Coronavirus and Smoking: What’s Your Risk?

"If you’re thinking about quitting or changing your behavior in some way, NOW is the time to do it. ... Ending tobacco or e-cigarette addiction now will improve your health and could possibly reduce your risk from this virus."
Paul Brunetta, MD
Co-author of "Learning to Quit"
COVID-19 and smoking

We’re all watching in horror as this global COVID-19 tragedy unfolds. The crisis directly impacts almost everyone. A global respiratory virus pandemic has caused pneumonia in over 140 countries. Coronavirus has infected more than 189,000 people in the US, and the real impact is likely many, many times this number. New reports from Italy and China suggest that more men than women are having serious lung infections. One theory behind this difference points out that smoking rates are much higher in men versus women in China, and are also higher in Italy

We don’t yet understand if risk of COVID-19 pneumonia is actually higher in smokers, and the emerging data on coronavirus infections should tell us. Anytime is a good time to think about ending cigarette or e-cigarette use to improve your health. NOW…April 2020, may be your time if you sense your motivation rising.


This new infection devastated China. A group of lung, ICU and radiology doctors at the Central Hospital of Wuhan published a study of 78 patients in January 2020 in the Chinese Medical Journal. All patients in the study had COVID-19 pneumonia, and approximately 15% worsened during their hospital stay. The group that worsened was compared to those who improved. Being older and having a history of smoking were determined to be two major baseline risk factors associated with increased severity.

A second interesting paper was published this February from the University of South Carolina. In order for the COVID-19 or SARS virus to get into lung cells to cause pneumonia, it needs to attach to a specific receptor on lung cells. An investigator evaluated the presence of the COVID-19 receptor in a large database of lung tissue samples (doi:10.20944/preprints202002.0051.v1). This analysis showed that a specific receptor, called ACE2, was higher in smokers versus non-smokers. In other words, smoking may make it easier for the coronavirus to bind to and infect the lungs of smokers compared to non-smokers.

A recent review (released March 20) of all available published data concluded that “smoking is most likely associated with the negative progression and adverse outcomes of COVID-19.”

Cigarette and e-cigarette impact on lung defenses

Taken together, these recent reports suggest a real possibility that smoking can make COVID-19 pneumonia worse. Smoking clearly makes outcomes much worse for people with regular flu infection. Smoking also increases the risk of hospitalization for pneumonia from influenza, at least in older people. 

Want to know why smoking increases your risk for infection? The nicotine in cigarettes reduces the motion of the hair-like cilia in your airways that help clear mucus from your lungs. Tar in your airways and airsacs causes immune cells to be occupied with trying to get rid of the tar and less able to respond to normal infections. Smokers produce more mucus and are at higher risk for both acute and chronic bronchitis compared to non-smokers.

Switching to vaping won’t help you either. Adolescents that use e-cigarettes have more respiratory symptoms than those that don’t use them. Vaping is associated with increased risk of asthma and bronchitis development. E-cigarettes have been shown to alter immune cells in the lungs, and the inhaled metal vapors directly harm cells lining the airway.

What to do to reduce your risk

If you’re thinking about quitting or changing your behavior NOW is the time to do it. The pandemic and the risk of COVID-19 will go on for many months. Ending tobacco or e-cigarette addiction now will improve your health and could possibly reduce your risk from this virus. Learning To Quit has many free resources, free chapters, a quit guide and other information. Every state has a free 1-800 number for people to call, as does the NCI (1-800 QUIT-NOW). Stopping cigarette smoking (and e-cigarette use) may be the most important thing you ever do for your health.

If not for yourself, think about quitting for someone else. Find inspiration in the selfless actions of others, especially people in the healthcare profession that are working every day to improve the health of the many sick people being tested and treated now. The truth is that your health and my health can have a direct impact on the health of other people. Stay safe!

by Paul Brunetta, MD

Co-author of Learning to Quit.

Dr. Paul Brunetta had his first cigarette at the age of nine and was able to quit just prior to medical school. He struggled through numerous quit attempts – determined not to be “that doctor who smokes.”

While working together at the UCSF Chest Clinic, Brunetta and Suzanne Harris discovered they shared a common mission: to prevent tobacco-related diseases by giving as many smokers as possible the tools they need to quit. In 1999, they founded the Fontana Tobacco Treatment Center at UCSF. Their program is now available to anyone in the new edition of Learning to Quit.

You’re Being Fooled: E-Cigarette Makers Sell a Smoke Screen to Hide the Truth

The runaway epidemic of e-cigarette use among teens has been grabbing news headlines since 2015. But despite concerns from parents and health care researchers about the potential health risks, many people mistakenly believe that e-cigarettes are safe.

