Impact of the cost-of-living crisis on the nature of attempts to stop smoking and to reduce alcohol consumption in Great Britain: A representative population survey, 2021-2022.

BACKGROUND: Smoking and excessive drinking place a strain on household budgets. We aimed to examine the impact of the cost-of-living crisis in Great Britain on the nature of smoking cessation and alcohol reduction attempts, and explore changes in health professionals offering support. METHODS: Data were from 14,567 past-year smokers and high-risk drinkers (AUDIT-C ≥5) participating in monthly representative surveys, January-2021 through December-2022. We estimated time trends in cost as a motive driving the most recent (smoking cessation/alcohol reduction) attempt, use of paid or evidence-based support, and receipt of GP offer of support for smoking cessation or alcohol reduction, and tested for moderation by occupational social grade. RESULTS: The proportion of attempts motivated by cost did not change significantly over time among smokers (25.4% [95%CI = 23.8-26.9%]), but increased between December-2021 and December-2022 among high-risk drinkers from less advantaged social grades (from 15.3% [95%CI 12.1-19.3] to 29.7% [20.1-44.1]). The only change in support use was an increase in smokers using paid support, specifically e-cigarettes (from 28.1% [23.7-33.3] to 38.2% [33.0-44.4]). Among those visiting their GP, the proportion who received an offer of support was similar over time among smokers (27.0% [25.7-28.2]) and high-risk drinkers (1.4% [1.1-1.6%]). CONCLUSIONS: There is limited evidence that the 2021/22 cost-of-living crisis affected the nature of attempts to stop smoking and reduce alcohol consumption, or receipt of GP offer of support. It is encouraging that use of evidence-based support has not declined and that use of e-cigarettes in quit attempts has increased. However, cost is increasingly motivating alcohol reduction attempts among less advantaged drinkers, and rates of GPs offering support, especially for alcohol reduction, remain very low.

Interventions to increase personal protective behaviours to limit the spread of respiratory viruses: A rapid evidence review and meta-analysis

PURPOSE: Increasing personal protective behaviours is critical for stopping the spread of respiratory viruses, including SARS-CoV-2: we need evidence to inform how to achieve this. We aimed to synthesise evidence on interventions to increase six personal protective behaviours (e.g. hand hygiene, face mask use) to limit the spread of respiratory viruses. METHODS: We used best practice for rapid evidence reviews. We searched Ovid MEDLINE and Scopus. Studies conducted in adults or children with active or passive comparators were included. We extracted data from published intervention descriptions on study design, intervention content, delivery mode, population, setting, mechanism(s) of action, acceptability, practicability, effectiveness, affordability, spill-over effects and equity impact. Study quality was assessed with Cochrane's risk of bias tool. A narrative synthesis and random-effects meta-analyses were conducted. RESULTS: We identified 39 studies conducted across 15 countries. Interventions targeted hand hygiene (n=30) and/or face mask use (n=12) and used two- or three-arm study designs with passive comparators. Interventions were typically delivered face-to-face and included a median of three behaviour change techniques. The quality of included studies was low. Interventions to increase hand hygiene (k=6) had a medium, positive effect (_d_=0.62, 95% CI=0.43-0.80, _p_<.001, I2=81.2%). Interventions targeting face mask use (k=4) had mixed results, with an imprecise pooled estimate (OR=4.14, 95% CI=1.24-13.79, _p_<.001, I2=89.67%). Between-study heterogeneity was high. CONCLUSIONS: We found low-quality evidence for positive effects of hand hygiene interventions, with unclear results for face mask use interventions. There was a lack of evidence for interventions targeting most behaviours of interest within this review.

Smoking and COVID Living Review (v11): a bayesian analysis

AIMS: To estimate the association of smoking status with rates of i) infection, ii) hospitalisation, iii) disease severity, and iv) mortality from SARS-CoV-2/COVID-19 disease. DESIGN: Living rapid review of observational and experimental studies with random-effects hierarchical Bayesian meta-analyses. Published articles and pre-prints were identified via MEDLINE and medRxiv. SETTING: Community or hospital. No restrictions on location. PARTICIPANTS: Adults who received a SARS-CoV-2 test or a COVID-19 diagnosis. MEASUREMENTS: Outcomes were SARS-CoV-2 infection, hospitalisation, disease severity and mortality stratified by smoking status. Study quality was assessed (i.e. ‘good', ‘fair' and ‘poor'). FINDINGS: v11 (searches up to 2021-02-16) included 405 studies with 62 ‘good' and ‘fair' quality studies included in unadjusted meta-analyses. 121 studies (29.9%) reported current, former and never smoking status with the remainder using broader categories. Recorded smoking prevalence among people with COVID-19 was generally lower than national prevalence. Current compared with never smokers were at reduced risk of SARS-CoV-2 infection (RR = 0.71, 95% Credible Interval (CrI) = 0.61-0.82, τ = 0.34). Data for former smokers were inconclusive (RR = 1.03, 95% CrI = 0.95-1.11, τ = 0.17) but favoured there being no important association (4% probability of RR ≥1.1). Former compared with never smokers were at increased risk of hospitalisation (RR = 1.19, CrI = 1.1-1.29, τ = 0.13), greater disease severity (RR = 1.8, CrI = 1.27-2.55, τ = 0.46) and mortality (RR = 1.56, CrI = 1.23-2, τ = 0.43). Data for current smokers on hospitalisation, disease severity and mortality were inconclusive (RR = 1.1, 95% CrI = 0.99-1.21, τ = 0.15;RR 1.26, 95% CrI = 0.92-1.73, τ = 0.32;RR = 1.12, 95% CrI = 0.84-1.47, τ = 0.42, respectively) but favoured there being no important associations with hospitalisation and mortality (49% and 56% probability of RR ≥1.1, respectively) and a small but important association with disease severity (83% probability of RR ≥1.1). CONCLUSIONS: Compared with never smokers, current smokers appear to be at reduced risk of SARS-CoV-2 infection while former smokers appear to be at increased risk of hospitalisation, greater disease severity and mortality from COVID-19. However, it is uncertain whether these associations are causal. v7 of this living review article has been published in _Addiction_ [https://doi-org.libproxy.ucl.ac.uk/10.1111/add.15276]

