Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Meta-Anal. Aug 28, 2021; 9(4): 353-376
Published online Aug 28, 2021. doi: 10.13105/wjma.v9.i4.353
Systematic review with meta-analysis of the epidemiological evidence in Europe, Israel, America and Australasia on smoking and COVID-19
Peter Nicholas Lee, Janette S Hamling, Katharine Jane Coombs
Peter Nicholas Lee, Katharine Jane Coombs, Department of Statistics, P.N. Lee Statistics and Computing Ltd., Sutton SM2 5DA, United Kingdom
Janette S Hamling, Department of Statistics, RoeLee Statistics Ltd., Sutton SM2 5DA, Surrey, United Kingdom
Author contributions: Lee PN conceived the study, checked the data entry and analysis, and wrote the paper; Coombs KJ carried out the literature searches and assisted in finalizing the paper; Hamling JS checked the literature searches, carried out the data entry and analysis, and assisted in finalizing the paper.
Supported by British-American Tobacco (Investments) Ltd., No. 5700014230; Japan Tobacco International S.A., No. 4700562109; and Philip Morris Products S.A., No 5700131814.
Conflict-of-interest statement: The authors have carried out consultancy work for many tobacco organizations.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2020 statement, and the manuscript was prepared and revised according to the PRISMA 2020 statement.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Peter Nicholas Lee, MA, Director, Senior Statistician, Department of Statistics, P.N. Lee Statistics and Computing Ltd., 17 Cedar Road, Sutton SM2 5DA, United Kingdom.
Received: April 3, 2021
Peer-review started: April 3, 2021
First decision: June 18, 2021
Revised: June 28, 2021
Accepted: August 23, 2021
Article in press: August 23, 2021
Published online: August 28, 2021

Previous meta-analyses related smoking to death or severe infection from coronavirus disease 2019 (COVID-19) in hospitalized patients, but considered only a few studies, did not adjust for demographics and comorbidities, and inadequately defined smoking.


To review and meta-analyse epidemiological evidence on smoking and COVID-19, considering a range of endpoints, populations and smoking definitions and the effect of adjustment.


Studies were identified from publications in English up to 30 September, 2020 involving at least 100 individuals, carried out in Europe, Israel, America or Australasia, not restricted to those with specific other diseases, and providing information relating smoking to various COVID-related endpoints. Meta-analyses were carried out for combinations of population and endpoint, with variation studied by smoking definition, adjustment level and other factors.


From 96 publications, 74 studies were identified, 37 in the United States, 10 in the United Kingdom, with up to four in the other countries. Three involved over a million individuals, and 37 involved less than a thousand. Adjusted results for smoking were available in 42 studies, with adjustment not considered in 20 studies. Results were considered by endpoint. No significant effect of smoking on COVID-19 positivity was seen in the general population, but there was a reduced risk in those tested. Best-adjusted estimates for current (vs never) smoking were 0.87 (95% confidence interval: 0.52-1.47) in the general population and 0.52 (0.43-0.64) in those tested. For those hospitalized due to COVID-19, unadjusted rates were significantly increased in current smokers (1.20, 1.01-1.42) and ever smokers (1.64, 1.41-1.91), but those adjusted for comorbidities showed no increase for current (0.82, 0.52-1.30) or ever smokers (1.00, 0.76-1.32). There was little evidence to suggest that smoking was associated with intensive care admission. For those hospitalized with COVID-19, best-adjusted estimates were 0.88 (0.72-1.08) for current smokers and 1.10 (0.99-1.22) for ever smokers. In those hospitalized with COVID-19, smoking was not significantly related to subsequent mechanical ventilation, with best-adjusted estimates of 1.12 (0.60-2.09) for current smokers and 1.05 (0.88-1.25) for ever smokers. For those hospitalized with severe COVID-19, best-adjusted estimates were 0.74 (0.49-1.12) for current smokers and 1.15 (0.87-1.51) for ever smokers; few estimates were adjusted for comorbidities. While smoking was associated with increased mortality in unadjusted analyses, the association disappeared after adjustment for comorbidities. For example, in those hospitalized with COVID-19, the unadjusted estimate for ever smokers of 1.59 (1.37-1.83) reduced to 1.07 (0.82-1.38) when adjusted for comorbidities. Studies on those with severe COVID-19 showed that smoking tended to be associated with worsening of the disease. However, no estimate was adjusted, even for demographics. Estimates did not clearly vary by location or study size, and there was too little evidence to usefully study variations by age, amount smoked or years quit.


The increased COVID-19 death rate in smokers seen in unadjusted analyses disappears following adjustment for demographics and comorbidities. Among those tested, smoking is associated with lower COVID-19 infection rates.

Keywords: Smoking, COVID-19, Meta-analyses, Review, Europe, America

Core Tip: Detailed analyses of 74 studies related smoking to being tested for coronavirus disease 2019 (COVID-19), having COVID-19, or suffering death or severe disease due to COVID-19. Various smoking indices were studied, as were the effects of adjusting for other factors. Although many studies provided limited unreliable results, consistent evidence showed that of those tested, smokers were less likely to have COVID-19. Among those positive for or hospitalized with COVID-19, there was a clear association between smoking and COVID-19 death and severity in unadjusted analyses, which disappeared following adjustment for comorbidities and demographics. Any adverse effects in smokers appear to derive from their poorer prior health status.