Unknown clinical relevancy of smoking status, antibody titers and

viral neutralizing activity in SARS-CoV-2 vaccinated individuals

Summary

• A review of 23 studies measuring antibody levels and/or their neutralizing activity

following vaccination evaluates the antibody kinetics and, to a lower extent, other
immune mediators mediating the protection. 17 studies found statistically significant
differences in the antibody kinetics between smokers and nonsmokers, suggesting
that smoking could decrease antibody levels at specific timepoints. The timepoints at
which decreases were identified were inconsistent and showed a wide variability
across those 17 studies. Furthermore, it was not possible to determine whether the
decrease was related to the duration of smoking or number of cigarettes smoked per
day.1 The potential clinical relevancy of these findings is unknown so far.

• The following considerations summarize the current knowledge related to the

immunity conferred by vaccination or previous infection against SARS-CoV-2 virus,
independently of the smoking status of the individuals:

• Antibody titers or antibody neutralizing activity are presently considered as

reliable surrogate markers for predicting the protection conferred by vaccination
and/or infection. Plasma antibody titers diminish over time, with variable half
lifes,2,3 both after vaccination or infection. The decay is generally faster in the
first 3 months after vaccination than later on. After 6 months the antibody decay
is further diminished at a lower rate and specific memory lymphocytes that
proliferate in presence of the virus are detected.4 At some point, the antibody
levels may drop below a protective threshold. On the other hand, for Covid-19
and other infectious diseases, the immune protection conferred by vaccination or
previous infection also involves B and T (CD4+ and CD8+) memory lymphocytes.
In addition to B5 and T lymphocytes, macrophages, monocytes and natural killer
leucocytes6 may contribute to the prophylactic effects in synergism with the
antibody mediated humoral immune response. Overall, antibody titers decay
over time,7 with variable half-lifes reported in different studies. To which extent
this decay influences the total immunity and the vaccine efficacy is unclear so
far.8,9 Nevertheless, it is prudent to assume long-term benefits of an initial strong
antibody response.10

• While the immune protection may decrease with time as neutralization levels
decline, when comparing the protection against severe infections with the
 protection against mild infections, it has been observed that “the protection from
severe infection may be considerably more durable given that lower levels of
response may be required or alternative responses (such as cellular immune
responses) may play a more prominent role.”11

• Importantly, at the population level and for a given type of vaccine type, the
antibody titers and antibody neutralizing activities following vaccination span
across 1 to 2 orders of magnitude.12 Furthermore, different types of vaccines, or
their sequential combinations, also lead to variable levels of antibodies though
these variations do not necessarily correlate with their efficacy and efficiency.13
Interestingly, natural infection often results in lower antibody levels than
following vaccination but confers a greater and longer protection at a given
antibody level.14

• The studies reported in Pubmed, the IVAC-WHO database (302 efficacy and
effectiveness studies in 38 countries reported up to 24th of May, 2022) and the
databases of the USA15 and the EU Center for Disease Control16 do not discuss the
effect of smoking on antibody levels, with only a few studies reporting the smoking
status that, in a weight of evidence, reach inconclusive results.

• For comparison, the influence of smoking appears unclear in studies evaluating the
antibody levels, efficacy and effectiveness of Influenza, Hepatitis B and Human
Papilloma virus vaccines. Two recent Cochrane reviews performed quantitative
analysis adjusted for confounders as sex, age, smoking, and comorbidities but did not
provide comments or conclusions on any detrimental effect of smoking on the
protection conferred by influenza vaccines.17

• Based on a weight of evidence analysis of all the published studies evaluating the
efficacy and effectiveness of COVID-19 vaccination, the pathophysiologic
mechanisms and, most importantly, the potential clinical relevancy of an
hypothetical association between smoking and immune response to SARS-CoV-2
virus infection or vaccines are yet unresolved. 18,19 Further scientific studies are
needed to give more light into this topic.
Relevant studies evaluating the smoking status and SARS-CoV-2 vaccine
antibody levels

