The effect of hookah use on COVID-19 related adverse outcomes: Lessons learned from integrating STEPs 2016 and national COVID-19 registration databases

INTRODUCTION Amidst the COVID-19 pandemic, an international effort has been concerted to identify the factors associated with more adverse outcomes to better allocate resources and perform more effective targeted preventive measures. This study aims to describe the risk of COVID-19 adverse outcomes among individuals with a history of being ever cigarette smokers and being ever hookah users. METHODS We combined two databases, including the Iran national registry of COVID-19 patients, including 2020 with 656258 hospitalized patients and STEPs survey 2016 with 30541 participants. After merging the two databases using the national ID, the association was investigated between being ever smoker or hookah user and the adverse outcomes of COVID-19 including death, need for a ventilation therapy, and admission in the intensive care unit (ICU), among 474 severe acute respiratory infections (SARI) cases and 211 PCR-positive patients. RESULTS Among 211 PCR-positive patients, 40 (19%) patients were ever hookah users and 28 (13.3%) were ever cigarette smokers. Death occurred in 27 (12.8%) patients and severe COVID-19 in 17 (11.6%). Among 211 PCRpositive patients, ever cigarette smokers had 4.2 times (95% CI: 1.1-15.4, p=0.03) higher odds of ICU admission and 4.2 times (95% CI: 1.1-15.4, p=0.03) increased odds for need of ventilation, compared with non-smokers. Besides, ever hookah users had 3.9 times (95% CI: 1.1-13.6, p=0.03) higher odds for need of ventilation therapy, compared with non-hookah users. CONCLUSIONS Tobacco use and hookah smoking were associated with adverse outcomes among COVID-19 patients in Iran.