The role of smoking in COVID-19 progression: a comprehensive meta-analysis.

The association between current smoking and coronavirus disease 2019 (COVID-19) progression remains uncertain. We aim to provide up-to-date evidence of the role of cigarette smoking in COVID-19 hospitalisation, severity and mortality. On 23 February 2022 we conducted an umbrella review and a traditional systematic review via PubMed/Medline and Web of Science. We used random-effects meta-analyses to derive pooled odds ratios of COVID-19 outcomes for smokers in cohorts of severe acute respiratory syndrome coronavirus 2 infected individuals or COVID-19 patients. We followed the Meta-analysis of Observational Studies in Epidemiology reporting guidelines. PROSPERO: CRD42020207003. 320 publications were included. The pooled odds ratio for current versus never or nonsmokers was 1.08 (95% CI 0.98-1.19; 37 studies) for hospitalisation, 1.34 (95% CI 1.22-1.48; 124 studies) for severity and 1.32 (95% CI 1.20-1.45; 119 studies) for mortality. Estimates for former versus never-smokers were 1.16 (95% CI 1.03-1.31; 22 studies), 1.41 (95% CI: 1.25-1.59; 44 studies) and 1.46 (95% CI 1.31-1.62; 44 studies), respectively. Estimates for ever- versus never-smokers were 1.16 (95% CI 1.05-1.27; 33 studies), 1.44 (95% CI 1.31-1.58; 110 studies) and 1.39 (95% CI 1.29-1.50; 109 studies), respectively. We found a 30-50% excess risk of COVID-19 progression for current and former smokers compared with never-smokers. Preventing serious COVID-19 outcomes, including death, seems the newest compelling argument against smoking.

Electronic cigarette use among adolescents in 17 European study sites: findings from the Global Youth Tobacco Survey.

BACKGROUND: As new findings on public health implications of electronic cigarette (e-cigarette) use emerge, its surveillance remains of utmost importance. This study examined the latest state of e-cigarette use in youth in 17 European study sites (i.e. 16 countries and the Federation of Bosnia and Herzegovina) using the Global Youth Tobacco Survey (GYTS). METHODS: This was an observational study. Cross-sectional data on students aged 11-17 years from the latest available GYTS round completed in 17 study sites were used to estimate crude and adjusted prevalence of e-cigarette use by sex and pocket money. Panel GYTS data from five countries were used for the trend analyses. All analyses were weighted to account for the survey design and non-response. RESULTS: Compared to 2014, the age-adjusted prevalence of e-cigarette use more than doubled in Georgia and Italy, and nearly doubled in Latvia. Significantly more male than female students aged 11-17 years reported use of e-cigarettes, with little to no confounding by age, grade and pocket money across countries. Youth with medium or higher amount of pocket money was 20-200% more likely to use e-cigarettes than those with fewer to no pocket money in 14 study sites. DISCUSSION: As e-cigarette use is becoming widespread throughout the world, there is variation in use among and between countries. Expanded and consistent surveillance of e-cigarette use by all World Health Organization member states is essential to generate data on the extent and correlates of youth e-cigarette use for evidence-based planning and evaluation of the electronic nicotine delivery systems and electronic non-nicotine delivery systems national and global control programmes.

Association between electronic nicotine delivery systems and electronic non-nicotine delivery systems with initiation of tobacco use in individuals aged < 20 years. A systematic review and meta-analysis.

