Are smokers protected against SARS-CoV-2 infection (COVID-19)? Lachapelle, F. COVID-19 preprints and their publishing rate: an improved method. Comorbidity and its impact on 1590 patients with COVID-19 in China: a nationwide analysis. It also notes . To date, there is no strong evidence (i.e., evidence based on causal research) that smokers are protected against SARS-CoV-2 infection. Smoking significantly worsens COVID-19, according to a new analysis by UC San Francisco of the association between smoking and progression of the infectious disease. 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. A study, which pooled observational and genetic data on . 0(0):1-11 https://doi.org/10.1111/all.14289 12. Finally, we address the role of primary healthcare providers in mitigating the consequences of erroneous claims about a protective effect of smoking. Lian, Jiangshan, Jin, Xi Analysis of Epidemiological and Clinical Features in Older Patients Tobacco causes 8 million deaths every year from cardiovascular diseases, lung disorders, cancers, diabetes, and hypertension.1 Smoking tobacco is also a known risk factor for severe disease and death from Virol. Shi Y, Yu X, Zhao H, Wang H, Zhao R, Sheng J. Talk to your doctor or health care . 2020;157:104821. COVID-19 attacks the lungs, and people who smoke or vape are at higher risk of developing lung infections. Jin X, Lian JS, Hu JH, Gao J, Zheng L, Zhang YM, et al. The connection between smoking, COVID-19. 3. For the safety of its patients, staff and visitors, Mayo Clinic has strict masking policies in place. [Smoking and coronavirus disease 2019 (COVID-19)]. & Niaura, R. Smoking, vaping and hospitalization for COVID-19. 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. However, the battle against tobacco use should continue, by assisting smokers to successfully and permanently quit. The report was published May 12, 2020, in Nicotine & Tobacco Research. The Journal of Infection. Researchers at the Piti Salptrire hospital in Paris are using nicotine patches as part of a study to see if nicotine can help prevent or slow down . Lancet 395, 10541062 (2020). Bethesda, MD 20894, Web Policies Cite this article. In combination with past findings, the current findings published today in the Nicotine and Tobacco Research journal support urgent recommendations to increase tobacco control efforts for countering COVID-19. Epidemiology. Tobacco smoking and COVID-19 infection Lancet Respir Med. ScienceDaily, 5 October 2022. Eleven faces of coronavirus disease 2019. 126: 104338. https://doi:10.1016/j.jcv.2020.104338 42. Here we use two examples (one Chinese and one French study) to illustrate the most common problems with these studies. And exhaled e-cigarette vapor may be even more dangerous. Smoking increases the risk of illness and viral infection, including type of coronavirus. Yang, X. et al. Prost K, Yip L, Williams V, Leis JA, Mubareka S. Severity of coronavirus respiratory tract infections in adults admitted to acute care in Toronto, Ontario. Have any problems using the site? Clinical characteristics of 145 patients with corona virus disease 2019 (COVID-19) in Taizhou, Zhejiang, China. Alharbi AS, Altwaim SA, Alharbi AS, Alsulami S. Cureus. Quitting smoking and vaping can help protect you and your family from COVID-19. There are currently no peer-reviewed studies that directly estimate the risk of hospitalization with COVID-19 among smokers. J Eur Acad Dermatol Venereol. Addiction (2020). The IP address used for your Internet connection is part of a subnet that has been blocked from access to PubMed Central. a fixed effects model: OR: 2.0 (95% CI 1.3 3.2). The impact of COPD and smoking history on the severity of COVID-19: a systemic review and meta-analysis. This definition allows individuals to have been a smoker the day before development of COVID-19 symptoms. 18, 20 (2020). doi: 10.1111/jdv.16738. Park JE, Jung S, Kim A, Park JE. Dove was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through grant number UL1 TR001860 and linked award KL2 TR001859. In addition, tobacco use has been proven to harm immune system and airway lining cells that contain cilia on their surface. 6. The lungs produce more of the ACE2 receptor/protein, which acts as a "doorway" for the virus. & Kachooei, A. R. Prevalence of comorbidities in COVID-19 patients: a systematic review and meta-analysis. HHS Vulnerability Disclosure, Help of America. Intern. It's common knowledge that smoking is bad for your health. Guan et al. Qeios. 