The association of smoking status with SARS-CoV-2 infection, hospitalisation and mortality from COVID-19: A living rapid evidence review with Bayesian meta-analyses (version 10)

AIMS: To estimate the association of smoking status with rates of i) infection, ii) hospitalisation, iii) disease severity, and iv) mortality from SARS-CoV-2/COVID-19 disease. DESIGN: Living rapid review of observational and experimental studies with random-effects hierarchical Bayesian meta-analyses. Published articles and pre-prints were identified via MEDLINE and medRxiv. SETTING: Community or hospital. No restrictions on location. PARTICIPANTS: Adults who received a SARS-CoV-2 test or a COVID-19 diagnosis. MEASUREMENTS: Outcomes were SARS-CoV-2 infection, hospitalisation, disease severity and mortality stratified by smoking status. Study quality was assessed (i.e. ‘good', ‘fair' and ‘poor'). FINDINGS: Version 10 (searches up to 15 December 2020) included 345 studies with 52 ‘good' and ‘fair' quality studies included in unadjusted meta-analyses. One-hundred-and-one studies (29.3%) reported current, former and never smoking status with the remainder using broader categories. Recorded smoking prevalence among people with COVID-19 was generally lower than national prevalence. Current compared with never smokers were at reduced risk of SARS-CoV-2 infection (RR = 0.69, 95% Credible Interval (CrI) = 0.58-0.82, τ = 0.36). Data for former smokers were inconclusive (RR = 1.03, 95% CrI = 0.94-1.13, τ = 0.18) but favoured there being no important association (8% probability of RR ≥1.1). Former compared with never smokers were at increased risk of hospitalisation (RR = 1.18, CrI = 1.07-1.31, τ = 0.14), greater disease severity (RR = 1.52, CrI = 1.12-2.06, τ = 0.29) and mortality (RR = 1.40, 95% CrI = 1.20-1.64, τ = 0.19). Data for current smokers on hospitalisation, disease severity and mortality were inconclusive (RR = 1.08, CrI = 0.95-1.23, τ = 0.18;RR = 1.26, CrI = 0.85-1.93, τ = 0.34;RR = 1.05, 95% CrI = 0.77-1.41, τ = 0.39, respectively) but favoured there being no important associations with hospitalisation and mortality (31% and 38% probability of RR ≥1.1, respectively) and a small but important association with disease severity (80% probability of RR ≥1.1). CONCLUSIONS: Compared with never smokers, current smokers appear to be at reduced risk of SARS-CoV-2 infection while former smokers appear to be at increased risk of hospitalisation, greater disease severity and mortality from COVID-19. However, it is uncertain whether these associations are causal. v7 of this living review article has been published in _Addiction _and is available here https://doi-org.libproxy.ucl.ac.uk/10.1111/add.15276

The association of smoking status with SARS-CoV-2 infection, hospitalisation and mortality from COVID-19: A living rapid evidence review with Bayesian meta-analyses (version 11)

AIMS: To estimate the association of smoking status with rates of i) infection, ii) hospitalisation, iii) disease severity, and iv) mortality from SARS-CoV-2/COVID-19 disease. DESIGN: Living rapid review of observational and experimental studies with random-effects hierarchical Bayesian meta-analyses. Published articles and pre-prints were identified via MEDLINE and medRxiv. SETTING: Community or hospital. No restrictions on location. PARTICIPANTS: Adults who received a SARS-CoV-2 test or a COVID-19 diagnosis. MEASUREMENTS: Outcomes were SARS-CoV-2 infection, hospitalisation, disease severity and mortality stratified by smoking status. Study quality was assessed (i.e. ‘good', ‘fair' and ‘poor'). FINDINGS: v11 (searches up to 2021-02-16) included 405 studies with 62 ‘good' and ‘fair' quality studies included in unadjusted meta-analyses. 121 studies (29.9%) reported current, former and never smoking status with the remainder using broader categories. Recorded smoking prevalence among people with COVID-19 was generally lower than national prevalence. Current compared with never smokers were at reduced risk of SARS-CoV-2 infection (RR = 0.71, 95% Credible Interval (CrI) = 0.61-0.82, τ = 0.34). Data for former smokers were inconclusive (RR = 1.03, 95% CrI = 0.95-1.11, τ = 0.17) but favoured there being no important association (4% probability of RR ≥1.1). Former compared with never smokers were at increased risk of hospitalisation (RR = 1.19, CrI = 1.1-1.29, τ = 0.13), greater disease severity (RR = 1.8, CrI = 1.27-2.55, τ = 0.46) and mortality (RR = 1.56, CrI = 1.23-2, τ = 0.43). Data for current smokers on hospitalisation, disease severity and mortality were inconclusive (RR = 1.1, 95% CrI = 0.99-1.21, τ = 0.15;RR 1.26, 95% CrI = 0.92-1.73, τ = 0.32;RR = 1.12, 95% CrI = 0.84-1.47, τ = 0.42, respectively) but favoured there being no important associations with hospitalisation and mortality (49% and 56% probability of RR ≥1.1, respectively) and a small but important association with disease severity (83% probability of RR ≥1.1). CONCLUSIONS: Compared with never smokers, current smokers appear to be at reduced risk of SARS-CoV-2 infection while former smokers appear to be at increased risk of hospitalisation, greater disease severity and mortality from COVID-19. However, it is uncertain whether these associations are causal. v7 of this living review article has been published in _Addiction_ [https://doi-org.libproxy.ucl.ac.uk/10.1111/add.15276]

