As more Americans anxiously wait their turn to get the COVID-19 vaccine, people are discovering that smokers are one of the priority groups for vaccination.

Some don’t agree with the guidance and have expressed their frustrations on social media. But health experts say the rationale is clear.

“I could see why people would feel as if that would be unfair but people who are smokers are in general at higher risk for getting sicker when they develop COVID-19,” said Dr. Samuel Kim, a thoracic surgeon at Northwestern Medicine in Chicago.

A study, published Jan. 25 in the peer-reviewed journal JAMA Internal Medicine, found that people who smoke or who have smoked in the past are more likely to be hospitalized or die from COVID-19 than people who haven’t smoked.

“The finding that smoking is associated with increased risk of poor outcome from COVID-19 is not surprising,” said study co-author Dr. Joe Zein, a pulmonologist at the Cleveland Clinic. “Smoking induces structural changes in the respiratory tract and compromises people’s ability to mount appropriate immune and inflammatory responses (against infections).”

Smokers are also more likely to have other diseases such as high blood pressure, coronary artery disease and chronic obstructive pulmonary disease, or COPD, which further increases their risk of bad outcomes, he added.

The Cleveland Clinic study found that COVID-19 patients who had smoked more than 30 pack-years (a figure derived by multiplying the number of packs per day times years of smoking) had 2.25 times higher odds of hospitalization and were 1.89 times more likely to die than those who never smoked.

Zein said it’s difficult to capture the link between smoking and worse COVID-19 outcomes because electronic medical records may misclassify patients. Instead of putting a patient down as a “former smoker,” they’re sometimes classified as “never smokers.”

Researchers at the University of California, Los Angeles, discovered how smoking worsens COVID-19 infections in a smoker’s airways in a November study published in the peer-reviewed journal Cell Stem Cell.

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The group infected cultures exposed to cigarette smoke and identical cultures that weren’t exposed and saw between two and three times more infected cells in the smoker cultures.

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Cigarette smoking is a significant risk factor for both bacterial and viral infections. Zein said smoking is associated with a 2- to 4-fold increased risk of invasive pneumococcal infection. The risk of influenza disease and severity also is significantly higher in smokers than nonsmokers, and in developing countries, smoking was associated with an increased risk of tuberculosis.

“If you think of the airways like the high walls that protect a castle, smoking cigarettes is like creating holes in these walls,” said Dr. Brigitte Gomperts, a professor of pulmonary medicine and member of the UCLA Jonsson Comprehensive Cancer Center. “Smoking reduces the natural defenses and that allows the virus to set in.”

Kim from Northwestern Medicine said some studies have found smoking also can impact the immune system so the body can’t clear infection as well as a normal person would. If the COVID-19 infection progresses to severe disease and lung damage, some patients require lung transplants.

“When you take a look at those lungs,” he said of the extreme COVID-19 cases, “those are worse than any other lung disease I’ve ever seen.”

Follow Adrianna Rodriguez on Twitter: @AdriannaUSAT.

Health and patient safety coverage at USA TODAY is made possible in part by a grant from the Masimo Foundation for Ethics, Innovation and Competition in Healthcare. The Masimo Foundation does not provide editorial input.

This article originally appeared on USA TODAY: CDC prioritizes smokers for COVID vaccine. Health experts explain why.

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