This Q&A is based on, and benefitted from, the most recent evidence on COVID-19 and tobacco use. Although evidence is still accumulating on the links between COVID-19 and tobacco, waterpipe and e-products use, current research suggests a possible association between smoking and increasing severity of COVID-19 symptoms. Therefore, it is important to raise awareness in this area. There are still research gaps that need to be addressed. As more research data become available, the Q&A will be updated accordingly.
What are the possible relations between tobacco use and the COVID19 pandemic?
Tobacco use may increase the risk of suffering from serious symptoms due to COVID-19 illness. Early research indicates that, compared to non-smokers, having a history of smoking may substantially increase the chance of adverse health outcomes for COVID-19 patients, including being admitted to intensive care, requiring mechanical ventilation and suffering severe health consequences [1] [2].
Smoking is already known to be a risk-factor for many other respiratory infections, including colds, influenza, pneumonia and tuberculosis [3]. The effects of smoking on the respiratory system makes it more likely that smokers contract these diseases, which could be more severe [4] [5]. Smoking is also associated with increased development of acute respiratory distress syndrome, a key complication for severe cases of COVID-19 [6], among people with severe respiratory infections [7] [8].
Any kind of tobacco smoking is harmful to bodily systems, including the cardiovascular and respiratory systems [9] [10]. COVID-19 can also harm these systems. Evidence from China, where COVID-19 originated, shows that people who have cardiovascular and respiratory conditions caused by tobacco use, or otherwise, are at higher risk of developing severe COVID-19 symptoms [11]. Research on 55 924 laboratory confirmed cases show that the crude fatality rate for COVID-19 patients is much higher among those with cardiovascular disease, diabetes, hypertension, chronic respiratory disease or cancer than those with no pre-existing chronic medical conditions [12]. This demonstrates that these pre-existing conditions may increase the vulnerability of such individuals to COVID-19.
Tobacco use has a huge impact on respiratory health and is the most common cause of lung cancer [13]. It is also the most important risk-factor for chronic obstructive pulmonary disease (COPD), which causes the swelling and rupturing of the air sacs in the lungs, reducing the lung’s capacity to take in oxygen and expel carbon dioxide, and the build-up of mucus, resulting in painful coughing and breathing difficulties [14] [15] [16]. This may have implications for smokers given that the virus that causes COVID-19 primarily affects the respiratory system often causing mild to severe respiratory damage [12], which could result in fatality. However, given that COVID-19 is a newly identified disease, the link between tobacco use and the disease needs further documentation and research.
In addition, there is an increased risk of more serious symptoms and death among COVID-19 patients who have underlying conditions, including cardiovascular diseases (CVDs) [17] [18]. The virus that causes COVID-19 (SARS-CoV-2) is from the same family as MERS-CoV and SARS-CoV, both of which have been associated with cardiovascular damage (either acute or chronic) [19] [20]. There is also evidence that COVID-19 patients that have more severe symptoms often have heart-related complications [21]. This relationship between COVID-19 and cardiovascular health is important because tobacco use and exposure to second-hand smoke are major causes of CVDs globally [22]. The effect of COVID-19 on the cardiovascular system could thus make pre-existing cardiovascular conditions worse. Additionally, a weaker cardiovascular system among COVID-19 patients with a history of tobacco use could make such patients more vulnerable to severe symptoms, thereby increasing the risk for those patients [23].
How can use of waterpipe contribute to the spread of COVID19?
The main ingredient used in waterpipe is tobacco, and its use has both acute and long-term harmful effects on the respiratory and cardiovascular systems [24] [25], likely increasing the risk of diseases including coronary artery disease and COPD [26].
The communal nature of waterpipe smoking means that a single mouthpiece and hose are often shared between users, especially in social settings [27]. In addition, the waterpipe apparatus (including the hose and chamber) itself may provide an environment that promotes the survival of microorganisms outside the body. Most cafés tend not to clean the waterpipe equipment, including the water jar, after each smoking session because washing and cleaning waterpipe parts is labour intensive and time consuming [28] [29]. These factors increase the potential for the transmission of infectious diseases between users [25].