The association of smoking status with SARS-CoV-2 infection, hospitalisation and mortality from COVID-19: A living rapid evidence review with Bayesian meta-analyses (version 12)

AIMS: To estimate the association of smoking status with rates of i) infection, ii) hospitalisation, iii) disease severity in hospitalised patients, and iv) mortality from SARS-CoV-2/COVID-19 disease. DESIGN: Living rapid review of observational and experimental studies with random-effects hierarchical Bayesian meta-analyses. Published articles and pre-prints were identified via MEDLINE and medRxiv . SETTING: Community or hospital. No restrictions on location. PARTICIPANTS: Adults who received a SARS-CoV-2 test or a COVID-19 diagnosis. MEASUREMENTS: Outcomes were SARS-CoV-2 infection, hospitalisation, disease severity and mortality stratified by smoking status. Study quality was assessed (i.e. ‘good,' ‘fair' and ‘poor'). FINDINGS: v12 (searches up to 2021-07-18) included 547 studies with 87 ‘good' and ‘fair' quality studies included in unadjusted meta-analyses. 171 studies (31.3%) reported current, former and never smoking status with the remainder using broader categories. Recorded smoking prevalence among people with COVID-19 was generally lower than national prevalence. Current compared with never smokers were at reduced risk of SARS-CoV-2 infection (RR = 0.67, 95% Credible Interval (CrI) = 0.60-0.75, τ = 0.27). Data for former smokers were inconclusive (RR = 0.99, 95% CrI = 0.94-1.05, τ = 0.12) but favoured there being no important association (<1% probability of RR ≥1.1). Former compared with never smokers were at increased risk of hospitalisation (RR = 1.27, CrI = 1.15-1.40, τ = 0.20), greater disease severity (RR = 1.69, CrI = 1.30-2.22, τ = 0.43) and mortality (RR = 1.59, CrI = 1.34-1.89, τ = 0.37). Current compared with never smokers were at increased risk of greater disease severity (RR 1.3, 95% CrI = 1.01-1.71, τ = 0.32). Data for current smokers on hospitalisation and mortality were inconclusive (RR = 1.10, 95% CrI = 0.97-1.24, τ = 0.23;RR = 1.13, 95% CrI = 0.90-1.40, τ = 0.41, respectively) but favoured there being no important associations (50% and 60% probability of RR ≥1.1, respectively). CONCLUSIONS: Compared with never smokers, current smokers appear to be at reduced risk of SARS-CoV-2 infection and increased risk of greater in-hospital disease severity, while former smokers appear to be at increased risk of hospitalisation, greater in-hospital disease severity and mortality from COVID-19. However, it is uncertain whether these associations are causal. This version (v12) will be the last regular update;however, yearly updates may continue as new evidence becomes available. v7 of this living review article has been published in _Addiction_ [https://doi.org/10.1111/add.15276]

The association of smoking status with SARS-CoV-2 infection, hospitalisation and mortality from COVID-19: A living rapid evidence review (version 3)

Background: SARS-CoV-2 is the causative agent of COVID-19, an emergent zoonotic disease which has reached pandemic levels and is designated a public health emergency of international concern. It is plausible that former or current smoking status are associated with infection, hospitalisation and/or mortality from COVID-19. Objective: We aimed to estimate the association of smoking status with rates of i) infection, ii) hospitalisation, iii) disease severity, and iv) mortality from SARS-CoV-2/COVID-19. Methods: We adopted recommended practice for rapid evidence reviews, which involved limiting the search to main databases and having one reviewer extract data and another verify. Published articles and pre-prints were identified via Ovid MEDLINE, medRxiv and expertise within the review team. We included observational studies with community-dwelling or hospitalised adults aged 16 years who had been tested for SARS-CoV-2 infection or diagnosed with COVID-19, providing that data on smoking status were reported. The National Institutes of Health's Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used to divide studies into ‘good', ‘fair' and ‘poor' quality to address objectives of this review. Studies were judged as ‘good' quality if they: i) had low levels of missing data on smoking status, ii) used a reliable self-report measure that distinguished between current, former and never smoking status, iii) used biochemical verification of smoking status and iv) adjusted analyses for potential confounding variables. Results: Sixty-seven studies were included, 30 of which were conducted in China, 12 in the US, six in the UK, four in France, three in Mexico, three in Spain, two across multiple international sites, two in Italy, and one each from Iran, Israel, Korea, Kuwait and Switzerland. Eleven studies did not state the source for information on smoking status. Fifty-one studies reported current and/or former smoking status but had high levels of missing data and/or did not explicitly state whether the remaining participants were never smokers. Notwithstanding recording uncertainties, compared with national prevalence estimates, recorded current and former smoking rates in most studies were lower than expected. In six ‘fair' quality studies, no significant difference was observed between current and never (RR = 0.78, 95% CI = 0.55-1.11, p = .17, I2 = 92%) or former and never smokers (RR = 1.07, 95% CI = 0.95-1.20, p = .24, I2 = 61%) in the risk of testing positive for SARS-CoV-2. In five ‘fair' quality studies, there was no significant difference between current and never (RR = 1.12, 95% CI = 0.74-1.69, p = .48, I2 = 84%) or former and never smokers (RR = 1.21, 95% CI = 0.82-1.79, p = .24, I2 = 81%) in the risk of requiring admission to hospital following diagnosis of COVID-19. In three ‘fair' quality studies, current smokers were at increased risk of greater disease severity compared with never smokers (RR = 1.37, 95% CI = 1.07-1.75, p = .01, I2 = 0%). No significant difference was observed between former and never smokers (RR = 1.51, 95% CI = 0.82-2.80, p = .19, I2 = 81%). In three ‘fair' quality studies, there were inconsistent results on mortality from COVID-19 in current and former compared with never smokers. Conclusions: Across 67 observational studies, there is substantial uncertainty about the associations between smoking and COVID-19 outcomes. The recorded smoking prevalence in hospitalised patients was lower than national estimates but this observation is inconsistent with there being no evidence of increased admission to hospital from five ‘fair' quality studies of people who tested positive. There was limited evidence from ‘fair' quality studies that current compared with never smoking is associated with greater disease severity in those hospitalised for COVID-19. Implications: Unrelated to COVID-19, smokers are at a greater risk of a range of serious health problems, requiring them to be admitt d to hospital. Given uncertainty around the association of smoking with COVID-19, smoking cessation remains a public health priority and high-quality smoking cessation advice including recommendations to use alternative nicotine should form part of public health efforts during this pandemic.