• A review of 23 studies measuring antibody levels and/or their neutralizing activity

following vaccination discusses in detail the data, methodologies and the unknown
health significance of the reported results focusing on antibody kinetics and, to a lower
extent, on other immune mediators mediating the protection. 17 studies found
statistically significant differences in the antibody kinetics between smokers and
nonsmokers, suggesting that smoking could influence antibody levels at specific
timepoints. These timepoints were inconsistent and variable across the studies.20 The
majority of studies also investigated the association of antibody titers specific to
SARS-CoV-2 virus with various factors as age, sex, comorbidities, socioeconomic
status, lifestyle and medications. In the Tohoku University study, no significant
difference was found between nonsmokers and smokers who smoke 20 or more
cigarettes per day, while smokers who smoke less than 20 cigarettes per day showed
significant difference from nonsmokers. The study performed by the University of
Milano-Bicocca showed a significant decrease in antibody titers at 60 days after
second vaccination among smokers, but the differences were not significant at 30, 90,
120, 150 and 180 days. A more recent study from this group, reported in Pubmed on
the 5th of April 2022, evaluated the vaccine antibody response though it did not report
the smoking status and the type of immunoassay system used did not allow the study
of the time trend of antibody levels.21 Other studies present certain limitations, some
of them discussed by the authors, often related to the sample size or measurements
restricted to only one time point.22

• Additional studies published after the mentioned review provide data on the effect of
smoking on vaccination:

o A recent study performed in Italy evaluated the post-vaccination antibody

levels response of three real-world cohorts. “Vaccinated subjects primed with
Astra Zeneca vaccine ChAdOx1-S and boosted with Biontech/Pfizer BNT162b2
vaccine were compared to homologous dosing (BNT162b2/BNT162b2 and
ChAdOx1-S/ChAdOx1-S). Serum samples were collected two months after
vaccination from a total of 1248 subjects. The results showed that the
heterologous vaccine schedule induced a significantly higher humoral response
followed by homologous BNT162b2/BNT162b2 and ChAdOx1-S/ChAdOx1-S
vaccines (p < 0.0001). Moreover, by analyzing factors (i.e., vaccine schedule,
sex, age, BMI, smoking, diabetes, cardiovascular diseases, respiratory tract
diseases, COVID-19 diagnosis, vaccine side effects) influencing the IgG anti-S
response, we found that only the type of vaccine affected the antibody titers”.23
 Out of 1248 subjects evaluated, complete information on the analyzed factors
was available for only 284 individuals. In these individuals, no effect was found
when comparing smokers (n=34) to non-smokers (n=250).

o In another study, in 6857 vaccinated health care individuals in Italy, the

seropositivity was > 97%. “The median IgG value was 990 BAU/mL (IQR 551–
1870), with most of subjects with previous SARS-CoV-2 infection or with
shorter time lapse (2–8 weeks) between vaccination and serology with values in
the highest quintile (>2080). At multivariable analysis, significant predictors of
lower values were increasing age, male, current smoking, immunodeficiency,
recent occupational contacts, and increasing time lapse from vaccination;
conversely, previous infection and recent household contacts were significantly
associated with higher IgG levels. Subjects with previous infection kept a very
high level (around 2000 BAU/mL) up to 120 days. These results, besides
supporting a high serological response up to 4–5 months, suggest predictive
factors of faster decay of IgG levels…. lower serological values were observed
among current smokers, subjects that self-reported an immunodeficiency or a
kidney disease, and for those with a longer time lapse (more than 16 weeks)
between vaccination and serological test. Significant predictors of lower
serological values are increasing age, male gender, being a current smoker,
having an immunodeficiency, and having had recent contacts with infected
colleagues in the workplace; furthermore, lower serological values increased by
an OR of 1.30 (95%CI 1.27–1.33) for each week of time lapse from vaccination.
Conversely, a previous SARS-CoV-2 infection and recent (in 2021) household
contacts significantly reduced the risk of belonging to lower quintiles, i.e., are
associated with higher IgG levels.”24

Association between antibody titers and other immune cells and mediators with
SARS-CoV-2 vaccine efficacy

• COVID-19 vaccination induces not only the antibody of humoral immunity but also
cell-mediated immunity. This is also found for other coronavirus infections in humans.
Antibody responses to alpha and beta coronavirus are not well maintained, and
reinfections are common within 12 months. T cell responses are generated but are of
relatively low magnitude, and their longevity is uncertain. “For SARS-CoV-1,
although antibody and B cell responses are relatively short lived and frequently
became undetectable within 4 years, T cell responses can be elicited after 17 years. T
cell responses to MERS appear to be more robust and sustained than humoral
immunity. Recent demonstration of MERS-specific cellular responses without
 seroconversion supports the concept of cellular sensitization without seroconversion.
Together, these data argue for the central importance of cellular immunity in the
control of HCoV infections.”25

