[ Thoracic Oncology How I Do It ]

Coronavirus Disease 2019 and Smoking

How and Why We Implemented a Tobacco Treatment Campaign
Adam Edward Lang, PharmD; and Aleksandra Yakhkind, MD

Smoking is associated with one of five deaths in the United States. Multimodality tobacco
treatment increases rates of successful cessation by at least 20%. The coronavirus disease
2019 pandemic has put a halt to many inpatient and outpatient medical visits that have been
deemed nonessential, including tobacco treatment. The transition to telehealth has been
wrought with challenges. Although data on the association between coronavirus disease 2019
and tobacco products are mixed, the overall health consequences of tobacco point towards
increased risk of morbidity and death that is associated with the virus. This leaves smoking as
one of the few readily modifiable risk factors in an environment understandably not set up to
prioritize cessation. A military health facility on Fort Eustis in Virginia runs a successful tobacco
treatment program and adapted it to pandemic times. This article describes the process and
lessons learned from this initiative. The model is applicable and scalable to government and
civilian health centers as health care adapts to a new normal. CHEST 2020; 158(4):1770-1776

KEY WORDS: COVID-19; pandemic; public health; smoking cessation; tobacco treatment

Smoking has been shown to be a risk factor with those who did not smoke.7 Although it
for disease severity and poor outcomes in is unclear to what extent the severity and
coronavirus disease 2019 (COVID-19), management of these conditions mitigate
which is the disease caused by severe acute risk,1 no other risk factors are as immediately
respiratory syndrome coronavirus 2 (SARS- modifiable as smoking.
CoV-2).1-3 It has been shown to increase the
Some researchers suggest a protective effect
risk of the development of various types of
of smoking and COVID-19 based on
viral infections and the incidence of
complications.4 Current smoking is epidemiologic data that were not controlled
for age and comorbidities and cell signaling
associated with poorer outcomes in those
hypotheses that were based on animal data.
with severe sepsis and septic shock5 and the
Although they have garnered media
development of acute respiratory disease
attention, they all conclude that the
syndrome in hospitalized patients.6 In a
cumulative risk of tobacco to the health of an
study that predicted the 90-day mortality
individual outweighs the theoretic benefits.8,9
rate from viral pneumonias (including
coronaviruses) in hospitalized patients, The Centers for Disease Control and
smokers were twice as likely to die compared Prevention and the World Health

ABBREVIATIONS: ACE 2 = Angiotensin converting enzyme 2; COVID- CORRESPONDENCE TO: Adam Edward Lang, PharmD, McDonald
19 = coronavirus disease 2019; SARS-CoV-2 = severe acute respiratory Army Health Center, 576 Jefferson Ave, Fort Eustis, VA 23604; e-mail:
syndrome coronavirus 2 a.edward.lang@gmail.com
AFFILIATIONS: From the Department of Primary Care (Dr Lang), Published by Elsevier Inc. under license from the American College of
McDonald Army Health Center, Fort Eustis, VA; and the Department Chest Physicians.
of Neurology (Dr Yakhkind), University of Pennsylvania Health Sys- DOI: https://doi.org/10.1016/j.chest.2020.06.013
tem, Philadelphia, PA.

1770 How I Do It [ 158#4 CHEST OCTOBER 2020 ]

Organization recommend against smoking to reduce the Tricare Online (patient portal) message was sent to
risk of harm from the disease.10,11 The World Health >29,000 patients who were enrolled with a primary care
Organization has gone as far as to caution against provider at McDonald Army Health Center. It described
reports that tobacco or nicotine may provide benefit the risk of COVID-19 in those who smoke and
against COVID-19 because there is not sufficient recommended tobacco treatment services through the
evidence for this claim.11 Given the conflicting resources detailed later.
information in the media and the challenges of coping
Interested patients could send an e-mail message to a
with a pandemic, we felt it of utmost importance to
monitored account if they wanted to quit. Clinic staff
adapt tobacco treatment, promote its importance, and
made appointments with a clinical pharmacist who has
continue to support patients in their efforts to quit
prescribing privileges within the Military Health System
during this unique time.
and is trained in tobacco treatment. Patients were also
provided with a link to the program Time to Quit, which
Tobacco Treatment in the Time of COVID-19 was created by the Health Net Federal Service, prior to
McDonald Army Health Center is a military treatment their appointment.12 This online tool has been
facility on Fort Eustis in Newport News, VA. It is an particularly useful during the pandemic because
ambulatory care center that provides primary and psychologist appointments may be limited and classes
specialty care services to active duty service members, may be cancelled temporarily.
their families, and retirees.
During the initial telehealth appointment, a concise
A tobacco treatment program has been run by the nicotine use history was conducted (e-Appendix 2). It
clinical pharmacy for >10 years. In 2019, it grew to assessed the types and quantity of nicotine products
target specific populations within the active duty used, the length of use, medical conditions that may
community in efforts to minimize tobacco use and limit medication options, the triggers and times that the
improve the health of the force. Educational products patient normally uses nicotine products, and an
and live and video-based programs were developed and overview of previous attempts to quit. This was followed
implemented. The COVID-19 pandemic emerged in the by a discussion of behavioral interventions and nicotine
midst of these efforts, putting the program to a halt. The withdrawal symptoms. Medication therapy options
team quickly restructured their efforts in a way that included varenicline, bupropion, and nicotine
applied to social distancing orders. This process and replacement therapy patches, gum, and lozenges, which
what was learned from it will be discussed. have proven efficacy and safety as both monotherapy
and in combination with each other.13 At the end of the
There are three ways that a nicotine user can come to see a
appointment, patients were provided with discharge
clinical pharmacist who manages their tobacco treatment
instructions through secure messaging or e-mail
at McDonald Army Health Center . They can self-refer, be
messaging (e-Appendix 3).
referred by their primary care provider, or be referred by a
specialist. Prior to their appointment with the clinical Patients had the option of obtaining their medications in
pharmacist, they must see a psychologist for an one of three ways: through their local Military Treatment
appointment regarding nicotine use, attend a tobacco Facility, through mail order, or through a retail pharmacy
treatment education class, or complete a online program. (coverage dependent). The military treatment facility
pharmacy had developed a drive-through only operation
When the pandemic was starting to be recognized in the
to reduce risk of viral spread. Patients were scheduled for at
United States, the tobacco treatment program
least two follow-up telehealth appointments to track
responded. A message was sent targeting all Tricare
progress, to provide behavioral intervention, and to
beneficiaries (active duty soldiers, family members, and
address any ongoing concerns.
retirees) in the Fort Eustis community via three means
of communication. On March 17, 2020, a message
was posted on the official McDonald Army Health What Was Learned and What to Consider
Center Facebook page, which has >3,400 followers With Future Campaigns
(e-Appendix 1). Five hundred and seventy Fewer patients responded than was anticipated, and the
administrators received an e-mail message to process was analyzed for how it can be improved. The
redistribute throughout their organizations, which three main takeaways from the campaign are detailed
include brigades and battalions on site. On March 18, a here and summarized in Table 1.

chestjournal.org 1771
TABLE 1 ] Barriers to Tobacco Treatment Campaign in the Time of Coronavirus Disease 2019 and Solutions
Variable Barrier Solution
Message Patients not subscribed to patient portal Counsel patients on signing up for patient portal
exposure
Administrators too busy to send messages to Send message to all organization constituents, not just
constituents administrators, and Reminder e-mail messages
Low electronic communication literacy Telephone line availability, advertising with television and
radio
Limited clinic phone answering capabilities Forward clinic number to personal or home phone of
due to quarantine providers or staff
Behavioral Lack of provider time and expertise for Involve behavioral health specialists
health counselling
Social isolation Provide with online and phone-based counseling support
resources
Resources Potential for overwhelming response, lack of Use clinic staff and questionnaires to gather medical and
provider time tobacco history
Primary care managers busy with surge Use clinical pharmacy or other providers who are certified in
responsiveness tobacco treatment
Not all tobacco treatment trained staff have Authorize standing order for tobacco treatment
prescribing authority medications
Virus exposure Use the mail-order pharmacy, 90-day prescriptions, and
telehealth

Broadening Message Exposure resource, especially to those in the population who do