The association of smoking status with SARS-CoV-2 infection, hospitalisation and mortality from COVID-19: A living rapid evidence review

Background: SARS-CoV-2 is the causative agent of COVID-19, an emergent zoonotic disease which has reached pandemic levels and is designated a public health emergency of international concern. It is plausible that former or current smoking status are risk factors for infection, hospitalisation and/or mortality from COVID-19. Objective: We aimed to estimate the rates of i) infection, ii) hospitalisation, iii) disease severity, and iv) mortality from SARS-CoV-2/COVID-19 stratified by smoking status. Methods: We adopted recommended practice for rapid evidence reviews, which involved limiting the search to main databases and having one reviewer extract data and another verify. Published articles and pre-prints were identified via MEDLINE, EPPI-Mapper and expertise within the review team. We included observational studies with community-dwelling or hospitalised adults aged 16 years who had been tested for SARS-CoV-2 or were diagnosed with COVID-19, providing that data on smoking status were reported. Studies were judged as high quality if they explicitly recorded current, former and never smoking status with low levels of missing data. Results: Twenty-eight studies were included, 22 of which were conducted in China, three in the US, one in Korea, one in France and one across multiple international sites with data predominantly collected in the UK. Eight studies did not state the source for information on smoking status. Twenty-five studies reported current and/or former smoking status but had high levels of missing data and/or did not explicitly state whether the remaining participants were never smokers. Notwithstanding these uncertainties, compared with national prevalence estimates, recorded current and former smoking rates in the included studies were generally lower than expected. Within the only study to report community SARS-CoV-2 infection by smoking status, current smokers appeared more likely to be tested but the rate for positive tests was lower. In two high-quality studies, results from a fixed-effects meta-analysis provided no evidence for an increased risk of hospitalisation among 657 current/former smokers who tested positive in the community (RR = 1.03, 95% CI = 0.93-1.14, p = 0.57). Among 1370 people hospitalised across two high-quality studies, there was greater disease severity in current/former smokers compared with never smokers (RR = 1.43, 95% CI = 1.15-1.77, p = .002). Three studies reporting on mortality did not explicitly state never smoking status. Conclusions: Across 28 observational studies, there is substantial uncertainty arising from the recording of smoking status on whether current and/or former smoking status is associated with SARS-CoV-2 infection, hospitalisation or mortality. There is low quality evidence that current and former smoking compared with never is associated with greater disease severity in those hospitalised for COVID-19. Implications: Unrelated to COVID-19, smokers are at a greater risk of a range of serious health problems requiring them to be admitted to hospital. Given uncertainty around the association of smoking with COVID-19, smoking cessation remains a public health priority and high-quality smoking cessation advice should form part of public health efforts during this pandemic.

The association of smoking status with SARS-CoV-2 infection, hospitalisation and mortality from COVID-19: A living rapid evidence review (version 6)

