Introduction Current evidence indicates that smoking worsens COVID-19 outcomes. However, when studies restricted their analyses to current smokers, the risks for COVID-19 severity and death are inconsistent. This meta-analysis explored the association between current smoking and the risk for mortality based on the studies that reported all three categories of smoking (current, former, and never smokers) to overcome the limitation of the previous meta-analyses which former smokers might have been classified as non-smokers. Methods We searched PubMed and Embase up to 1 January 2021. We included studies reporting all three categories of smoking behaviors of COVID-19 patients and mortality outcomes. A random-effects meta-analysis and meta-regression were used to examine relationships in the data. Results A total of 34 articles with 35,193 COVID-19 patients was included. The meta-analysis confirmed the association between current smoking (OR 1.26, 95% CI: 1.01-1.58) and former smoking (OR 1.76, 95% CI: 1.53-2.03) with COVID-19 mortality. We also found that the risk for COVID-19 death in current smokers does not vary by age, but significantly drops by age in former smokers. Moreover, current smokers in non-high-income countries have higher risks of COVID-19 death compared with high-income countries (OR 3.11, 95% CI: 2.04-4.72 vs. OR 1.14, 95% CI: 0.91-1.43; p=0.015). Conclusions Current and former smokers are at higher risk of dying from COVID-19. Tobacco control should be strengthened to encourage current smokers to quit and prevent the initiation of smoking. Public health professionals should take the COVID-19 pandemic as an opportunity to promote smoking prevention and cession. Implications This study makes an important contribution to the existing literature by distinguishing between current and former smoking and their separate effects on COVID-19 mortality. We also explore the effects by age of patients and country income level. Findings from this study provide empirical evidence against misinformation about the relationship between smoking and COVID-19 mortality.

Background Most Thai transgender people (TG) do not use gender-affirming hormone therapy (GAHT) under medical supervision. Aim To understand the current real-world characteristics of GAHT among TG. Methods A cross-sectional survey was conducted using an online questionnaire between September and December 2020. TG, who resided in Thailand for more than 1 year, were included. Self-reported demographic data and characteristics of GAHT were obtained. The reported GAHT were compared to the reference regimen recommended by the 2017 Endocrine Society Clinical Practice Guideline. Outcomes The characteristics of GAHT used among TG and factors associated with hormonal use outside the reference regimen were reported. Results A total of 401 TG were included in the analysis. Of these, 249 (62%) were transgender men (TM). Most TM (81%) and transgender women (88%) were using GAHT. Only 297 TG provided a complete hormone regimen. A total of 224 TG (75%) used GAHT outside the reference regimen. The main reasons in TM were using intramuscular testosterone with a higher dose per injection and less frequent intervals. In transgender women, using oral contraceptive pills and cyproterone acetate 12.5 mg/d were the two most common reasons. A univariate analysis revealed factors associated with hormonal use outside the reference regimen, including age at a survey participation (OR 1.04, 95%CI 1.00–1.08, P = .047), age at hormone initiation (OR 1.04, 95%CI 1.01–1.08, P = .015), TM (OR 2.08, 95%CI 1.22–3.56, P = .007) and using GAHT, not under medical supervision (OR 1.78, 95%CI 1.04–3.05, P = .037). The multivariate analysis showed that only living outside the capital city was solely statistically significant (AOR 1.77, 95%CI 1.02–3.05, P = .041). Clinical Implications Enhancing health literacy in GAHT among TG is crucial, especially TG not living in the capital city. Strengths and Limitations This study demonstrates a current real-world practice of GAHT use among TG, both under and not under medical care. However, the causality could not be concluded due to the nature of the cross-sectional observation study, and results come with a recall bias. Conclusion There is a high prevalence of GAHT use outside the reference regimen. The only factor associated with hormonal use outside the reference regimen is living outside the capital city.