ASH Ireland

Stark findings highlight increased health risk smokers face from COVID-19.

Current smokers are 80 per cent more likely to be admitted to hospital and significantly more likely to die from COVID-19 compared with those who have never smoked, new research has revealed.

The study led by researchers from Oxford University in the UK, analysed data from primary care records, COVID-19 test results, hospital admissions data and death certificates to look for associations between smoking and COVID-19 infection severity from January to August 2020 in 421,469 participants of the UK Biobank, all of whom had had their genetic make-up analysed when they agreed to take part in 2006-10. 

This was the first study of its kind to examine observational and genetic data on smoking and COVID-19.

During the study period, 13,446 people took a COVID-19 swab (PCR) test, 1,649 of whom tested positive; 968 required admission to hospital; and 444 died as a result of their infection. 

The majority of those involved in the study or 59 per cent had never smoked; over a third (37%) were former smokers; and only 4 per cent were current smokers. Among current smokers, most (71%) were light or moderate smokers (1-19 cigarettes/day); only 29 per cent were heavy smokers (20+/day).

Compared with those who had never smoked, current smokers were 80% more likely to be admitted to hospital and significantly more likely to die from COVID-19.

The researchers also assessed whether a genetic predisposition to smoking and heavy smoking might have a role in COVID-19 severity among 281,105 of the original participants living in England. 

This revealed that a genetic predisposition to smoking was associated with a 45 per cent higher risk of infection and a 60 per cent higher risk of hospital admission for COVID-19. 

It also revealed that a genetic predisposition to smoke more heavily was associated with a more than doubling in the risk of infection; a 5-fold increase in the risk of hospital admission; and a 10-fold increase in the risk of death from the virus.

While the researchers acknowledged that they relied only on hospital COVID-19 test data rather than on more representative community data, they nevertheless point to the similarity of the findings in both sets of analyses. 

Commenting Norma Cronin, chairperson of ASH Ireland, Council of the Irish Heart Foundation said, “The stark findings of this latest piece of research highlights the increased health risk that smokers face from the dangers of COVID-19. We would always encourage smokers to quit for the enormous health benefits, but particularly now with COVID-19 still live in our communities, we would implore those smoking to avail of all HSE quit supports and kick the habit once and for all.

“The COVID-19 pandemic has been tragic for all of us so we are deeply concerned for the health and safety of the hundreds of thousands of smokers in Ireland as this research suggests that they are up to 80 per cent more likely to be admitted to hospital with Coronavirus. Countless lives have been lost tragically to Covid-19, so in light of this research, we would urge smokers to quit once and for all.’’

In a linked podcast, lead researcher Dr Ashley Clift had a clear message for smokers. 

“Our results strongly suggest that smoking is related to your risk of getting severe COVID, and just as smoking affects your risk of heart disease, different cancers, and all those other conditions we know smoking is linked to, it appears that it’s the same for COVID. So now might be as good a time as any to quit cigarettes and quit smoking.”

Support is available to stop smoking

Quit.ie is Ireland’s dedicated smoking cessation service and smokers can give themselves the best chance of stopping by following the plan, which sees thousands of people successfully give up each year.

The HSE QUIT service provides personalised, free support by phone, email, SMS and live chat. Smokers can free call 1800 201 203 or visit www.QUIT.ie for stop smoking tips and resources, a free QUIT Kit, and to create a QUIT Plan. Peer-to-peer support is available on the QUIT Facebook Page www.facebook.com/HSEQUIT or on Twitter at HSE QUIT @HSEQuitTeam  #TheLastStop #QuitandWin.

(Smoking and COVID-19 outcomes: an observational and Mendelian randomisation study using the UK Biobank cohort doi:10.1136/thoraxjnl-2021-217080)

Background

A report investigating the growing popularity of e-cigarettes among young people in Ireland was carried and prepared for on behalf of the HSE Tobacco Control Operational Unit. The report can be found below, along with a background to it and a statement from Dr. Patrick Doorley, chair of ASH Ireland, Council of the Irish Heart Foundation.

With the growth in popularity of e-cigarettes in recent years, there is concern in terms of their use by young people. In Ireland, there is no mandatory age restriction on the sale of e-cigarettes and their marketing may promote adolescent use. Nicotine exposure can harm adolescent brain development, and may act as a ‘gateway’ to smoking initiation among the youth. The study aimed to obtain an in-depth understanding of current knowledge, attitudes and behaviour of schoolchildren in terms of e-cigarette use.

Eight focus groups were undertaken in a convenience sample of three schools. This included an all-boy (Cavan), an all-girl (Sligo), and a mixed gender (Louth) school. Each focus group discussed vaping among schoolchildren in Ireland, attitudes to e-cigarettes/vaping, the accessibility and availability of e-cigarette products, the health effects of vaping, and the combined use of vaping, smoking and alcohol. All focus groups were audio recorded and transcribed, from which a number of key themes were identified.

Statement from Dr. Patrick Doorley, chair of ASH Ireland, Council of the Irish Heart Foundation

Vaping is less harmful than smoking but still not safe . E-cigarettes contain thousands of chemicals many of which are toxic, but there are not many programmes which educate children about the their harmful effects. While e-cigarettes may assist hardened smokers to quit, recent reports, such as this focus group which indicate an increased use of these devices among young people in Ireland is exceptionally alarming, particularly as they have been found to be a gateway to traditional smoking.

Therefore, to protect young people from taking up e-cigarettes and transitioning to smoking, it is imperative that the government introduce all measures that will protect adolescents from taking it up.

This focus group study among schoolchildren indicated that e-cigarettes are popular among Irish schoolchildren but there is a lack of information about e-cigarettes from school education programmes. This must be remedied as young people will make the right decision based on their health when provided the right information.

Unsurprising e-cigarettes are used in a number of different settings, particularly in under age discos. Peer pressure in social settings such as these drives take-up of harmful habits such as e-cigarettes, smoking, and drinking alcohol. Clearly devious tactics on social media by these e-cigarette companies, many of them owed by traditional tobacco companies, have marketed these products to young people as cool must-have devices, without highlighting the addictive or health-harming consequences.

Sweet and fruity flavours are among the most popular and are relatively easy to access through social media and other channels.

While most participants had discussed smoking with their parents,there was a lack of awareness of the warning labels concerning e cigarettes. Tobacco cigarettes remain more popular than e cigarettes, particularly at discos and  alcohol consumption may be a contributory factor in the decision to experiment

In light of these alarming trends, the report recommends the following measures, which ASH Ireland, Council of the Irish Heart Foundation fully support.

• Legislation on e-cigarette sales should be fast tracked by the Department of Health and a comprehensive plan to prevent initiation of e cigarette use by children developed.
• Government should develop a regulatory system to oversee and control online sales of tobacco and e cigarettes.
• Restrictions in terms of product placement, accessibility and visibility at the point of sale is recommended.
• There should be mandatory e-cigarette warnings in outlets selling e-cigarettes
• There should be restrictions on flavours which are attractive to children.
• There should be better communication on the effects of e-cigarettes and the impact of those communications should be evaluated.
• Anti-smoking education programmes should be incorporated into the school curriculum which should include up to date information on the adverse health effects.
• The governance of underage discos should be reviewed.

Background
A target date of 2025 has been set for Ireland to become tobacco free, i.e., less than 5% of the population smoking . A key recommendation of Tobacco Free Ireland is to “promote tobacco free campuses for all third-level institutions in consultation with key stakeholders”. (Department of Health, 2013)

Establishing smoke-free campuses in third-level institutions is an important step in de-normalising smoking and acting as a deterrent to young people first taking up smoking while in third-level education.

In order to record the number of third-level institutions that have implemented or plan to implement a smoke-free campus in Ireland, ASH Ireland, Council of the Irish Heart Foundation conducted a survey of third-level institutions in Ireland.

Methods

Sample
A list of Health Promotion Officers or other individuals responsible for healthy campus life was identified by internet research and referrals. Using this list, ASH Ireland, Council of the Irish Heart Foundation emailed the contacts in the third-level institutions with a questionnaire in relation to their policies on a smoke-free campus.

Response Rate
A total of twenty-seven third-level institutions around the island of Ireland were identified and sent questionnaires via email between April and May 2019. Ten full responses were received from the first round and one additional response was received from the second round. No other responses were received thereafter, giving a total of 11 out of 27 responses (41% response rate).

Data requested

Each questionnaire to the third-level institutions included the following questions:

1. Is your University/College/IT a smoke-free campus? (if no, please skip to question 9, N/A will apply for intervening questions)?

2. If yes to the above, in what year did it implement a smoke-free campus?

3. Is the smoke-free campus enforced? If so, please describe how.

a. Please describe the levels of compliance and describe how this is measured’

4. Do you know how many of your students/staff smoke?

5. How welcoming are or were the students and staff to having a smoke-free campus?

6. What were the top 5 complaints/challenges against implementing a smoke-free campus? (e.g. where do smokers go, how will it be enforced?)

7. What were the top 5 benefits? (e.g. Reduction in litter in smoke-free campus?)

8. Have there been any unintended or unforeseen consequences arising from having a smoke-free campus? (e.g. people congregating in one area just outside the campus premises to smoke, etc.)

9. If the University/College/IT has not introduced smoke-free campus yet, is it planning on becoming a smoke-free campus and if so, by what year?

10. If the University/College/IT is not planning on implementing a smoke-free campus, what are the reasons behind this?

Results

1. Is your University/College/IT a smoke-free campus?

Of the eleven responses received, three third-level institutions replied that they had implemented a smoke-free campus (11% of all third-level institutions or 27% of those that responded). The remaining eight third-level institutions that replied stated that they did not have smoke-free campuses.

2. If yes to the above, in what year did it implement a smoke-free campus?

All three third-level institutions that had implemented a smoke-free campus had initiated it in different years – 2013, June 2015, and 2019

3. Is the smoke-free campus enforced? If so, please describe how.

Compliance is enforced in two out of three third-level institutions that have smoke-free campuses. In the first of these institutions, there are student and staff inductions and thereafter Estate and Support Services actively enforce the policy.

The second institution enforces compliance by having a blue line that everyone is asked to go outside the line if they wish to smoke. At the third institution, compliance is not enforced but rather requested by ambassadors who circuit the campus four times per week reminding people of the policy.

3a. Please describe the levels of compliance and describe how this is measured’?

Of the three third-level institutions with smoke-free campuses, one reported an 83% compliance to tobacco free zones, the second reported that compliance is normally very good and that CCTV is used to observe boundaries and anyone observed breaching the policy is spoken to and asked to move away from the campus.

The final of the three institutions reported that compliance is not measured but that smokers congregate at the gates outside the designated blue line so people have made the permanent switch to smoking off campus.

4. Do you know how many of your students/staff smoke?

Only one of the eleven institutions that responded to the questionnaire provided information on this question. They provided details of student smoking but stated they do not have data on staff.

5. How welcoming are or were the students and staff to having a smoke-free campus?

All three third-level institutions that had implemented a smoke-free campus reported a generally welcome approach to smoke-free campuses by the student and staff body. One institution reported that initially the support was neutral 50:50 but rose to 71% by 2019.

6. What were the top 5 complaints/challenges against implementing a smoke-free campus?

Two of the three third-level institutions that had implemented smoke-free campuses provided data on this question. A summary of the complaints/challenges faced can be seen below:

• Where do residents go at night
• What about people using the 24-hour library. If they go off-campus they can’t get back on
• What about banquets and conferences on campus
• What about on-campus pub
• What about visitors or tourists who visit the campus?
• Shelter for smokers
• How to enforce the policy, deal with non-compliance
• Whether to include vaping

7. What were the top 5 benefits?

Two of the three third-level institutions that had implemented smoke-free campuses provided data on this question. A summary of the benefits reported can be seen below:

• Opportunity to raise smoking as an issue when people are becoming addicted rather than in 20 years’ time (most 20-year olds are 40 before they stop)
• Clean campus
• Fresh air
• Obtain budget for health promotion in general
• Healthier workplace
• Nice to walk in the doors without having to walk through a crowd of smokers as happened in the past
• More support/promotion of quitting
• People report they have cut down/quit
• It came in time to prevent the use of vaping on campus, before this habit became so commonplace

8. Have there been any unintended or unforeseen consequences arising from having a smoke-free campus

All three third-level institutions that had implemented smoke-free campuses reported consequences arising from having a smoke-free campus.
Some of these consequences are summarised below:

• Cohort of undergraduate students who were not interested in the policy and continued to smoke
• Students congregating just outside the designated smoke-free campus and smoking there – often nearby other businesses, buildings and hotels
• ‘Hidden’ areas where smoking takes place around campus
• Cigarette ends, coffee cups and other litter accumulating in these areas where smokers are congregating

9. If the University/College/IT has not introduced a smoke-free campus yet, is it planning to and if so, by what year?

Eight of the eleven third-level institutions that had responded reported that they had not implemented a smoke-free campus. Of these eight:

• Two stated they were planning to implement smoke-free campuses in the 2019/2020 academic year
• Four stated they were in the early development/consultation process of implementing a smoke-free campus
• The remaining two had ambitions to one day become smoke-free campuses but had no plans in place yet

10. If the University/College/IT is not planning on implementing a smoke-free campus, what are the reasons behind this?

Some of the reasons reported by third-level institutions are as follows:

• Staff would resist it
• Smokers find it discriminatory
• The institution fears that it could not attract future students
• Where would the smokers go?
• No security to enforce it
• Student union shop sells cigarettes
• Students union had no interest in pursuing it when raised
• Other issues of higher priority taking precedence

Summary, Conclusion, Recommendations

Of the 27 third-level institutions surveyed during the period May – June 2019, 41% responded (n=11).

• 11% (n=3) reported that their campuses were smoke-free

• 7% (n=2) reported that they were planning to implement a smoke-free campus in the 2019/2020 academic year)

• 15% (n=4) reported that they were in the early development/consultation stages of implementing a smoke-free campus

• 7% (n=2) reported that they had no plans in place yet to implement a smoke-free campus but stated they hoped to achieve it one day

The Irish Heart Foundation continuously monitors international research on smoking-related issues to identify new and better ways to reduce smoking rates. As part of this work, the Irish Heart Foundation partnered with the Irish Cancer Society to carry out an extensive review of emerging research regarding e-cigarettes and heated tobacco products (HTP). Having considered the available evidence and the views of the major international bodies such as the World Health Organisation in relation to these products, we must urge caution in relation to e-cigarettes and HTP.

Although it is generally accepted that e-cigarettes are less harmful than tobacco, there is insufficient research to date on their long-term impact on users. Several studies have also highlighted that they are less effective than other smoking cessation tools at helping people quit for good. The Irish Heart Foundation is also deeply concerned about how a whole new generation of children are at risk of becoming addicted to nicotine due to cynical marketing tactics directed at them by e-cigarette brands.

You can read the full paper here – Position paper on e-cigarettes and HTP ICS and IHF and view the accompanying infographic here – Infographic e-cigarettes.

Date: 28/02/2019

Recipient: Department of Health

Re: Tobacco industry-funded organization is not a partner of public health

We, ASH Ireland, Council of the Irish Heart Foundation, a group that advocates for reduced tobacco use and associated disease, disability and death, join almost 300 organizations and experts from around the world in welcoming the World Health Organization (WHO)’s reiteration that “WHO will not partner with the Foundation (for a Smoke-Free World [FSFW]). Governments should not partner with the Foundation and the public health community should follow this lead.”

This reiteration was made in response to FSFW’s outreach to the WHO Executive Board recently. FSFW is an entity funded entirely by Philip Morris International (PMI), which has a “known history of funding research to advance its own vested interest.”

With a whopping $1-billion committed funding from PMI, FSFW is offering to fund research on agriculture, economics, and medical science, including so-called smoking alternatives such as electronic nicotine delivery systems (including IQOS, a device PMI aggressively markets).

As a Party to the WHO Framework Convention on Tobacco Control (WHO FCTC), the Irish government is obliged to protect its public health and tobacco control policies against tobacco industry interference under Article 5.3 of the WHO FCTC. Compliance with this treaty provision requires governments to, among others, reject contributions and partnerships from the tobacco industry and those furthering its interests like FSFW.

The tobacco industry is a peril to the health and welfare of the Irish public. The tobacco industry has a long-established record of blocking, delaying or diluting any kind of tobacco control policy that is aimed at reducing the prevalence of smoking in Ireland. ASH Ireland, Council of the Irish Heart Foundation will continue to advocate for increased tobacco taxation, a greater level of investment in smoking cessation support services and additional tobacco control measures.

Only this month, another powerful tobacco company, British American Tobacco (BAT), announced its latest global tobacco marketing strategy—promote its vaping products in Formula One. In the past, such a tie-up to promote cigarette brands had facilitated worldwide exposure of tobacco products to millions of people due to Formula One’s “considerable appeal among youth and young adults.”

It is in this new era of global marketing strategies by an industry whose addictive, lethal products kill millions of people that we are urging your office to be vigilant about preventing industry interference including the PMI-funded FSFW. We also urge your office to reject funding from any entity or research funded by the tobacco industry and those furthering its interests.

Likewise, we appeal to your office to send a letter to the Health Research Board and other similar research institutes and educational institutions to warn them that research results from the tobacco industry and those funded by it such as FSFW must be rejected or disregarded by the government.

We must not be complicit in any act that supports an industry determined to undo the public health gains that took years of hard work to achieve. We look forward to working with you on effective measures to protect health policies from tobacco industry interference.

Sincerely,

Dr. Patrick Doorely,

Chairperson, ASH Ireland, Irish Heart Foundation

ASH Letter to Government WHO PMI