Incidence and Case-Fatality Ratio of COVID-19 infection in relation to Tobacco Smoking, Population Density and Age Demographics in the USA: could Particulate Matter derived from Tobacco Smoking act as a Vector for COVID-19 transmission?
Authors: Baron Yves Muscat 
Published: October 2020

ABSTRACTBACKGROUNDTobacco smoking is known to increase the risk for bacterial and viral respiratory infections and this also applies to second-hand smoking. Smoking has been shown to increase the severity of COVID-19 infection and the consequent risk for intra-tracheal ventilation in smokers. Tobacco smoking exposes the user and nearby individuals to very high concentrations of particulate matter in a short period of time. Genes appertaining to COVID-19 have been found adherent to particulate matter. Particulate matter has been shown to travel beyond the social distance of 2 metres up to 10 metres. COVID-19 related mortality has been linked to elevated atmospheric levels of the particulate matter, PM2.5. The aim of the study was to observe the incidence of infection rate and case fatality ratios in the USA, comparing States with partial bans on tobacco smoking, to States with more restrictive smoking regulation, exploring a possible link between smoke-related particulate matter and COVID-19 transmission.METHODOLOGYTwo groups of USA States, differentiated by the degree of smoking legislative restrictions, had a number of variables compared. The incidence of COVID-19 infection, case-fatality ratio and testing frequency were obtained from the John Hopkins Coronavirus Resource Centre. The degree of smoking bans in the USA States was obtained from the websites of the Nonsmokers Rights Foundation. The percentage of the State population which smokes was collected from the Centres of Disease Control database. Population density, Body Mass Index and population percentages of individuals 65+/75+years were obtained from databases concerning USA demographics.RESULTSWith the available data there was no significant difference in COVID-19 testing prevalence between the partial smoking ban group and the more restrictive regulated group. The incidence of COVID-19 infection in the States with limited bans on tobacco smoking was 2046/100,000 (sd+/-827) while the infection incidence in States with more restrictive rulings on tobacco smoking was 1660/100,000 (sd+/-686) (p<0.038). The population percentage of smokers in States with minor limitations to smoking was 18.3% (sd+/-3.28), while States with greater smoking restrictions had a smoking population percentage of 15.2% (sd+/-2.68) (p<0.0006).The two populations of both groups did not differ numerically (p<0.24) and numbered 157,820,000 in the partial smoking ban group and 161,439,356 in the more restrictive group. Population density correlated significantly with the case-fatality ratio (R=0.66 p<0.0001), as did the 75+year age group (R=0.29 p<0.04). Reflecting the possibility of trans-border transmission, the smoking status of adjacent partial smoking ban States may influence the COVID-19 incidence of bordering States (e.g. Utah) even if the smoking regulations of the latter were stricter than the former.Other factors that could impact the COVID-19 pandemic in the USA such as the State case-fatality ratio, population density, population percentage with elevated body mass index and the percentage of the state population aged 65years or above did not show any significant difference between both groups of States.CONCLUSIONStates in the USA with high levels of tobacco smoking and limited regulation had significantly higher rates of COVID-19 infection incidences than States with greater smoking restrictions. Population density and the age group of 75+years, showed a positive significant correlation with the case-fatality ratio. Besides the adverse effects of tobacco smoking on pulmonary defences, it would be interesting to explore the possibility of infection transmission via coronavirus-laden particulate matter from exhaled fumes derived from tobacco smoking.