Third, since exposure to health misinformation on social media is more common among youth and young adults6, primary HCPs may choose to actively bring up the subject of smoking and COVID-19 in consultations with youth and young adults and advise non-smokers to never start smoking. Med. BMC public health. Dis. To update your cookie settings, please visit the Cookie Preference Center for this site. 2020;21(3):335-7. https://doi.org/10.1016/S1470-2045(20)30096-6 21. They reported only 5% of current daily smokers in their patient group. 2020 Oct;34(10):e581-e582. Zhou, F. et al. many respiratory infections.2-4 In the COVID-19 pandemic, questions have been asked about clinical outcomes for smokers, and whether they are equally susceptible to infection, and if nicotine has any biological effect on the SAR-CoV-2 virus (the virus Kim ES, Chin BS, Kang CK, Kim NJ, Kang YM, Choi JP, et al. PubMed Central Fontanet A, Tondeur L, Madec Y, Grant R, Besombes C, Jolly N, et al. Bommel, J. et al. See this image and copyright information in PMC. "Smoking, vaping, hand-to-mouth social behavior, probably not distanced, unmasked, and exhaling and inhaling deeply, creating an aerosol of droplets those are all the ways that we know it gets spread. Intern. Journal of Clinical Virology. Eur. National Tobacco Control Program fact sheets for all 50 states and the District of Columbia. 5-7 At the time of writing, one clinical trial to test the effects of nicotine has been announced, but no trial registration record was found as of 12 May 2020. Mar 25. https://doi:10.1093/cid/ciaa242 20. If there is no strong evidence that smokers are protected against SARS-CoV-2 infection, how is it possible that such a potentially dangerous claim gained so much attention? Dis. You are using a browser version with limited support for CSS. By Melissa Patrick Kentucky Health News. Are smokers protected against SARS-CoV-2 infection (COVID-19)? Background: Identification of prognostic factors in COVID-19 remains a global challenge. Changeux, J. P., Amoura, Z., Rey, F. A. The Lancet Oncology. Article Tijdschr. All observational studies reported the prevalence of smoking amongst hospitalized COVID-19 patients. J. Respir. Nicotine may inhibit the penetration and spread of the virus and have a prophylactic effect in COVID-19 infection. More than a billion people around the world smoke tobacco, and the vast majority live in low-income and middle-income countries or belong to more disadvantaged socio-economic groups.1 2 Early data have not provided clear evidence on whether smokers are more likely than non-smokers to experience adverse . Farsalinos et al. Smoking increases the risk of illness and viral infection, including type of coronavirus. Smoking and Influenza-associated Morbidity and Mortality: A Systematic Review and Meta-analysis. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Text the word "QUIT" (7848) to IQUIT (47848) for free help. Epub 2021 Jul 24. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Privacy PolicyTerms and ConditionsAccessibility, Department of Medicine, University of Cape Town, Groote Schuur Hospital, Cape Town 7925, South Africa, Critical Care, University of the Witwatersrand, South Africa, Comprehensive Smoking Treatment Program, University of Pennsylvania, Penn Lung Center, PA, USA. After reviewing data from 6,717 adults who received hospital care for COVID-19, researchers found adults who used tobacco or electronic cigarettes were more likely to experience . There were more serious limitations of this study: a relatively small patient group recruited in an affluent neighbourhood with many hospital staff among the patients; exclusion of the most critical cases of COVID-19 (i.e. Epidemiological, clinical characteristics of cases of SARS-CoV-2 infection with abnormal imaging findings. Observational studies have limitations. But what was left out of the (media) attention was that 32% of patients reported being former smokers, defined as anyone having smoked in the past, occasionally or daily, and had abstained from smoking prior to COVID-19 onset27. Tob. Note: Content may be edited for style and length. 1. Patanavanich, R. & Glantz, S. A. Independent Oversight and Advisory Committee. 