The science of smoking and COVID-19

Presented by Alaska Native Tribal Health Consortium

At this point, everyone is familiar with the steps to take to guard against COVID-19: Wash your hands well with soap and water. Stay six feet from others outside your home. Cover your cough. Avoid touching your face.

Here’s one that you don’t hear as much: Stop smoking.

While some COVID-19 risk factors have to do with age, chronic illness or immunocompromisation, there’s one that’s tied directly to a different kind of medical concern -- addiction to cigarettes. While smoking cigarettes doesn’t necessarily make you more likely to become infected with the novel coronavirus, smokers who do contract COVID-19 may be more likely to have serious or fatal cases than non-smokers.

Why might COVID be harder on smokers? The answer lies in the lungs.

COVID-19 and your breathing health

“Not everyone is affected equally by COVID-19,” said Dr. Thomas Kelley, a pulmonologist at the Alaska Native Medical Center.

While about 80 percent of patients experience mild to moderate symptoms, others develop a “devastating” lung infection, according to Kelley. These infections inflame the alveoli, fine sacs in the deepest portions of the lungs. This inflammation interferes with the body’s ability to take in the oxygen it needs and expel the carbon dioxide it doesn’t.

“This can cause the development of viral pneumonia that may show up as ‘ground-glass opacities’ on chest X-rays and CAT scans of the lungs,” Kelley said. Ground-glass opacities, which indicate that a lung is sick, are often also seen in scans of patients with diseases like congestive heart failure and viral pneumonia.

About 14 percent of COVID-19 patients come down with severe cases, usually affecting both lungs. When this happens, the alveoli can fill with fluid and debris. And about 5 percent of patients develop critical cases of acute respiratory distress syndrome (ARDS), which can damage lungs -- extensively, permanently, and sometimes fatally.

“Patients this sick usually require admission to an intensive care unit, where they are often provided higher concentrations of supplemental oxygen and closely monitored for further deterioration,” Kelley said. “If they do get worse, they may be placed on mechanical ventilation.”

This is where the danger to smokers comes in.

“What it comes down to is: COVID-19 is a disease that attacks your respiratory system,” said Crystal Meade, program manager for the Alaska Native Tribal Health Consortium’s Tobacco Prevention Program. “So if you’re a tobacco user or vaper, you’re already at increased risk of respiratory infections.”

Smoking is tied to eight out of 10 cases of chronic obstructive pulmonary disease (COPD), which causes emphysema, and research has found that both smokers and COPD patients are at higher risk for severe illness and death from COVID-19.

Preliminary research also suggests that smoking provides COVID-19 additional points of entry into the lungs. COVID-19 infections start when the virus binds itself to the ACE2 receptor, a protein found on the surface of the lung. Researchers have found that smokers have more ACE2 receptors -- meaning a smoker’s lungs have more spots where the virus can attach and begin its destructive work.

“Think of your immune system,” Meade said. “Think of it being weakened by tobacco use already. With COVID-19, there are certain populations that are at higher risk. If you take these comorbidities and then you add them together and take COVID-19 and put it on top of that … When you start adding in all these health disparities, it’s definitely harder to fight it off.”

Even for patients who survive severe cases, the damage from ARDS can be lasting or even permanent.

“Some patients likely will experience some recovery to their lung function over time and others may not,” Kelley said. “We do know that patients with ARDS often require weeks to months of rehabilitation to get their strength back. These patients often experience shortness of breath and fatigue months and even years out from their original infection.”

Additionally, while there is currently no evidence about the relationship between electronic cigarettes and COVID-19, what we already know about vaping is enough to indicate that vape users are probably also at higher risk for harm from the virus, according to Kelley.

“Intuitively, given that existing evidence indicates that e-cigarettes are harmful and increase the risk of heart disease and lung disorders, (it) would appear that their use also increases the risk of developing severe infection and death in ‘vapers’ exposed to the COVID-19 virus,” Kelley said.

‘No better time than now to quit’

About one in five adult Alaskans -- more than 110,000 people -- smoke cigarettes; among Alaska Native people, that figure jumps to around one in three. If there’s good news, it’s that Meade said her program has seen increased interest in tobacco cessation since the start of the pandemic.

“It’s definitely on people’s minds,” she said. “We’ve had comments like, ‘I’ve been contemplating quitting for a while, but this was the motivation I needed.’”

In response to “hunker down” orders this spring, ANTHC’s free tobacco cessation program adapted quickly to ensure it would still be able to help anyone who is ready to quit.

“We’ve had to make quite a bit of adjustments in how we offer our treatment, but we are super lucky that we have the technology and the means to offer the treatment still,” Meade said. “We are able to do consultations over the phone, and then we’re actually in the process of being able to do virtual consultations using telehealth.”

Whether or not the motivation to quit comes from the threat of COVID, it’s important that it comes from the smoker themselves, Kelley said.

“The bottom line is that despite all the evidence of the dangers of smoking and how smoking may increase the risk of COVID-19 infection severity and death related to it, smokers will quit when they feel that they are ready to quit,” he said. “As physicians, we can and should encourage them to quit at every visit.”

Some patients may find that the choice is made for them. During the weeks or even months that an ARDS patient is in the ICU and then a rehabilitation center, they won’t be able to smoke at all -- “a sort of forced smoking cessation,” as Kelley described it.

“This is not the kind of approach I would want to take to smoking cessation if I were a smoker,” he added.

For Meade, the motivation -- and empathy -- to help others try to quit is rooted in a personal loss. Her mother was diagnosed with lung cancer in 2014 and passed away the following spring, seven years after she defeated a cigarette addiction that had lasted more than four decades.

“That was her way of dealing with stress,” Meade said. “It was her outlet. It was her break. I get that now.”

That experience helps Meade stay driven to help Alaskans quit -- and stay quit. The yearlong program she leads at ANTHC is designed to help participants develop strategies for the times when they’re likely to struggle.

“Maybe sometimes you can quit cold turkey, and you’re quit a month or two and something happens,” she said. “All of a sudden you have a very stressful situation that you haven’t prepared for as far as your tobacco use. What we really aim to do is talk with the patient and come up with what we call a ‘quit plan.’”

Nationally, less than 10 percent of smokers successfully quit each year, but ANTHC’s program typically sees about 40 percent of participants make it to the six-month mark, according to Meade.

With COVID-19 still circulating in Alaska, she said she hopes more smokers will use the virus as motivation to kick the habit for good.

“There’s really no better time than now to quit your tobacco use,” Meade said.

ANTHC’s Tobacco Prevention Program offers free tobacco cessation services to ANTHC employees and patients of the Alaska Native Medical Center. To enroll in the program, call (907) 729-4343. If you are not enrolled in the Tribal health system, you can find free smoking cessation resources through Alaska’s Tobacco Quit Line at AlaskaQuitLine.com or by phone at 1-800-QUIT-NOW.

This story was sponsored by Alaska Native Tribal Health Consortium, a statewide nonprofit Tribal health organization designed to meet the unique health needs of more than 175,000 Alaska Native and American Indian people living in Alaska.

This story was produced by the creative services department of the Anchorage Daily News in collaboration with Alaska Native Tribal Health Consortium. The ADN newsroom was not involved in its production.