The Society of Thoracic Surgeons

Smoking Increases Risk for COVID-19 Complications—So It’s a Great Time to Quit

14-Apr-2020 4:05 PM EDT, by The Society of Thoracic Surgeons

By Matthew A. Steliga, MD

(originally published on The Patient Guide to Heart, Lung, and Esophageal Surgery from The Society of Thoracic Surgeons)

The effects of the COVID-19 pandemic, sometimes referred to as the coronavirus, have touched nearly every community around the world. Many areas continue to see sharp rises in the number of cases, with more than 1.6 million confirmed cases and 97,000 deaths at the time this article was published.

This is undoubtedly the largest pandemic to sweep the globe in generations. Our information technology has given researchers the ability to learn about this disease in real time as it evolves and moves around the world. We are fortunate to have constantly updated data, and scientists continually are learning about ways to decrease disease transmission and the risk factors that are linked with poorer outcomes.

Risk Factors for Complications

Anyone, even younger people, can require hospitalization or die from COVID-19, but we have learned that those with advanced age, chronic lung or heart disease, diabetes, and obesity are at increased risk. People with weakened immune systems from chemotherapy, diseases affecting their immune system, or medications that suppress immune function also can have increased risk of poorer outcomes from COVID-19.

While some risk factors cannot be changed, one particular risk factor can change—smoking or vaping.

Smoking and Lung Infections

As COVID-19 is a virus that primarily attacks the lungs, anything that harms the lungs can weaken patients and result in more severe effects if people do become infected. It is well known that smoking results in worse outcomes in people with pneumonia or influenza, and we are learning that smoking can pose significant risks in those with COVID-19.

Our lungs continually are exposed to fungi, bacteria, and viruses in the air, but we have mechanisms in place to help defend our bodies from infection. The mucus that lines our airways provides an effective barrier to capture these infectious agents, and tiny hairs on the cells lining our windpipes called cilia work to move that mucus up and out of the lungs.

Smoking creates thicker mucus that is harder to move and paralyzes the cilia, making it impossible to transport that mucus up and out. This leads to more particles and infectious agents trapped in the lungs and more difficulty in clearing out this material. Those who smoke have a greater chance of getting respiratory infections, and when one does have an infection, it is harder to recover from it. Even an occasional cigarette or secondhand smoke has been linked to increased risks from acute respiratory distress syndrome.

Researchers looking at COVID-19 and smoking have limited data thus far, but one early report from China evaluated 78 hospitalized patients (39 men, 39 women) with COVID-19 and assessed risk factors in patients who progressed versus those who improved or stabilized. They found the odds of COVID progression (requiring a higher level of care, ventilator, and/or death) during hospitalization to be 14 times higher in those with a smoking history. Death rates in China are higher in men versus women, and it is postulated that higher smoking rates in men in that country may be implicated.

Electronic Cigarettes

Electronic cigarettes have gained popularity in many countries. Some users incorrectly perceive that e-cigarettes have no risk of harm. However, use of e-cigarettes can suppress immune function, and some research suggests that it impairs mucus clearance and the body’s ability to fight infection.

We do not have clear long-term data about e-cigarette use and COVID-19, but it is agreed that the best way to avoid complications from COVID-19 is to keep your lungs as clean and healthy as possible.

How to Quit

Some people are able to quit unaided or “cold turkey” by stopping abruptly. This may be the simplest method of cessation, but many are unable to remain abstinent without some type of support or assistance.

During a time that COVID-19 is sweeping through many communities, there are some aspects of this pandemic that could be barriers to cessation, whereas some actually may support cessation. Social distancing and staying at home is automatically associated with not congregating in bars and other places where people may smoke as part of social interaction. People are encouraged to leave their homes only for essentials like groceries. Financial difficulties may provide a greater incentive to kick a costly habit. However, boredom, anxiety, and stress associated with health and economic challenges may increase cravings.

​Fortunately, many resources that can help people quit smoking or vaping are free and accessible at home, either online or by telephone. Every state in the US and nearly every country has a telephone quit line that provides free guidance from trained experts. Some also will mail nicotine patches, gum, or lozenges to enrollees.

The phone number in the US is 1-800-QUIT-NOW (1-800-784-8669), which automatically will route to your state’s cessation program based on your location. Many other resources exist online, including information from the CDC, a text messaging program, and smartphone apps.

Cessation Medications

In addition to counseling or support from an app or other program, many who smoke or use e-cigarettes benefit from medications to support a quit attempt. The most common type of medications are in the category of nicotine replacement therapy (NRT), which are tested, approved, and safe ways of delivering nicotine in measured amounts to improve chances of quitting.

The most common types of NRT are nicotine patches, which are slow-acting forms of NRT that provide a steady amount of nicotine for several hours and can decrease cravings. Gum or lozenge forms of NRT provide a faster-acting delivery of nicotine, which can help when cravings hit. NRT patches, gum, and lozenges are all available in the US over-the-counter in pharmacies and some grocery stores. Specific advice regarding side effects is available online or can be discussed with a pharmacist or cessation expert through the quit line, but in general, NRT medications are not harmful and certainly safer than smoking.

Some studies demonstrate a benefit to using “combination NRT” with a long-acting patch used as a baseline dose, supplemented with either a gum or lozenge for breakthrough cravings. Speak with a physician, cessation counselor, or pharmacist for guidance about combination NRT strategies.

Also available are an FDA-approved nicotine nasal spray and nicotine inhaler, both of which are available only by prescription. These have more side effects of nasal or mouth irritation and usually are not the first type of NRT to be recommended. Medications such as varenicline or bupropion are available by prescription and also can improve cessation success rates. Speak with your doctor about whether they may be right for you.

Benefits of Cessation

At this point, we are seeing the public health impact of COVID-19 and certainly are concerned about mitigating risks in the short term. Decreasing incidence of COVID-19 infections through distancing and less contact is crucial.

Smoking cessation may play a role in reducing risk of infection and decreasing severity for those who do get it. For those who quit and improve lung function, this could theoretically make a difference between someone who is hospitalized and stabilizes versus someone who progresses to need intensive care. We constantly are learning about best practices of treating this viral pandemic. Much is still unknown, but we do know that changes to improve lung function and decrease risk could help a patient recover more quickly.

The benefits of cessation will not end when this pandemic passes. For those who quit smoking now, there are innumerable health benefits that will impact people for the rest of their lives, including a lower risk of chronic obstructive pulmonary disease, heart attack, lung cancer, head and neck cancer, bladder cancer, and many other types of cancer. In addition to handwashing, distancing, and staying at home, quitting now is one of the healthiest steps people can take, and this will have continued benefits for years to come. Cessation is possible—and fortunately, many of the tools are conveniently available, even when staying at home.


The opinions expressed in this article are those of the author and do not necessarily reflect the views of The Society of Thoracic Surgeons.

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