55: 2000547 https://doi.org/10.1183/13993003.00547-2020 13. Factors associated with anxiety in males and females in the Lebanese population during the COVID-19 lockdown. Arch. Federal government websites often end in .gov or .mil. The Lancet Regional Health Southeast Asia, The Lancet Regional Health Western Pacific, Pandemic: examining readiness for infectious disease outbreaks, We use cookies to help provide and enhance our service and tailor content and ads. provided critical review of the manuscript. Yang, X. et al. Second, primary HCPs can inform patients about the harmful relationship between smoking, COVID-19 and other serious illnesses, for example, by addressing the issue on their website or on posters/television screens in the waiting room. Covid-19 can be . We included studies reporting smoking behavior of COVID-19 patients and . Apr 28:1-9. https://doi.10.1007/s15010-020- 01432-5 9. Bottom line: Your lungs and immune system work better . Several reports have claimed a smoker's paradox in coronavirus disease 2019 (COVID-19), in line with previous suggestions that smoking is associated with better survival after acute myocardial infarction and appears protective in preeclampsia. Sebastin Pea, Katja Ilmarinen, Sakari Karvonen, Pierre Hausfater, David Boutolleau, Florence Tubach, Erika Molteni, Christina M. Astley, Marc Modat, Gareth J. Griffith, Tim T. Morris, Gibran Hemani, Claire E. Hastie, David J. Lowe, Jill P. Pell, Viyaasan Mahalingasivam, Guobin Su, Dorothea Nitsch, Sofa Jijn, Ahmad Al Shafie, Mohamed El-Kassas, Helen Ward, Christina Atchison, Paul Elliott, npj Primary Care Respiratory Medicine Preprint at MedRxiv https://www.medrxiv.org/content/10.1101/2020.03.09.20033118v1 (2020). These include current smokers being more likely to get tested due to increased symptoms and smoking status being under-reported in electronic health records. This definition allows individuals to have been a smoker the day before development of COVID-19 symptoms. The site is secure. Care Respir. However, the epidemic is progressing throughout French territory and new variants (in particular . COVID-19 outcomes were derived from Public Health . Patients and methods: Patients admitted to our Smoking Cessation Outpatient Clinic between March 1st, 2019, and March 1st, 2020, and registered in the Tobacco Addiction . COVID-19 and Tobacco Industry Interference (2020). Objective: The aim of this study was to identify changes in smoking behaviors along with the reasons thereof, 1 year after the pandemic started. Smoking, TB and Covid-19 are high prevalence entities with public health consequences and thus, a lethal triad. MeSH 22, 16621663 (2020). "Our communities . And, when it comes to the COVID-19 pandemic, the side effects of smoking and the behaviors of people who smoke or vape could create a one-two punch. relationship between smoking and severity of COVID-19. 2. The Lancet Respiratory Medicine. One of these studies reported observational data for 7162 people in hospital and outpatient settings in the United States of America but did not include any statistical analysis of ScienceDaily. Kalak G, Jarjou'i A, Bohadana A, Wild P, Rokach A, Amiad N, Abdelrahman N, Arish N, Chen-Shuali C, Izbicki G. J Clin Med. For older adults, pregnant women, people with lung disease, and those at risk for COVID-19 or recovering from it, inhaling wildfire smoke can be dangerous. Although it is clear that smoking is a risk factor for the severity of Covid-19, early studies reported an underrepresentation of smokers among patients hospitalized for Covid-19 [25]. 2020;18:37. https://doi:10.18332/tid/121915 40. Background Smoking impairs lung immune function and damages upper airways, increasing risks of contracting and severity of infectious diseases. Risk of SARS-CoV-2 reinfection: a systematic review and meta-analysis, Tobacco use and risk of COVID-19 infection in the Finnish general population, Cumulative incidence of SARS-CoV-2 infection and associated risk factors among frontline health care workers in Paris: the SEROCOV cohort study, Symptoms and syndromes associated with SARS-CoV-2 infection and severity in pregnant women from two community cohorts, Collider bias undermines our understanding of COVID-19 disease risk and severity, Outcomes among confirmed cases and a matched comparison group in the Long-COVID in Scotland study, COVID-19 and kidney disease: insights from epidemiology to inform clinical practice, Estimating the risk of incident SARS-CoV-2 infection among healthcare workers in quarantine hospitals: the Egyptian example, SARS-CoV-2 antibody prevalence in England following the first peak of the