Smoking and COVID-19 — why now is the time to quit

Everything is difficult right now, and that’s especially true if you're trying to quit smoking because of COVID-19, but here’s why you should do it anyway.
Pack of cigarettes
“Most health systems and quit-lines have been increasing their services during the pandemic to give potential quitters more access to effective counseling resources,” said the American Cancer Society's Jeffery Drope.Getty Images

It may be harder to quit smoking during the pandemic — especially when many smokers are stuck at home and feeling depressed, stressed, anxious or bored. But COVID-19 has given many people a good reason to try.

While some early data seemed to suggest that smokers were being hospitalized for COVID-19 less often than nonsmokers, and that therefore nicotine had a potentially protective effect against the novel coronavirus, clinical data is now telling a very different story.

Are smokers less likely to get coronavirus? No.

Dr. Panagis Galiatsatos, the director of the Tobacco Treatment Clinic at Johns Hopkins Bayview and a volunteer medical spokesperson for the American Lung Association, told TODAY that the early data suggesting smokers might be less likely to get COVID-19 came from retrospective cross-sectional — or observational — trials. “You can never infer causation from an observational trial,” he said, adding that such trials are meant to “point toward variables to explore.”

While low cases of smokers were reported, said Galiatsatos, “smoking data has historically been flawed in how it’s captured in the hospital, which could be a confounder to this. A prospective trial, identifying smokers and non-smokers now, and following them in the future to see if they acquire COVID-19 — and their outcomes — would be the definitive way to attempt to establish causation.”

Galiatsatos explained that he and his colleagues in the School of Medicine and the School of Public Health at Johns Hopkins have been working on a “massive systematic review of all the publications put out [on the subject] so far,” and based on their analysis, he said, “we’ve found that those who smoke are more likely to suffer more severe symptoms of COVID-19.” The finding isn’t surprising, he said, “because it’s what we’ve known all along: People who smoke tend to have worse outcomes from infection.”

Jeffery Drope, the scientific vice president of economic and health policy research for the American Cancer Society (ACS), has arrived at the same conclusion. “The research is showing consistently that smokers who become infected with COVID-19 are experiencing worse outcomes and are more likely to require intensive treatment, [such as a] ventilator,” he said.

This week, the World Health Organization published a scientific review and meta-analysis of peer-reviewed literature focused on smoking and COVID-19. Based on the evidence available, researchers concluded that smoking appears to be “associated with increased severity of disease and death in hospitalized COVID-19 patients.”

So far there is no evidence that vaping worsens COVID-19 outcomes, but both Drope and Galiatsatos pointed out that there hasn’t been as much research into it, so more research is needed before conclusions can be drawn.

Smoking, vaping and respiratory infections

“Smoking is an established risk factor for respiratory infections, including influenza, because it undermines the immunological response that a person can otherwise mount against a viral infection,” said Drope. “It’s hypothesized that this is likely to also be the case with COVID-19.” He adds that there is a strong indirect relationship between smoking and pre-existing conditions, such as chronic obstructive pulmonary disease (aka COPD) and heart disease, that have emerged as risk factors for COVID-19 severity and death. “The evidence is less clear for vaping,” he said, “but there is emerging evidence that vaping causes lung damage and this is likely to make it harder for [people who vape] to fight off respiratory infections.”

Galiatsatos added that the chemical makeup and the tar content of combustible cigarettes weakens the defenses of the lungs. “When you inhale either the e-cigarette vape or the cigarette’s smoke, it … allows dangerous bacteria and other microbes [into the lungs],” he said. “If you add a bad virus like COVID-19, it will ravage the lungs.”

How to quit smoking while in quarantine

There’s no doubt that the circumstances of the pandemic can make quitting smoking even harder. But Drope said that the fear of contracting the novel coronavirus seems to be spurring more people to try to quit. “All of the anecdotal evidence from quit-lines and health systems suggests that the number of people trying to quit tobacco products is increasing, even markedly among some groups,” he said.

For his patients at Johns Hopkins, Galiatsatos recommends a 3-step game plan. “What I tell all my patients is, first of all, if you want to quit, that’s fantastic. But I really try to emphasize thinking through when and why you like to smoke.” Smoking provides a mental health benefit for many people, he said, and when they try to quit, they’re letting go of a mechanism they’ve relied on to help them cope — often for years. “So then you have to look at how you’re going to replace that with better strategies that aren’t going to be harmful to your health.” That’s the first step.

The second step is to alert your health care provider that you’re quitting smoking. Some people want to quit on their own, and Galiatsatos doesn’t trivialize that. However, he also warns that “you’re working against a product that has seeped into the most subconscious parts of your brain and it will fire off your cravings to smoke.” For that reason, he suggests talking to your doctor about pharmacological agents that can help ease your cravings and symptoms of withdrawal.

The third step in the quit plan involves finding a support system — whether it’s a quit-line, a family member or friend, or a group — that holds no judgment and can check in with you regularly. “Quitting smoking is like a chronic disease and the way you manage it should be similar,” said Galiatsatos. “You’d get your blood pressure checked for hypertension or you’d test your blood [if you had diabetes]. You do that to see how you’re doing and to [identify] where your successes and struggles are.” A support entity should be checking in on your progress quitting smoking for the same reasons. You should let them know what’s working, what’s not working and whether you’re having any side effects from medications you might be taking.

Similarly, Drope says the ACS recommends using a combination of FDA-approved nicotine-replacement therapies (NRTs), which are often available over the counter, and medications — along with counseling to effectively quit smoking. “Most health systems and quit-lines have been increasing their services during the pandemic to give potential quitters more access to effective counseling resources,” he said.

Finally, Galiatsatos emphasized that quitting smoking is only the first part of the journey. The possibility for relapse is high, he said, so you need to put the game plan in place to help you remain smoke-free. “As one of my patients put it,” he said, “‘Quitting smoking is easy. I’ve done it thousands of times.’ In this pandemic, people may quit for a week, and then relapse for another week. They need help to quit and remain successfully quit.”