age 30 years avoids >97% of it. Policy and practice At this time during COVID-19 pandemic, it is the right time that Fig. 1 Burden of smoking in COVID-19 patients and role of the ongoing concern about the COVID-19 outbreak undoubtedly smoking cessation. Smoking is associated with increased risk of offers a ‘learnable window’, when smokers will be exclusively open severe COVID-19 and mortality that are linked with ACE 2 to smoking consultation for smoking cessation. This has been seen overexpression and frequent hand to mouth movement. The health in a recent study that found the rate of smoking cessation cost of COVD-19-associated morbidity can be reduced via the promotion of smoking cessation through apps, public health increased from 23% before COVID-19 to 31% during COVID-19 campaigns, telehealth models and the hospital quality measures. pandemic . Such health and financial benefits are maximised by psychological and pharmacological interventions that delivered HOW CAN WE SUPPORT SMOKING CESSATION DURING THE from specialist smoking cessation services . However, smoking COVID-19 PANDEMIC? cessation services should be more resilient and change their traditional delivery models in response to COVID-19 by using Why smokers should quit? telehealth tools, such as expanding telecommunications and With over 8,000,000 deaths per year due to direct or indirect interactive assistance capabilities, and allow remote access to exposure, smoking remains a major global health issue especially nicotine replacement products . Further, promoting tech-driven in low- and middle-income countries. Indeed, in the context of approach by using quitting smoking apps is more beneficial to COVID-19, this number is expected to go up, but the time has not increase the odds of quitting success. A randomised clinical trial gone by to quit smoking. With an average light smoker published recently compared the efficacy of two smartphone consuming 10–15 cigarette/day, including an average of up to applications for smoking cessation, and found that smokers who 22,23 13 puffs per cigarette and each puffs duration of 1.5 s (refs. ). used the iCanQuit app (teaches acceptance of smoking triggers) This shows that an average smoker has a hand to their mouth had 1.49 times higher odds of quitting smoking compared with between 130 and 195 times. This translates into 195–293 s more, those who used the QuitGuide app (depends on avoiding in which the hand is on the lip per day compared with non- 34 smoking triggers) . This elevates apps as an effective way of smokers. This is especially interesting giving that the SARS-CoV-2 quitting smoking, particularly apps that depend on accepting the can survive on surfaces for days depending on the medium of existence of cravings rather than trying to eliminate them. shedding. This provides a possible hypothesis for the increased Indeed, using such strategies would reduce the smoking burden risk of SARS-CoV-2 infection and/or re-infection in smokers on healthcare systems. A recent study synthesised that best compared to non-smokers. Therefore, both smokers and health- hospitals should be required to deliver smoking cessation, and care providers should be aware of this practice behaviour. such a service provision should be considered as a quality According to a recent study, many smokers showed substantial measure for accreditation and recognition . Furthermore, policy- levels of interest expressed in accessing various forms of cessation makers and healthcare providers should consider the information assistance, during COVID-19 compared before COVID-19 (ref. ). delivery preferences of smokers when campaigning about This shows that smokers understand how to reduce the risk of smoking cessation (see Fig. 1). A recent study reported that most COVID-19 by addressing their smoking. Action on Smoking and of the smokers preferred to receive such information through a Health (Ash) calculates that around a million smokers stopped television channel (61%), followed by online news (36%), social smoking during COVID-19, an additional 550,000 have attempted media (31%), and email (31%) . Indeed, policymakers should to quit and 2.4 million have been reduced to smoke cigarettes, establish innovative strategies to increase the uptake to the npj Primary Care Respiratory Medicine (2021) 22 Published in partnership with Primary Care Respiratory Society UK 1234567890():,; JS Alqahtani et al. smoking cessation therapies, and eventually raise the chances of 22. Fagan, P. & Rigotti, N. A. Light and intermittent smoking: the road less traveled. Nicotine Tob. Res 11, 107–110 (2009). quitting to promote greater patients and system outcomes. 23. Ross, K. C., Dempsey, D. A., St Helen, G., Delucchi, K. & Benowitz, N. L. The influence of puff characteristics, nicotine dependence, and rate of nicotine metabolism on daily nicotine exposure in African American Smokers. Cancer CONCLUSION Epidemiol. Biomark. Prev. 25, 936–943 (2016). Beyond the health and financial benefits of avoiding tobacco use 24. Pettigrew, S. et al. Preferences for tobacco cessation information and support before COVID-19 pandemic, an increase in quit rates may help to during covid-19. J. Addict. Med. 14, e362–e365 (2020). minimise public SARS-CoV-2 transmission and the associated 25. ASH. Action on Smoking and Health (Ash). https://ash.org.uk/category/media-and- severity with current smokers. Enhancing smoking cessation trials news/press-releases-media-and-news/ (2020). during this pandemic is a clinical priority and should be 26. Alqahtani, J. S. et al. Risk factors for all-cause hospital readmission following thoroughly endorsed. 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