Consistent with this, evidence has shown that waterpipe use is associated with an increased risk of transmission of infectious agents, including respiratory viruses, Epstein Barr virus, Herpes Simplex virus, tuberculosis, Heliobacter pylori, and Aspergillus [30] [31] [32] [33] [34] [35].
Social gatherings also provide ample opportunity for the virus that causes COVID-19 to spread [36]. Since waterpipe smoking is typically an activity that takes place within groups in public settings [27], and waterpipe use increases the risk of transmission of diseases, it could also encourage the transmission of COVID-19 in social gatherings. When waterpipe use takes place in indoor areas, as it does in many places, the risk could be higher.
Will strengthened tobacco control measures help in this context?
In 2008, WHO introduced the MPOWER technical package, which is based on the tobacco demand-reduction articles of the WHO Framework Convention on Tobacco Control (WHO FCTC). These measures are as follows:
Monitor tobacco use and prevention policies.
Protect people from tobacco use.
Offer help to quit tobacco use.
Warn about the dangers of tobacco.
Enforce bans on tobacco advertising, promotion and sponsorship.
Raise taxes on tobacco.
Strengthened tobacco control measures, including tobacco-free public places and the protection of people from second-hand smoke as per Article 8 of the WHO FCTC and its Guidelines could reduce the risk of suffering from severe symptoms. Lower rates of tobacco use will reduce rates of many respiratory and cardiovascular conditions that are associated with more serious COVID-19 symptoms and mortality.
Good respiratory and cardiovascular health is important for a COVID-19 patient to positively respond and successfully recover from the disease.
Reducing the demand for tobacco products, including waterpipe products, will discourage the social gatherings associated with these products that contribute to the spread of the virus.
In addition, improved tobacco control could substantially reduce the background demand placed on health systems at this time, allowing more resources to be focused on treating COVID-19 patients. Research shows that the introduction of comprehensive, enforced smoke-free laws around the world was followed by significant reductions in hospital admissions for a wide variety of acute cardiac and respiratory diseases [37].
Specifically regarding waterpipe use, since it is often overlooked in tobacco control efforts, there is a significant opportunity for positive health outcomes at this time, both with respect to COVID-19 and generally, if immediate comprehensive tobacco control measures are taken that include the control of waterpipe.
Countries can use WHO’s highly effective, evidence-based MPOWER policy package to support their formulation and implementation of tobacco control measures to protect public health.
How can regional tobacco control legislation support the limitation of the virus spreading?
The WHO FCTC and the MPOWER policy package apply at both the global level and the regional level within the Eastern Mediterranean Region. Countries should seek to limit the use of waterpipe and other tobacco use in order to reduce its well documented health impact and improve people’s respiratory and cardiovascular health.
Controlling tobacco use and reducing waterpipe use may be important for reducing the risk of the transmission of the virus that causes COVID-19. It is important that the control of waterpipe use is taken especially seriously at this time and within a comprehensive approach to control all tobacco use, in light of the WHO FCTC obligations and MPOWER recommendations.
In general, WHO recommends that countries fully implement the WHO FCTC and the MPOWER policy package. This includes a comprehensive ban on all forms of tobacco use, including waterpipe use, in all indoor (and, as appropriate, outdoor) public places (including cafes and restaurants). Such a ban may help prevent any increased risk of transmission of the virus that causes COVID-19 related to waterpipe use. Countries are encouraged to ensure that this ban is in place and fully enforced.
Why is this a good time to try and quit tobacco and waterpipe use?
Tobacco use dramatically increases the risk of many serious health problems, including both respiratory problems (like lung cancer, TB and COPD) and CVDs. While this means that it is always a good idea to quit tobacco use, quitting tobacco and waterpipe use may be especially important at this time to reduce the harm caused by COVID-19. The absence of smoking helps reduce touching the mouth with the fingers. Also, it is possible that current smokers would better manage any pre-existing conditions if they do become infected because quitting tobacco use has an almost immediate positive impact on lung and cardiovascular function and these improvements increase as time goes on [3]. Such improvements may increase the ability of COVID-19 patients to respond to the infection and potentially reduce the risk of developing severe symptoms.
