The effect of laboratory-verified smoking on SARS-CoV-2 infection: results from the Troina sero-epidemiological survey

Intern Emerg Med. 2022 Sep;17(6):1617-1630. doi: 10.1007/s11739-022-02975-1. Epub 2022 Apr 14.


Previous research yielded conflicting results on the association between cigarette smoking and risk of SARS-CoV-2 infection. Since the prevalence of smoking is high globally, the study of its impact on COVID-19 pandemic may have considerable implications for public health. This study is the first to investigate the association between the SARS-CoV-2 antibody sero-positivity and biochemically verified smoking status, to refine current estimates on this association. SARS-CoV-2-specific IgG and serum cotinine levels (a well-known marker of tobacco exposure) were assessed in a large sero-epidemiological survey conducted in the town of Troina (Sicily, Italy). A propensity score matching was carried out to reduce the effect of possible factors on SARS-CoV-2 infection risk among study participants. Of the 1785 subjects included in our study, one-third was classified as current smokers, based on serum cotinine levels. The overall proportion of subjects with positive serology for SARS-CoV-2 IgG was 5.4%. The prevalence of SARS-CoV-2 antibody positivity and previous COVID-19 diagnosis were reduced in smokers. This reduced prevalence persisted after adjusting for possible confounders (such as sex, age, previous infection, chronic conditions, and risk group) at regression analyses, and the point estimates based on the PS-matched models resulted consistent with those for the unmatched population. This study found a lower proportion of positive SARS-CoV-2 serology among current smokers, using direct laboratory measures of tobacco exposure and thus avoiding possible bias associated with self-reported smoking status. Results may also serve as a reference for future clinical research on potential pharmaceutical role of nicotine or nicotinic-cholinergic agonists against COVID-19.

Keywords: Antibody persistence; COVID-19; Cotinine; SARS-CoV-2-specific immunoglobulin; Sero-prevalence; Smoking.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Antibodies, Viral
  • COVID-19 Testing
  • COVID-19* / epidemiology
  • Cotinine
  • Humans
  • Immunoglobulin G
  • Pandemics
  • SARS-CoV-2
  • Smoking / adverse effects
  • Smoking / epidemiology


  • Antibodies, Viral
  • Immunoglobulin G
  • Cotinine