Aims: : To estimate the association of smoking status with rates of i) infection, ii) hospitalisation, iii) disease severity, and iv) mortality from SARS-CoV-2/COVID-19 disease. Design: Living rapid review of observational and experimental studies with random-effects hierarchical Bayesian meta-analyses. Published articles and pre-prints were identified via Ovid MEDLINE and medRxiv. Setting: Community or hospital with no restrictions on location. Participants: Adults who had received a test for SARS-CoV-2 infection or a diagnosis of COVID-19. Measurements: Outcomes were SARS-CoV-2 infection, hospitalisation, disease severity and mortality stratified by smoking status. Study quality was assessed. Findings: Version 6 with searches up to 17 July 2020 included 174 studies with 26 included in meta-analyses. Thirty-nine studies reported current, former and never smoking status. Notwithstanding recording uncertainties, compared with adult national prevalence estimates, recorded current smoking rates were generally lower than expected. Current compared with never smokers were at reduced risk of SARS-CoV-2 infection (RR = 0.74, 95% Credible Interval (CrI) = 0.56-0.97, τ = 0.46). Former compared with never smokers were at somewhat increased risk of infection but data were inconclusive (RR = 1.06, 95% CrI = 0.94-1.20, τ = 0.19). Current (RR = 1.05, CrI = 0.82-1.34, τ = 0.29) and former (RR = 1.20, CrI = 1.03-1.44, τ = 0.19) compared with never smokers were both at somewhat increased risk of hospitalisation with COVID-19, but data for current smokers were inconclusive. Current (RR = 1.15, CrI = 0.80-1.66, τ = 0.29) and former (RR = 1.51, CrI = 1.06-2.15, τ = 0.36) compared with never smokers were at increased risk of greater disease severity, but data for current smokers were inconclusive. Current (RR = 1.89, 95% CrI = 0.77-3.41, τ = 0.51) and former (RR = 1.93, 95% CrI = 1.33-2.66, τ = 0.19) compared with never smokers had increased risk of in-hospital death, but data for current smokers were inconclusive. Conclusions: There is uncertainty about the associations of smoking with COVID-19 outcomes. Recorded smoking prevalence among people with COVID-19 was generally lower than national prevalence. Current smokers were at reduced risk of infection. Former smokers were at increased risk of hospitalisation, disease severity and mortality, while data for current smokers favoured no important associations but were inconclusive.

The association of smoking status with SARS-CoV-2 infection, hospitalisation and mortality from COVID-19: A living rapid evidence review with Bayesian meta-analyses (version 8)

Aims: : To estimate the association of smoking status with rates of i) infection, ii) hospitalisation, iii) disease severity, and iv) mortality from SARS-CoV-2/COVID-19 disease. Design: Living rapid review of observational and experimental studies with random-effects hierarchical Bayesian meta-analyses. Published articles and pre-prints were identified via MEDLINE and medRxiv. Setting: Community or hospital. No restrictions on location. Participants: Adults who received a SARS-CoV-2 test or a COVID-19 diagnosis. Measurements: Outcomes were SARS-CoV-2 infection, hospitalisation, disease severity and mortality stratified by smoking status. Study quality was assessed (i.e. ‘good', ‘fair' and ‘poor'). Findings: Version 8 (searches up to 22 September 2020) included 256 studies with 36 ‘good' and ‘fair' quality studies included in meta-analyses. Sixty-seven studies (26.2%) reported current, former and never smoking status with the remainder using broader categories. Recorded smoking prevalence among people with COVID-19 was generally lower than national prevalence. Current compared with never smokers were at reduced risk of SARS-CoV-2 infection (RR=0.72, 95% Credible Interval (CrI) = 0.57-0.89, τ = 0.40). Data for former smokers were inconclusive (RR=1.02, 95% CrI = 0.92-1.13, τ = 0.18) but favoured there being no important association (7% probability of RR ≥1.1). Former compared with never smokers were at somewhat increased risk of hospitalisation (RR=1.19, CrI = 1.03-1.43, τ = 0.17), greater disease severity (RR=1.52, CrI = 1.12-2.05, τ = 0.29) and mortality (RR=1.35, 95% CrI = 1.09-1.73, τ = 0.26). Data for current smokers on hospitalisation, disease severity and mortality were inconclusive (RR=1.06, CrI = 0.82-1.35, τ = 0.27;RR=1.26, CrI = 0.85-1.96, τ = 0.34;RR=1.10, 95% CrI = 0.69-1.67, τ = 0.50, respectively) but favoured there being no important associations with hospitalisation and mortality (35% and 51% probability of RR ≥1.1, respectively) and a small but important association with disease severity (79% probability of RR ≥1.1). Conclusions: Compared with never smokers, current smokers appear to be at reduced risk of SARS-CoV-2 infection while former smokers appear to be at increased risk of hospitalisation, greater disease severity and mortality from COVID-19. However, it is uncertain whether these associations are causal.

The association of smoking status with SARS-CoV-2 infection, hospitalisation and mortality from COVID-19: A living rapid evidence review with Bayesian meta-analyses (version 7)

Aims: : To estimate the association of smoking status with rates of i) infection, ii) hospitalisation, iii) disease severity, and iv) mortality from SARS-CoV-2/COVID-19 disease. Design: Living rapid review of observational and experimental studies with random-effects hierarchical Bayesian meta-analyses. Published articles and pre-prints were identified via MEDLINE and medRxiv. Setting: Community or hospital. No restrictions on location. Participants: Adults who received a SARS-CoV-2 test or a COVID-19 diagnosis. Measurements: Outcomes were SARS-CoV-2 infection, hospitalisation, disease severity and mortality stratified by smoking status. Study quality was assessed (i.e. ‘good', ‘fair' and ‘poor'). Findings: Version 7 (searches up to 25 August 2020) included 233 studies with 32 ‘good' and ‘fair' quality studies included in meta-analyses. Fifty-seven studies (24.5%) reported current, former and never smoking status. Recorded smoking prevalence among people with COVID-19 was generally lower than national prevalence. Current compared with never smokers were at reduced risk of SARS-CoV-2 infection (RR=0.74, 95% Credible Interval (CrI) = 0.58-0.93, τ = 0.41). Data for former smokers were inconclusive (RR=1.05, 95% CrI = 0.95-1.17, τ = 0.17) but favoured there being no important association (21% probability of RR ≥1.1). Former compared with never smokers were at somewhat increased risk of hospitalisation (RR=1.20, CrI = 1.03-1.44, τ = 0.17), greater disease severity (RR=1.52, CrI = 1.13-2.07, τ = 0.29), and mortality (RR=1.39, 95% CrI = 1.09-1.87, τ = 0.27). Data for current smokers were inconclusive (RR=1.06, CrI = 0.82-1.35, τ = 0.27;RR=1.25, CrI = 0.85-1.93, τ = 0.34;RR=1.22, 95% CrI = 0.78-1.94, τ = 0.49 respectively) but favoured there being no important associations with hospitalisation and mortality (35% and 70% probability of RR ≥1.1, respectively) and a small but important association with disease severity (79% probability of RR ≥1.1). Conclusions: Due to incomplete recording of smoking status, there is uncertainty about the associations of smoking with COVID-19 outcomes. Current smokers were at reduced risk of SARS-CoV-2 infection. Former smokers were at increased risk of hospitalisation, disease severity and mortality from COVID-19, while data for current smokers inconclusively favoured no large associations with these outcomes.

