Some health experts have speculated that vaping is causing younger patients in the U.S. to be hospitalized with Covid-19 at a higher rate than anticipated. Felberbaum declined to comment on whether the FDA was investigating a possible connection.

Earlier this week, Nora Volkow, director of the National Institute on Drug Abuse, wrote a blog post warning that the coronavirus “could be an especially serious threat to those who smoke tobacco or marijuana or who vape.”

E-cigarettes have been touted by some as less risky than smoking. But any increased harm associated with Covid-19, and the FDA’s direct language linking the products to lung damage, could boost detractors who have raised questions about the potential that vaping can lead to health problems.

Last year, some vapers began coming down with a mysterious and sometimes deadly lung illness. Those cases have been linked to products containing THC, the active ingredient in marijuana.

The FDA under President Donald Trump originally took a largely hands-off approach to regulating e-cigarettes, but began to change course in 2018 to stem an epidemic of youth use. After multiple delays, e-cigarette makers have until May to apply to the FDA for clearance to continue marketing their products. None have received FDA approval to market themselves as less risky than smoking.

UPDATED 01 APRIL 2020

Smokers and vapers who are infected with the new coronavirus could possibly expect a more severe infection, health experts warn.

Many advisories have focused on the risk facing older people, those with chronic conditions such as diabetes, and people with compromised immune systems, such as cancer patients. But doctors also caution that users of electronic cigarettes and tobacco are more in danger from the new coronavirus than the average healthy person.

If you vape, “you’re going to make lungs more vulnerable to severe infection,” said Dr Panagis Galiatsatos, an American Lung Association spokesman who is also director of the tobacco treatment clinic at Johns Hopkins Hospital, in Baltimore.

Vaping introduces toxic chemicals that harm lung cells and change their metabolism, Galiatsatos said, and it also curbs the body’s immune system.

Data from China’s coronavirus outbreak showed infected smokers and residents of cities with high levels of air pollution had more severe symptoms, he said. Galiatsatos predicted use of e-cigarettes will have the same effect.

A study of 78 patients with Covid-19 pneumonia in Wuhan, China, published recently in the Chinese Medical Journal, listed history of smoking as one factor contributing to poorer patient outcomes.

Stanton Glantz, director of the University of California, San Francisco (UCSF) Center for Tobacco Control Research and Education, cited that study in a recent online UCSF commentary.

“The odds of disease progression (including to death) were 14 times higher among people with a history of smoking,” he wrote, calling on the public to stop smoking and vaping, and to also steer clear of second-hand smoke.

Because vaping is a recent phenomenon, less is known about its harmful long-term effects than about smoking tobacco, which has been studied for decades.

But e-cigarettes have come under growing scrutiny since last year when more than 2 000 cases of severe lung damage and death were reported among vapers. Most of those cases were associated with products containing an additive called vitamin E acetate, and THC, the psychoactive component of marijuana, according to the US Centers for Disease Control and Prevention.

As cases of Covid-19 continue to spread, the consequences for smokers and vapers should soon be clear. But evidence pointing to poorer outcomes already exists.

Dr Sucharita Kher, director of the outpatient pulmonary clinic at Tufts Medical Center in Boston, said animal studies have shown e-cigarette vapour “adversely affects the lung cells’ ability to fight against a virus”.

She added that smokers also have a higher rate of hospitalisation for influenza, another viral respiratory infection.

But Kher added that the Chinese data do not prove smoking caused worse outcomes for Covid-19 pneumonia patients. They do, however, show a link. There’s much to learn about the virus, she said.

“We have to interpret it with caution,” she explained.

Vaping substances that contain THC or nicotine “definitely has short-term health consequences,” said Dr Alexa Mieses, a family doctor in Durham, North Carolina, who expects studies will eventually show similar long-term links.

Researchers know tobacco smoking has long-term consequences, including chronic obstructive pulmonary disease (COPD), emphysema or cancer, she said, but no long-term studies have yet been done on vaping.

