We have read with interest the article by Pastor Esplà et al. and we agree with the authors that smoking is a risk factor for severe clinical course of COVID-19.1 To this respect we have also to consider that among patients hospitalized for SARS-CoV-2 related pneumonia, the prevalence of active smokers is very low, whatever the country we consider, from China to Europe and United States of America.2,3

There is a critical difference between the role of smoking (current/former) in the severe outcomes in COVID-19 and the quite low prevalence of active smokers among patients hospitalized for COVID-19. This is a very important issue since in the first case we all agree that smokers have more severe outcomes in COVID-19 probably due to the many comorbidities affecting smokers (active/former). In the second case, i.e. the low prevalence of current smokers among patients hospitalized for COVID-19, the main point is that current smoking seem to be “protective” towards the SARS-CoV-2 induced severe clinical complications.

To this respect there are data showing that among COVID-19 patients, significantly more former smokers were hospitalized and died from COVID-19 than current or never smokers.4 Thus there is the need to understand the possible mechanisms allowing cigarette smoking to dampen the inflammatory response during infection by SARS-CoV-2 strongly reducing the severe complications of SARS-CoV-2 infection, mainly interstitial pneumonia and ARDS.5

Thus, we fully agree with Pastor Esplà et al. in considering each occasion as a useful opportunity to quit smoking,1 thus reducing its well known unhealthy consequences. But considering the present SARS-CoV-2 pandemy, the lack of effective pharmacological treatments, and the reported ‘protective’ effects of active smoking towards severe COVID-19 complications, smoke cessation in current smokers could be suggested after SARS-CoV-2 vaccination!