The timing and platform in which the message goes out not use electronic communication.
to patients is important. The original campaign message
went out during a tumultuous time. Community spread Behavioral Intervention
of COVID-19 was beginning: a state of emergency had The 2020 Report of the Surgeon General, along with
been declared in Virginia, the governor sent a message clinical practice guidelines from the United States
on March 13 for schools to close starting March 16, and Preventive Services Task Force, United States Public
restrictions were implemented on restaurants, Health Service, and the American College of Cardiology
recreation, entertainment, gatherings, and nonessential all highlight the importance of behavioral intervention
retail businesses. Health Protection Condition levels, a for tobacco treatment in addition to
Department of Defense public health emergency pharmacotherapy.13,14 Key aspects of a tobacco
management framework that communicates key treatment appointment are education about nicotine
protective measures to the community, were escalating withdrawal symptoms and behavioral interventions.
rapidly. It is likely that many patients missed the Behavioral intervention techniques include cognitive
message given the context or did not have the behavioral strategies (stimulus control, stress reduction,
bandwidth to consider a nonemergent medical avoidance, delay tactics, reframing) and motivational
appointment. Army administrators may also have been interviewing that is based on theories of behavior change
too inundated with pandemic preparedness duties to (health belief model, transtheoretical model, social
pass the message throughout their organizations. cognitive/learning theory). These methods can be used
to target a patient’s perceptions of smoking and help
Not all patients subscribe to secure messaging through
them change behaviors that facilitate cessation of
the Tricare Online patient portal or use Facebook or
use.14,15 Smoking cessation telephone counseling, as
even e-mail messaging. It is essential to plan to have a
performed in our protocol, has been shown to be
phone number that patients can call to reach a provider
effective at improving rates of quitting.15,16
who is working from home in the setting of foreseen or
unforeseen clinic closure. Outreach via various media Although it is preferable to have all patients see a
sources, such as local newspapers and television stations, behavioral health provider, this is not possible in many
can broaden public exposure to the message and settings due to limited resources. Referrals to a

1772 How I Do It [ 158#4 CHEST OCTOBER 2020 ]

behavioral health provider should be discussed with having as much of the essential visit logistics completed
patients who are felt to be having a particularly hard ahead of time as possible would allow for more
time coping, who have low self-efficacy, who have a bandwidth for counseling and for more patients to be
history of struggles with cessation, or who express treated. Support staff can call a patient before their visit
interest in seeing a behavioral health provider. to document pertinent history, or patients can fill out a
questionnaire through a secure messaging platform that
A pandemic may lead to an even higher need for
details pertinent medical and nicotine use history to the
behavioral health services to help with depression and
provider.
anxiety that stems from isolation from friends and family,
financial hardship, and increased stress. Normally, life There is no single algorithm for tobacco treatment. The
stressors are staggered over time in a population. In a provider should recognize that, just like with other
pandemic, everyone experiences the same stressor at the chronic disease states, treatment is patient specific. Some
same time. This may mean that the tobacco treatment patients may require two 21-mg patches at once; some
clinician has to take on an even greater role in the patients may need triple medication therapy, and other
behavioral health aspects of their patients if behavioral patients may not be able to tolerate twice daily
health provider capacity is decreased. varenicline or bupropion and need to take it once daily.
Different approaches work for different patients, so
Although more free time may provide patients with
flexible dosing and treatment durations should be
motivation to quit, it may also be a deterrent due to
available for patients depending on how their treatment
struggles with stress and isolation. Major life events may
progresses.
increase use in those already using, cause former users to
reinitiate use, and make it less likely for those that are Another consideration is to limit virus exposure in this
using to quit. Self-efficacy is an important predictor of vulnerable population and respond to patient fears.
abstinence rates, and outcomes are best when confidence Patients may have heard that tobacco or nicotine could
in quitting is reinforced by community or a provider.14 protect them from SARS-CoV-2, may be less likely to
contact their providers for help with tobacco treatment
Follow up is key during a pandemic because the impact
if they do not know that telemedicine is an option, or
of population-wide social, psychological, and behavioral
may be afraid to reach out because they see going to a
changes are uniquely challenging in the setting of
provider or a pharmacy as a risk to their health.
isolation. At least three total telehealth appointments
should take place to provide effective care.15 Additional It is important to reach out to the patient in such times
resources such as quit lines (1-800-QUIT-NOW), text to inform them of the risks and the resources available,
messaging programs, phone applications, and online which include telehealth (in the form of tobacco
services offer counseling support that can supplement treatment as well as behavioral health), and mail-order
the telehealth interaction.13,15 Another resource that prescriptions. No show and follow-up rates, which can
augments patient-provider interactions is the Time to be higher with tobacco treatment compared with other
Quit program that highlights the reasons that people appointments, may actually be reduced due to telehealth.
smoke, management of withdrawal symptoms, health The telehealth appointment generally is initiated by the
benefits of cessation, and maintenance of motivation. provider as opposed to being dependent on the patient
to show up at the clinic.
Resource Utilization and Practical Considerations
Last, providers have to adapt to telehealth technology
In a pandemic, physicians, nurse practitioners, and
and to scheduling remotely. The ideal type of
physician assistants may be pulled from their outpatient
appointment depends on the patient population. Older
roles for acute care. A pharmacist trained in tobacco
patients may have less access to audiovisual resources,
treatment is an ideal provider to treat these patients. A
and the telephonic appointment may be the only option.
standing order for varenicline, bupropion, and various
As telehealth expands, the abilities and needs of the
types of nicotine replacement therapy by a physician
patient must come first. Clinics are often faced with
permits those medications to be available to patients,
questions about whether payors cover telehealth.
even if they are seen by a health care provider without
Providers should be aware that the federal government
prescribing privileges.
has eased restrictions on telehealth services during the
As response rates go up, providers have to prepare to pandemic, making them much more accessible. An
handle an increased volume of telehealth visits. As such, extensive guide on the use of telehealth to support

