Introduction: Patients with mental illness, especially serious mental illness, still have significantly higher rates of tobacco smoking, smoke more and start at a younger age than the general population with well-known repercussions on morbidity and mortality. Tobacco smoking “culture” is admittedly still very present in psychiatric settings with the habitual smoking together (without masks), sharing of cigarettes, picking up discarded butts and the many other associated problematic behaviours and routines.
Vulnerability to COVID-19 may also be higher in patients with mental illness due to psychosocial factors with greater challenges for self-care and risk assessment. The use of tobacco, electronic and heat-not-burn devices may also contribute to higher risk of infection and more severe course of illness.
Aim: To review literature on the implications of tobacco smoking in times of the COVID-19 pandemic with special concern for patients with mental illness.
Methods: Pubmed search on the 6th of July, 2020, for tobacco/tobacco smoking and COVID-19; tobacco and coronavirus; tobacco and SARS-CoV-2.
Results: Thirtyeight articles were considered relevant and reported the following findings.
During the COVID-19 crisis there were many factors that contributed to starting to smoke, to relapse in ex-smokers and to smoking more due to stress, anxiety, depressive symptoms and boredom. Many smokers stocked up on tobacco. Confinement, fear of COVID-19, spending more time with family and less social interaction may have apparently, but to a lesser degree, contributed to decreased smoking or cessation for some smokers.
Tobacco smoking is associated with higher risk of infection, more severe course of illness with higher rates of admission to ICUs, need for ventilation and death but some articles suggest that tobacco smoking might actually be protective. Higher risk of infection is hypothesized to be due to upregulation of ACE2 receptors to which the SARS-CoV-2 virus attaches and to more contact with the mouth and face when smoking. The more severe course of illness may be due to tobacco related lung damage, cerebral and cardiovascular illness, hypercoagulation states and other comorbidities associated with tobacco smoking and immunological dysregulation. However, smoking´s upregulation of ACE2 might actually contribute to less severe and not worse course of illness and nicotine acting on α₇ acethylcholine receptors may lessen hyper-immune responses in COVID-19 among other beneficial effects.
Tobacco smoking was also associated with the respiratory spread of COVID-19 and contaminated surfaces by exhaled smoke, aerosols, cough and saliva and recommendations and bans on smoking may be important strategies to control spread of COVID-19.
Conclusions: Tobacco smoking has long been an important issue for the mental and physical health, quality of life and well-being for patients with mental health illnesses and despite controversies and in the context of COVID-19, is even more important. Mental health services benefit from this awareness and should strive to provide smoking reduction and cessation programmes and adapt existing ones to restrictions. Mental health policies should also address tobacco smoking on inpatient units and wards, outpatient and other mental health services.
Further studies are needed to study potential benefits of treatment with nicotine.
No conflict of interest