41 found a statistically significant Text the word "QUIT" (7848) to IQUIT (47848) for free help. Smoking is known to increase the risk of infection of both bacterial and viral diseases, such as the common cold, influenza and tuberculosis1, and smoking is a putative risk factor for Middle East respiratory syndrome coronavirus infection2. This was likely due to the small sample size with only 55 participants, of whom 20 were smokers. Background Smoking impairs lung immune function and damages upper airways, increasing risks of contracting and severity of infectious diseases. A HCPs advice for smoking cessation has always been very important, but in these COVID-19 times it is more urgent than ever before. Lancet. Han L, Ran J, Mak YW, Suen LK, Lee PH, Peiris JSM, et al. In epidemiology, cross-sectional studies are the weakest form of observational studies. An official American Thoracic Society public policy statement: novel risk factors and the global burden of chronic obstructive pulmonary disease. Federal government websites often end in .gov or .mil. Dis. Preprint at https://www.qeios.com/read/WPP19W.4 (2020). Epub 2020 Jun 16. RNvZ-S reports personal fees from Novartis, GlaxoSmithKline, AstraZeneca, Roche, Boehringer Ingelheim, Cipla, Merck Sharpe & Dohme, and Pfizer, outside of the submitted work. Also, <50% of the COVID-19 preprints uploaded in the first few months of the pandemic (JanuaryApril) have been published in peer-reviewed journals so far5. Information in this post was accurate at the time of its posting. Lancet. Careers. Patanavanich, R. & Glantz, S. A. All included studies were in English. Critical Care. Grundy, E. J., Suddek, T., Filippidis, F. T., Majeed, A. on the association between smoking and COVID-19, including 1) risk of infection by SARS-CoV-2; 2) hospitalization with COVID-19; and 3) severity of COVID-19 outcomes amongst hospitalized patients such as admission into intensive care units (ICU), Zhang JJ, Dong X, Cao YY, Yuan YD, Yang YB, Yan YQ, et al. Although likely related to severity, there is no evidence to quantify the risk to smokers 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 . A report of the Surgeon General. 8600 Rockville Pike BackgroundCigarette smoking has been proven to be a risk factor in the development of many diseases. Please enter a term before submitting your search. N Engl J Med. 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. Active smoking is not associated with severity of coronavirus disease 2019 (COVID-19). 92, 19151921 (2020). We investigated the association between smoking and COVID-19 during an outbreak of the disease on a naval vessel. 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. 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. 2020. severe infections from Covid-19. 2020;382(18):1708-20. https://doi:10.1056/NEJMoa2002032 14. "Our communities . All authors approved the final version for submission. To update your cookie settings, please visit the Cookie Preference Center for this site. https://doi.org/10.1093/cid/ciaa270 24. Emami, A., Javanmardi, F., Pirbonyeh, N. & Akbari, A. Electronic address . The highest achievable outcome in cross-sectional research is to find a correlation, not causation. Vardavas et al.40 analysed data from 5 studies totalling 1549 patients and calculated a relative risk that indicated a non-significant The European Respiratory Journal. Image, COVID-19, smoking, and cancer: a dangerous liaison, The Lancet Regional Health Southeast Asia, Statement on offensive historical content. Archives of Academic Emergency Medicine. 18, 63 (2020). These studies, in which smoking status was not a primary exposure of interest, were subsequently brought together in several systematic reviews and meta-analyses19,20,21,22,23,24,25. This study aims to determine the practices, nicotine dependency profile, association with exhaled carbon monoxide (eCO) level, and pulmonary function (PF) among adult product users and non-smokers. B, Zhao J, Liu H, Peng J, et al. 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. Heterogeneity in the clinical presentation of SARS-CoV-2 infection and COVID-19 progression underscores the urgent need to identify individual-level susceptibility factors that . Use of PMC is free, but must comply with the terms of the Copyright Notice on the PMC site. We use cookies to help provide and enhance our service and tailor content and ads. National and international media were interested in this story and we soon began receiving questions about this topic in general practice. The challenge for studies of COVID-19 is to have large enough sample sizes to allow correction for confounders, such as hypertension, diabetes, obesity, race, sex, and chronic obstructive pulmonary disease (COPD), all of which might be associated with tobacco smoking and poor outcomes. 2020 Jul 2;383(1):e4. 182, 693718 (2010). 