Objective: Smoking status does not indicate the amount or length of tobacco use, and thus, it is an imperfect measure to assess the association between cigarette smoking and severe coronavirus disease 2019 (COVID-19) outcomes. This investigation assessed whether cigarette smoking status, intensity of smoking (i.e., average daily packs of cigarettes smoked), duration of smoking, and pack-years of smoking are associated with severe outcomes among adults diagnosed with COVID-19. Methods: We conducted a retrospective, cross-sectional study in which we identified consecutive patients diagnosed with COVID-19 at the University of Cincinnati healthcare system between 13 March 2020 and 30 September 2020 who had complete information on smoking status, severe COVID-19 outcomes, and covariates (i.e., demographics and comorbidities). We used logistic regression to evaluate the associations of smoking status and intensity of smoking with COVID-19 severity, defined as hospitalization, admission to intensive care unit (ICU), or death, adjusting for sociodemographics and comorbidities. Results: Among the 4611 COVID-19 patients included in the analysis, 18.2% were current smokers and 20.7% were former smokers. The prevalence of COVID-19 outcomes was 28.9% for hospitalization, 9.8% for ICU admission, and 1.4% for death. In the adjusted analysis, current smoking (AOR: 1.23, 95% CI: 1.02–1.49), former smoking (AOR: 1.28, 95% CI: 1.07–1.54), and pack-years of smoking (AOR: 1.09, 95% CI: 1.02–1.17) were associated with a higher prevalence of hospitalization. Average daily packs of cigarettes smoked was associated with a higher prevalence of hospitalization (AOR: 1.30, 95% CI: 1.10–1.53) and ICU admission (AOR: 1.23, 95% CI: 1.04–1.44). Conclusions: Smoking status, pack-years, and intensity of smoking were associated with hospitalizations in patients with COVID-19 and intensity of smoking was associated with ICU admission. The findings underscore the need for detailed information beyond smoking status when evaluating smokers with COVID-19 so that the potential for adverse sequelae may be optimally managed in at-risk patients.
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