• This mixed picture for other coronavirus infections is consistent with studies showing
that, while the titers of antibodies or their neutralizing activities are often higher
after vaccination than after SARS-CoV-2 infection,26 the lower or similar levels of
protection in vaccinated individuals suggests that other immune responses are
important in addition to the antibody mediated protection.27 Adding more complexity,
there are also studies showing that previously infected non-vaccinated individuals
have more diverse antibody types and lower total antibody levels than vaccinated
individuals and their antibodies have a higher half-life.

• Interestingly, in unvaccinated people, several studies found a lower incidence of

seropositivity (presence of SARS-CoV-2 antibodies) among active smokers28,29 as well
as lower levels of IgG among seropositive current smokers30;31. Some of these studies
show a higher share of seropositivity among former smokers compared to never
smokers. Interestingly, the authors of the systematic review on antibody levels in
relation to the smoking status have just published the first study so far investigating
the association between the SARS-CoV-2 antibody seropositivity and biochemically
verified smoking status (using serum cotinine levels). 1785 subjects were assessed.
One-third were classified as current smokers. This study found a lower proportion of
seropositive subjects among current smokers. 32 In these studies, seropositivity is
interpreted as a marker of increased susceptibility to infection.

Smoking status and SARS-CoV-2 vaccine efficacy and effectiveness are rarely
reported and inconclusive in the studies published in Pubmed, IVAC-WHO,
US-CDC and EU-CDC databases.

• The IVAC-WHO database of studies evaluating the efficacy and effectiveness of

COVID-19 vaccination was consulted. Efficacy refers to the degree to which a vaccine
prevents disease, and possibly also transmission, under ideal and controlled
circumstances comparing a vaccinated group with a placebo group. Effectiveness
refers to how well it performs in the real world. The studies evaluated all available
vaccines and known variants globally. Only a few studies reported data related to
smoking status and none of them addressed the effect of smoking status.33

• A just published large study using Real World Evidence in the USA shows that, out of
402485 vaccinated individuals who did not develop COVID-19 (measured by RT-PCR
 and/or presence of antibodies against nucleocapsid protein), 30.1% were current or
former smokers and 69.5% were non-smokers. In a group of 6860 vaccinated
individuals who developed COVID-19, 28.3% were current or former smokers and
71.7% were non-smokers.34

• One study in Italy on type 2 Diabetes patients showed that Biontech/Pfizer

vaccinated patients with poor glycemic control have lower levels of neutralizing
antibodies as well as other markers of cellular mediated immune responses against
SARS-Cov-2 virus when compared with type 2 Diabetes patients with adequate
glycemic control. The patients were evaluated along 1 year after the vaccination.
Since 16.3% of the 196 patients with adequate glycemic control were smokers and
37.6% of the 298 patients with poor glycemic control were smokers, the study does
not allow to infer causal-effect relationships in relation to smoking.35

• An study in Scotland found that, at 14 days or longer since the first vaccine dose
(Biontech or Astra Zeneca), “there were 883 COVID-19 hospital admissions and 541
deaths in almost 2.57 million individuals. Being an ex-smoker was associated with an
increased risk of severe COVID-19 events. Current smokers had no increased risk.
The increased risk observed in ex-smokers was lower than the increased risks found
for older age, increasing number of underlying comorbidities, recent admission to
hospital, being in a high-risk occupation, being a care home resident, being male and
being socioeconomically deprived.”36

• One study in Mexico on 1607 individuals vaccinated with 5 types of vaccines (most of
them with Biontech or Astra Zeneca) suggests that “the effectiveness of COVID-19
vaccines may be reduced in a subset of adults who are elderly, or are smokers, obese
or have type 2 diabetes mellitus.” The Risk Ratios were 1.09 and 1.07 in bivariate
and multivariate analysis, respectively.37

• One study in USA, 8,554 vaccinated participants reported the following information
to an on-line registry: COVID-19 test results, vaccination (Pfizer, Moderna, or
Johnson & Johnson), COVID-19 symptoms and perceived severity. The percent of
smokers was similar amongst the individuals with and without COVID-19.38