The association of smoking status with SARS-CoV-2 infection, hospitalisation and mortality from COVID-19: A living rapid evidence review (version 4)

Background: SARS-CoV-2 is the causative agent of COVID-19, an emergent zoonotic disease which has reached pandemic levels and is designated a public health emergency of international concern. It is plausible that former or current smoking status is associated with infection, hospitalisation and/or mortality from COVID-19. Objective: We aimed to estimate the association of smoking status with rates of i) infection, ii) hospitalisation, iii) disease severity, and iv) mortality from SARS-CoV-2/COVID-19 disease. Methods: This is a living evidence review with frequent updates. We adopted recommended practice for rapid evidence reviews, which involved limiting the search to main databases and having one reviewer extract data and another verify. Published articles and pre-prints were identified via Ovid MEDLINE, medRxiv and expertise within the review team. We included observational or experimental studies with community-dwelling or hospitalised adults aged 16 years who had received a test for SARS-CoV-2 infection or a diagnosis of COVID-19, providing that data on smoking status were reported. Studies were judged as ‘good' quality if they: i) had low levels of missing data on smoking status (i.e.

The association of smoking status with SARS-CoV-2 infection, hospitalisation and mortality from COVID-19: A living rapid evidence review (version 5)

Background: SARS-CoV-2 is the causative agent of COVID-19, an emergent zoonotic disease which has reached pandemic levels and is designated a public health emergency of international concern. It is plausible that former or current smoking status is associated with infection, hospitalisation and/or mortality from COVID-19. Objective: We aimed to estimate the association of smoking status with rates of i) infection, ii) hospitalisation, iii) disease severity, and iv) mortality from SARS-CoV-2/COVID-19 disease. Methods: This is a living evidence review with frequent updates. We adopted recommended practice for rapid evidence reviews, which involved limiting the search to main databases and having one reviewer extract data and another verify. Published articles and pre-prints were identified via Ovid MEDLINE, medRxiv and expertise within the review team. We included observational or experimental studies with community-dwelling or hospitalised adults aged 16 years who had received a test for SARS-CoV-2 infection or a diagnosis of COVID-19, providing that data on smoking status were reported. Studies were judged as ‘good' quality if they: i) had low levels of missing data on smoking status (i.e.

The association of smoking status with SARS-CoV-2 infection, hospitalisation and mortality from COVID-19: A living rapid evidence review with Bayesian meta-analyses (version 9)

AIMS: To estimate the association of smoking status with rates of i) infection, ii) hospitalisation, iii) disease severity, and iv) mortality from SARS-CoV-2/COVID-19 disease. DESIGN: Living rapid review of observational and experimental studies with random-effects hierarchical Bayesian meta-analyses. Published articles and pre-prints were identified via MEDLINE and medRxiv. SETTING: Community or hospital. No restrictions on location. PARTICIPANTS: Adults who received a SARS-CoV-2 test or a COVID-19 diagnosis. MEASUREMENTS: Outcomes were SARS-CoV-2 infection, hospitalisation, disease severity and mortality stratified by smoking status. Study quality was assessed (i.e. ‘good', ‘fair' and ‘poor'). FINDINGS: Version 9 (searches up to 27 October 2020) included 279 studies with 42 ‘good' and ‘fair' quality studies included in unadjusted meta-analyses. Seventy-nine studies (28%) reported current, former and never smoking status with the remainder using broader categories. Recorded smoking prevalence among people with COVID-19 was generally lower than national prevalence. Current compared with never smokers were at reduced risk of SARS-CoV-2 infection (RR = 0.69, 95% Credible Interval (CrI) = 0.57-0.83, τ = 0.38). Data for former smokers were inconclusive (RR = 1.02, 95% CrI = 0.93-1.12, τ = 0.18) but favoured there being no important association (5% probability of RR ≥1.1). Former compared with never smokers were at somewhat increased risk of hospitalisation (RR = 1.17, CrI = 1.04-1.36, τ = 0.17), greater disease severity (RR = 1.52, CrI = 1.12-2.06, τ = 0.29) and mortality (RR = 1.39, 95% CrI = 1.16-1.69, τ = 0.23). Data for current smokers on hospitalisation, disease severity and mortality were inconclusive (RR = 1.06, CrI = 0.89-1.27, τ = 0.23;RR = 1.26, CrI = 0.86-1.94, τ = 0.34;RR = 1.05, 95% CrI = 0.71-1.49, τ = 0.45, respectively) but favoured there being no important associations with hospitalisation and mortality (32% and 39% probability of RR ≥1.1, respectively) and a small but important association with disease severity (80% probability of RR ≥1.1). CONCLUSIONS: Compared with never smokers, current smokers appear to be at reduced risk of SARS-CoV-2 infection while former smokers appear to be at increased risk of hospitalisation, greater disease severity and mortality from COVID-19. However, it is uncertain whether these associations are causal. v7 of this living review article has been published in _Addiction _and is available here https://doi-org.libproxy.ucl.ac.uk/10.1111/add.15276

E-cigarettes to Augment Stop Smoking In-person Support and Treatment with varenicline (E-ASSIST): a pragmatic randomised controlled trial.

