Assessing COVID-19 Severity Risk in Smokers, Vape Users: Q&A with Jonathan Winickoff, MD, MPH

Individuals with respiratory illnesses and immunosuppression are amongst the high-risk group for severe COVID-19. But many physicians wonder about the risk level for patients who smoke or vape tobacco products. In this Q&A, Jonathan Winickoff, MD, MPH, pediatrician at Mass General for Children and director of Pediatric Research at the Massachusetts General Hospital Tobacco Research & Treatment Center, explains what is known and unknown about COVID-19 in regards to smoking and vaping.

Q: How does smoking and vaping affect the lungs of a normally healthy person?

Winickoff: Most people are aware that smoking tobacco leads to chronic lung disease, COPD, heart disease, stroke and cancers. Vaping is a newer product, but we do know it can cause asthma, lung inflammation and damage the immune response against viruses and bacteria.

Both smoking and vaping weaken the body's defenses and diminish the body's natural ability to fight infection in young people and adults. Cilia, small hair-like fibers in the lungs, help protect the body by expelling bacteria, viruses and other toxicants. But tobacco smoke and electronic cigarette aerosol cause a temporary paralysis of these cilia and make it harder for the body to fight off viruses and bacteria.

Q: How does that change if someone also has contracted COVID-19?

Winickoff: Anything that causes the body to become immunocompromised can increase the chances of contracting COVID-19 and increases the likelihood that COVID-19 will be severe. Smoking and vaping might also increase the spread of the coronavirus because of the hand-to-mouth behavior and increased coughing and sputum production that comes from the use of tobacco products.

Initial evidence suggests tobacco smoke can increase angiotensin-converting enzyme-2 (ACE2) in the lungs, which is the binding site for COVID-19. More binding sites could be particularly dangerous because the amount of the virus that gets into the body may be higher, leading to a more severe case of infection.

We know that tobacco smoke and vaping aerosol create partial paralysis in cilia so they can't help expel mucus, viruses and bacteria from the body as easily. There's also evidence that vaping affects neutrophils and macrophages in the lung that are necessary for fighting off viruses.

Even though the science is still out, we continue to and always recommend that people quit smoking and vaping. Now more than ever, quitting smoking and vaping has higher urgency.

Q: How does smoking and vaping weaken a patient's ability to recover from the virus if they were to get it?

Winickoff: Because smoking and vaping damages the body's ability to fight off viruses and other bacteria, it means a patient with COVID-19 can have a harder time fighting off any secondary infections.

We do not have any direct studies about COVID-19 and this phenomenon yet, but we do know that smoking and vaping increases the chances of bacterial and viral infections. So this a theoretical risk until more data is available.

Q: What concerns do you have on long-term effects?

Winickoff: Once the lung has sustained injury from a serious infection like COVID-19, it is damaged. It is important for patients to avoid any additional damage to their lungs to ensure a full recovery. Anything that diminishes the lung capacity or increases the chances of asthma or chronic lung diseases creates excess risks.

For someone who smokes and catches COVID-19, they are more likely to be admitted to the intensive care unit or be placed on a ventilator or even die as a result of the infection.

Q: When physicians are screening potential COVID-19 patients, should they ask about their smoking or vaping habits?

Winickoff: Yes, I would stress to physicians that it's important to keep gathering information because all the answers are not in yet about vaping and smoking and their relationship with COVID-19's severity. Here is the screening question that is being used at major medical centers during the COVID-19 pandemic:

Do you currently smoke or vape?

a. (Yes) Which of the following do you regularly do? (select all that apply)

i. Smoke cigarettes
ii. Vape nicotine (e-cigarettes)
iii. Smoke marijuana
iv. Vape marijuana

Note additional exposures and risk factors in the patient's medical record so that we can go back as researchers and help quantify the effects of these additional risk factors.

And as a clinician on the front lines myself, our first job is to immediately take care of the patient in front of us. If the patient comes in short of breath, the clinician should immediately meet their needs and help stabilize them. Even though these data points are extremely important, the immediate care of the patient always has to come first.

Q: Do you have specific recommendations for providers?

Winickoff: The science is still emerging, so I would say stay tuned for more updates. For now, know:

• That smoking and vaping may be a risk factor for more severe disease
• How to screen for vaping and smoking use
• What to do when you get a positive screen
• Where to refer patients for help with smoking and vaping cessation
• Free resources for patients looking to quit smoking or vaping:
• 1-800-QUIT-NOW, call 1-800-784-8669
• SmokefreeTXT, text "QUIT" (7848) to IQUIT (47848)

Those are key for clinicians to keep in mind right now. And be sure to follow the related research as it develops so that we have a better understanding of the magnitude of risks and additional therapies that emerge to help people off of tobacco products. That way physicians can bring those to bear to help people and help our patients recover.