• A recently published study on Biontech and Astra Zeneca vaccines in 212.012

individuals in the UK, shows that “antibody positivity decreases with age, and is
higher in females and those with previous infection. Antibody positivity is lower in
transplant recipients, obese individuals, smokers and those with specific
comorbidities.”39

• As for the vast majority of studies reported in Pubmed, the IVAC-WHO database, the
 databases of the USA40 and the EU Center for Disease Control41 do not report the
smoking status of vaccinated individuals or the effect of smoking on antibody levels
and clinical outcomes. The EU CDC describes in a protocol the intention to collect
these data.42 In summary, the vaccine efficacy is not solely related to the antibody
titers or their viral neutralizing activity. In addition, the pathophysiologic
mechanisms and, most importantly, the potential clinical relevancy of an
hypothetical association between smoking and immune response to SARS-CoV-2
virus or vaccines are yet unresolved.43

Smoking status and correlation of antibody titers with protection for other
vaccines (Hepatitis B, Human Papilloma Virus, Influenza)

A review on COVID-19 vaccines indicates that “for different viral infections, such as
influenza, measles, and hepatitis A and B viruses, correlates of protection are usually
based on the level of antibody acquired from vaccination or natural infection that is able
to significantly reduce the risk of infection or reinfection. However, correlates of
protection have yet to be defined for COVID-19”.44 Our review of studies on vaccines for
other diseases shows the following:

Hepatitis B
• It is interesting to note that, for hepatitis B vaccination, smoking was independently
associated with lower antibody responses in persons receiving buttock injections but
not in persons receiving arm injections.45 Other studies showed that Hepatitis B
vaccination was less immunogenic in smokers than in non-smokers.46

Human papillomavirus
• A very recent study in Japan in 7253 (vaccinated and non-vaccinated) women
evaluates the effectiveness of human papillomavirus (HPV) vaccine against
precancerous lesions of uterine cervical cancer and the difference in the effectiveness
based on smoking status. HPV bivalent/quadrivalent vaccination was effective in
protecting against cervical intraepithelial neoplasia but insufficient in smokers. The
number of cases with different degrees of neoplasia was very small in vaccinated and
non-vaccinated individuals.47

• An study in 103 young women in Finland found that vaccinated smokers had similar
levels of anti-HPV16 and HPV18 antibodies compared to vaccinated non-smokers
7 months post-vaccination, whereas high avidity HPV16/18 antibodies was less
frequently observed in smokers than in non-smokers.48 However, previous studies on
HPV16/18 vaccine questioned the relevance of low-high avidity antibodies.49
Influenza
• For influenza vaccines, one study in young adults on 28 929 vaccination events during
two influenza seasons, including 22 734 live attenuated vaccinations and 6195
trivalent inactivated influenza vaccinations, found that, “in the final adjusted model,
the relative effectiveness of the two vaccine types did not differ by smoking
status”50 and previous studies have reported that daily habitual smoking, alcohol
consumption, and regular exercise have no effect on influenza vaccine efficacy. 51
Another study in 2731 medical professionals in Japan found that smoking had no
effect on the influenza vaccine efficacy.52

• One study in the Netherlands in 1531 elderly subjects reported that smokers (n=379)
had a higher rise in antibody titers 3 weeks after vaccination for two of the four
strains of vaccines administered and the decline in titers after 5 months was similar
for smokers and non-smokers. The authors conclude that “smoking has no clinical or
preventive significance for risk of influenza in the elderly.”53

• A greater antibody response to influenza vaccine was also found in smokers in

another study.54 In contrast, other two studies found no greater antibody response in
smokers compared to non-smokers after vaccination.55

• On the other hand, an study in ≥65 years people (728 influenza cases and 1826
controls) found that influenza vaccine effectiveness in preventing hospitalization was
21% (95% CI: -2 to 39) in current/ex-smokers and 39% in non-smokers. This study did
not evaluate antibody titers.56

• Overall, in spite of the numerous studies of the efficacy and effectiveness of influenza
vaccines, the influence of smoking appears unclear since the first studies addressing
this factor published in the late sixties. Two recent Cochrane reviews performed
quantitative analysis adjusted for confounders as sex, age, smoking, and
comorbidities but did not provide comments or conclusions on any detrimental effect
of smoking on the vaccine benefits.57