BACKGROUND: We examined whether, in adults receiving behavioural support, offering e-cigarettes together with varenicline helps more people stop smoking cigarettes than varenicline alone. METHODS: A two-group, parallel-arm, pragmatic randomised controlled trial was conducted in six English stop smoking services from 2019-2020. Adults enrolled onto a 12-week programme of in-person one-to-one behavioural smoking cessation support (N=92) were randomised to receive either (i) a nicotine e-cigarette starter-kit alongside varenicline or (ii) varenicline alone. The primary outcome was biochemically-verified abstinence from cigarette smoking between weeks nine-to-12 post quit-date, with those lost to follow-up considered not abstinent. The trial was stopped early due to COVID-19 restrictions and a varenicline recall (92/1266 participants recruited). RESULTS: Nine-to-12-week smoking abstinence rates were 47.9% (23/48) in the e-cigarette-varenicline group compared with 31.8% (14/44) in the varenicline-only group, a 51% increase in abstinence among those offered e-cigarettes; however, the confidence interval (CI) was wide, including the possibility of no difference (risk ratio [RR]=1.51, 95%CI=0.91-2.64). The e-cigarette-varenicline group had 43% lower hazards of relapse from continuous abstinence than the varenicline-only group (hazards ratio [HR]=0.57, 95%CI=0.34-0.96). Attendance for 12 weeks was higher in the e-cigarette-varenicline than varenicline-only group (54.2% versus 36.4%; RR=1.49, 95%CI=0.95-2.47), but similar proportions of participants in both groups used varenicline daily for ≥8 weeks after quitting (22.9% versus 22.7%; RR=1.01, 95%CI=0.47-2.20). Estimates were too imprecise to determine how adverse events differed by group. CONCLUSION: Tentative evidence suggests offering e-cigarettes alongside varenicline to people receiving behavioural support may be more effective for smoking cessation than varenicline alone. IMPLICATIONS: Offering e-cigarettes to people quitting smoking with varenicline may help them remain abstinent from cigarettes, but the evidence is tentative because our sample size was smaller than planned - caused by COVID-19 restrictions and a manufacturing recall. This meant our effect estimates were imprecise, and additional evidence is needed to confirm that providing e-cigarettes and varenicline together helps more people remain abstinent than varenicline alone.

Cutting down, quitting and motivation to stop smoking by self-reported COVID-19 status: Representative cross-sectional surveys in England.

AIM: To examine the association of self-reported COVID-19 disease status with cutting down, past-month and past-year quit attempts and motivation to stop smoking. DESIGN AND SETTING: Repeat cross-sectional survey, representative of the adult population in England. PARTICIPANTS: Past-year smokers, n = 3338 (aged ≥ 18 years) responding between May 2020 and April 2021. MEASUREMENTS: Outcomes were (i) currently cutting down, (ii) having made a quit attempt in the past month, (iii) having made a quit attempt in the past year and (iv) motivation to stop smoking. The explanatory variable was self-reported COVID-19 disease status (belief in never versus ever had COVID-19). Covariates included age, sex, occupational grade, region, children in the household, alcohol use and survey month. FINDINGS: Of past-year smokers, 720 (21.6%) reported past-COVID-19 infection and 48 (1.4%) reported current COVID-19 infection. In adjusted analyses, rates of currently cutting down [adjusted odds ratio (aOR) = 1.12, 95% confidence interval (CI) = 0.93-1.34], past-year quit attempts (aOR = 0.99, 95% CI = 0.82-1.19) and motivation to stop smoking (aOR = 1.04, 95% CI = 0.89-1.23) were comparable in those who did and did not report ever having had COVID-19. People who reported ever having had COVID-19 had 39% higher odds than those without of attempting to quit in the past month, but the confidence interval contained the possibility of no difference (aOR = 1.39, 95% CI = 0.94-2.06) and for some the quit attempt may have occurred before they had COVID-19. CONCLUSION: During the first year of the COVID-19 pandemic in England, rates of reducing smoking and attempting to quit in the past year were similar in smokers who did or did not self-report ever having had COVID-19. There was also little difference in motivation to stop smoking between groups. However, causal interpretation is limited by the study design, and there is potential misclassification of the temporal sequence of infection and changes to smoking behaviour.

Patterns and predictors of adherence to health-protective measures during COVID-19 pandemic in the UK: cross-sectional and longitudinal findings from the HEBECO study.