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. Dong X, Cao YY, Lu XX, Zhang JJ, Du H, Yan YQ, et al. In the early months of the COVID-19 pandemic, most studies describing the relationship between smoking and COVID-19 were based on Chinese patient groups11,12,13,14,15,16,17,18. Views expressed here do not necessarily reflect those of ScienceDaily, its staff, its contributors, or its partners. "Past research has shown that smoking increases the risk of COVID-19 disease severity, but the risk of infection had been less clear," said UC Davis tobacco researcher and lead author of the study Melanie Dove. Recently, a number of observational studies found an inverse relationship between smoking and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (coronavirus disease 2019 (COVID-19)), leading to a (social) media hype and confusion among scientists and to some extent the medical community. Complications of Smoking and COVID-19. According to the CDC, wildfire smoke contains gas and particles of burned trees, vegetation and buildings. 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. Background: Identification of prognostic factors in COVID-19 remains a global challenge. 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 . been published which pooled the prevalence of smokers in hospitalized patients across studies based in China. Smoking marijuana, even occasionally, can increase your risk for more severe complications from Covid-19, the disease caused by the novel coronavirus. COVID-19, there has never been a better time to quit. Would you like email updates of new search results? 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. Smoking and vaping lower the lung's immune response to infection. 2018;18(1):574. https://doi.org/10.1186/s12889-018-5484-8 4. with Coronavirus Disease 2019 (COVID-19) Outside Wuhan. If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You are using a browser version with limited support for CSS. in SARS-CoV-2 infection: a nationwide analysis in China. In this article, we shed light on the process that resulted in the misinterpretation of observational research by scientists and the media. Much of the global focus on tobacco prevention and cessation focuses around non-infective respiratory, cardiovascular, and cancer related deaths, and much of the e-cigarette promotional rhetoric revolves around potentially saving billions of lives that . 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. 2020 Oct;34(10):e581-e582. Arcavi, L. & Benowitz, N. L. Cigarette smoking and infection. Google Scholar, The Netherlands Expertise Centre for Tobacco Control, Trimbos Institute, Utrecht, The Netherlands, Naomi A. van Westen-Lagerweij,Marc C. Willemsen&Esther A. Croes, Department of Health Promotion, Maastricht University, Maastricht, The Netherlands, Naomi A. van Westen-Lagerweij&Marc C. Willemsen, Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands, Eline Meijer,Elisabeth G. Meeuwsen&Niels H. Chavannes, You can also search for this author in Zhao Q, Meng M, Kumar R, Wu Y, Huang J, Lian N, et al. "Past research has shown that smoking increases the risk of COVID-19 disease severity, but the risk of infection had been less clear," said UC Davis tobacco researcher and lead author of the study . Global center for good governance in tobacco control. factors not considered in the studies. Independent Oversight and Advisory Committee. 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. National Library of Medicine The study at a major Paris hospital suggests a substance in tobacco - possibly nicotine - may be stopping patients who smoke from catching Covid-19. As we confront the coronavirus, it is more important than ever for smokers to quit and for youth and young adults to stop using all tobacco products, including e . The impact of COPD and smoking history on the severity of Covid-19: A systemic review and meta-analysis. 22, 16621663 (2020). The ranking is a tribute Moreyounger adultsare being diagnosed with colon cancer also known as colorectal cancer and at more advanced stages of the disease, says the American Science Saturday: Researchers elucidate details about the role of inflammation in liver regeneration, Mayo Clinic again recognized as Worlds Best Hospital in Newsweek rankings, Mayo Clinic Minute: Why millennials should know colon cancer symptoms, Mayo Clinic Q&A podcast: Mayo Clinic expands living liver donation program, Consumer Health: 10 ways to avoid complications of diabetes. 2020 May;29(3):245-246. doi: 10.1136/tobaccocontrol-2020-055807. A total of 26 observational studies and eight meta-analyses were identified. Data from the British Cold Study is available on the Carnegie Mellon University The Common Cold Project website. We included studies reporting smoking behavior of COVID-19 patients and . 31, 10 (2021). A report of the Surgeon General. Tijdschr. Mar16. These results did not vary by type of virus, including a coronavirus. Gut. Perhaps smoking-induced inflammation of the upper respiratory mucosa provides low-degree protection against transmission of viral infection. 