COVID-19: Why Are Kashmir’s Elderly More At Risk?

Among various other factors, that greatly increase the chances of getting infected to COVID-19, poor lung health among elderly population has been found to significantly increase the chances of contracting the viral disease, exacerbating the disease condition & poor prognosis to available treatment strategies. Hookah smoking is very common among majority of our elderly population & could have devastating consequences if the infection spreads in Kashmir.

Sheikh Umar Ahmad

Almost everyone’s grandfather starts his day with hookah smoking in Kashmir. It is not a new normal, but exists in Kashmir since times immemorial. Not so to everybody’s surprise, our majority elderly population suffers from metabolic disorders including obesity, cardiovascular problems, diabetes among various other issues that put them at greater risk of developing other associated comorbidities. There has been a significant increase among the population both old & young who take to smoking including the traditional hookah as a means of stress buster in the conflict zone of Kashmir.

Smoking of any form significantly reduces the lung hygiene, immunity & puts one at a greater risk of developing cancer & other infective disorders. This might be the best time for smokers to try and quit or cut down smoking, because the World Health Organisation (WHO) suspect positive correlation of smoking and contracting COVID-19 disease and that people with smoking habits are more prone to coronavirus infection. And the reason is simple- smoking cigarettes or vaping affects one’s lungs, thereby increasing the chances of a smoker developing serious condition on contracting the infection.

The WHO, in its FAQ’s section on coronavirus infection have put forth that smokers are likely to be more vulnerable to COVID-19 as the act of smoking greatly increases the possibility of transmission of the virus from hand to mouth and afterwards when a person touches anything that later on comes in contact to other uninfected person. Moreover, as it is already know that smoking reduces the lung function or reduce the lung capacity, increases the inflammatory markers which would greatly increase the risk of serious illnesses & hence the chances of getting infections as in the present case coronavirus becomes more complicated, reveals Dr. Adarsh Pratap Singh, Senior Resident and President, Resident Doctors’ Association, All India Institutes of Medical Sciences (AIIMS). So, in cases where people are infected with the coronavirus, the chances of those with a history of smoking or an existing habit may lead to the development of a severe infection & may be the reason why there is both high contraction & high mortality rate among elderly population world over. Furthermore, the oxygen exchange alveolar cells in the lungs of smokers are already damaged to quite an extent, depending on the degree and frequency of their smoking habit, making them more predisposed at developing more severe symptoms on getting infected to COVID-19.

As per Quit, a cancer program run by the Cancer Council Victoria in association with the Australian Department of Health, state that smokers are generally at higher risk of respiratory tract infections, like lung and chest infections, but there is currently not enough evidence & more studies are required to establish & to be certain that people who smoke are at higher risk of being infected with the coronavirus (COVID-19). However, it is a concluding fact that people with poor lung function as a result of smoking or anything else, may be at higher risk of complications if they do become infected with the virus.

Furthermore, Dr. Stanton A Glantz, Professor of Medicine at the Center for Tobacco Control Research and Education, quotes in an article in the Scientific American, that stopping smoking in the current circumstances while also avoiding secondhand exposures would be a sensible thing to do as we don’t have much details available yet how the pre-dated exposure to smoking greatly impacting the respiratory health could be contributing in disease contraction & poor prognosis. Hypotheses and associations are being drawn between the infections and smoking, it is important that there is no evidence yet that points to causation. This means that while smoking may act as a risk factor or increase the chances of a COVID-19 patient developing a severe infection, but given the fact that there is no established cause and effect relationship between the two, we can predict on theoretical considerations that smoking may have an impact in pushing it further, the COVID-19 disease.   