BACKGROUND: This systematic review described the association between electronic nicotine delivery systems and electronic non-nicotine delivery systems (ENDS/ENNDS) use among non-smoking children and adolescents aged <20 years with subsequent tobacco use. METHODS: We searched five electronic databases and the grey literature up to end of September 2020. Prospective longitudinal studies that described the association between ENDS/ENNDS use, and subsequent tobacco use in those aged < 20 years who were non-smokers at baseline were included. The Joanna Briggs Institute Critical Appraisal Checklist was used to assess risk of bias. Data were extracted by two reviewers and pooled using a random-effects meta-analysis. We generated unadjusted and adjusted risk ratios (ARRs) describing associations between ENDS/ENNDS and tobacco use. FINDINGS: A total of 36 publications met the eligibility criteria, of which 25 were included in the systematic review (23 in the meta-analysis) after exclusion of overlapping studies. Sixteen studies had high to moderate risk of bias. Ever users of ENDS/ENNDS had over three times the risk of ever cigarette use (ARR 3·01 (95% CI: 2·37, 3·82; p<0·001, I2: 82·3%), and current cigarette use had over two times the risk (ARR 2·56 (95% CI: 1·61, 4·07; p<0·001, I2: 77·3%) at follow up. Among current ENDS/ENNDS users, there was a significant association with ever (ARR 2·63 (95% CI: 1·94, 3·57; p<0·001, I2: 21·2%)), but not current cigarette use (ARR 1·88 (95% CI: 0·34, 10·30; p = 0·47, I2: 0%)) at follow up. For other tobacco use, ARR ranged between 1·55 (95% CI 1·07, 2·23) and 8·32 (95% CI: 1·20, 57·04) for waterpipe and pipes, respectively. Additionally, two studies examined the use of ENNDS (non-nicotine devices) and found a pooled adjusted RR of 2·56 (95% CI: 0·47, 13·94, p = 0.035). CONCLUSION: There is an urgent need for policies that regulate the availability, accessibility, and marketing of ENDS/ENNDS to children and adolescents. Governments should also consider adopting policies to prevent ENDS/ENNDS uptake and use in children and adolescents, up to and including a ban for this group.

Prevalence of electronic nicotine delivery systems and electronic non-nicotine delivery systems in children and adolescents: a systematic review and meta-analysis.

BACKGROUND: There are concerns that the use of electronic nicotine delivery systems (ENDS) and electronic non-nicotine delivery systems (ENNDS) in children and adolescents could potentially be harmful to health. Understanding the extent of use of these devices is crucial to informing public health policy. We aimed to synthesise the prevalence of ENDS or ENNDS use in children and adolescents younger than 20 years. METHODS: In this systematic review and meta-analysis, we undertook an electronic search in five databases (MEDLINE, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Embase, and Wiley Cochrane Library) from Jan 1, 2016, to Aug 31, 2020, and a grey literature search. Included studies reported on the prevalence of ENDS or ENNDS use in nationally representative samples in populations younger than 20 years and collected data between the years 2016 and 2020. Studies were excluded if they were done in those aged 20 years or older, used data from specialist panels that did not apply appropriate weighting, or did not use methods that ensured recruitment of a nationally representative sample. We included the most recent data for each country. We combined multiple national estimates for a country if they were done in the same year. We undertook risk of bias assessment for all surveys included in the review using the Joanna Briggs Institute Critical Appraisal Checklist (by two reviewers in the author list). A random effects meta-analysis was used to pool overall prevalence estimates for ever, current, occasional, and daily use. This study was prospectively registered with PROSPERO, CRD42020199485. FINDINGS: The most recent prevalence data from 26 national surveys representing 69 countries and territories, with a median sample size of 3925 (IQR 1=2266, IQR 3=10 593) children and adolescents was included. In children and adolescents aged between 8 years and younger than 20 years, the pooled prevalence for ever (defined as any lifetime use) ENDS or ENNDS use was 17·2% (95% CI 15-20, I2=99·9%), whereas for current use (defined as use in past 30 days) the pooled prevalence estimate was 7·8% (6-9, I2=99·8%). The pooled estimate for occasional use was 0·8% (0·5-1·2, I2=99·4%) for daily use and 7·5% (6·1-9·1, I2=99·4%) for occasional use. Prevalence of ENDS or ENNDS use was highest in high-income geographical regions. In terms of study quality, all surveys scored had a low risk of bias for the sampling frame used, due to the nationally representative nature of the studies. The most poorly conducted methodological feature of the included studies was subjects and setting described in detail. Few surveys reported on the use of flavours or types of ENDS or ENNDS. INTERPRETATION: There is significant variability in the prevalence of ENDS and ENNDS use in children and adolescents globally by country income status. These findings are possibly due to differences in regulatory context, market availability, and differences in surveillance systems. FUNDING: World Health Organization and the Bill & Melinda Gates Foundation.

Estimated and projected prevalence of tobacco smoking in males, Eastern Mediterranean Region, 2000-2025.

BACKGROUND: Three global reports published by the World Health Organization (WHO) report trends in the prevalence of tobacco smoking from 2000 to 2025 based on data from national surveys. AIMS: The is study aimed to: (i) compare current and projected prevalence rates of tobacco smoking presented in these reports for males ≥ 15 years in countries of the Eastern Mediterranean Region; and (ii) assess changes in the prevalence rates in the context of changes in tobacco monitoring and control policies in these countries. METHODS: Regional and country-level data on tobacco smoking were extracted from the trend reports. Percentage point differences between the estimated prevalence of tobacco smoking in 2010 and the projected prevalence in 2025 were calculated for countries with available data. Data on implementation of national surveys and policies on tobacco use were obtained from relevant WHO reports. RESULTS: In the latest trend report (2019), the prevalence of male current tobacco smoking is projected to decrease by less than 2 percentage points in the Region (from 33.1% in 2010 to 31.2% in 2025). The projections for male tobacco smoking for 2025 in the 2019 report are more encouraging than in the 2015 report in seven of the eight countries of the Region. For five of these seven countries, implementation of tobacco monitoring and tobacco control policies improved over the same period. CONCLUSIONS: Countries of the Region need to conduct additional national tobacco-use surveys to improve the accuracy of prevalence estimates and projections. Such data can help guide policy-makers to implement policies to control tobacco smoking.

Smoking prevalence in the Eastern Mediterranean Region.

BACKGROUND: Three global reports issued by the World Health Organization (WHO) track and report on trends in the prevalence of tobacco smoking from 2000 to 2025 based on data from national surveys. AIMS: This review aimed to compare regional and country-level projections for current tobacco smoking as presented in the WHO trend reports. These changes were considered in the context of improved monitoring and tobacco control policies. METHODS: Regional and country-level results in the WHO trend reports were considered in terms of the projected percentage point increase of current tobacco smoking between 2000 and 2025. Data on national surveys and policy implementation came from the relevant WHO reports. RESULTS: In the 2019 trend report, the prevalence of current tobacco smoking among males is projected to decrease by less than 2 percentage points by 2025. Eight countries featured in both the 2015 and 2019 WHO trend reports. Seven of these countries indicated a more encouraging projection (a decline in their projected increase between 2000 and 2025) for current male tobacco smoking in the 2019 report than in the 2015 report. For five out of these seven countries, their monitoring and tobacco control policy implementation improved over the same period. CONCLUSION: Countries in the Region should implement additional national surveys to improve the accuracy of prevalence estimates, allow further projections to be performed and motivate policy-makers to make positive policy changes. Solutions to under-reporting biases during surveys should be considered. Governments should use trend projections to guide effective tobacco control policies to reduce tobacco use in the Region.

Current Tobacco Smoking, Quit Attempts, and Knowledge About Smoking Risks Among Persons Aged ≥15 Years - Global Adult Tobacco Survey, 28 Countries, 2008-2016.

Each year, tobacco use causes approximately 7 million deaths worldwide, including approximately 6 million among tobacco users and an estimated 890,000 among nonsmokers exposed to secondhand smoke (1). Tobacco use is a leading preventable cause of disease globally and has been determined to cause adverse health outcomes such as coronary heart disease, stroke, and multiple types of cancer, including lung cancer (2-4). Approximately 80% of the world's 1.1 billion tobacco smokers reside in low- and middle-income countries (4). Some persons do not fully understand the health risks associated with tobacco smoking (5-9), and studies have indicated that increasing knowledge about the adverse health effects of smoking can contribute to decreases in smoking, increases in cessation attempts, and increases in successful cessation (3,7,10). CDC analyzed 2008-2016 Global Adult Tobacco Survey (GATS) data from 28 countries to assess tobacco smoking prevalence, quit attempts, and knowledge about tobacco smoking risks among persons aged ≥15 years. Across countries, the median prevalence of tobacco smoking was 22.5%, and a median of 42.5% of tobacco smokers had made a quit attempt in the preceding 12 months. The median prevalences of knowing that tobacco smoking causes stroke, heart attack, and lung cancer were 73.6%, 83.6%, and 95.2%, respectively. Implementation of proven tobacco control interventions, including strategies that increase knowledge about the health risks posed by tobacco use, might help to reduce tobacco use and tobacco-related disease, including heart disease, stroke, and lung cancer (3-5).

Implementation of key demand-reduction measures of the WHO Framework Convention on Tobacco Control and change in smoking prevalence in 126 countries: an association study.

BACKGROUND: The WHO Framework Convention on Tobacco Control (WHO FCTC) has mobilised efforts among 180 parties to combat the global tobacco epidemic. This study examined the association between highest-level implementation of key tobacco control demand-reduction measures of the WHO FCTC and smoking prevalence over the treaty's first decade. METHODS: We used WHO data from 126 countries to examine the association between the number of highest-level implementations of key demand-reduction measures (WHO FCTC articles 6, 8, 11, 13, and 14) between 2007 and 2014 and smoking prevalence estimates between 2005 and 2015. McNemar tests were done to test differences in the proportion of countries that had implemented each of the measures at the highest level between 2007 and 2014. Four linear regression models were computed to examine the association between the predictor variable (the change between 2007 and 2014 in the number of key measures implemented at the highest level), and the outcome variable (the percentage point change in tobacco smoking prevalence between 2005 and 2015). FINDINGS: Between 2007 and 2014, there was a significant global increase in highest-level implementation of all key demand-reduction measures. The mean smoking prevalence for all 126 countries was 24·73% (SD 10·32) in 2005 and 22·18% (SD 8·87) in 2015, an average decrease in prevalence of 2·55 percentage points (SD 5·08; relative reduction 10·31%). Unadjusted linear regression showed that increases in highest-level implementations of key measures between 2007 and 2014 were significantly associated with a decrease in smoking prevalence between 2005 and 2015). Each additional measure implemented at the highest level was associated with an average decrease in smoking prevalence of 1·57 percentage points (95% CI -2·51 to -0·63, p=0·001) and an average relative decrease of 7·09% (-12·55 to -1·63, p=0·011). Controlling for geographical subregion, income level, and WHO FCTC party status, the per-measure decrease in prevalence was 0·94 percentage points (-1·76 to -0·13, p=0·023) and an average relative decrease of 3·18% (-6·75 to 0·38, p=0·079). This association was consistent across all three control variables. INTERPRETATION: Implementation of key WHO FCTC demand-reduction measures is significantly associated with lower smoking prevalence, with anticipated future reductions in tobacco-related morbidity and mortality. These findings validate the call for strong implementation of the WHO FCTC in the WHO's Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013-2020, and in advancing the UN's Sustainable Development Goal 3, setting a global target of reducing tobacco use and premature mortality from non-communicable diseases by a third by 2030. FUNDING: Health Canada, Canadian Institutes of Health Research, Ontario Institute for Cancer Research and Canadian Cancer Society Research Institute.

Global trends and projections for tobacco use, 1990-2025: an analysis of smoking indicators from the WHO Comprehensive Information Systems for Tobacco Control.

BACKGROUND: Countries have agreed on reduction targets for tobacco smoking stipulated in the WHO global monitoring framework, for achievement by 2025. In an analysis of data for tobacco smoking prevalence from nationally representative survey data, we aimed to provide comprehensive estimates of recent trends in tobacco smoking, projections for future tobacco smoking, and country-level estimates of probabilities of achieving tobacco smoking targets. METHODS: We used a Bayesian hierarchical meta-regression modelling approach using data from the WHO Comprehensive Information Systems for Tobacco Control to assess trends from 1990 to 2010 and made projections up to 2025 for current tobacco smoking, daily tobacco smoking, current cigarette smoking, and daily cigarette smoking for 173 countries for men and 178 countries for women. Modelling was implemented in Python with DisMod-MR and PyMC. We estimated trends in country-specific prevalence of tobacco use, projections for future tobacco use, and probabilities for decreased tobacco use, increased tobacco use, and achievement of targets for tobacco control from posterior distributions. FINDINGS: During the most recent decade (2000-10), the prevalence of tobacco smoking in men fell in 125 (72%) countries, and in women fell in 156 (88%) countries. If these trends continue, only 37 (21%) countries are on track to achieve their targets for men and 88 (49%) are on track for women, and there would be an estimated 1·1 billion current tobacco smokers (95% credible interval 700 million to 1·6 billion) in 2025. Rapid increases are predicted in Africa for men and in the eastern Mediterranean for both men and women, suggesting the need for enhanced measures for tobacco control in these regions. INTERPRETATION: Our findings show that striking between-country disparities in tobacco use would persist in 2025, with many countries not on track to achieve tobacco control targets and several low-income and middle-income countries at risk of worsening tobacco epidemics if these trends remain unchanged. Immediate, effective, and sustained action is necessary to attain and maintain desirable trajectories for tobacco control and achieve global convergence towards elimination of tobacco use. FUNDING: Ministry of Health, Labour and Welfare, Japan; Ministry of Education, Culture, Sports and Technology, Japan; Department of Health, Australia; Bloomberg Philanthropies.