What are the key lessons learnt from previous experiences?
From previous experience in responding to MERS-CoV and SARS-CoV, general precautions should be taken, especially in social gatherings [36].
Waterpipes may be a catalyst for social gatherings in environments that could increase disease transmission.
Previous evidence shows that smoking has adverse effects on the survival of individuals with infectious diseases [38]. Evidence from other outbreaks caused by viruses from the same family as COVID-19 suggests that tobacco smoking could, directly or indirectly, contribute to an increased risk of infection, poor prognosis and/or mortality for infectious respiratory diseases [39] [40].
Is it safe to use tobacco including waterpipe at home during the COVID-19 pandemic?
It is not safe to use tobacco at home. Using tobacco at home is associated with the same risks as tobacco use in public places [3]. Tobacco use, including waterpipe use, in any setting is harmful to the health of the user and anyone who breathes in the tobacco smoke.
The home setting is often the place where both children and adults are most exposed to second-hand smoke [41] [42]. Children are especially susceptible to second-hand smoke exposure, which has been shown to increase their risk of lower respiratory tract infections, asthma, middle ear disease and other debilitating health conditions [3]. Children exposed to second-hand smoke are also prone to suffer more severe symptoms of respiratory syncytial infection (like COVID-19, respiratory syncytial infection is a form of viral pneumonia) [43]. There may be an increased danger of second-hand smoke exposure during the COVID-19 pandemic because more people, including smokers and the people they live with, are spending longer periods of time in their homes as part of ‘lockdown measures’ imposed by some countries to reduce disease transmission.
In addition, exposure to third-hand smoke at home might be increased [44]. Third-hand smoke is the persistent residue resulting from tobacco smoke (e.g. from cigarette or waterpipe smoke) that accumulates in dust, objects, and on surfaces in homes where tobacco has been used and is re-emitted into the air [45]. Children are exposed to third-hand smoke toxicants via inhalation, ingestion, and dermal transfer [45] [46].
In response to the COVID-19 pandemic, 15 countries in the Eastern Mediterranean Region have introduced new measures to ban waterpipe use in all public places (while two had already banned its before the pandemic). Despite the ban on use in public places, waterpipe use in the home has persisted. In some instances, people are able to have waterpipe delivered to their homes, facilitating access during the COVID-19 pandemic [47]. It is important to note that waterpipe use at home is harmful to the user, as well as to non-users who breathe in second-hand smoke. The impact of tobacco smoke on respiratory and cardiovascular health, as well as the risk of transmission of infectious agents through shared waterpipe use, are of serious concern during the COVID-19 pandemic.
Why are e-cigarettes not a "safer" alternative during the COVID-19 pandemic and beyond?
Evidence reveals that electronic nicotine delivery systems (ENDS) and electronic non-nicotine delivery systems, more commonly referred to as e-cigarettes, are harmful to health and undoubtedly unsafe. E-cigarette emissions typically contain nicotine and other toxic substances that are harmful to both users and non-users who have been exposed to the aerosols second-hand [49] [50]. The use of e-cigarettes also increases the risk of heart disease and lung disorders [51] [52].
Given the growing evidence that e-cigarette use could be associated with lung injuries and in recent times the link to an outbreak of lung injury in the USA [48] [49] [53], described as ‘e-cigarette or vaping product use associated lung injury’ (EVALI) [53], COVID-19 may have implications for e-cigarette users. This is because the COVID-19 virus affects the respiratory tract. Further, e-cigarette use may suppress immune and inflammatory-response genes in nasal epithelial cells in a similar way to cigarette smoke [55], which may predispose e-cigarette users to COVID-19. The hand-to-mouth action by e-cigarette users may also put them at increased risk of contracting the disease. If e-cigarette devices are shared, the risk of transmission is also likely to be increased. Given that some countries are in lockdown and access to e-cigarettes may be limited, especially for youth, the sharing of devices may be more common under these circumstances.
