With 120859 deaths in 2018, cardiovascular disease (CVD) is the leading cause of death in Spain (28.3%). Sex-disaggregated data for CVD in Spain show differences in mortality between men (46.3%) and women (53.7%). Surprisingly, although men (51%) and women (49%) are getting infected by COVID-19 at similar rates, men have been dying from COVID-19 at a significantly higher rate (4.4%) than women (2.5%), and the sex differences regarding vulnerability in those with COVID-19 and preexisting CVD seem to be again reflected in men (35%) and women (26%). Emerging evidence suggests that these discrepancies could potentially be due to gendered differences such as patterns and prevalence of smoking. In this regard, approximately 10% of cardiovascular disease is globally attributed to smoking, with smoking prevalence in 2017 among men in Spain being approximately 25.6% but only 18.8% in women.

These hypotheses could be coupled with new available evidence from the WHO on COVID-19, warning that a weaker cardiovascular system among COVID-19 patients with a history of tobacco use could make such patients susceptible to severe symptoms, thereby increasing the chance of death. According to the recent (18 March 2020) systematic review of Vardavas and Nikitara, smoking is most likely associated with the negative progression and adverse outcomes of COVID-19.