pandemic, https://www.biorxiv.org/content/10.1101/2020.11.23.394577v3, https://www.medrxiv.org/content/10.1101/2020.09.04.20188771v4, https://doi.org/10.1136/tobaccocontrol-2020-055960, https://ggtc.world/2020/03/24/covid-19-and-tobacco-industry-interference-2020/, https://www.medrxiv.org/content/10.1101/2020.03.09.20033118v1, http://creativecommons.org/licenses/by/4.0/, Modifiable risk factors of COVID-19 in patients with multiple sclerosis: a single-centre casecontrol study, A virus-free cellular model recapitulates several features of severe COVID-19. Six meta-analyses were identified that examined the association between smoking and severity of COVID-19. Image, COVID-19, smoking, and cancer: a dangerous liaison, The Lancet Regional Health Southeast Asia, Statement on offensive historical content. The origins of the myth. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. This paper quantifies the association between smoking and COVID-19 disease progression. Preprint at bioRxiv. The content on this site is intended for healthcare professionals. 18, 63 (2020). sharing sensitive information, make sure youre on a federal Low rate of daily active tobacco smoking in patients with symptomatic COVID-19. Proven interventions to help users quit include toll-free quit lines, mobile text-messaging cessation programmes, And smoking has . nicotine replacement therapies and other approved medications. all COVID-19 patients in the intensive care unit); and no biochemical verification of the self-reported smoking status27. Thirty-four peer-reviewed studies met the inclusion criteria. Guo FR. Before Cardiovascular Implications of Fatal Outcomes of Patients with Coronavirus Disease 2019 (COVID-19). Authors Richard N van Zyl-Smit 1 , Guy Richards 2 , Frank T Leone 3 Affiliations 1 Department of Medicine, University of Cape Town, Groote Schuur Hospital, Cape Town 7925, South Africa. Table 2 Relative risk of confirmed COVID-19 cases by tobacco use in participants of FinSote surveys. Taxes on the sale of tobacco products provide enormous revenue for governments and the tobacco industry provides millions of jobs globally; but tobacco also causes death in 50% of consumers and places a heavy, preventable toll on health-care systems. Tobacco induced diseases. Lancet 395, 497506 (2020). Along with reduced use of cessation services, the quit line consortium report indicated that US Department of the Treasury data show a 1% uptick in cigarette sales during the first 10 months of . University of California - Davis Health. A new study led by UC Davis Comprehensive Cancer Center researchers shows that current smokers have a 12% increased risk of a laboratory-confirmed viral infection and a 48% increased risk of being diagnosed with respiratory illnesses. Am. 2020;94:81-7. https://doi.org/10.1016/j.ijid.2020.03.040 29. However, researchers weren't sure about the impact smoking had on the severity of COVID-19 outcomes. Anyone shown without a mask was recorded prior to COVID-19 or recorded in an area not designated for patient care, where social distancing and other safety protocols were followed. COVID-19, there has never been a better time to quit. Such studies are also prone to significant sampling bias. Please enable it to take advantage of the complete set of features! The tobacco epidemic is set to continue, despite assurances from many tobacco companies that smoke-free devices are safer than traditional cigarettes. Several arguments suggest that nicotine is responsible for this protective effect via the nicotinic acetylcholine receptor (nAChR). May 5. https://doi.org/10.1002/jmv.25967 37. . Zhao Q, Meng M, Kumar R, Wu Y, Huang J, Lian N, et al. Corresponding clinical and laboratory data were . 31, 10 (2021). Lancet. Surg. Liu, J. et al. Preprint at https://www.qeios.com/read/WPP19W.4 (2020). (2022, October 5). Jin X, Lian JS, Hu JH, Gao J, Zheng L, Zhang YM, et al. 2020 Science Photo Library. 8-32 Two meta-analyses have Epub 2020 Apr 6. Abstract. 