New insights into the paradox between smoking and the risk of SARS-CoV-2 infection (COVID-19): Insufficient evidence for a causal association.

AIMS: Previous studies have reported a 'smoker's paradox', where people who smoke appear to be protected against Severe Acute Respiratory Syndrome CoronaVirus-2 (SARS-CoV-2) infection (COVID-19). This conflicts with well-established evidence that people who smoke are generally more vulnerable to respiratory infections. In this study, we aimed to validate the association between smoking and SARS-CoV-2 infection in a general Dutch population, and to evaluate the evidence underlying the possible causal relationship between smoking and SARS-CoV-2 infection by applying a modern adaptation of the Bradford Hill criteria. METHODS: In total, 57,833 participants from the Lifelines Cohort Study were included in the analysis. Smoking status, including never smoker, current smoker, and former smoker, was derived from the Lifelines general assessment between 2014 and 2017, while SARS-CoV-2 infection status was derived from an additional COVID-19 questionnaire from 2021 to 2022. Logistic regressions were used for the association between smoking status and infection status. The adapted Bradford Hill's criteria, including the strength of association (including an analysis of plausible confounding), plausibility, temporality and study design suitability, were applied to evaluate the existing literature. RESULTS: We found, compared with never smokers, an increased risk of SARS-CoV-2 infection for former smokers (odds ratio (OR)=1.07, 95% confidence interval (CI)=1.01-1.13), but a reduced risk for current smokers (OR=0.85, 95% CI=0.79-0.92), after adjusting for several relevant covariates. However, we discerned a possible explanation of the smoker's paradox since we observed that current smokers were more likely to be non-responders to the COVID-19 questions and, more importantly, these non-responders were more likely to have other established risk factors for SARS-CoV-2 infection. CONCLUSIONS: There is insufficient evidence to suggest that smoking protects against SARS-CoV-2 infection. According to the adapted Bradford Hill's criteria, we observed a high inconsistency between study results, a high possibility for residual confounding and no clear evidence for biological plausibility. Future studies should include linkage with the confirmed testing results from national healthcare registries to mitigate avoidable bias.

Risk of death due to COVID-19 among current and former smokers in the Netherlands: a population-based quasi-cohort study.

BACKGROUND: Research on smoking as a risk factor for death due to COVID-19 remains inconclusive, with different studies demonstrating either an increased or decreased risk of COVID-19 death among smokers. To investigate this controversy, this study uses data from the Netherlands to assess the relationship between smoking and death due to COVID-19. METHODS: In this population-based quasi-cohort study, we linked pseudonymized individual data on smoking status from the 2016 and 2020 'Health Monitor Adults and Elderly' in the Netherlands (n = 914 494) to data from the cause-of-death registry (n = 2962). Death due to COVID-19 in 2020 or 2021 was taken as the main outcome. Poisson regression modelling was used to calculate relative risks (RRs) and 95% CIs of death due to COVID-19 for current and former smokers compared with never smokers while adjusting for relevant confounders (age, sex, educational level, body mass index and perceived health). RESULTS: Former smokers had a higher risk of death due to COVID-19 compared with never smokers across unadjusted (RR, 2.22; 95% CI, 2.04-2.42), age-sex-adjusted (RR, 1.38; 95% CI, 1.22-1.55) and fully adjusted (RR, 1.30; 95% CI, 1.16-1.45) models. Current smokers had a slightly higher risk of death due to COVID-19 compared with never smokers after adjusting for age and sex (RR, 1.21; 95% CI, 1.00-1.48) and after full adjustment (RR, 1.08; 95% CI, 0.90-1.29), although the results were statistically non-significant. CONCLUSIONS: People with a history of smoking appear to have a higher risk of death due to COVID-19. Further research is needed to investigate which underlying mechanisms may explain this.

The delivery of Ask-Advise-Connect for smoking cessation in Dutch general practice during the COVID-19 pandemic: results of a pre-post implementation study.

