Tomorrow is John Prine’s birthday. He would have been 80. He will have been dead 6 ½ years, having breathed his last 4/7/20 on a ventilator at Vanderbilt’s hospital, one of the first high profile names to be claimed by COVID. He’d acquired the bug in France, where he was completing what would be his last tour. Sure, he’d looked like a physical wreck for
years, survivor of 2 cancer operations. Still, the loss was profound, and those blessed to know him and his work still miss him terribly. With his vast body of work, his wit and wisdom are still there for any who seek.
When John’s tunes waft over my speakers, the words are familiar as I know them all by heart. The mind can wander in such situations, and last night that’s what happened. The thought goes something like this: might John still be alive today if he’d ignored the advice of his doctors? Stay with me on this, as I’m not blowing smoke, as it were. Both of John’s cancers – the head and neck mass resected in1998 and the lung cancer resected in 2013 -were tobacco related. John’s always been a smoker, so when his docs told him he should never go near a cigarette, it was a hard sentence. He complied, but not without the ex-smoker’s longing immortalized in his next to last hit “When I get to heaven” (1). Among the activities he says he’ll do when he gets there is “smoke a cigarette that’s nine miles long”.
Was good patient John hamstringing himself of an important defense as he faced the pandemic? One vastly underreported observation from those times is that cigarette smokers seem to be protected from COVID. The first hint came from a French hospital where most COVID patients were nonsmokers in a country where 80% of the population smokes. Yet, most of those hospitalized with COVID were non-smokers. Similar results were reported from China, where over half the male population smokes. Based on that, I began giving kudos to my clinic mates sneaking out to the bus stop for a smoke (2,3). So far as I recall, none of them got COVID.
A number of similar studies quickly emerged, showing a similar protective effect of smoking in Italy, Germany, the UK, the USA, Israel, Iran, South Korea, Kuwait, Mexico, Spain, and Switzerland. That tobacco smoke might mitigate COVID infection was not implausible. Tobacco down regulates the expression of the ACE2 receptor, to which COVID binds to enter lung tissue. Nicotine has anti-inflammatory activity and also dampens ACE2 expression. Nitric oxide, introduced with the smoke, has antiviral effects. Smoking warms lung tissue, invoking one of the most primitive defenses: heat.
The backlash was swift and heavy. Writers seemed more eager to protect populations from the ills of smoking than consider something that might help them confront a feared infection. Epidemiology studies are easy to pick apart, and boy did they. Some positive papers still crept out, like Norden et al’s look at COVID mortality and smoking across 40 countries, which produced this interesting graph (4).
Looks to me like more smokers = lower mortality.
Since then, two schools have emerged regarding smoking and COVID. The majority say that, oh yes, smoking is bad all around (5). As a lung toxin, it renders those tissues more susceptible to COVID invasion, and harder to clear same. Of course, all those tobacco diseases become the comorbidities associated with worse outcomes. Nicotine has been bandied about as the agent from cigarette smoke that might be used a protectant, with some evidence that might be a valid tactic (6). My take is that it’s something in that maelstrom of smoke that enters the lung with each puff. Now, the traditional approach of modern medical science when confronted by a natural phenomenon with potential health benefits is to work on isolating the compound from the mess so as to patent it and allow $$$ to be made. I see no evidence that that is happening here.
Yes, it’s sad that John is gone. Even if a much enjoyed puff of smoke might have swatted off that French virus, it didn’t happen and life goes on. So, if you’re facing a situation with a high probability of COVID exposure, I offer you the same advice I always gave my nurses at the bus stop: smoke ‘em if you got ‘em!
*from Bob Seger’s 3rd album “Smokin’ Ops”
References
1. John Prine – When I Get To Heaven (Lyric Video). YouTube. https://youtu.be/l0EiV423j0M?si=KLsaxyeAIdgHjkOn
2. Ike B. smokin’ Corona. WordPress 3/18/20. https://theviewfromharbal.com/2020/03/18/smokin-corona/
3. Ike B. smoke ‘em if you got ‘em. WordPress. 4/23/20. https://theviewfromharbal.com/2020/04/23/smoke-em-if-you-got-em/
4. Norden MJ, Avery DH, Norden JG, Haynor DR. National Smoking Rates Correlate Inversely with COVID-19 Mortality. medRxiv preprint, June 14, 2020. this version posted June 14, 2020. https://doi.org/10.1101/2020.06.12.201298
5. Kramer I, Zhu Y, Van Westen-Lagerweij NA, Dekker LH, Mierau JO, Croes EA. New insights into the paradox between smoking and the risk of SARS-CoV-2 infection (COVID-19): Insufficient evidence for a causal association. Scand J Public Health. 2025 Jul;53(5):552-559. doi: 10.1177/14034948241253690. Epub 2024 Jul 31.
6. Piasecki TM, Smith SS, Baker TB, Slutske WS, Adsit RT, Bolt DM, Conner KL, Bernstein SL, Eng OD, Lazuk D, Gonzalez A, Jorenby DE, D’Angelo H, Kirsch JA, Williams BS, Nolan MB, Hayes-Birchler T, Kent S, Kim H, Lubanski S, Yu M, Suk Y, Cai Y, Kashyap N, Mathew JP, McMahan G, Rolland B, Tindle HA, Warren GW, An LC, Boyd AD, Brunzell DH, Carrillo V, Chen LS, Davis JM, Deshmukh VG, Dilip D, Ellerbeck EF, Goldstein AO, Iturrate E, Jose T, Khanna N, King A, Klass E, Mermelstein RJ, Tong E, Tsoh JY, Wilson KM, Theobald WE, Fiore MC. Smoking Status, Nicotine Medication, Vaccination, and COVID-19 Hospital Outcomes: Findings from the COVID EHR Cohort at the University of Wisconsin (CEC-UW) Study. Nicotine Tob Res. 2023 May 22;25(6):1184-1193. doi: 10.1093/ntr/ntac201.
