A new paper published online in the Annals of the American Thoracic Society discusses how smoking may affect risk for COVID-19 and the types of research that are needed to better understand the link between smoking and COVID-19 risk.
In "Smoking and COVID-19: The Real Deal," Enid Neptune, MD, and Michelle N. Eakin, PhD, of the Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, discuss research to date on this topic and propose areas of research that can help clarify this relationship.
Studies have shown that current smokers with COVID-19 have twice the risk of dying in the hospital as nonsmokers. However, the data on whether tobacco use increases the risk of SARS-CoV-2 infection is mixed.
"The relationship between smoking and COVID-19 is complex, and much of the research to date has been inconclusive or contradictory," said Dr. Neptune. "To resolve this issue, rigorous study design is needed. This research should accurately confirm smoking exposure, with readouts that distinguish infection from sickness and provide an objective assessment of confounding factors."
Dr. Neptune adds that a significant amount of research has focused on whether smoking has an effect on lung ACE2, a protein that provides an entry point for SARS-CoV-2 (the virus that causes COVID-19) to attach itself to cells inside the airways and airspace of the lungs. "The use of ACE2 expression as a quantifiable index of SARS-CoV-2 infectivity and morbidity is highly problematic," she said. "A strenuous exploration of how and whether tobacco smoke and nicotine affect SARS-CoV-2 infectivity or viral load (amount of virus) is needed to provide context to the ACE2 expression data."
According to Drs. Neptune and Eakin, the following topics should also be addressed in future research:
Measurements of the activity of RAS processing enzymes and the proteins produced by this activity in smoking and non-smoking COVID patients would provide some guidance for pilot therapeutic studies.
"There are several other areas of smoking-COVID research that might be explored, beyond those discussed in our paper," Dr. Neptune said. These include:
Dr. Neptune concludes, "Our paper shows that the impact of tobacco exposure on the development of COVID-19 is challenging to address with clinical studies, and needs rigorous validation with cell and animal studies. Taken together, the multiple published studies on smoking and COVID have not yet resolved the issue. Our intention in publishing this paper is to identify the interpretative challenges of the overall dataset and recommend ways forward."
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