chestjournal.org 1773
tobacco cessation was created by the American Lung Rodent studies have shown a reduction in ACE2
Association.17 Long term, the widespread expression with cigarette smoke and nicotine in rats
implementation of telehealth may allow us to provide with pulmonary arterial hypertension due to
tobacco treatment to those in more rural areas who smoking.32,33 Although down-regulation of ACE2 could
previously would not have had the ability to follow up in decrease SARS-CoV-2 infection,8 it leads to an increase
person on a monthly basis. in vasoconstriction, vascular permeability,
inflammation, and acute lung injury downstream.
Review of the Literature Human studies have shown that cigarette smoke actually
There is no template for telehealth, let alone tobacco up-regulates ACE2 expression in the lungs, which could
treatment, during a pandemic. The literature that does lead to an increased risk of SARS-CoV-2 infection.34,35
exist is in support of such an intervention. Smoking has Either way, the effects of nicotine and smoking on
innumerable adverse health effects, and evidence points COVID-19 infection are inconclusive at best. Even if
towards increased disease severity and worse outcomes there was an protective effect of nicotine, nicotine
in patients who smoke and experience COVID-19.1-3 replacement therapy is substantially safer and less habit-
Also, the use of inhaled products or smokeless tobacco forming than tobacco use; clinical trials would be needed
requires the user to put their hands near their mouth, to determine the efficacy and safety of this approach.
which increases the risk of transmission of disease.18 A Overall, there are many deleterious effects that nicotine
better understanding of the interplay between smoking exhibits on the human body, so for now, the definite
and COVID-19 can help us learn more about the risks outweigh the potential benefits.
pathophysiologic effect of each of them individually and
Coagulation and Cardiovascular
identify targets for possible therapies and interventions.
In our review of the literature, we found that both severe Smoking, along with high nicotine and cotinine levels,
acute respiratory syndrome-related coronaviruses and have been shown to put smokers in a prothrombotic
smoking dysregulate the immune system, cell signaling, state.36 Risk of VTE has been shown to be higher in
coagulation, and the cardiovascular system, which smokers than former smokers or nonsmokers and may
cumulatively can lead to poor outcomes. cause a synergistic effect when combined with COVID-
19, which triggers the extrinsic coagulation cascade
Immune Modulation through cytokine storm.37-39 Interim guidance from the
Cigarette smoke has been shown to up-regulate International Society of Thrombosis and Haemostasis
inflammation through activation of nuclear factor has recommended prophylactic dose low-molecular-
kappa-light-chain-enhancer of activated B cells, tumor weight heparin for all patients who are admitted to the
necrosis factor-a, IL-1beta, and neutrophils19,20 and to hospital for COVID-19 without contraindications.38
down-regulate successful immune function.21-24 This This guidance may be of even greater importance in
effect is proportional to an increase in smoking and does smokers.
not subside immediately after discontinuation of
Myocarditis is another complication that is associated
use.25-27 Patients with SARS-CoV-2 have been shown to
with COVID-19 through an unclear mechanism.40
have elevated levels of the inflammatory cytokines
Smoking has been correlated with myocarditis in
tumor necrosis factor-a, IL-2R, and IL-6 on
people41 and has been shown to exacerbate the severity
presentation, and the virus causes lymphocytopenia.28,29
of viral myocarditis in mice through a presumed
Cell Signaling and Viral Entry mechanism of catecholamine and adrenergic agonism.42
The mechanisms that coronaviruses use to get into cells
affect downstream signaling pathways that may Conclusion
potentiate immune system dysregulation in parallel with Tobacco treatment is important to decrease the risks of a
smoking. SARS-CoV and SARS-CoV-2 enter cells myriad of health conditions. Quitting smoking during a
through cell wall proteins related to the renin- pandemic is an unprecedented challenge for patients
angiotensin system.30 The SARS-CoV spike (S) protein, and health care providers. We describe the process
once bound to Angiotensin converting enzyme 2 through which we learned the steps that lead to a
(ACE2), expeditiously down-regulates ACE2 successful tobacco treatment campaign in the setting of a
expression31; it is presumed that SARS-CoV-2 has the pandemic. They include a standing order for medication
same effect.30 therapy, appropriately timed campaign advertisement

