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Smoking, Health Inequity, and COVID-19

Disease outbreaks expose the fissures in society and COVID-19 is no exception. Populations at increased risk for complications include the immunocompromised, people with pre-existing conditions, and the elderly (1). Tobacco smoking negatively impacts the immune system and increases the risk for a wide range of chronic diseases (1). People who smoke are more likely to be living with mental illness, have a problematic substance use disorder, and experience homelessness (2). All of which are not mutually exclusive and can increase the risk for both chronic disease and susceptibility to COVID-19 complications and death. This is in addition to the increased risk of exposure to COVID-19 among the poor, who are more likely to smoke, and less likely to have housing, paid sick leave, employment protections, and access to COVID-19 government benefit systems (2,3). Moreover, in past pandemics like the H1N1 pandemic, multiple epidemiologic studies reported greater levels of hospitalization in Indigenous communities and highly deprived neighborhoods in Canada. The studies also documented similar occurrences among people who lived on low incomes, those in poorer neighborhoods, and racialized populations in the United States (4). Pre-existing conditions and access to health care did not account for the all of the observed inequalities in H1N1 hospitalization rates in Canada and the United States; which underscores the importance of upstream factors such as socio-economic disadvantage in outbreak prevention and management (4).

Independent of the increased risk of disease and exposure in populations with smoking related health inequities, the relationship between smoking and COVID-19 adverse disease prognosis is assumed. Vardavas and Nikitara (2020) conducted a systematic review of studies that investigated the association between smoking and COVID-19. They found that smokers were more likely than their non-smoker counterparts to experience severe symptoms (RR=1.4, 95% CI: 0.98–2.00), require admission to ICU, require mechanical ventilation, and die from COVID-19 related complications (RR=2.4, 95% CI: 1.43–4.04) (5).

The battle against tobacco is far from over. Since the 1964 United States Surgeon General Report on Smoking and Health, causally linking smoking to lung cancer, significant gains have been made in reducing the rates of tobacco use in the West. However, tobacco smoking continues to rise in vulnerable and marginalized populations, including but not limited to people living in poverty, people living with mental illness, racialized populations, Indigenous populations, and the 2SLGBTQ+ community (6). This is in large part due to a marked class shift in tobacco smoking in the 20th century, fueled by the marketing of tobacco products to disadvantaged populations experiencing high levels of poverty, racism, marginalization, and historical and ongoing trauma (7). Smoking is a health equity and social justice issue with smokers dying 13 years sooner than non-smokers (6).

The COVID-19 pandemic illuminates existing health inequities in society. Smoking related health disparities lead in number of preventable cases of morbidity and premature mortality, as evidenced by a 28-year longitudinal study which found smoking to be a greater source of health inequity than an individual’s social position (8). In the aftermath of the pandemic, it is imperative we take stock of the differential impact of the virus on vulnerable populations, and the importance of health disparity reduction as a means to potentially curtail the severity of future disease outbreaks.


  1. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet [Internet]. 2020;395(10229):1054–62. Available from:
  2. Pakhale S, Kaur T, Charron C, Florence K, Rose T, Jama S, et al. Management and Point-of-Care for Tobacco Dependence (PROMPT): A feasibility mixed methods community-based participatory action research project in Ottawa, Canada. BMJ Open. 2018;
  3. Raub A, Chung P, Batra P, Earle A, Bose B, Jou J, et al. Paid leave for personal illness: A detailed look at approaches across OECD countries. 2018; Available from: Report – Personal Medical Leave OECD Country Approaches.pdf
  4. Rowel R, Sheikhattari P, Barber TM, Evans-Holland M. Introduction of a guide to enhance risk communication among low-income and minority populations: A grassroots community engagement approach. Health Promot Pract. 2012;13(1):124–32.
  5. Vardavas C, Nikitara K. COVID-19 and smoking: A systematic review of the evidence. Tob Induc Dis. 2020;18(March):1–4.
  6. Cole HM, Fiore MC. The war against tobacco: 50 Years and counting. JAMA – J Am Med Assoc. 2014;311(2):131–2.
  7. Pakhalé S, Folan P, Neptune E, Sachs D. Retail Tobacco Sale in the Community. Should Pharmacies Sell Tobacco Products? American Thoracic Society; 2015.
  8. Gruer L, Hart CL, Gordon DS, Watt GCM. Effect of tobacco smoking on survival of men and women by social position: a 28 year cohort study. Bmj. 2009;338(feb17 2):b480–b480.
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