As we know that more severe covid-19 infections often feature pneumonia, an infection in the lungs that causes swelling and sometimes difficulty breathing and some of the cases even worsen further and produce acute respiratory distress syndrome (ARDS) in which fluid in the lungs blocks breathing, requiring intensive care and sometimes leading to death. Earlier research in this line has shown that smokers tend to be more prone to pneumonia, including its most severe and deadly forms. There is fairly strong evidence that air pollution increases the risk of acute low respiratory infections and is thought of that it may have contributed to the extent of the outbreak in Wuhan & this potential link between air quality in Wuhan and the novel coronavirus outbreak requires further studies to establish the fact. As of now, we can predict on theoretical considerations that there may be both short term & long term effects associated with smoking that could be negatively affecting the treatment prognosis of patients contracting COVID-19 as well as the differential contraction of disease among younger & elderly population, given the fact that elderly population is associated with other long term disease conditions including metabolic syndrome among others. Similarly, smoking leads to heart and lung disease, which also leaves one predisposed towards worse covid-19 outcomes but doesn’t establish directly that smoking/air pollution worsens COVID-19 and would need to be evaluated in further studies.

Now taking a curious case of Kashmiris. We are well aware of the fact that hookah smoking among elderly population is at all time high in Kashmir & cigarette smoking among younger population is even higher than the national average. Previous studies conducted have shown that about a sixth of the population aged 74 years in Kashmir has Stage I or higher chronic airflow limitation (CAL), but that only 0.73% report doctor-diagnosed COPD, (Chronic Obstructive Pulmonary Disorder). Further, previous peak flow meter-based survey reported a prevalence of chronic bronchitis in Kashmir of 7.7%, with higher prevalence among smokers and those living in poorly ventilated houses. The single most important cause of airflow obstruction has been reported to be mostly due to smoking, particularly due to traditional hookah smoking among the older population. It has also been reported earlier that hookah smoking confers a higher risk of lung cancer compared to cigarette smoking may be an important contributory factor in causing Chronic airflow limitation as well.

These earlier studies conducted so far with regard to assessing the poor lung health among elderly population in Kashmir addicted to hookah smoking has revealed interesting facts that majority of the population in Kashmir are used to Hookah smoking more so, our elderly population. The lung hygiene among the same population group concerned is very poor & most are suffering due to chronic airflow limitation that ultimately lead to chronic obstructive pulmonary disorder & thereby reducing the functional capacity of lungs. Now given the facts as have been revealed from small preliminary studies and as released by WHO from time to time, since the coronavirus epidemic has swirled across globe. People with poor lung hygiene representing the elderly population in any population group, have been found to be more predisposed at contracting coronavirus disease and are also found to develop more severe pneumonic symptoms that has greatly contributed in increasing the mortality rate among elderly population.

Majority of population in Kashmir is in the senior age group and as most of them are addicted to hookah smoking and this presents a grim picture . It may also slightly change the mortality curve if we consider the prevalence of hookah smoking in Kashmir and its positive correlation with coronavirus mortality rate as predicted from preliminary findings. Before we see anything like that in Kashmir if it takes an epidemic shape & in absence of any scientific proof available yet regarding the correlation of smoking & contracting coronavirus disease among elderly’s, it is imperative that we strictly adhere to health advisories issued time to time by WHO as well as by our local healthcare authorities to reduce the chances of infection. It is clear to a certain degree that previous active history of smoking greatly impacts the disease outcomes, what we can do meanwhile is to avoid rush, avoid gatherings, stay at our homes, so that anything worst can be prevented from happening in absence of any well off healthcare facilities available at our disposal.

P.S: This is a theoretical prediction based on key scientific findings available on the subject; original facts may be different as facts unfold.

References:

WHO updates on Novel COVID-19.

Koul PA, Hakim NA, Malik SA, et al. Prevalence of chronic airflow limitation in Kashmir, North India: results from the BOLD study. Int J Tuberc Lung Dis. 2016;20(10):1399–1404. doi:10.5588/ijtld.15.0968.

• Nazir Ahmad Lone, Tanveer Ahmad Malik and Shahid Hussain Naikoo contributed to this report. Authors are working as senior reseach fellows in Experimental Toxicology at CSIR – Indian Institute of Integrative Medicine Jammu, Jammu & Kashmir.

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