1774 How I Do It [ 158#4 CHEST OCTOBER 2020 ]

and efficient telehealth services, and the availability of 5. Alroumi F, Abdul Azim A, Kergo R, et al. The impact of smoking on
patient outcomes in severe sepsis and septic shock. J Intensive Care.
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interplay between smoking and coronaviruses are consumption, and risk of ARDS: a 15-year cohort study in a
managed care setting. Chest. 2000;117(1):163-168.
lacking, both tobacco and COVID-19 contribute to lung
7. Guo L, Wei D, Zhang X, et al. Clinical features predicting mortality
injury, immune dysregulation, hypercoagulation, and risk in patients with viral pneumonia: the MuLBSTA score. Front
cardiomyopathy. Tobacco treatment runs the risk of Microbiol. 2019;10:2752.

being de-emphasized when the priority is “essential” 8. Changeux JP, Amoura Z, Rey F, et al. A nicotinic hypothesis for
Covid-19 with preventive and therapeutic implications. C R Biol.
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more important during this time and should be 9. Rossato M, Russo L, Mazzocut S, Di Vincenzo A, Fioretto P,
Vettor R. Current smoking is not associated with COVID-19. Eur
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2019 (COVID-19): Information for People who are at Higher Risk
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need-extra-precautions/groups-at-higher-risk.html. Accessed April
Key Points 15, 2020.
 Smoking is the only immediately modifiable risk 11. World Health Organization: WHO statement: Tobacco use and
COVID-19. https://www.who.int/news-room/detail/11-05-2020-
factor of COVID-19 disease severity. who-statement-tobacco-use-and-covid-19. Accessed May 22, 2020.
 Reports of the protective effects of smoking on 12. Time to Quit. Health Net Federal Services. https://www.hnfs.com/
COVID-19 are unfounded. Rather, both detrimentally content/hnfs/home/tw/bene/wellness/wellness_programs/online-
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13. Substance Abuse and Mental Health Services Administration, Office
coagulation, and heart function. of the Surgeon General. Publications and Reports of the Surgeon
 This should motivate both providers and patients to General. Smoking Cessation: A Report of the Surgeon General.
Washington (DC): US Department of Health and Human Services;
prioritize tobacco treatment as an essential medical 2020.
intervention. 14. Barua RS, Rigotti NA, Benowitz NL, et al. 2018 ACC expert
 There are no data or template for tobacco treatment consensus decision pathway on tobacco cessation treatment. J Am
Coll Cardiol. 2018;72(25):3332-3365.
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 Our model used a standing order for medication with smoking cessation in the treatment of tobacco use. Health Serv
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therapy, media to spread an appropriately timed
16. Stead LF, Hartmann-Boyce J, Perera R, et al. Telephone counselling
message, efficient telemedicine, redistribution of tasks for smoking cessation. Cochrane Database Syst Rev. 2013;(8):
between support staff and providers, and effective CD002850.
multidisciplinary behavioral interventions. 17. American Lung Association. Telehealth as a Vehicle to Support
Tobacco Cessation, 2018. https://www.lung.org/getmedia/0df40b1c-
 This model is applicable and scalable to health sys- cca4-4f8d-b17f-1c0ef19052a1/telehealth-tobacco-cessation.pdf.pdf.
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18. Oberg M, Jaakkola MS, Woodward A, et al. Worldwide burden of
Acknowledgments disease from exposure to second-hand smoke: a retrospective
analysis of data from 192 countries. Lancet. 2011;377(9760):139-146.
Financial/nonfinancial disclosures: None declared.
19. Zhang C, Qin S, Qin L, et al. Cigarette smoke extract-induced p120-
Other contributions: The opinions or assertions contained herein are mediated NF-kB activation in human epithelial cells is dependent on
the private views of Adam Edward Lang and the co-author and do not the RhoA/ROCK pathway. Sci Rep. 2016;6:23131.
necessarily represent the view of the Department of Defense or its 20. Ryder MI, Saghizadeh M, Ding Y, et al. Effects of tobacco smoke on
components. the secretion of interleukin-1beta, tumor necrosis factor-alpha, and
Additional information: The e-Appendixes can be found in the transforming growth factor-beta from peripheral blood
Supplemental Materials section of the online article. mononuclear cells. Oral Microbiol Immunol. 2002;17(6):331-336.
21. Guzik K, Skret J, Smagur J, et al. Cigarette smoke-exposed
neutrophils die unconventionally but are rapidly phagocytosed by
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