COVID-19, smoking, and inequalities: a cross-sectional survey of adults in the UK

  1. Sarah E. Jackson
  2. Jamie Brown
  3. Lion Shahab
  4. Andrew Steptoe
  5. Daisy Fancourt
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Abstract

Objectives

To examine associations between smoking and COVID-19 relevant outcomes, taking into account the influence of inequalities and adjusting for potential confounding variables.

Design

Online cross-sectional survey.

Setting

UK.

Participants

53,002 men and women aged ≥18y.

Main outcome measures

Confirmed and suspected COVID-19, worry about catching and becoming seriously ill from COVID-19, and adherence to protective behaviours. Socioeconomic position was defined according to highest level of education (post-16 qualifications: yes/no).

Results

Compared with never smokers (0.3% [95%CI 0.2-0.3%]), prevalence of confirmed COVID-19 was higher among current (0.6% [0.4-0.8%]) but not ex-smokers (0.2% [0.2-0.3%]). The associations were similar before (current: OR 2.14 [1.49-3.08]; ex-smokers: OR 0.73 [0.47-1.14]) and after (current: OR 1.79 [1.22-2.62]; ex-smokers: OR 0.85 [0.54-1.33]) adjustment for potential confounders. For current smokers, this was moderated by socioeconomic position, with higher rates relative to never smokers only seen in those without post-16 qualifications (OR 3.53 [2.04-6.10]). After including suspected cases, prevalence was higher among current smokers (11.2% [10.6-11.9%], OR 1.11 [1.03-1.20]) and ex-smokers (10.9% [10.4-11.5%], OR 1.07 [1.01-1.15]) than never smokers (10.2% [9.9-10.6%]), but remained higher only among ex-smokers after adjustment (OR 1.21 [1.13-1.29]). Current and ex-smokers had higher odds than never smokers of reporting significant stress about catching (current: OR 1.43 [1.35-1.52]; ex-smokers: OR 1.15 [1.09-1.22]) or becoming seriously ill from COVID-19 (current: OR 1.34 [1.27-1.43]; ex-smokers: OR 1.22 [1.16-1.28]). Adherence to recommendations to prevent the spread of COVID-19 was generally high (96.3% [96.1-96.4%]), but lower among current than never smokers (OR 0.70 [0.62-0.78]).

Conclusions

When assessed by self-report in a population sample, current smoking was independently associated with confirmed COVID-19 infection. There were socioeconomic disparities, with the association only apparent among those without post-16 qualifications. Smokers reported lower adherence to guidelines despite being more worried than non-smokers about catching or becoming seriously ill from COVID-19.

Registration

The analysis plan was pre-registered on Open Science Framework ( <ext-link xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="uri" xlink:href="https://osf.io/pcs49/">https://osf.io/pcs49/</ext-link> ).

What is already known on this topic

  • Former or current smoking can increase the risk of respiratory viral and bacterial infections and is associated with worse outcomes for those infected.

  • However, data from several countries indicate that rates of current smoking are substantially lower among hospitalised COVID-19 patients than would be expected based on population-level smoking prevalence.

What this study adds

  • Data from a large population-based sample of adults in the UK conflict with the hypothesis that smoking is protective against COVID-19 infection; rather, we found that current smoking was independently associated with increased odds of confirmed COVID-19 infection after adjusting for relevant confounders.

  • Socioeconomic disparities were evident, with the association between smoking and confirmed COVID-19 only apparent among those without post-16 qualifications.

  • Smokers reported lower adherence to guidelines despite being more worried than non-smokers about catching or becoming seriously ill from COVID-19.

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