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Primary care
Is there a smoker’s paradox in COVID-19?
  1. Muhammad Shariq Usman1,
  2. Tariq Jamal Siddiqi1,
  3. Muhammad Shahzeb Khan2,
  4. Urvish K Patel3,
  5. Izza Shahid4,
  6. Jawad Ahmed1,
  7. Ankur Kalra5,
  8. Erin D Michos6
  1. 1Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
  2. 2Department of Internal Medicine, John H Stroger Hospital of Cook County, Chicago, Illinois, USA
  3. 3Department of Public Health and Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
  4. 4Department of Internal Medicine, Ziauddin University, Karachi, Pakistan
  5. 5Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
  6. 6Department of Cardiovascular Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  1. Correspondence to Dr Muhammad Shariq Usman, Internal Medicine, Dow University of Health Sciences, Karachi, SD 74200, Pakistan; shariqusman{at}


Although it is well established that cigarette smoking is associated with morbidity and mortality in several respiratory infections, data from recent studies suggest that active smokers are underrepresented among patients with COVID-19. This has led to claims that a ‘smoker’s paradox’ may exist in COVID-19, wherein smokers are protected from infection and severe complications of COVID-19. We aimed to review and summarise existing literature in this context. Electronic databases were searched for articles that reported prevalence of smokers among patients with COVID-19 or studied any association of smoking with outcomes among patients with COVID-19. We identified several biases and knowledge gaps which may give the false impression that smoking is protective in COVID-19. As of now, the data supporting smoker’s paradox claims are limited and questionable. Plausible biologic mechanisms by which smoking might be protective in COVID-19 include an anti-inflammatory effect of nicotine, a blunted immune response in smokers (reducing the risk of a cytokine storm in COVID-19) and increased nitric oxide in the respiratory tract (which may inhibit replication of SARS-CoV-2 and its entry into cells). On the other hand, smoking may worsen susceptibility and prognosis in COVID-19, in a manner similar to other respiratory infections. The claims of a protective effect must be viewed with extreme caution by both the general population as well as clinicians. Further investigations into the interaction between smoking and COVID-19 are warranted to accurately assess the risk of contracting COVID-19 among smokers, and progression to mechanical ventilation or death in patients suffering from it.

  • coronavirus disease 2019
  • COVID-19
  • smoking
  • nicotine
  • tobacco
  • outcomes

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  • Contributors MSU, TJS, AK and EDM contributed to conception of study and MSK and UKP contributed to study design. IS and JA contributed to literature search and MSU, TJS and MSK contributed to study selection. MSU, TJS, IS and JA contributed to initial manuscript draft. MSK, UKP, AK and EDM critically revised the manuscript for important intellectual content. MSU and TJS have contributed equally and are co-first authors. All authors have read and approved the final version of manuscript and agree to be accountable for accuracy and integrity of all aspects of the work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval No human participants were involved in the study and it uses publicly available data.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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