Does coronavirus present an incremental risk to people who vape? The notion is by no means irrational. While the aerosol produced by e-cigarettes contains vastly fewer toxins and carcinogens than cigarette smoke and those present exist at much lower levels, vapor is not comparable to fresh air.
However, early media coverage seems to be trending toward the kind of distortion that we saw with the vaping “epidemic” last fall. At that time, the frightening rash of lung disease and deaths were not due to commercial nicotine vaping products, as was alleged for months, but rather to contaminated THC.
Consider the headlines now. “Doctors Say Vaping Could Make Coronavirus Worse for Young People,” warned a headline in the New York Post last weekend. A Morning Joe health column written by two physicians echoed the threat, “Vaping: One of the Best Ways to Trash Your Lungs and Maybe Die if you Catch Coronavirus.” Even the surgeon general weighed in on the Today Show on Monday, saying that, “we don’t know if [vaping] is the only cause” among younger people who are stricken with COVID-19.
At this time, however, no hard data link vaping with risk of developing COVID-19. Smoking, by comparison, is a well-known hazard for infection from both bacteria and viruses. Unfortunately, some experts are sending confusing messages to vapers in the midst of COVID-19 anxiety. “In terms of immunosuppressant and inflammatory effects, e-cigarettes might be doing more bad things than cigarettes—but both are really bad,” according to a University of San Francisco researcher. A pulmonary specialist in Palm Beach County told MSNBC: “Vaping causes interstitial lung disease and is additive to any toxicity from the virus.” A Scientific American article claimed that vaping does “well-established harm to the immune system.”
One problem here is that scaring people is not how you change their behavior. “Warning without giving viable options strikes me as negligence,” says David Sweanor, a tobacco control expert on the University of Ottawa’s faculty of law. “To say ‘quit smoking and vaping or you might die’ is to increase panic and assure that your advice will be discounted.”
What to do?
First, empower vapers. Instead of alarming them with fears, we should give them a novel alternative. And not gum or patches, as so many have already tried those and failed. A better alternative is smokeless tobacco.
Snus has been used for decades by Swedish men; Sweden has the lowest rate of smoking-related diseases in Europe, the world’s lowest rate of lung cancer in males, and one of the lowest mouth cancer rates in the EU. A Swedish company has also introduced ZYN, a new pouch product that contains just nicotine and flavor. Both snus and ZYN are available in the U.S.
Second, be realistic. Not all vapers are going to switch to smokeless tobacco in the face of the pandemic—and if vaping is made to seem as dangerous as smoking, some will simply return to smoking.
That worrisome prospect mobilized Riccardo Polosa, a physician and pulmonologist at the University of Catania in Italy. On March 12 he worked through an Italian organization of producers of electronic cigarettes and e-liquids to pressure government officials to keep vape shops open during the imposed shut down.
As Polosa said in an interview, “I thought it was terribly wrong to keep tobacconists open and vape shops closed for the simple reason that in a situation of high anxiety and stress, people will smoke even more and mainly at home where they are confined and they will expose a lot of bystanders to the risks of tobacco smoke.” Keeping vape shops open gave them an alternative.
Also distressing to Polosa is the likelihood “the hundreds of thousands of vapers across Italy will go back to smoking to maintain their nicotine needs.” In a time with rare ICU beds, “that would be extremely detrimental to the national health system.”
Polosa’s campaign was a success. One day after he issued his plea, the Ministry of Health and the prime minister said that besides tobacconists, vape shops can stay open to provide for the needs of people who vape. France and Greece, too, have exempted vape shops from their coronavirus-related shut down and, as of this writing, vaping advocates in Canada and South Africa are asking for the same consideration—especially because some of “essential” businesses that are open are free to sell cigarettes.
And in the U.K., an organization called Action on Smoking and Health has offered this welcome perspective: “Some media are also reporting that vapers face additional risks from coronavirus. The evidence for this is far less clear. Smokers who have switched to vaping should be reassured that this is better for them than smoking.”
Third, keep in mind that media coverage is not necessarily the best source of information on vaping. The claim that vaping compromises the immune system is speculative, but that hasn’t stopped sensational reports. Markers of immune suppression have been found when cells taken from the lungs and respiratory tracts of human subjects are exposed to vapor condensate, but these analyses are preliminary, and at best understood as precursors to studies in living individuals.
“We know that inhaled corticosteroids are massively more impactful on experimental models of immunity,” Polosa offered as context, “And yet in real life, asthmatic patients and other regular users of inhaled corticosteroids are not immunosuppressed.”
Further context demands that research on vaping and possible infection with SARS-CoV-2, the scientific name of the virus that produces COVID-19, take into account the fact that regular vapers are generally former smokers. This reality complicates the interpretation of susceptibility to infection and of any lung injury that’s detected.
In addition, there is no evidence that vaping causes “interstitial lung disease,” or fibrous scarring. Hundreds of thousands of former smokers have been vaping for at least 10 years to date without evidence of meaningful injury to their lungs. And in the short term—within weeks of switching and up to three years later—former smokers with chronic obstructive pulmonary disease and asthma experience improved lung function.
Over the longer-term, it must be said, vaping might cause impairment in lung function—though surely less injury than had vapers continued to smoke—and epidemiologists must monitor their health for years to come.
Dubious advice to vapers in the midst of the pandemic is, lamentably, consistent with a well-established pattern of misinformation regarding the subject of e-cigarettes and vaping.
Compare the response to coronavirus. Public health experts are striving heroically to amass quality data and accurately communicate the latest intelligence to the public. Vaping is just one front in that massive effort and it deserves the same level of care.
Sally Satel, MD, is a resident scholar at the American Enterprise Institute and a visiting professor at Columbia University’s Irving Medical Center.