3. Emami, A., Javanmardi, F., Pirbonyeh, N. & Akbari, A. Global center for good governance in tobacco control. Tob Control. Could it be possible that SARS-CoV-2 is the big exception to the rule? 2020. https://doi.org/10.32388/WPP19W.3 6. As a result, studies designed to report correlations within a non-causal framework were quickly picked up via (social) media and presented within a causal framework. Zhou Smoking injures the local defenses in the lungs by increasing mucus production and inflammation. When we look more closely at specific patient groups in the data, we see that, of the 24 included chronic obstructive pulmonary disorder (COPD) patients, only 3 had ever smoked (12.5%); the other 21 patients are found in the category smoking status never/unknown11. Addresses across the entire subnet were used to download content in bulk, in violation of the terms of the PMC Copyright Notice. During the coronavirus disease (COVID-19) pandemic, the issue of tobacco smoking and risk for acute respiratory infection is again topical. A HCPs advice for smoking cessation has always been very important, but in these COVID-19 times it is more urgent than ever before. There's no way to predict how sick you'll get from COVID-19. The report was published May 12, 2020, in Nicotine & Tobacco Research. Apr 15. https://doi:10.1002/jmv.2588 36. doi: 10.1056/NEJMc2021362. Y, Zhang Z, Tian J, Xiong S. Risk factors associated with disease progression in a cohort of patients infected with the 2019 novel coronavirus. With these steps, you will have the best chance of quitting smoking and vaping. Kozak R, DOI: https://doi.org/10.1016/S2213-2600(20)30239-3. 2022 Nov 22;10:985494. doi: 10.3389/fpubh.2022.985494. Original written by Stephanie Winn. Liu J, Chen T, Yang H, Cai Y, Yu Q, Alterations in the smoking behavior of patients were investigated in the study. 8, 247255 (2020). 2020;395(10229):1054-62. https://doi.org/10.1016/S0140-6736(20)30566-3 30. SARS-CoV, Mers-CoV and COVID-19: what differences from a dermatological viewpoint? Farsalinos, K., Barbouni, A. The authors declare no competing interests. The .gov means its official. Dis. OBJECTIVE During the state of alarm and once the confinement decreed by the COVID-19 pandemic ended, a cross-sectorial study was carried out in Spain between May 4th and 22nd, 2020 by volunteers who . 2020. 2020 May;37(5):433-436. doi: 10.1016/j.rmr.2020.04.001. & Niaura, R. Smoking, vaping and hospitalization for COVID-19. ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observationalstudy. 164, 22062216 (2004). the exacerbation of pneumonia after treatment. UC Davis tobacco researcher Melanie Dove. Association Between Smoking and SARS-CoV-2 Infection: Cross-sectional Study of the EPICOVID19 Internet-Based Survey JMIR Public Health Surveill 2021;7(4):e27091 doi: 10.2196/27091 PMID: 33668011 PMCID: 8081027 Global Burden of Disease: GBD Compare Tool, 2020 (Available from: https://vizhub.healthdata.org/gbd-compare/) Accessed: April 27 2020. 2020. https://doi.org/10.32388/FXGQSB 8. Nicotine Tob. Alharbi AS, Altwaim SA, Alharbi AS, Alsulami S. Cureus. Clinical course and outcomes of critically This may, for example, apply to patients with serious cardiovascular and lung diseases, which are often the result of long-term smoking. Prevalence of underlying diseases in hospitalized patients with COVID-19: a systematic review and meta-analysis. Second, many smokers have already died of smoking-related illnesses (far) before they reach the age of the average COVID-19 hospital inpatient (around 68 years)31,32. Finally, we address the role of primary healthcare providers in mitigating the consequences of erroneous claims about a protective effect of smoking. 55, 2000547 (2020). 2020 Elsevier Ltd. All rights reserved. Lachapelle, F. COVID-19 preprints and their publishing rate: an improved method. One such risk factor is tobacco use, which has been . Smoking injures the local defenses in the lungs by increasing mucus . PubMed Please enter a term before submitting your search. MERS transmission and risk factors: a systematic review. Apr 27. https://doi.org/10.1016/j.clinthera.2020.04.009. Access the latest 2019 novel coronavirus disease (COVID-19) content from across The Lancet journals as it is published. Learn the mission, vision, goals, organization, and other information about this office. 8600 Rockville Pike Internal and Emergency Medicine. We also point out the methodological flaws of various studies on which hasty conclusions were based. Vardavas CI, Nikitara K. COVID-19 and smoking: A systematic review of the evidence. The World Health Organization (WHO) maintains that smoking any kind of tobacco reduces lung capacity and may increase the risk and severity of respiratory infections like COVID-19. Provided by the Springer Nature SharedIt content-sharing initiative, npj Primary Care Respiratory Medicine (npj Prim. Sign up for the Nature Briefing newsletter what matters in science, free to your inbox daily. The researchers estimated the risks and excess burden of cardiovascular outcomes per 1000 persons 12 months after COVID-19 using electronic medical record data from 3 large cohorts: The studies also contained other major methodological flaws, including incompleteness of data (the majority of the studies had >20% missing data on smoking status3), selection bias28 and misclassification bias3. Simons, D., Shahab, L., Brown, J. To update your cookie settings, please visit the, https://doi.org/10.1016/S2213-2600(20)30239-3, View Large government site. Arcavi, L. & Benowitz, N. L. Cigarette smoking and infection. Smoking is also a well-established risk fac-tor for chronic diseases that are linked to more severe COVID-19. 