COVID-19 Outcome and Tobacco Product Use: Case-Control and Retrospective Cohort Studies Using Nationwide Samples

Conflicting evidence exists regarding the association between smoking and the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We investigated the association between combustible cigarette (CC) smoking, noncombustible tobacco product (NCTP) use, and the use of any tobacco product with various coronavirus disease 2019 (COVID-19) outcomes.

A case-control study was conducted using the Korea Disease Control and Prevention Agency-COVID19-National Health Insurance Service (NHIS) cohort. A retrospective cohort study was conducted using 12,571,698 individuals from the NHIS cohort. Logistic regression evaluated the association between CC smoking, NCTP use, and use of any tobacco product with SARS-CoV-2 infection. Poisson regression evaluated the association between these forms of tobacco product use and COVID-19-related hospitalization and mortality.

In the case-control study, we identified 30,878 cases of SARS-CoV-2 infection. The odds ratios (95% confidence intervals [CIs]) for SARS-CoV-2 infection were lower among current CC smokers (0.51, 0.48-0.54), current- and former-NCTP users (0.80, 0.74-0.88; 0.82, 0.74-0.91), and current users of any tobacco product (0.52, 0.49-0.55) relative to never user controls. In retrospective cohort study, we identified 16,521 COVID-19-related hospitalization and 362 COVID-19-related deaths. The relative risks (95% CIs) for COVID-19-related hospitalization were lower among current CC smokers (0.51, 0.48-0.54) and current users of any tobacco product (0.53, 0.50-0.56) relative to never user controls. There was no association between the use of tobacco product and COVID-19-related mortality.

Current CC smokers and current users of any tobacco product showed reduced risk of SARS-CoV-2 infection and COVID-19-related hospitalization. It remains uncertain whether these relationships are causal.