BACKGROUND: The Ask-Advise-Connect approach can help primary care providers to increase the number of smokers that attempt to quit smoking and enrol into cessation counselling. The approach has not yet been implemented in general practice in the Netherlands. The aim of this study was to investigate the influence of a comprehensive implementation strategy on the delivery of Ask-Advise-Connect for smoking cessation within Dutch general practice during the COVID-19 pandemic. METHODS: A pre-post study was conducted between late 2020 and early 2022, and included 106 Dutch primary care providers (GPs, practice nurses and doctor's assistants). Participation lasted nine months: during the first three months participants delivered smoking cessation care as usual (pre-intervention); the implementation strategy came into effect after three months and participants were followed up for another six months (post-intervention). The implementation strategy consisted of two meetings in which participants were educated about Ask-Advise-Connect, made agreements on the implementation of Ask-Advise-Connect and reflected on these agreements. Participants also received online educational materials and a desk card as reminder. The changes in the proportions of 'Ask' and 'Advise' over time were modelled using linear mixed effects models. A descriptive analysis was conducted with regard to referrals to cessation counselling. RESULTS: Participants provided consultations to 29,112 patients (both smokers and non-smokers). Results of the linear mixed effects model show that the proportion of patients that were asked about smoking ('Ask') significantly decreased in the first three months (pre-intervention), but slightly increased again after the implementation strategy came into effect (post-intervention). No significant change over time was found with regard to the proportion of patients advised to quit smoking ('Advise'). Descriptive statistics suggested that more participants proactively (vs. passively) referred patients to cessation counselling post-intervention ('Connect'). CONCLUSIONS: The findings indicate that a comprehensive implementation strategy can support primary care providers in offering smoking cessation care to patients, even under stressful COVID-19 conditions. Additional implementation efforts are needed to increase the proportion of patients that receive a quit advice and proactive referral.

Implementation of ask-advise-connect for smoking cessation in Dutch general practice during the COVID-19 pandemic: a mixed-methods evaluation using the CFIR framework.

BACKGROUND: The Ask-Advise-Connect (AAC) approach can help primary care providers to increase the number of people who attempt to quit smoking and enrol into cessation counselling. We implemented AAC in Dutch general practice during the COVID-19 pandemic. In this study we describe how AAC was received in Dutch general practice and assess which factors played a role in the implementation. METHODS: A mixed-methods approach was used to evaluate the implementation of AAC. Implementation took place between late 2020 and early 2022 among 106 Dutch primary care providers (general practitioners (GPs), practice nurses and doctor's assistants). Quantitative and qualitative data were collected through four online questionnaires. A descriptive analysis was conducted on the quantitative data. The qualitative data (consisting of answers to open-ended questions) were inductively analysed using axial codes. The Consolidated Framework for Implementation Research was used to structure and interpret findings. RESULTS: During the study, most participants felt motivated (84-92%) and able (80-94%) to apply AAC. At the end of the study, most participants reported that the AAC approach is easy to apply (89%) and provides advantages (74%). Routine implementation of the approach was, however, experienced to be difficult. More GPs (30-48%) experienced barriers in the implementation compared to practice nurses and doctor's assistants (7-9%). The qualitative analysis showed that especially external factors, such as a lack of time or priority to discuss smoking due to the COVID-19 pandemic, negatively influenced implementation of AAC. CONCLUSIONS: Although AAC was mostly positively received in Dutch general practice, implementation turned out to be challenging, especially for GPs. Lack of time to discuss smoking was a major barrier in the implementation. Future efforts should focus on providing additional implementation support to GPs, for example with the use of e-health.

Proactive Referral to Behavioral Smoking Cessation Programs by Healthcare Staff: A Systematic Review.

INTRODUCTION: Behavioral smoking cessation programs are an effective tool for quitting smoking, yet remain underused by smokers. Proactive referral may be a promising strategy for healthcare staff to connect smokers to such programs. AIMS AND METHODS: The aim of this study was to gain insight into the effectiveness and implementability of proactive referral of smokers to behavioral smoking cessation programs by healthcare staff. A systematic review was conducted using five databases. Effectiveness of proactive referral was defined as the proportion of referred smokers who enrolled in a behavioral smoking cessation program. To determine the implementability of proactive referral, measures of feasibility, acceptability, adoption, and referral rates were included as variables of interest. Out of 6686 screened records, 34 articles were eligible for review. A narrative synthesis approach was used. RESULTS: The majority of the included studies investigated proactive referral within an e-referral system, combined with one or more intervention components that enhance implementation. Overall, proactive referral resulted in higher enrollment rates, especially among low-income smokers, and was found to be feasible, adoptable, and acceptable to healthcare staff. E-referral systems performed better in terms of implementability compared to fax referral systems. About half of the studies were of good quality. Many studies lacked information which resulted in lower-quality scores. CONCLUSIONS: The literature provides evidence that the proactive referral of smokers to behavioral smoking cessation programs by healthcare staff is effective and implementable across different settings. Based on the results, e-referral systems may be preferable to fax referral systems in terms of implementability. IMPLICATIONS: This systematic review demonstrated that proactive referral has the potential to increase the reach of smoking cessation programs and reduce inequalities in access to such programs. In the selection and implementation of behavioral smoking cessation programs with a proactive referral component, stakeholders (eg, policymakers, healthcare funders, and healthcare professionals) may benefit from taking different aspects of proactive referral systems into account, such as the type of proactive referral system used and additional strategies which can enhance the implementability of the system.

