France is once again the source of a new hype over a potential therapy for COVID-19: nicotine.
Paris rushed to restrict the sale of nicotine products over the past weekend, banning their sale online, to avoid shortages of products such as nicotine gum and patches.
It wasn’t any sudden onset of smokers’ remorse that prompted the scramble, but news that French scientists were looking to start a clinical trial administering nicotine patches as a potential protective medicine to battle the coronavirus.
That announcement followed a study in a Paris hospital suggesting cigarette smokers are less likely to be hospitalized with COVID-19.
The country has already seen fanfare over another controversial would-be coronavirus cure, when Marseille based doctor Didier Raoult put forward the use of anti-malarial drug chloroquine, without adequate scientific evidence and despite serious potential side effects.
If nicotine in cigarettes indeed protects smokers, it would overturn the common-sense assumptions about an activity linked to worsening lung function.
Unlike with chloroquine, there’s no indication so far that scientific interest over nicotine has generated a rush to French pharmacies — despite the government’s preemptive move — nor has it prompted the sort of social media fueled hype that made Raoult a celebrity.
Yet the news risks once again blurring carefully crafted messages from health authorities.
The World Health Organization in its own informational materials has said that smokers are “likely to be more vulnerable to COVID-19.”
The health authority argues that the movement associated with smoking makes infections more likely because of increased contact between lips and fingers. Furthermore, smokers may already be suffering from lung diseases, which increase the risk of hospitalization.
A strange cure
If nicotine in cigarettes indeed protects smokers, it would overturn the common-sense assumptions about an activity linked to worsening lung function, given that the severe cases of the virus are associated with respiratory failure.
Those principles have guided the broader global response, as countries around the world have restricted the use of tobacco products since the viral outbreak.
India, for example has clamped down on chewing tobacco for fear that it could propagate the disease, while numerous states across the Middle East have stopped cafes and shops from serving water pipes to customers. South Africa went as far as banning cigarette sales altogether, though it has since relaxed the restriction.
Vinayak Prasad, the program manager leading the WHO’s Tobacco Free Initiative, said the organization isn’t discounting the French study. A panel of experts will look at the data alongside other evidence and put out an official communication shortly, he noted.
But for the time being, he said, the WHO stands by its message: The risk of COVID-19 and the severity of an eventual infection are likely to be higher when smoking.
“We have sufficient information from previous epidemics like SARS and others,” Prasad explained. “We have seen that these are viruses that are targeting the lungs.”
“It’s a no brainer that the severity of infection would be higher among long standing smokers, especially if they have comorbidities,” he added, referring to other associated medical conditions.
The Paris study
The origin of the nicotine trial proposal lies in a study of coronavirus patients in the hospital Pitié-Salpêtrière in Paris.
Researchers observed a significantly lower-than-expected number of smokers being treated in the French hospital when compared with the smoking rate among the general French population. In a subsequent paper, they theorized that a link exists between nicotine and a protective effect from the virus.
The evidence is by no means unanimous, however. For one, the study has not yet been peer reviewed. Meanwhile, other scientific literature has taken the opposite conclusion.
A meta-analysis of 12 different papers, in fact, found a significant association between smoking and progression of COVID-19, with smokers more at risk of the disease getting worse than non-smokers.
Ivan Berlin, a physician and associate professor of clinical pharmacology at the Pitié-Salpêtrière hospital, the same one where the French study was conducted, was unsparing in his criticism.
“This paper has no level of evidence — it’s not even a low evidence,” Berlin said.
The professor noted that the French study looked only at current smokers and non-smokers. That means the sample might exclude recent quitters who had been smoking until recently.
Furthermore, the study compared COVID-19 positive patients to the general population from a 2018 survey. That’s a problem, says Berlin, because the data isn’t up to date. Furthermore, the general population sample didn’t accurately reflect the patient group, which was sicker and had more comorbidities than the general population.
Filippos Filippidis, a senior lecturer in public health at Imperial College London and expert member of the European Respiratory Society’s Tobacco Control Committee, agreed that not knowing the smoking history of the patients in the Paris study is a serious gap.
“What creates things like cancer and strokes is not nicotine but poisonous substances in the cigarette” — Peter Liese, German MEP
“Old people or people with other conditions are more likely to be hospitalized for COVID-19, but those people — because they’re so fragile — would be more likely to have quit smoking,” he pointed out. By extension, “it would be likely that a very small proportion are current smokers.”
The scientists who conducted the study declined to comment, but Florence Tubach, one of the study co-authors, stressed in an article in Le Monde that the potential effect of nicotine is still a hypothesis for now.
“I maintain the conditional [when talking about it] because our work remains observational,” she said.
German MEP Peter Liese, health spokesman for the European People’s Party, said that it’s crucial in any case to distinguish between tobacco and nicotine.
“What creates things like cancer and strokes is not nicotine but poisonous substances in the cigarette,” Liese said. He noted the study wouldn’t examine the use of smoking but of nicotine, which can be administered in patches or gum, for example.
The issue has encapsulated the difficulties that health authorities face in managing communication at a time when people are looking for a lifeline even though the science isn’t settled.
The MEP said that experts must walk a fine line, remaining careful whenever there’s uncertainty while continuing to communicate strongly.
“That’s an uncomfortable situation,” he said.
For current smokers, however, he had a simple message: “I would strongly advise everyone to quit smoking.”
“And if you don’t think you can quit altogether, e-cigarettes and nicotine patches are alternatives that most likely don’t have negative effects on the lung,” Liese added. “If there’s a protective effect, even better.”
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