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. One of the main limitations of this study is that the mild common coronavirus 229E may have different biological and health effects than other coronaviruses, including SARS-CoV-2. The Covid-19 pandemic has highlighted the importance of maintaining a healthy lifestyle and reducing risk factors that can worsen disease. The studies, however, made comparisons without adjusting for a number of factors that are associated with smoking status, such as age, gender, socio-economic status, ethnicity and occupation. Cluster of COVID-19 in northern France: A retrospective closed cohort study. 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. Eur. The site is secure. 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. Liu J, Chen T, Yang H, Cai Y, Yu Q, 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. It is possible that the period of self-isolation and lockdown restrictions during this pandemic could be used by some as an opportunity to quit smoking, but realistically only a minority of people will achieve cessation. 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. 18(March):20. https://doi.org/10.18332/tid/119324 41. 2020. An official website of the United States government. J. By Melissa Patrick Kentucky Health News. In response to the CMAJ News article by Lauren Vogel,1 we would like to highlight a method of transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that is underrecognized in Canada.. A hookah (shisha or waterpipe) is a single- or multistemmed instrument that has been used for smoking various flavoured substances, such as cannabis, tobacco and opium, for centuries and is . An official website of the United States government. The New England Journal of Medicine. Most recent smoking status was determined from primary care records (70.8%) and UK Biobank questionnaire data (29.2%). Preprint at https://www.qeios.com/read/Z69O8A.13 (2020). 18, 58 (2020). Tob. A, Mechanistic studies postulate that the increased susceptibility to infection might be due to upregulation of the angiotensin converting enzyme 2 (ACE2) receptor, the main receptor used by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to gain entry to host mucosa and cause active infectionan apparently unique mechanism to this virus. Clinical infectious diseases : an official publication of the Infectious Diseases Society Karagiannidis, C. et al. Lippi et al.38 analysed data from 5 studies totalling 1399 patients and found a non-significant association between smoking and severity. Nicotine Tob. Tobacco and nicotine derivatives uses are multiple in nature. Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China. Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China. 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. Google Scholar. Wan, S. et al. 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. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Global Burden of Disease: GBD Compare Tool, 2020 (Available from: https://vizhub.healthdata.org/gbd-compare/) Accessed: April 27 2020. We encourage HCPs to use the information provided by recognised international organisations, such as the World Health Organisation. 2020 Science Photo Library. Nicotine Tob. Addresses across the entire subnet were used to download content in bulk, in violation of the terms of the PMC Copyright Notice. official website and that any information you provide is encrypted HHS Vulnerability Disclosure, Help 2020;69(13):382-6. Risk Factors Associated with Clinical Outcomes in 323 COVID-19 Hospitalized Patients in Wuhan, China. Smoking impairs the immune system and almost doubles the risk of, Data from the previous Middle Eastern respiratory syndrome coronavirus (MERS) and severe respiratory syndrome coronavirus (SARS) is scarce. Acad. University of California - Davis Health. Although scientific discussions could be continued afterwards on the preprint servers, the media and many scientists did not follow these discussions. Secondhand smoke has always been a killer, but COVID-19 has made exposure to tobacco smoke potentially deadlier. 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. Get the latest science news in your RSS reader with ScienceDaily's hourly updated newsfeeds, covering hundreds of topics: Keep up to date with the latest news from ScienceDaily via social networks: Tell us what you think of ScienceDaily -- we welcome both positive and negative comments. The health The rates of daily smokers in in- and outpatients . Guo FR. The .gov means its official. Population-based studies are needed to address these questions. Naomi A. van Westen-Lagerweij. Zheng Y, Xiong C, Liu Y, Qian X, Tang Y, Liu L, et al. ScienceDaily. Smoking also reduces our immunity, and makes us more susceptible to . The aim of this study was to use Mendelian randomization (MR) techniques to assess the causalities between smoking, alcohol use and risk of infectious diseases. UC Davis tobacco researcher Melanie Dove. 2020. Reed G ; Hendlin Y . Case characteristics, resource use, and