A threat to overall health

“My gut … or I should say, my medical education, leads me to believe” years of e-cigarette use will eventually be linked to these or similar outcomes, Mieses said.

“First and foremost, vaping and smoking don’t just affect your respiratory system, but pose a threat to your overall health,” she said.

Mieses and Kher recommended people who wish to quit vaping contact their family doctor for help.

Kher noted that vaping has not been shown to be an effective smoking-cessation aid and e-cigarette users are more likely to become tobacco smokers. She said seven drugs have been approved by the US Food and Drug Administration to help people quit smoking, but there is no approved medicine for those wanting to quit e-cigarettes.

“I highly recommend they talk to their doctors and try to quit vaping or try to cut down,” she said.

READ | Coronavirus: Basic protective measures

READ | Coronavirus | Concerns about if, and how it spreads in the air? Here are the facts

READ | Undetected cases may be driving coronavirus spread

^{Image credit: iStock}

March 23, 2020

As people across the U.S. and the rest of the world contend with coronavirus disease 2019 (COVID-19), the research community should be alert to the possibility that it could hit some populations with substance use disorders (SUDs) particularly hard. Because it attacks the lungs, the coronavirus that causes COVID-19 could be an especially serious threat to those who smoke tobacco or marijuana or who vape. People with opioid use disorder (OUD) and methamphetamine use disorder may also be vulnerable due to those drugs’ effects on respiratory and pulmonary health. Additionally, individuals with a substance use disorder are more likely to experience homelessness or incarceration than those in the general population, and these circumstances pose unique challenges regarding transmission of the virus that causes COVID-19. All these possibilities should be a focus of active surveillance as we work to understand this emerging health threat.

Image by CDC/ Alissa Eckert, MS; Dan Higgins, MAMS

This illustration, created at the Centers for Disease Control and Prevention (CDC), reveals ultrastructural morphology exhibited by coronaviruses. Note the spikes that adorn the outer surface of the virus, which impart the look of a corona surrounding the virion, when viewed electron microscopically. A novel coronavirus, named Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), was identified as the cause of an outbreak of respiratory illness first detected in Wuhan, China in 2019. The illness caused by this virus has been named coronavirus disease 2019 (COVID-19).

NIH has posted a compilation of updates for applicants and grantees, including a Guide Notice on administrative flexibilities and accompanying FAQs.

SARS-CoV-2, the virus that causes COVID-19 is believed to have jumped species from other mammals (likely bats) to first infect humans in Wuhan, capital of China’s Hubei province, in late 2019. It attacks the respiratory tract and appears to have a higher fatality rate than seasonal influenza. The exact fatality rate is still unknown, since it depends on the number of undiagnosed and asymptomatic cases, and further analyses are needed to determine those figures. Thus far, deaths and serious illness from COVID-19 seem concentrated among those who are older and who have underlying health issues, such as diabetes, cancer, and respiratory conditions. It is therefore reasonable to be concerned that compromised lung function or lung disease related to smoking history, such as chronic obstructive pulmonary disease (COPD), could put people at risk for serious complications of COVID-19.

Co-occurring conditions including COPD, cardiovascular disease, and other respiratory diseases have been found to worsen prognosis in patients with other coronaviruses that affect the respiratory system, such as those that cause SARS and MERS. According to a case series published in JAMA based on data from the Chinese Center for Disease Control and Prevention (China CDC), the case fatality rate (CFR) for COVID-19 was 6.3 percent for those with chronic respiratory disease, compared to a CFR of 2.3 percent overall. In China, 52.9 percent of men smoke, in contrast to just 2.4 percent of women; further analysis of the emerging COVID-19 data from China could help determine if this disparity is contributing to the higher mortality observed in men compared to women, as reported by China CDC. While data thus far are preliminary, they do highlight the need for further research to clarify the role of underlying illness and other factors in susceptibility to COVID-19 and its clinical course.