BACKGROUND: Adherence to health-protective behaviours (regularly washing hands, wearing masks indoors, maintaining physical distancing, carrying disinfectant) remains paramount for the successful control of COVID-19 at population level. It is therefore important to monitor adherence and to identify factors associated with it. This study assessed: 1) rates of adherence, to key COVID-19 health-protective behaviours and 2) the socio-demographic, health and COVID-19-related factors associated with adherence. METHODS: Data were collected on a sample of UK-based adults during August-September 2020 (n = 1,969; lockdown restrictions were eased in the UK; period 1) and November 2020- January 2021 (n = 1944; second UK lockdown; period 2). RESULTS: Adherence ranged between 50-95%, with higher adherence during the period of stricter measures. Highest adherence was observed for wearing masks indoors (period 1: 80.2%, 95%CI 78.4%-82.0%, period 2: 92.4%, 95%CI 91.1%-93.6%) and lowest for carrying own disinfectant (period 1: 48.4%, 95%CI 46.2%-50.7%, period 2: 50.7%, 95%CI 48.4%-53.0%). Generalized estimating equation models indicated that key factors of greater odds of adherence included being female, older age, having higher income, residing in England, living with vulnerable individuals and perceived high risk of COVID-19. CONCLUSIONS: Targeted messages to different demographic groups may enhance adherence to health-protective behaviours, which is paramount for the control of airborne respiratory diseases. PROTOCOL AND ANALYSIS PLAN REGISTRATION: The analysis plan was pre-registered, and it is available at https://osf.io/6tnc9/ .

Longitudinal changes and correlates of meeting WHO recommended levels of physical activity in the UK during the COVID-19 pandemic: Findings from the HEBECO study.

BACKGROUND: The COVID-19 pandemic has seen repeated government enforced restrictions on movement. This study aimed to evaluate longitudinal trends in physical activity (PA) in a self-selected UK-based sample and identify the key correlates of these trends. METHODS: From 23 April 2020 to 30 January 2021, measures of PA engagement were collected in a sample of 1,947 UK-based adults. Generalised estimating equations (GEE) explored trends in PA engagement over time, and how sociodemographic, health and contextual factors impacted participant's attainment of World Health Organization (WHO) recommended levels of PA (constituting muscle strengthening activity (MSA), and moderate or vigorous PA (MVPA)). RESULTS: While one in five achieved the recommended levels of PA in the first UK lockdown in April-June 2020 (19.5%, 95%CI: 17.8-21.3%) and a similar proportion in June-July 2020 (17.7%, 95%CI: 16.1-19.5%), this reduced during the period of eased restrictions in August-September 2020 (15.2%, 95%CI: 13.7-16.9%) and the second UK lockdown in November 2020-January 2021 (14.1%, 95%CI: 12.6-15.9%). Similar trends were observed for MSA and MVPA individually. Better quality of life, higher socioeconomic position and pre-COVID-19 PA levels were associated with meeting the WHO recommended levels of PA, while those living with overweight or obesity, a limiting health condition, or isolating showed the inverse associations. Time-specific associations with MSA or MVPA were observed for gender and age. CONCLUSION: Reductions in PA levels throughout the first strict lockdown continued without reversal during the ensuing period. The association of negative change with socioeconomic and health-related indices points towards deepening health inequities during the pandemic.

Prevalence of use and real-world effectiveness of smoking cessation aids during the COVID-19 pandemic: a representative study of smokers in England.

AIM: To measure whether the prevalence of use and real-world effectiveness of different smoking cessation aids has changed in England since the coronavirus disease 2019 (COVID-19) pandemic. DESIGN: Representative monthly cross-sectional surveys, January 2015-June 2021. SETTING: England. PARTICIPANTS: A total of 7300 adults (≥18 y) who had smoked within the previous 12 months and had made ≥1 quit attempt during that period. MEASUREMENTS: The independent variable was the timing of the COVID-19 pandemic (pre-pandemic [January 2015-February 2020] vs pandemic [April 2020-June 2021]). We analysed (i) the association between the pandemic period and self-reported use (vs non-use) during the most recent quit attempt of: prescription medication (nicotine replacement therapy [NRT]/varenicline/bupropion), NRT bought over-the-counter, e-cigarettes, traditional behavioural support and traditional remote support (telephone support/written self-help materials/websites) and (ii) the interaction between the pandemic period and use of these cessation aids on self-reported abstinence from quit date to survey. Covariates included age, sex, social grade, level of cigarette addiction and characteristics related to the quit attempt. FINDINGS: After adjustment for secular trends, there was a significant increase from the pre-pandemic to pandemic period in the prevalence of use of traditional remote support by past-year smokers in a quit attempt (OR = 2.18; 95% CI, 1.42-3.33); specifically telephone support (OR = 7.16; 95% CI, 2.19-23.45) and websites (OR = 2.39; 95% CI, 1.41-4.08). There was also an increase in the prevalence of use of prescription medication (OR = 1.47; 95% CI, 1.08-2.00); specifically varenicline (OR = 1.66; 95% CI, 1.09-2.52). There were no significant changes in prevalence of use of other cessation aids after adjustment for secular trends. People who reported using prescription medication (OR = 1.41; 95% CI, 1.09-1.84) and e-cigarettes (OR = 1.87; 95% CI, 1.62-2.16) had greater odds of reporting abstinence than people who did not. There were no significant interactions between the pandemic period and use of any cessation aid on abstinence, after adjustment for covariates and use of the other aids, although data were insensitive to distinguish no change from meaningful modest (OR = 1.34) effects (Bayes factors 0.72-1.98). CONCLUSIONS: In England, the COVID-19 pandemic was associated with an increase in use of remote support for smoking cessation and varenicline by smokers in a quit attempt up to June 2021. The data were inconclusive regarding an association between the pandemic and changes in the real-world effectiveness of popular smoking cessation aids.