https://doi.org/10.15218/ejnm.2025.04 Erbil j. nurs. midwifery, Vol. 8, No. (1), May 2025 Original Article COVID-19 among Smokers and Non-smokers in Erbil City, Kurdistan Region, Iraq ABSTRACT Background and objectives: Coronavirus disease (COVID-19), a severe respiratory syn- drome caused by a novel strain of coronavirus (SARS-CoV-2), became a global public health concern and was declared a pandemic by WHO. The associations between smoking and COVID-19 infection and the outcomes were ambiguous. This study aimed to deter- mine the associations of self-reported confirmed cases of COVID-19 among smokers and to compare it with the rate among non-smokers in Erbil City. Methods: This cross-sectional house survey was conducted between September 2021 and June 2022 through a multi-stage cluster sampling method on a sample of 2601 respond- ents in Erbil city through direct interviews using a specially designed questionnaire to col- lect data. Results: The mean age was 38.75 + 13.79 years (range 18 to 76 years). More than half (58.9%) of the sample were males. The proportion of current daily smokers was 44.3%, and 33.2% were those who had never smoked before. 17.5% of the sample were infected by the COVID-19 virus during the pandemic. There was a statistically significant associa- tion between the occurrence of COVID-19 and the age, gender, marital status, education level, occupation, smoking status, and socioeconomic level of participants. Conclusion: The occurrence of COVID-19 among smokers was significantly higher than among non-smokers. A statistically significant association was found between self- reported confirmed cases of COVID-19 and the age, gender, marital status, education lev- el, occupation, smoking status, and socioeconomic level of participants. Keywords: Smoking; Household; Survey; COVID-19; Non-smokers Kareem Jamal Hamad; Department of Nursing, Soran Technical College, Erbil Polytechnic University, Kurdistan Region, Iraq (Correspondence: kareem.hamad@epu.edu.iq) Namir Ghanim Al-Tawil; Department of Community Medicine, College of Medicine, Hawler Medical University, Erbil, Kurdistan Region, Iraq. 30 Received: 28/04/2024 Accepted: 18/12/2024 Published: 30/05/2025 Copyright ©2025The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:kareem.hamad@epu.edu.iq?subject=kareem.hamad@epu.edu.iq mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.04 Erbil j. nurs. midwifery, Vol. 8, No. (1), May 2025 Original Article Since being reported in China in late De- cember 2019, coronavirus disease (COVID- 19), which is a severe acute respiratory syndrome caused by a novel strain of coro- navirus (SARS-CoV-2) became a global pub- lic health concern and then on March 11, 2020, WHO declared COVID-19 a pandemic [1]. Although at first associations between smoking and COVID-19 infection and the outcomes were ambiguous, to date the reported data about tobacco smoking and COVID-19 disease adverse prognosis re- main controversial [2]. Smoking is the greatest risk factor for developing chronic obstructive pulmonary disease (COPD) leading to pulmonary inflammation. Smok- ing in addition to COPD is related to all- cause mortality due to cancer (mainly lung cancer) [3], other respiratory infections, and cardiovascular disease [4, 5]. Up to re- searchers' knowledge, it was necessary to evaluate the smoking status and the risk of coronavirus infection. As a result, this cross -sectional house survey was carried out to determine the association between self- reported confirmed cases of COVID-19 among smokers and to compare it with the rate among non-smokers. A descriptive cross‐sectional household survey was carried out among a sample of residents in Erbil city to determine the as- sociations of self-reported confirmed cases of COVID-19 among smokers and to com- pare it with the rate among