Mentioning smoking cessation assistance during healthcare consultations matters: findings from Dutch survey research.

BACKGROUND: Smoking cessation assistance (SCA) can help smokers to successfully quit smoking. It is unclear to what extent hearing about SCA from a healthcare professional is associated with using SCA during a quit attempt. METHODS: We used pooled survey data from the 2016, 2018 and 2020 'Module Substance Use' survey in the Netherlands (N = 5928). Multivariate logistic regression analyses were used to determine the association between having heard about SCA from one or more healthcare professionals in the last year and the use of SCA during the most recent quit attempt in the last year. We used two models: model 1 included any type of assistance; model 2 included assistance typically recommended by treatment guidelines (i.e. counselling and pharmacotherapy). RESULTS: Hearing about any type of SCA from a healthcare professional in the last year was significantly associated with using any type of SCA during the most recent quit attempt [odds ratio (OR) = 2.96; 95% confidence interval (CI) 2.16-4.06; P < 0.001]. We found the strongest association between hearing about counselling and/or pharmacotherapy and using counselling and/or pharmacotherapy (OR = 5.40; 95% CI 4.11-11.60; P < 0.001). The odds of using SCA was not significantly higher for smokers who had heard about it from two or more healthcare professionals compared to one healthcare professional (OR = 1.38; 95% CI 0.79-2.42; P = 0.26). CONCLUSIONS: Healthcare professionals can play a greater role in stimulating the use of SCA, especially counselling and pharmacotherapy, by mentioning it to smokers during consultations.

[Crucial role for healthcare providers in the PURE smoke-free campaign]. / Cruciale rol zorgverleners bij campagne PUUR rookvrij.

Smoking is still one of the leading causes of death in the Netherlands and worldwide. The current pandemic has made the importance of smoking cessation even more visible. With the smoking cessation campaign PURE smoke-free (in Dutch: PUUR rookvrij), the Dutch government aims to encourage smokers to quit smoking. Physicians and other healthcare providers play an indispensable role in stimulating smokers to quit. In practice, potential opportunities to discuss smoking are often missed by healthcare providers; the PURE smoke-free campaign can help with this.

[Patients who smoke: should we ignore the addiction or take care of the patient?] / Rokers in de spreekkamer.

Smoking cessation yields large health gains, especially in times of COVID-19. Compared to measures to stop COVID-19, tobacco control is lagging behind. We studied smoking-cessation-care in the Netherlands, using qualitative interviews with physicians (N=55) and questionnaires among physicians and other healthcare providers (HCPs; N=883) in 2017. Who is responsible for what? Three actors emerged: the patient who smokes (end responsible for quitting), the HCP (quit-advice, counseling or referral) and the government (create a society that stimulates "smoke-free"). Many HCPs do not ask about smoking, nor advise to quit. The task-division is unclear, as smoking causes multiple diseases that are part of multiple disciplines and specializations. HCPs that see smoking as a serious addiction are more inclined to ensure adequate smoking-cessation-care for their patients. Fortunately, there are positive developments as well, both within healthcare as society, and ways in which you can contribute.

The referral of patients to smoking cessation counselling: perceptions and experiences of healthcare providers in general practice.