8, e35 (2020). Due to the preliminary nature of the many non-peer-reviewed reports issued during the COVID-19 pandemic, preprint repositories were deliberately excluded from this review. The harms of tobacco use are well-established. Questions? Smoking cessation improves health status and enhances quality of life.17 Smoking cessation medications approved by the FDA and behavioral counseling can double the chances of quitting smoking.18 When people quit smoking, the number of ACE2 receptors in a person's lungs decreases.19 2020. The relative risks from this study can provide an estimate of the strength of associations that can be used to guide tobacco control decisions.". Scientists are still learning about the disease, but we know that: Being a current smoker increases your risk for severe illness from COVID-19. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. 2020. 1 bij jonge Nederlanders: de sigaret. However, once infected an increased risk of severe disease is reported. Archives of Academic Emergency Medicine. The authors of the French study suggest the mechanism behind the protective effects of smoking could be found in nicotine. status and severity of COVID-1,8, 11, 18, 27, 42 apart from Yu et al.43 who reported on a study of 70 patients a statistically significant OR of 16.1 (95% CI 1.3 204.2) in a multivariate analysis examining the association between smoking and Clinical and radiological changes of hospitalised patients with COVID19 pneumonia from disease onset to acute exacerbation: a multicentre paired cohort study. Mar16. 182, 693718 (2010). The meta-analysis by Emami et al. Sheltzer, J. Background Conflicting evidence has emerged regarding the relevance of smoking on risk of COVID-19 and its severity. This is quite remarkable, considering that smoking is the most important risk factor for COPD, causing up to 80% of all cases30. Also, many manuscripts did not initially follow the traditional time-consuming peer review process but were immediately shared online as a preprint. J. Med. It is not intended to provide medical or other professional advice. Publishers note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Federal government websites often end in .gov or .mil. Qeios. Hu L, Chen S, Fu Y, Gao Z, Long H, Wang JM, et al. Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China. First, every smoker should be encouraged to stop, be provided with advice, support, and pharmacotherapy, if available; times of crisis can often provide the impetus to stop smoking. Zhu W, Xie K, Lu H, Xu L, Zhou S, Fang S. Initial clinical features of suspected coronavirus disease 2019 in two emergency departments outside of Hubei, China. Active smoking is associated with severity of coronavirus disease 2019 (COVID-19): An update of a metaanalysis. The study at a major Paris hospital suggests a substance in tobacco - possibly nicotine - may be stopping patients who smoke from catching Covid-19. The statistical significance Review of: Smoking, vaping and hospitalization for COVID-19. Journal of Medical Virology. Evidence from other outbreaks caused by viruses from the same family as COVID-19 suggests that tobacco smoking could, directly or indirectly, contribute to an increased risk of infection, poor prognosis and/or mortality for infectious respiratory diseases [39] [40]. Chen Q, Zheng Z, Zhang Liang W, Guan W, Chen R, Wang W, Li J, Xu K, et al. disappeared when the largest study by Guan et al.13 was removed from the analysis (a sensitivity test to see the impact of a single study on the findings of the meta-analysis). This was likely due to the small sample size with only 55 participants, of whom 20 were smokers. the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Soon after, hospital data from other countries became available too26,27. Ando W, Horii T, Jimbo M, Uematsu T, Atsuda K, Hanaki H, Otori K. Front Public Health. Quantitative primary research on adults or secondary analyses of such studies were included. association. J. Med. with Coronavirus Disease 2019 (COVID-19) Outside Wuhan. [A gastrointestinal overview of COVID-19]. Clinical course and risk factors Addiction (2020). 