ABSTRACT
The relationship between smoking and coronavirus disease 2019 (COVID-19) severity remains unclear. This study aimed to investigate the effect of smoking status (current smoking and a smoking history) on the clinical severity of COVID-19. Data of all enrolled 588 patients, who were referred to 25 hospitals in Jiangsu province between January 10, 2020 and March 14, 2020, were retrospectively reviewed. Univariate and multivariate regression, random forest algorithms, and additive interaction were used to estimate the importance of selective predictor variables in the relationship between smoking and COVID-19 severity. In the univariate analysis, the proportion of patients with a current smoking status in the severe group was significantly higher than that in the non-severe group. In the multivariate analysis, current smoking remained a risk factor for severe COVID-19. Data from the interaction analysis showed a strong interaction between the number of comorbidities in patients with COVID-19 and smoking. However, no significant interaction was found between smoking and specific comorbidities, such as hypertension, diabetes, etc. In the random forest model, smoking history was ranked sixth in mean decrease accuracy. Active smoking may be significantly associated with an enhanced risk of COVID-19 progression towards severe disease. However, additional prospective studies are needed to clarify the complex relationship between smoking and COVID-19 severity.