1 See Ferrara P et al. 2022.

2 See Pegu P et al. 2021.
3 See Mateus J et al. 2021.
4 See Levin E et al. 2021.
5 See Turner J et al. 2021.
6 See Bi J. 2022.
7 See Lau E et al. 2021.
8 See Cohen K et al. 2021.
9 See Klasse P et al. 2021.
10 See Meschi S at al. 2021. Based on the antibody titers-efficacy sigmoidal curves described in various studies, it may be

hypothesized that the higher the slope, that depends on the region of the curve, the higher is the influence of the antibody
titers on the efficacy.
11 See Khoury D et al. 2021.
12 See Sahin U et al. 2021 and Jalkanen P et al. 2021.
13 See Steensels D et al. 2021. During 10 weeks after the second dose, this study demonstrated, more than two times
“higher humoral immunogenicity of the Moderna compared with the Biontech vaccine, in infected as well as uninfected
participants, and across age categories. The higher mRNA content in Moderna compared with Biontech and the longer
interval between priming and boosting for mRNA-12733 (4 weeks vs 3 weeks for BNT162b2) might explain this difference.
A relationship between neutralization level after SARS-CoV-2 vaccination and protection against COVID-19 has been
demonstrated by several studies. As such, the height of the humoral response after vaccination, which correlates with
neutralizing antibody titers, might be clinically relevant. Limitations of this study include the lack of data on cellular
immunity and on neutralizing antibodies...Whether the observed difference in antibody level translates to a difference in
the duration of protection, the protection against variants of concern, and the risk of transmission needs further
investigation.”
14 See Wei J et al. 2022. and Heinz F et al. 2021. For most of the commonly used vaccines, antibodies prevent/decrease

virus infectivity trough binding with viral proteins, mainly through physico-chemical interactions with the regulatory
binding domain of the spike S protein.
15 See USA CDC. 2022.
16 See EU CDC. 2022.
17 See the two Cochrane reviews on vaccine efficacy on elderly and healthy adults. 2018.
18 See Warzawski J et al. 2022.
19 See Warzawski J et al. 2022. See the Japanese Association for Infectious Disease “Recommendation on COVID-19

vaccine”.
20 See Ferrara P et al. 2022.
21 See Ponticelli D et al. 2022.
22 See Effect of Smoking on COVID-19 Vaccine Induced Antibody Titers. JT-JTI SRA Product Science & Health. 2022.
23 See Barocci S et al. 2022.
24 See Costa C et al. 2022.
25 See Moss P. 2022.
26 See Ferrari D et al. 2021 and Swiss Covid-19 National Task Force Policy brief. 2021.
27 See Swiss Covid-19 National Task Force Policy brief. 2021.
28 See Lombardi A et al. 2021.
29 See Scozzari G et al. 2021.
30 See Sandri M et al. 2021.
31 See Scozzari G et al. 2021.
32 See Tomasselli V et al. 2022.
33 See IVAC-WHO impact studies. See also IVAC-WHO Effectiveness studies and Efficacy studies.
34 See Song Q et al. 2022.
35 See Marfella R et al. 2022.
36 See Agrawal U et al. 2021.
37 See Murillo E et al. 2022.
38 See Reynolds W et al. 2022.
39 See Ward H et al. 2022.
40 See USA CDC. 2022.
41 See EU CDC. 2022.
42 See EU CDC protocol for COVD-19 vaccine effectiveness. 2022.
43 See Warzawski J et al. 2022.
44 See Fergie J et al. 2021.
45 See Shaw F et al. 1989.
46 See Meier M et al. 2020. See also Winter A et al. 1994.
47 See Hikari T et al. 2022.
48 See Namujju P et al. 2014.
49 See Kemp T et al. 2012.
50 See Woolpert T et al. 2014.
51 See Szabo G et al. 2009.
52 See Kenzaka T et al. 2021.
53 See Cruijff M et al. 1999.
54 See Finklea J et al. 1971.
55 See MacKenzie J et al. 1976. See also Knowles G et al. 1981.
56 See Godoy et al. 2018.
57 See the two Cochrane reviews on vaccine efficacy on elderly and healthy adults. 2018.