In addition, the scientific evidence regarding the effectiveness of ENDS as a smoking cessation aid is still being debated. To date, in part due to the diversity of ENDS products and the low certainty surrounding many studies, the potential for ENDS to play a role as a population-level tobacco cessation intervention is unclear. Tobacco users should quit completely and not switch to e-cigarettes, which pose health risks of their own, and are not safe [56]. The safest approach is not to use either tobacco products or e-cigarettes [53]. Using any of these products may increase the risk of COVID-19 patients suffering more severe illness.
Tobacco users who want to quit should use tried and tested interventions such as brief advice from health professionals, and national quit lines or cessation interventions delivered via mobile text message (i.e. m-cessation for tobacco cessation), where available.
What is next?
This document is based on the most updated available evidence. It will be updated as new evidence emerges.
In the context of COVID-19, countries are encouraged to take the needed action to protect the public from the devastating health consequences of tobacco use in light of their international commitments under the WHO FCTC and WHO recommendations.
Additional resources
There are many additional resources related to tobacco, waterpipe and e-cigarette use and COVID-19 that have been published by WHO and other organizations. Here are some key online resources.
Coronavirus (COVID-19): effective options for quitting smoking during the pandemic. London: Cochrane Special Collection; 2020.
COVID-19 and smoking: resources, research and news. London: Tobacco Control (BMJ); 2020.
COVID-19 and tobacco industry interference. Thailand: Global Center for Good Governance in Tobacco Control; 2020.
COVID-19 and tobacco policy and communication toolkit. Washington D.C.: Action on Smoking and Health; 2020.
COVID is no joke, it gets worse with smoke. Washington D.C.: Pan American Health Organization; 2020.
COVID-19: quit smoking and vaping to protect your lungs. Washington D.C.: Campaign for Tobacco-Free Kids; 2020.
COVID-19: the connection to smoking and vaping, and resources for quitting. Washington DC: Truth Initiative; 2020.
COVID-19: tobacco use and vaping. New Delhi: World Health Organization Regional Office for South-East Asia; 2020.
Increased risk of COVID-19 infection amongst smokers and amongst waterpipe users. Beirut: WHO FCTC Knowledge Hub for Waterpipe Tobacco Smoking; 2020.
Links between smoking and COVID-19. Bath: Stopping Tobacco Organizations and Products (STOP); 2020.
People who are at higher risk of severe illness. Atlanta: U.S. Centres for Disease Control; 2020.
Q&A: tobacco and COVID-19. Geneva: World Health Organization; 2020.
Resources for tobacco use control as part of COVID-19 response. Copenhagen: World Health Organization Regional Office for Europe; 2020.
Smoking and COVID-19: factsheet. New York: Vital Strategies; 2020.
Statement on COVID-19 and smoking. Paris: The Union; 2020.
Smoking and COVID-19: scientific brief. Geneva: World Health Organization; 2020.
Tobacco control during the COVID-19 pandemic: how we can help. Geneva: WHO FCTC Secretariat; 2020.
Tobacco tactics: COVID-19. Bath: University of Bath Tobacco Control Research Group; 2020.
What do we know about tobacco use and COVID-19? Atlanta: Tobacco Atlas; 2020.
WHO statement: tobacco use and COVID-19. Geneva: World Health Organization; 2020.
World no tobacco day 2020 and COVID-19: social media tiles. Manila: World Health Organization Regional Office for the Western Pacific; 2020.
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Additional information
Many countries in the Eastern Mediterranean Region have reported cases of COVID-19. The WHO is actively involved in supporting Member States prepare and respond to the outbreak. Further, regularly updated information about COVID-19 and the WHO’s work can be found here.
For information on countries that took action to strengthen tobacco control in light of COVID-19, please contact the Tobacco Free Initiative, WHO EMRO:
