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Every spring, state and territorial quit lines—a mainstay of tobacco use reduction efforts—get a spike in calls. The bump comes from the annual Tips from Former Smokers campaign, a US Centers for Disease Control and Prevention initiative that tells gripping stories of people who suffer with life-altering conditions because of smoking.
But last spring was different. Hard-hitting Tips ads encouraging smokers to call 1 (800) QUIT-NOW, the national quit line portal, began on March 23, 2020, as the country went into pandemic lockdown. Even as the CDC separately warned that smokers could be at greater risk of becoming severely ill from COVID-19, the emotional stories didn’t have their usual impact.
Within weeks, it was clear to quit line operators that the pandemic had triggered a substantial drop in the number of people interested in free, evidence-based, cessation services, which include motivational counseling, information, and sometimes nicotine replacement therapies.
“The Tips campaign is one of the things that really drives people to the quit lines,” Thomas Ylioja, PhD, clinical director for health initiatives at Denver’s National Jewish Health, which operates cessation services in 20 states, said in an interview. “Not seeing that [increase] made us very concerned.”
In fact, calls to the portal were down 39% during April, May, and June 2020 compared with the second quarter of 2019, according to a report from the nonprofit North American Quitline Consortium. The figures indicate that volume never fully recovered. For the year, calls decreased by 27% nationally to 525 609, the lowest since 2007.
Experts worry that the pandemic interrupted decades of progress in minimizing tobacco use even as smoking heightens the risk of severe COVID-19 illness. Along with reduced use of cessation services, the quit line consortium report indicated that US Department of the Treasury data show a 1% uptick in cigarette sales during the first 10 months of 2020 after 4% or 5% annual declines since 2015.
As Ylioja put it, 2020 may have been “a lost year of people being able to quit smoking.”
What’s the Risk?
Although knowledge about COVID-19 and smoking is still evolving, smokers may have received mixed messages about their risk early in the pandemic. Data suggesting that smokers were underrepresented among COVID-19 patients sparked speculation that smoking might even have a protective effect—a notion that public health authorities roundly dismissed.
Research shows that both vaping and smoking damage lungs and alter immune responses, increasing susceptibility to respiratory viruses. Several studies have associated smoking with worse COVID-19 outcomes. A meta-analysis in the Journal of Medical Virology concluded that current and former smokers have a significantly increased risk of developing severe COVID-19 and that former smokers have a significantly increased risk of dying of the disease. An analysis of 8910 patients hospitalized with COVID-19 at 169 hospitals on 3 continents found that 9.4% of current smokers died before they were discharged compared with 5.6% of former smokers or nonsmokers.
However, it’s unclear whether smokers are more susceptible to infection with SARS-CoV-2. Although findings so far have been mixed, the World Health Organization has indicated that tobacco users are at greater risk of being infected through the mouth while they’re smoking. A recent Nature Medicine study showed that SARS-CoV-2 infection can occur in the mouth via cells in the minor salivary glands and gingiva that harbor the angiotensin-converting enzyme 2 receptor and the TMPRSS2 enzyme, which the novel coronavirus uses to enter cells.
The study’s authors, from the National Institutes of Health and the University of North Carolina at Chapel Hill, wrote that “the oral cavity represents a robust and underappreciated site for SARS-CoV-2 infection.”
Stressors Take Their Toll
For some smokers, the pandemic has been a motivating force. At a media briefing in March to raise awareness of cessation services, longtime California smoker Katie Rodgers said she managed to quit after gazing at news images of patients with COVID-19 who were “lined up on gurneys” and breathing with a respirator. “I don’t want to die alone in a hospital,” she said.
So why haven’t more smokers followed suit? Experts offered several reasons.
For many, smoking serves as a coping mechanism for the grief, economic stress, isolation, and racial unrest of the last year. “A lot of people associate smoking unfortunately with relaxation,” Catherine Saucedo, deputy director of the University of California, San Francisco (UCSF) Smoking Cessation Leadership Center, noted during the briefing. It’s also been easier to light up as people spent less time at offices, restaurants, and other places with smoking bans.
Lockdowns and medical appointment cancelations also played a role. Clinicians had fewer chances to discuss tobacco use with patients, refer them to cessation services, and write prescriptions for cessation medications, as the US Preventive Services Task Force recommends.
Physicians sometimes initiate cessation treatment during an office or telehealth visit and refer patients to a quit line for the remainder of their care, consortium President and Chief Executive Officer Linda Bailey, JD, MHS, said via email. “We know from the [US Public Health Service Clinical Practice Guideline: Treating Tobacco Use and Dependence] that 3 or more counseling sessions along with a full course of medication is the level of treatment most likely to help a smoker successfully quit,” Bailey noted. But according to consortium data provided to JAMA, clinician referrals to quit lines fell by about 20% in 2020.
It’s unclear whether quit line promotions decreased in some states as public health resources shifted to encourage COVID-19 mitigation measures such as mask-wearing and social distancing. However, Bailey said in some cases the tone toward smokers became more empathetic. Colorado’s digital media ads became less “cessation-focused,” Tara Dunn, a tobacco communications specialist with the state health department, said in an interview. “The messaging was along the lines of, ‘You’re not alone. It’s a stressful time. It’s OK if you’re not ready to quit right now,’” she said.
Trying to Restore Momentum
These barriers add to the ways that COVID-19 has compounded health disparities, experts say. Like COVID-19, tobacco use disproportionately affects vulnerable populations including individuals with mental illness and low incomes, American Indian and Alaska Native populations, Black individuals, and people who are lesbian, gay, bisexual, or transgender. In 2019, 45% of quit line callers reported having a mental illness, and 52% were uninsured or enrolled in Medicaid.
“Smoking has become a social justice issue,” Saucedo said, “and with COVID in the mix, there is this double jeopardy for these folks.”
Given the overlap between smoking and mental illness, clinicians shouldn’t hesitate to offer cessation services to patients while they are undergoing treatment for substance misuse disorders and other behavioral health conditions, Brian Hurley, MD, president-elect of the American Society of Addiction Medicine’s board of executive officers, advised at the briefing. A myth that quitting impedes recovery from mental illness feeds “a perception among providers of, one thing at a time,” he said, adding that people with mental health disorders and addiction are just as ready to quit as those in the general population.
As the pandemic continues, cessation advocates are trying to regain momentum. In March, the UCSF leadership center launched a social media campaign, I COVID QUIT, to inspire smokers to quit for their mental and lung health.
Cessation advocates also suggested ways for physicians to step up their efforts, including offering multiple medications to meet a patient’s individual needs and writing full 8- to 12-week prescriptions when making a quit line referral so the patient’s health insurance will cover the cost. Some quit lines offer about 2 weeks of free medications, Bailey said, but their resources are limited and they can’t bill insurance.
Strong social support, environmental support like media campaigns, and easy access to medication and counseling are the keys to success, Saucedo said. “We can help [smokers] understand that they can quit and there is help, and with COVID this is a really a good time to try.”
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Jaklevic MC. COVID-19 and the “Lost Year” for Smokers Trying to Quit. JAMA. 2021;325(19):1929–1930. doi:10.1001/jama.2021.5601
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