Smokers 'Do Much Worse' With Coronavirus — and Many Are Now Trying to Quit

In her 40 years of smoking, Katie Kennedy has tried to quit four times, but always returned to cigarettes. This time, her fifth, she is turning to a new mental image when a craving comes on: rows of COVID-19 patients hooked up to ventilators.

Kennedy’s dad also smoked. He was on a ventilator before he died, and Kennedy was struck by how invasive the machine was, and how much discomfort and distress it inflicted on him. She vowed never to die like that.

“I just decided it's time to protect my lungs as much as I can,” said Kennedy, 59, who started a cessation class in Sacramento in March. “COVID-19 is quite a motivator.”

Early studies suggest that smokers who develop COVID-19 are 14 times more likely to need intensive treatment compared to nonsmokers, and twice as likely to die. Doctors in California are seizing this moment to highlight the connection between COVID-19 and smoking as another reason people should quit.

The California Smokers’ Helpline (1-800-NO-BUTTS), which provides free advice to help people stop smoking, is redirecting  research money to give callers two weeks of nicotine patches at no cost, sent directly to their homes.

Calls to the helpline were actually down 27.5% in March, as compared to the same month last year — a drop counselors attribute mainly to people feeling too stressed out to consider quitting. Nonetheless, they say some callers are referencing the coronavirus and the utter upheaval of the stay-at-home order as their inspiration to quit.

“I spoke with a gentleman last week who is seriously taking this time to reorganize his life,” said Nallely Espina, a counselor with the helpline. “He’s setting a new routine for himself at home and staying away from his smoker friends, which was one of his main triggers.”

Another smoker, in his mid-20s, was prompted to call after he read a news article about how young people who smoke could have more severe health complications if they contract the virus, she said.

About half of Espina's callers are using the time at home to revamp their habits, starting yoga, meditation and eating a healthier diet, she said. But the other half are supremely frazzled, being trapped inside with their families.

Espina helped one dad come up with some new coping strategies.

“Going outside and having that cigarette, it’s his time out from the kids,” she said. “So for him, we decided let's still go outside, but instead of having a cigarette, maybe you spend those minutes doing a few pushups and burpees. And he loved that idea, he went for it.”

California public health agencies are incorporating information about the link between smoking and the coronavirus into their social media and public outreach messages, building on a 30-year legacy of aggressive anti-smoking campaigns and policies.

California was the first state to ban smoking on airplanes and in restaurants and bars, and over the years has added numerous other public spaces to that list, making smoking logistically difficult and culturally unpopular. As a result, it has the second-lowest smoking rate in the country — 11.3% of the population — after Utah, where Mormon values are attributed with keeping smoking to 8.9%.

Pondering Smoking’s Role in Spread and Severity

While health advocates are nudging smokers to quit, some researchers are also pondering whether California’s low-smoking rate will have any impact on how the state fares through the pandemic.

“It’s a really great question,” said Ruth Malone, a professor emerita of nursing at UCSF, who has studied tobacco control for 20 years. “Smokers do much worse if they contract the virus, which is not too surprising given that it attacks lung tissue. There is also some new research suggesting that it might even promote transmission because of the particular pathways that it hooks onto.”

Proving a correlation would require sophisticated modeling to isolate smoking as a risk factor from the many other factors that seem to contribute to the geographic differences in the spread and severity of the virus. Some of those factors include population density, when the virus was introduced into a community and the timing of mitigation measures, like shelter-in-place orders, which California was the first state to institute.

Researchers have long known that smoking makes it harder to fight off respiratory infections because it increases mucus production and paralyzes cilia, the hair-like fibers in the respiratory tract and lungs that normally flush invaders out.

“If any organism gets down there in the lower airways, whether it’s the coronavirus or another virus, you've got the mucus that it can get stuck in, and it can't get whisked away because the cilia are not working,” said John Swartzberg, professor emeritus of infectious diseases at UC Berkeley. “So those organisms have a perfect home.”

Newer science indicates smoking may also increase a person’s chance of contracting the coronavirus, because tobacco increases certain enzyme receptors in a cell — angiotensin-converting enzyme-2 — where scientists believe the virus attaches and infects it, said Marcos Garcia-Ojeda, an immunologist at UC-Merced.

Imagine a human cell as a house that has doors and windows where the virus can enter, he added. “If you smoke, now you have increased the amount of windows and doors for the virus to come in,” he said. 

Tobacco-control advocates are calling on the Centers for Disease Control and Prevention to collect more robust data on the connection between smoking and the coronavirus. The development of a reliable and widely available coronavirus antibody test could also help characterize the connection.

“Once we start doing very robust antibodies studies, we'll be able to take a population of people infected and see how many of them are smokers versus nonsmokers. Then you could see what the morbidity in each group is,” said Swartzberg. “That study would be very simple to do.”

Figuring out if low smoking rates contribute to a reduction of overall infections would be harder, requiring more complex models that can control for other potential factors. For example, the smoking rate in New York City — the epicenter of the coronavirus pandemic in the U.S. — is roughly the same as in California. That could either invalidate the idea that a low-smoking rate would be protective, experts say, or it indicates that smoking is just one of many variables that influence the impact the outbreak has at the population level.

“We went to physical distancing policies and closing nonessential businesses a few days earlier than New York. I think those were a critical few days,” said John Balmes, a pulmonologist and professor of medicine at UCSF. “Also, we’re less densely populated than many of the eastern and Midwestern cities.”

On the other hand, California has a large homeless population, where close quarters and poor sanitation give the virus greater chance of spreading. And before the shutdown, pockets of the state had high levels of air pollution, another factor researchers would like to better understand.

In the meantime, doctors are relying on what they do know to persuade people to try to quit smoking now. “Once you stop smoking or vaping, your lungs, your immune system, they start getting better within minutes,” said Elisa Tong, a physician at UC Davis and project director for the University of California Tobacco Cessation Network.

Katie Kennedy has been learning these lessons at her smoking cessation class, which is now offered online. But being cooped up at home has presented some challenges for her.

“My husband smokes,” Kennedy said. “And that's probably the biggest trigger.”

It was their ritual to smoke together, she said. The times she has relapsed, it was always with him. Now that they’re stuck at home with each other nonstop, there’s constant temptation.

“There is the thought that passes through my brain, ‘Oh, he's going out for a cigarette, that sounds good,’” she said. “Well, when I get that urge, I know it's the nicotine talking. So I pop a nicotine lozenge and take a deep breath and try to busy myself with something else.”