non-smokers. The study was conducted in Erbil city, the capital of the Kurdistan Region-Iraq, be- tween September 1, 2021, and June 30, 2022.A sample of 2601 residents of both genders, aged 18 years or over, who gave their consent to participate in the study, comprised the sample selected using a multi-stage cluster sampling method, and 25% of quarters in each municipality were chosen randomly based on the administrative map of the city, and then through the systematic random sampling method, households in each quarter were selected (Table 1). Data was collected through direct interviews with the participants using a specially designed questionnaire comprising socio- demographic and economic features, besides smoking-related questions. Smoking status was determined using the WHO criteria for smoking as a current daily smoker, an occasional smoker, an ex- smoker, and a never-smoker [6]. The socioeconomic level of participants was calculated based on the socioeconomic index for health research in Iraq [7].Data were analyzed using the SPSS software (version 25). Means were calculated to summarize numerical variables and proportions for the categorical variables. The Chi-square test was used to compare the proportions. A p-value of ≤ 0.05 was considered statistically significant. Ethical approval for this study was granted by the Ethics Committee of the College of Medicine, Hawler Medical University (2020/11/4, Number 7). Informed consent was provided by all participants; verbal consent was taken from all the samples and they had been informed about the purpose of the study. 31 Copyright ©2025 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. INTRODUCTION METHODS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.04 Erbil j. nurs. midwifery, Vol. 8, No. (1), May 2025 Original Article A total of 795 (30.6%) were semi-skilled manual workers, and 1182 (45.4%) per- ceived that their economic situation was from middle socioeconomic levels (Table 2). The mean age + SD was 38.75 + 13.790 years. About one-quarter (25.1%) of the sample were 50 or older. More than half (58.9%) were males and married (57.1%). Concerning education level, 30% were illit- erate or had a primary education level. 32 Copyright ©2025The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. RESULT Table 1: Distribution of the required sample according to the Erbil quarters Municipality Municipality population 250/100,000 No. of quarters 25% of quarters No. of sample/ quarter Required Sample M 1 45576 147.048556 11 3 49 147 M 2 96276 310.629405 22 6 52 311 M 3 110964 358.019457 26 7 51 358 M 4 338100 1090.86170 34 9 121 1091 M 5 97884 315.817532 23 6 53 316 M 6 117040 377.623349 25 6 63 378 Total 805840 2,599.9999 141 37 2601 Table 2: Distribution of the study population by socio-demographic characteristics Variables No. (%) Age Groups Less than 20 176 (6.8) 20 - 29 647 (24.9) 30 - 39 597 (23) 40 - 49 525 (20.2) 50 and more 656 (25.1) Gender Female 1069 (41.1) Male 1532 (58.9) Marital Status Single 984 (37.8) Married 1485 (57.1) Divorced 21 (0.8) Widowed 111 (4.3) Education Illiterate/ Primary 781 (30) Intermediate 306 (11.8) High school or vocational 469 (18) Graduates* 1045 (40.2) Occupation Unskilled manual 534 (20.5) Semi-skilled manual 795 (30.6) Skilled manual 693 (26.6) Others** 579 (22.3) Socioeconomic Level Low 1134 (43.6) Middle 1182 (45.4) High 285 (11) Total 2601 (100) * Including Institute, College, and higher education ** Including associate professionals, skilled or highly professionals, and senior managers https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.04 Erbil j. nurs. midwifery, Vol. 8, No. (1), May 2025 Original Article As presented in Table 3, more than 44% of the participants were current daily smok- ers, 14.5% were occasional smokers, 8% were ex-smokers and about one-third (33.2%) never