outcomes of 10 021 patients with COVID-19 admitted to 920 German hospitals: an observational study. Financial support for ScienceDaily comes from advertisements and referral programs, where indicated. Apr 23;S0163-4453(20)30234-6. https://doi:10.1016/j.jinf.2020.04.021 38. Dis. Clinical Infectious Diseases. Unauthorized use of these marks is strictly prohibited. and JavaScript. With these steps, you will have the best chance of quitting smoking and vaping. FOIA 2020. In France, researchers first suggested that nicotine may play a role in protecting smokers9, triggering a run on nicotine products among the general public. Experts worry that the pandemic interrupted decades of progress in minimizing tobacco use even as smoking heightens the risk of severe COVID-19 illness. Ned. International Society for Infectious Diseases. Internal and Emergency Medicine. Quantitative primary research on adults or secondary analyses of such studies were included. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Chen Q, Zheng Z, Zhang Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Download Citation | Live to die another day: novel insights may explain the pathophysiology behind smoker's paradox in SARS-CoV-2 infection | The severe acute respiratory coronavirus 2 (SARS-CoV . MERS transmission and risk factors: a systematic review. Med. https://ggtc.world/2020/03/24/covid-19-and-tobacco-industry-interference-2020/ (2020). Mortal. The statistical significance This is quite remarkable, considering that smoking is the most important risk factor for COPD, causing up to 80% of all cases30. & Perski, O. Only cohort studies of sufficient size, in which a group of patients is followed over a longer period of time, would be able to determine whether smokers are actually protected against SARS-CoV-2 infection or not. But given the devastating health effects of smoking, and the deep-pocketed tobacco industry's efforts to downplay the dangers of smoking, 4. This was the first association between tobacco smoking and chronic respiratory disease. The risk of transmitting the virus is . Table 2 Relative risk of confirmed COVID-19 cases by tobacco use in participants of FinSote surveys. 2020. CAS 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. C. R. Biol. Simons, D., Shahab, L., Brown, J. Introduction: Preliminary reports indicated that smokers could be less susceptible to coronavirus SARS-CoV-2, which causes Covid-19. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. For more information and all your COVID-19 coverage, go to theMayo Clinic News Networkandmayoclinic.org. Host susceptibility to severe COVID-19 and establishment of a host risk score: findings ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observationalstudy. But some stress-reducing behaviors are alarming to medical experts right now namely vaping and smoking of tobacco . Scientists are still learning about the disease, but we know that: Being a current smoker increases your risk for severe illness from COVID-19. A number of recent studies have found low percentages of smokers among COVID-19 patients, causing scientists to conclude that smokers may be protected against SARS-CoV-2 infection. The https:// ensures that you are connecting to the Learn the mission, vision, goals, organization, and other information about this office. 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 . Preprint at MedRxiv https://www.medrxiv.org/content/10.1101/2020.09.04.20188771v4 (2020). 343, 3339 (2020). Emerg. Allergy 75, 17301741 (2020). "Smoking increases the risk of illness and viral infection, including type of coronavirus." Children exposed to second-hand smoke are also prone to suffer more severe . Farsalinos et al. Cases with a history of smoking achieved a higher rate of COVID-19 disease progression as opposed to those having not smoked (OR 1.53, 95% CI 1.29-1.81, P < 0.00001), while no significant association could be found between smoking status and COVID-19 disease progression (OR 1.23, 95% CI 0.93-1.63, P = 0.15). J. Intern. 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C, Zhang X, Wu H, Wang J, et al. Induc. Corresponding clinical and laboratory data were . Tob Control. Farsalinos, K., Barbouni, A. He says the COVID-19 pandemic is an opportunity for people who smoke to recognize the serious health risks associated with the addiction and consider quitting. 2020. Original written by Stephanie Winn. It is not intended to provide medical or other professional advice. / Nicotine Dependence Center / Mayo Clinic", "And we know from the previous coronavirus outbreaks, especially the MERS (Middle East respiratory syndrome) outbreak, that smokers were more susceptible to infection and more likely to get more serious infection," says Dr. Hays. Accessibility Eighteen of the 26 observational studies containing data on smoking status by severity of COVID-19 outcomes.