This study aimed to analyze the correlation between smoking and coronavirus disease 2019 (COVID-19) severity by region and gross domestic product (GDP). The regions were categorized by continent and GDP rankings. Studies conducted between June 3, 2020 and March 27, 2023 were searched to compare the severity of COVID-19 between smokers and non-smokers according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Compared with never-smokers, the smokers’ COVID-19 severity scores were 1.48 (confidence interval [CI]: 1.25–1.75) in Asia, 1.24 (CI: 1.05–1.46) in the Middle East, 1.32 (1.21–1.45) in Europe, 1.39 (1.30–1.49) in North America, 1.69 (1.22–2.34) in South America, and 2.87 (1.82–4.53) in Africa. By GDP, the smokers’ COVID-19 severity scores were higher than those of never-smokers: 1.42 (1.32–1.53) in high-GDP countries, 1.33 (1.25–1.41) in middle-GDP countries (11th–50th), and 1.53 (0.85–2.76) in low-GDP countries. The COVID-19 severity in smokers was significantly higher in low-GDP countries than in high- and middle-income countries. The high COVID-19 death rate among smokers in the African continent and low-GDP countries is thought to stem from the lack of medical management systems compared with other countries. In addition to medical treatment, environmental or socioeconomic factors can increase the severity.