smoked. A total of 460 (30.1%) of the sample started cigarette smoking at the age of 15-19 years, while the lowest rate, 87 (5.7%) indicated less During the COVID-19 pandemic, 17.5% of the study population was infected by the virus. The majority of those infected by the Virus (87%) stopped smoking during the than 15 years. Less than half (46.6%) of the participants have ever tried waterpipe smoking; 835 (68.9%) started waterpipe smoking at an age of fewer than 30 years. Regarding the frequency of waterpipe smoking, the highest rate (37.2%) smoked waterpipe every day. disease period, but mostly (almost all of them) (99.2%) returned to smoking after recovery (Table 4). 33 Copyright ©2025 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 3: Distribution of the study population by smoking-related characteristics Variables No. (%) Smoking Status (n=2601) Current daily smoker 1153 (44.3) Occasional smoker 376 (14.5) Ex-smoker 207 (8) Never smoker 865 (33.2) Age of starting cigarette smoking (n=1529) Less than 15 87 (5.7) 15 – 19 460 (30.1) 20 – 24 440 (28.7) 25 – 29 290 (19) 30 and more 252 (16.5) Ever tried waterpipe smoking? (n=2601) No 1390 (53.4) Yes 1211 (46.6) Age of starting waterpipe smoking (n=1211) Less than 15 21 (1.7) 15 – 19 241 (19.9) 20 – 24 333 (27.5) 25 – 29 240 (19.8) 30 and more 376 (31.1) Frequency of Waterpipe smoking (n=1211) Everyday 450 (37.2) Once Weekly 193 (15.9) Once every 2-4 days 381 (31.5) Sometimes 187 (15.4) Table 4:Distribution of the study population by COVID-19-related characteristics Variables No. (%) During the COVID-19 pandemic been infected by the virus? (n=2601) No 2147 (82.5) 454 (17.5) If Yes, did you stop smoking during the disease period? (n=454) No 59 (13) 395 (87) Returned to smoking after symptoms disappeared? (n=395) No Yes 3 (0.8) 392 (99.2) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.04 Erbil j. nurs. midwifery, Vol. 8, No. (1), May 2025 Original Article 34 than among non-smokers (0.7%). The in- fection with COVID-19 was slightly higher among the age group 40-49 years com- pared to the other age groups, divorced, skilled manual /non-manual workers, and participants who were from high socioec- onomic levels. Table 5 shows that the occurrence of COVID-19 was significantly (P= 0.001) high- er among males (24.5%) than among fe- males (7.3%) and among those from the intermediate education level (26.5%) than the other groups. The confirmed cases of COVID-19 among smokers were (29.2%) which was significantly (P= 0.001) higher Copyright ©2025 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 5:Infection with COVID-19 by socio-demographic characteristics of the sample Variables Infected by COVID-19 Total P-value Yes No No. (%) No. (%) Age Groups Less than 20 19 (10.8) 157 (89.2) 176 0.012 20 - 29 126 (19.5) 521 (80.5) 647 30 - 39 105 (17.6) 492 (82.4) 597 40 - 49 106 (20.2) 419 (79.8) 525 50 and more 98 (14.9) 558 (85.1) 656 Gender Female 78 (7.3) 991 (92.7) 1069 0.001 Male 376 (24.5) 1156 (75.5) 1532 Marital Status Single 182 (18.5) 802 (81.5) 984 0.001 Married 264 (17.8) 1221 (82.2) 1485 Divorced 4 (19) 17 (81) 21 Widowed 4 (3.6) 107 (96.4) 111 Education Illiterate/ Primary 113 (14.5) 668 (85.5) 781 0.001 Intermediate 81 (26.5) 225 (73.5) 306 High school or vocational 93 (19.8) 376 (80.2) 469 Graduates* 167 (16) 878 (84) 1045 Occupation Unskilled manual 69 (12.9) 465 (87.1) 534 0.002 Semi-skilled manual 138 (17.4) 657 (82.6) 795 Skilled manual /non-manual 148 (21.4) 545 (78.6) 693 Others** 99 (17.1) 480 (82.9) 579 Smoking No 7 (0.7) 1065 (99.3) 1072 0.001 Yes 447 (29.2) 1082 (70.8) 1529 Socioeconomic Level Low 167 (14.7) 967 (85.3) 1134 0.006 Middle 231 (19.5) 951 (80.5) 1182 High 56 (19.6) 229 (80.4) 285 Total 454 (17.5) 2147 (82.5) 2601 * Including institute, college, and higher education ** Including associate professionals, skilled or highly skilled professionals, and senior managers. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.04 Erbil j. nurs. midwifery, Vol. 8, No. (1), May 2025 Original Article ICU admission, which was 88% lower in heavy smokers compared to non-smokers [15]. In contrast, a study reported that cur- rent smoking was independently associat- ed with self-reported confirmed COVID-19 infection [2]. Additionally, several studies revealed a substantial association between smoking history and several negative out- comes, such as severe COVID-19 and mor- tality [16-18]. The occurrence of COVID-19 among smok- ers was significantly higher than among non-smokers. A statistically significant as- sociation was found between self-reported confirmed cases of COVID-19 and age, gen- der, marital status, education level, occu- pation, smoking status, and socioeconomic level. The authors report no conflict of interest. This study is authors-based funded. (1) Shastri MD, Shukla SD, Chong WC, Kc R, Dua K, Patel RP, et al. Smoking and COVID-19: What we know so far. Respiratory Medicine. 2021 Jan;176:106237. doi: 10.1016/ j.rmed.2020.106237. Epub 2020 Nov 19. PMID: 33246296; PMCID: PMC7674982. (2) Jackson SE, Brown J, Shahab L, Steptoe A, Fancourt D. COVID-19, smoking and inequal- ities: a study of 53 002 adults in the UK. To- bacco Control. 2021 Dec;30(e2):e111-e121. doi: 10.1136/tobaccocontrol-2020-055933. Epub 2020 Aug 21. PMID: 32826387. (3) Biondini D, Semenzato U, Bonato M, Tinè M, Bazzan E, Damin M, et al. Lymphopenia is linked to an increased incidence of cancer in smokers without COPD. European Respirato- ry Journal. 2019;54(suppl 63):PA2586. DOI: 10.1183/13993003.congress-2019.PA2586 (4) Aikphaibul P, Theerawit T, Sophonphan J, Wacharachaisurapol N, Jitrungruengnij N, Puthanakit T. Risk factors of severe 35 The study found that below half of the participants were from the middle socio- economic level. This result is consistent with a study on a group of men in Mosul, Iraq [8]. In this study, (44.3%) were cur- rent daily smokers. Numerous studies demonstrate a substantial variance in the reported prevalence of current smoking, (40.08%) in Saudi Arabia [9], and (26.4%) in Libya [10]. The discrepancies in the re- ported prevalence of smoking may be ex- plained by the various study sites, sample frames, demographics of the enrolled populations, and cultural and religious considerations. Self-reported cases of COVID-19 during the pandemic were about (17.5%). The majority of those in- fected by the virus (87%) stopped smok- ing during the disease period but most (99.2%) returned to smoking after recov- ery. The infection by the COVID-19 virus was significantly higher among the age group 40-49 years (20.2%), males (24.5%), divorced (19.0%), and those with an inter- mediate education level (26.5%). In this study, infection by the COVID-19 virus was significantly more (21.4%) among partici- pants who worked in skilled manual or non-manual occupations; furthermore, COVID-19 among smokers (29.2%) was significantly higher than among non- smokers (0.7%). The reported role and association of smoking with COVID-19 are highly controversial. Several studies agreed that COVID-19 was more prevalent among smokers than non-smokers [2, 11, 12], while the opposite result was report- ed by other studies [13, 14]. A prospective cohort study conducted early in the pan- demic about the risk of severe COVID-19 disease among 8.3 million participants in the UK observed that smokers had a no- ticeably lower probability of developing COVID-19 disease and being admitted to the ICU and reported the incidence of Copyright ©2025The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Discussion CONCLUSION CONFLICT OF INTEREST FUNDING References https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.04 Erbil j. nurs. midwifery, Vol. 8, No. (1), May 2025 Original Article (13) Lippi G, Henry BM. Active smoking is not associated with severity of coronavirus dis- ease 2019 (COVID-19). European Journal of Internal Medicine. 