BACKGROUND: Few European smokers receive professional counselling when attempting to quit smoking, resulting in suboptimal success rates and poor health outcomes. Healthcare providers in general practice play an important role in referring smokers to smoking cessation counselling. We chose the Netherlands as a case study to qualitatively explore which factors play a role among healthcare providers in general practice with regard to referral for smoking cessation counselling organised both inside and outside general practice. METHODS: We conducted four focus groups and 18 telephone interviews, with a total of 31 healthcare providers who work in general practice. Qualitative content analysis was used to identify relevant factors related to referral behaviours, and each factor was linked to one of the three main components of the COM-B behaviour model (i.e., capability, opportunity and motivation) as well as the six sub-components of the model. RESULTS: Dutch healthcare providers in general practice typically refer smokers who want to quit to counselling inside their own general practice without actively discussing other counselling options, indicating a lack of shared decision making. The analysis showed that factors linked to the COM-B main components 'capability' and 'opportunity', such as healthcare providers' skills and patients' preferences, play a role in whether patients are referred to counselling inside general practice. Factors linked to all three COM-B components were found to play a role in referrals to counselling outside general practice. These included (knowledge of) the availability and quality of counselling in the region, patients' requests, reimbursement, and sense of urgency to refer. The identified factors can both act as barriers and facilitators. CONCLUSIONS: The findings of this research suggest that more smokers can be reached with smoking cessation counselling if implementation interventions focus on: (i) equipping healthcare providers with the knowledge and skills needed to refer patients; (ii) creating more opportunities for healthcare providers to refer patients (e.g., by improving the availability and reimbursement of counselling options); and (iii) motivating healthcare providers to discuss different counselling options with patients.

Introducing hepatitis C virus healthcare pathways in addiction care in the Netherlands with a Breakthrough project: a mixed method study.

BACKGROUND: People who inject drugs (PWID) are disproportionally affected by the hepatitis C virus (HCV) infection. In the Netherlands, active HCV transmission in PWID has practically been halted but uptake of HCV testing and linkage to care remains insufficient in this risk group. A national HCV in Addiction Care (HAC) quality improvement project based on the Breakthrough methodology (i.e. Breakthrough project) aimed to secure proper linkage to care in PWID by introducing local HCV healthcare screening and treatment pathways in addiction care units. AIM: To qualitatively appraise the local HCV healthcare pathways; to evaluate the yield in terms of number of PWID screened, diagnosed, referred, and treated; and to identify best practices and barriers to successful participation in the HAC Breakthrough project. METHODS: Between 2013 and 2016, 12 units of addiction care centers throughout the Netherlands participated in two series of a HAC Breakthrough project. Local multidisciplinary teams created HCV healthcare pathways. Quality assessment of HCV healthcare pathways was performed retrospectively and data on screening results was collected. In-depth interviews were conducted to elucidate best practices and essential elements for successful participation. RESULTS: In total, six HCV healthcare pathways were submitted by ten teams of which 83% was judged to be of "good" or "sufficient" quality. Uptake of HCV-antibody screening was 40% (N = 487/1219) and uptake of HCV-RNA in HCV-antibody positives was 59% (N = 107/181). The project resulted in 76 (6%) newly detected cases of persistent HCV viremia. Of all HCV-RNA positives, 92% was referred to a hepatitis treatment center. In 39% (N = 27/70) of those referred, treatment initiation was documented and 82% (N = 22/27) achieved a sustained virological response. Teams identified several best practices including motivational counseling training, oral swabs for anti-HCV testing, facilitating complementary HCV RNA testing, and supervised hospital visits. CONCLUSION: The HAC Breakthrough project has brought about good quality HCV healthcare pathways in the majority of participating addiction care centers and has successfully linked PWID with ongoing HCV viremia to care. Uptake of HCV screening and treatment after referral were identified as the main gaps to be closed in the HCV cascade of care to achieve final HCV elimination in Dutch PWID (i.e. micro-elimination).

[Electronic cigarettes: use, health risks, and effectiveness as a cessation method]. / De elektronische sigaret: Gebruik, gezondheidsrisico's, en effectiviteit als stopmethode.

The use of electronic cigarettes (e-cigarettes) among adults in the Netherlands is increasing but is still relatively low. Increasing numbers of young people abroad are experimenting with e-cigarettes but no trend data for the Netherlands are available to date. Young people who experiment with e-cigarettes are principally those young people who already smoke conventional cigarettes or have done so in the past; the same applies to adults. There are no indications that experimenting with e-cigarettes can lead to tobacco addiction. Although the vapour from e-cigarettes contains substances that are harmful to health, the health risks from the use of e-cigarettes are far smaller than those from smoking conventional cigarettes. Too few research data are available to be able to conclude that e-cigarettes are an effective aid to smoking cessation.