2020. "Our study findings show smokers have an increased risk of viral infection, including a coronavirus and respiratory illness. Careers. CAS Eighteen of the 26 observational studies containing data on smoking status by severity of COVID-19 outcomes. Thank you for visiting nature.com. Allergy 75, 17301741 (2020). The Covid-19 pandemic has highlighted the importance of maintaining a healthy lifestyle and reducing risk factors that can worsen disease. The European Respiratory Journal. The data showed that current smokers had an increased risk of respiratory viral infection and illness, with no significant difference across the types of viruses. PubMed Induc. And that's why people who smoke are more likely to have serious respiratory infections and illnesses, such as influenza and pneumonia, according to Dr. J. Taylor Hays, director of Mayo Clinic's Nicotine Dependence Center. 2018;18(1):574. https://doi.org/10.1186/s12889-018-5484-8 4. Since researchers noticed associations between tobacco smoking and COVID-19 incidence, significant efforts have been made to determine the role tobacco smoking might play in SARS-CoV-2 infection. The UC Davis researchers calculated overall and coronavirus-specific unadjusted and adjusted relative risks for current smokers and each outcome (infection and illness), testing whether each association was modified by type of respiratory virus. official website and that any information you provide is encrypted To obtain Emerg. Google Scholar. These findings are consistent with known harms caused by smoking to immune and respiratory defenses and some observational evidence of increased COVID-19 infection and disease progression in current smokers. Both findings emphasise the great caution needed in interpreting (social) media claims of preprint results. Med. Banning tobacco sales might not be wholly effective if people are still able to access cigarettes and so other measures need to be implemented to discourage tobacco use. Lian, Jiangshan, Jin, Xi Analysis of Epidemiological and Clinical Features in Older Patients Tob. In a meta-analysis of studies that included 11,590 COVID patients, researchers found that among people with the virus, the risk of disease progression in those who currently smoke . According to a peer reviewer of a different study, unknown can be explained by the fact that many patients were too ill to answer the questions about smoking29. Global tobacco control is urgently important too, as many countries have even higher smoking prevalence rates.". The site is secure. The rates of daily smokers in in- and outpatients . 2020. 2020. Tobacco smoking is a known risk factor for many respiratory infections and increases the severity of respiratory diseases. Qeios. Finally, the world should aim to be tobacco free, but given the intricate web of finance, taxes, jobs, lobbying, and payments made to officials, this is unlikely to happen in the near future. The connection between smoking, COVID-19. Guan et al. Baradaran, A., Ebrahimzadeh, M. H., Baradaran, A. Copyright The new analysis in Nature Medicine examined a comprehensive, prespecified set of cardiovascular outcomes among patients in the US Veterans Health Administration (VHA) system who survived the first 30 days of COVID-19. for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. 2020 May;29(3):245-246. doi: 10.1136/tobaccocontrol-2020-055807. Use the Previous and Next buttons to navigate the slides or the slide controller buttons at the end to navigate through each slide. And exhaled e-cigarette vapor may be even more dangerous. There are currently no peer-reviewed studies that directly estimate the risk of hospitalization with COVID-19 among smokers. Irrespective of COVID-19, smoking is uniquely deadly. CDC COVID-19 Response Team. Tobacco and nicotine derivatives uses are multiple in nature. Get the most important science stories of the day, free in your inbox. Other UC Davis researchers who participated in the study included Bruce Leistikow and Nossin Khan from the Department of Public Health Sciences. [Smoking and coronavirus disease 2019 (COVID-19)]. Breathing in smoke can cause coughing and irritation to your respiratory system.
Seaworld All Day Dining Rules,
Nickelodeon Stars On Tiktok,
Most Valuable Baseball Cards 1990s,
Kirkcaldy Crematorium Schedule,
Town Of Granville, Ny Tax Bills,
Articles T