2020 May;75:107-108. doi: 10.1016/j.ejim.2020.03.014. (14) Hopkinson NS, Rossi N, El-Sayed Moustafa J, Laverty AA, Quint JK, Freidin M, et al. Cur- rent smoking and COVID-19 risk: results from a population symptom app in over 2.4 million people. Thorax. 2021 Jul;76(7):714- 722. doi: 10.1136/thoraxjnl-2020-216422. (15) Hippisley-Cox J, Young D, Coupland C, Chan- non KM, Tan PS, Harrison DA, et al. Risk of severe COVID-19 disease with ACE inhibitors and angiotensin receptor blockers: cohort study including 8.3 million people. Heart. 2020 Oct;106(19):1503-1511. doi: 10.1136/ heartjnl-2020-317393. (16) Williamson EJ, Walker AJ, Bhaskaran K, Ba- con S, Bates C, Morton CE, et al. Factors as- sociated with COVID-19-related death using OpenSAFELY. Nature. 2020 Aug;584 (7821):430-436. doi: 10.1038/s41586-020- 2521-4. (17) Ponsford MJ, Gkatzionis A, Walker VM, Grant AJ, Wootton RE, Moore LSP, et al. Car- diometabolic Traits, Sepsis, and Severe COVID-19: A Mendelian Randomization In- vestigation. Circulation. 2020 Nov 3;142 (18):1791-1793. doi: 10.1161/ CIRCULATIONAHA.120.050753. (18) Jiménez-Ruiz CA, López-Padilla D, Alonso- Arroyo A, Aleixandre-Benavent R, Solano- Reina S, de Granda-Orive JI. COVID-19 y tabaquismo: revisión sistemática y metaa- nálisis de la evidencia [COVID-19 and Smok- ing: A Systematic Review and Meta-Analysis of the Evidence]. Archivos de Bronconeumo- logia. 2021 Jan;57:21-34. Spanish. doi: 10.1016/j.arbres.2020.06.024. hospitalized respiratory syncytial virus infec- tion in tertiary care center in Thailand. In- fluenza and Other Respiratory Viruses. 2021 Jan;15(1):64-71. doi: 10.1111/irv.12793. (5) Yoon JG, Noh JY, Choi WS, Lee J, Lee JS, Wie SH, , et al. A comparison of epidemiology and clinical outcomes between influenza A H1N1pdm09 and H3N2 based on multicen- ter surveillance from 2014 to 2018 in South Korea. Influenza and Other Respiratory Vi- ruses. 2021 Jan;15(1):99-109. doi: 10.1111/ irv.12795. (6) Nasser AMA, Zhang X. Knowledge and fac- tors related to smoking among university students at Hodeidah University, Yemen. Tobacco Induced Diseases. 2019;17:42. doi: 10.18332/tid/109227. (7) Omer W, Al-Hadithi T. Developing a socioec- onomic index for health research in Iraq. Eastern Mediterranean Health Journal. 2017;23(10):670-677.doi: 10.26719/2017.23.10.670. (8) Ahmed RR, Al-Tawil NG. Role of obligatory banning of smoking in 2014 - 2016 on the smoking habits of a group of men in Mosul, Iraq. Zanco Journal of Medical Sciences. 2021 Aug. 9;25(2):577-85. Available from: https://zjms.hmu.edu.krd/index.php/zjms/ article/view/842 (9) Albangy FH, Mohamed AE, Hammad SM. Prevalence of smoking among male second- ary school students in Arar City, Saudi Ara- bia. Pan African Medical Journal. 2019 Apr 8;32:156. doi: 10.11604/ pamj.2019.32.156.18558. (10) El Shareif HJ. Prevalence, pattern, and atti- tudes of smoking among libyan diabetic males: A clinic-based study. Ibnosina Journal of Medicine and Biomedical Sciences. 2019;11(4):171-175. Available from: https:// doi.org/10.4103/ijmbs.ijmbs_37_19 (11) Zhang H, Ma S, Han T, Qu G, Cheng C, Uy JP, et al. Association of smoking history with severe and critical outcomes in COVID-19 patients: A systemic review and meta- analysis. European Journal of Integrative Medicine. 2021 Apr;43:101313. doi: 10.1016/j.eujim.2021.101313. (12) Tattan-Birch H, Perski O, Jackson S, Shahab L, West R, Brown J. COVID-19, smoking, vap- ing and quitting: a representative popula- tion survey in England. Addiction. 2021 May;116(5):1186-1195. doi: 10.1111/ add.15251. 36 Copyright ©2025 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/