A June, 2020 study is providing further evidence that smokers are largely underrepresented in COVID-19 cases – a finding that Tobacco Harm Reduction 101 first looked into in early May.

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Researchers conducted “a population-based study among over 3,000,000 adult members of Clalit Health Services, the largest health provider in Israel.” Over 114,000 individuals underwent COVID-19 testing and 4,011 had positive cases. Of the positive cases, the mean age of individuals was 43.38 years old and 48.6 percent were females. Regarding smoking status, 78.2 percent of positive COVID cases were never smokers. Only 10 percent of positive cases were current smokers and 11.7 percent of positive COVID-19 cases were former smokers. This is one of the largest studies to date that examines smoking status and COVID-19 occurrence.

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Other studies have examined the prevalence of smokers in COVID-19 cases and have reached similar conclusions: smokers are largely underrepresented among patients diagnosed with novel coronavirus.

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For example, in an April 3, 2020 Morbidity and Mortality Weekly Report, the Centers for Disease Control and Prevention (CDC) published data on 5,143 COVID-19 patients. Of these, only 96, or 1.3 percent, were classified as current smokers. Only 165 patients, or 2.3 percent, were classified as former smokers. An April 28 COVID-19 Weekly Report issued by the Oregon Health Authority included information on underlying conditions for 73 COVID-19 deaths, of these only one was a current smoker and 18 were former smokers.

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The underrepresentation of smokers in positive COVID-19 cases is bewildering many in the public health community. Although smokers are more likely to develop more severe issues if they do contract the novel coronavirus, they are largely not becoming infected, overall.

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Researchers are currently looking into nicotine’s role in COVID-19 prevalence. One theory is that nicotine reacts to the “angiotensin-converting enzyme (ACE) 2, which is relevant because coronaviruses bind to ACE2.” Indeed, after a study was published in France that found low incidences of smokers in COVID-19 cases, officials limited the sales of nicotine replacement therapies.

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Policymakers should take note of the role of nicotine in COVID-19 cases, should this substance truly protect persons from contacting the illness. Despite growing alarmism that are spearheaded by anti-smoking campaigns, nicotine is not relatively harmful.

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Research continues to indicate that it is the smoke created by the burning of tobacco that causes the most harm from combustible cigarettes. There are an estimated 600 ingredients in each tobacco cigarette, and “when burned, [they] create more than 7,000 chemicals.” As a result of these chemicals, cigarette smoking is directly linked to cardiovascular and respiratory diseases, numerous types of cancer, and increases in other health risks among the smoking population.

Throughout the years, researchers have noted that there are tobacco harm reduction options for smokers who are unable or unwilling to quit smoking.

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There is no significant scientific evidence connecting major health problems with the use of nicotine alone. According to Raymond Niaura, Ph.D., professor of social and behavioral sciences at New York University’s College of Global Public Health, existing evidence “indicates that nicotine itself, while not completely benign, carries substantially lower risks than smoking.” This conclusion is shared by the U.S. surgeon general and the U.K. Royal College of Physicians, which agrees “nicotine, while addictive, is not the primary cause of smoking-related diseases.” In a comprehensive study of nicotine health effects, Niaura noted “that even very high doses of medicinal nicotine had little effect on cardiovascular function.”

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Moreover, many adults are currently using smokeless tobacco products and have shown no adverse effects due to nicotine found in those products. For example, smokeless tobacco poses much lower health risks than smoking, despite containing nicotine. A 2009 Biomed Central study analyzed “all the epidemiological evidence linking smokeless tobacco use and cancer.” Using data from 89 studies, the authors identified “the relative risk of cancer among smokeless tobacco users, compared with non-users of nicotine.” The study found “very little evidence” of smokeless tobacco producing elevated cancer risks. Another review of the epidemiologic studies, conducted in 2011, found snus and smokeless tobacco use to be “99% less hazardous than smoking.”

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It is imperative for policymakers to pay attention to the latest studies examining nicotine’s role in COVD-19 prevalence. Research increasingly indicates that smokers are underrepresented in coronavirus case and that nicotine may provide protective benefits. As more and more states seek to regulate tobacco and vapor products, it is of the upmost importance they do not block access to tobacco harm reduction products.

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Nothing in this analysis is intended to is intended to influence the passage of legislation, and it does not necessarily represent the views of Tobacco Harm Reduction 101. For more information on tobacco and vapor products, please visit https://www.thr101.org.