The phrase “e-cigarettes may be safer than cigarettes” is the statement that tobacco and e-cigarette companies want us to use to distract us from the real issue. It didn’t happen overnight. The industry has been training the public for years to believe that they care about public health by declaring their commitment to “a smoke-free future” or what Philip Morris calls its future “beyond cigarettes.” Smoke and cigarettes are the bad guys, they’ve declared, so those new “smoke free” products that don’t involve tobacco rolled up in a piece of paper and set on fire must be the good guys.

We’ve all been duped. I fell into the trap myself as I was trying to make sense of the unregulated JUUL epidemic and the flood of news articles about teenage nicotine addiction. Never mind smoke free—the issue is nicotine addiction and the dangerous chemicals contained in e-cigarettes that have yet to be thoroughly investigated. Nicotine is one of the most addictive substances on earth, and JUUL products deliver twice as much nicotine as any other e-cigarette product. When we allow vaping advocates and e-cigarette companies to use the defense “e-cigarettes are safer than cigarettes,” we’re letting the industry win.

Any company that sells and promotes an addictive substance is exploiting the user’s loss of control to ensure customer loyalty, i.e., a constant revenue stream, with complete indifference to the potential health hazards their product may cause. And each addicted customer pays into the advertising and promotion that expands the company’s reach to recruit more addicts.

There’s open debate about whether switching to e-cigarettes is an effective way to stop smoking. A recent British study published in the New England Journal of Medicine found that smokers had twice as much success staying tobacco-free when they used e-cigs than using other nicotine replacement therapies. But the rates were still low: only 18 percent were tobacco-free after a year.  There are other smoking cessation medications that don’t require people to inhale metal fumes associated with e-cigarettes. And 80 percent of people in this study were still on e-cigarettes at one year compared to nine percent of patch users.

This comparison about relative safety needs to start from the perspective of the individual. That’s the only perspective that really matters in the end. What are the forms of nicotine that almost any smoker can get within 10 minutes of their apartment or house? There are three: cigarettes, e-cigarettes, and Nicotine Replacement Therapy (NRT). Let’s compare these three options. The first two are intensely addictive, and in comparison, NRT has low to no addiction potential. The critical factor that makes something addictive is how quickly it’s absorbed into your blood stream and how rapidly it gets to your brain. The smoke from cigarettes and vapor from e-cigarettes get absorbed rapidly through the huge surface area of your lungs, flooding your brain with a surge of nicotine in seconds. By contrast, NRT contains a regulated, measured form of “clean” nicotine that is slowly absorbed either through the skin (as a patch) or via the mouth (as gum or lozenge), and therefore has a very low addiction potential.

When you smoke cigarettes, you inhale tar laced with dozens of carcinogens in addition to carbon monoxide. E-cigarettes, far from being “clean” or “safe,” contain a super-heated metal coil that releases metal fumes when it vaporizes the nicotine fluid. Metal particles as well as chemicals used to flavor e-cigs can damage the lining cells of your airways. A study by Harvard scientists found the chemicals in 90 percent of e-cigarettes they tested. Co-author Joseph Allen, an assistant professor, said: “workers are warned about the dangers of inhaling the same flavoring chemicals. Why aren’t e-cig users receiving the same warnings?”

Your lungs should be breathing in only clean, fresh air. Any other inhaled pollutant can cause acute or chronic inflammation, and in the case of cigarettes, multiple forms of cancer. The true health effects of  e-cigarettes are only beginning to be studied.

As a pulmonary specialist, my ultimate goal for smokers is to see them leave their nicotine addiction behind, not just switch from one nicotine addiction to another. Most smokers have a desire to quit. Nicotine addiction is intense, and quitting isn’t easy, but it can definitely be done. Don’t help these companies by trading one form of nicotine addiction for another. Take the right step and end the devastating impact of nicotine addiction altogether by remembering that there are safer and better choices out there that don’t involve inhaling harmful substances. I’ve never met a smoker who regretted quitting. But I’ve met too many who regretted continuing their addiction until it was too late.

Paul Brunetta, MD

Additional Links

Parents Against Vaping e-Cigarettes (PAVE) have created a cheat sheet to educate parents about the potential dangers of e-cigarettes. It’s available for download.





“No Judgments, Just Help”

Here’s a really well produced spot from our friends at the California Smokers’ Helpline.

Smokers can call them at 800-NO-BUTTS or visit to access free information on quitting.