Vaping, like smoking, may also harm lung health. Whether it can lead to COPD is still unknown, but emerging evidence suggests that exposure to aerosols from e-cigarettes harms the cells of the lung and diminishes the ability to respond to infection. In one NIH-supported study, for instance, influenza virus-infected mice exposed to these aerosols had enhanced tissue damage and inflammation.

People who use opioids at high doses medically or who have OUD face separate challenges to their respiratory health. Since opioids act in the brainstem to slow breathing, their use not only puts the user at risk of life-threatening or fatal overdose, it may also cause a harmful decrease in oxygen in the blood (hypoxemia). Lack of oxygen can be especially damaging to the brain; while brain cells can withstand short periods of low oxygen, they can suffer damage when this state persists. Chronic respiratory disease is already known to increase overdose mortality risk among people taking opioids, and thus diminished lung capacity from COVID-19 could similarly endanger this population.

A history of methamphetamine use may also put people at risk. Methamphetamine constricts the blood vessels, which is one of the properties that contributes to pulmonary damage and pulmonary hypertension in people who use it. Clinicians should be prepared to monitor the possible adverse effects of methamphetamine use, the prevalence of which is increasing in our country, when treating those with COVID-19.

Other risks for people with substance use disorders include decreased access to health care, housing insecurity, and greater likelihood for incarceration. Limited access to health care places people with addiction at greater risk for many illnesses, but if hospitals and clinics are pushed to their capacity, it could be that people with addiction—who are already stigmatized and underserved by the healthcare system—will experience even greater barriers to treatment for COVID-19.  Homelessness or incarceration can expose people to environments where they are in close contact with others who might also be at higher risk for infections. The prospect of self-quarantine and other public health measures may also disrupt access to syringe services, medications, and other support needed by people with OUD.

We know very little right now about COVID-19 and even less about its intersection with substance use disorders. But we can make educated guesses based on past experience that people with compromised health due to smoking or vaping and people with opioid, methamphetamine, cannabis, and other substance use disorders could find themselves at increased risk of COVID-19 and its more serious complications—for multiple physiological and social/environmental reasons. The research community should thus be alert to associations between COVID-19 case severity/mortality and substance use, smoking or vaping history, and smoking- or vaping-related lung disease. We must also ensure that patients with substance use disorders are not discriminated against if a rise in COVID-19 cases places added burden on our healthcare system.

As we strive to confront the major health challenges of opioid and other drug overdoses—and now the rising infections with COVID-19—NIDA encourages researchers to request supplements that will allow them to obtain data on the risks for COVID-19 in individuals experiencing substance use disorders.

This content is also available in Spanish – COVID-19: Las posibles implicaciones para las personas con trastornos por consumo de drogas.

Additional Links

Latest Information from the CDC on Coronavirus Disease 2019 (COVID-19)

• Coronavirus.gov
• Coronavirus Disease 2019 (COVID-19) (CDC)
• What the U.S. Government is Doing (USA.gov) – (En Espanol)
• Latest Research Information from NIH
  • Notice of Special Interest (NOSI) regarding the Availability of Administrative Supplements and Urgent Competitive Revisions for Research on the 2019 Novel Coronavirus
• COVID-19 Information from NIDA
• COVID-19 Information from SAMHSA

Methods:

Patients tested positive for the COVID-19 based on nucleic acid detection were included in this study. Patients were admitted to 3 tertiary hospitals in Wuhan between December 30, 2019, and January 15, 2020. Individual data, laboratory indices, imaging characteristics, and clinical data were collected, and statistical analysis was performed. Based on clinical typing results, the patients were divided into a progression group or an improvement/stabilization group. Continuous variables were analyzed using independent samples t-test or Mann-Whitney U test. Categorical variables were analyzed using Chi-squared test or Fisher exact test. Logistic regression analysis was performed to explore the risk factors for disease progression.

Results:

Seventy-eight patients with COVID-19-induced pneumonia met the inclusion criteria and were included in this study. Efficacy evaluation at 2 weeks after hospitalization indicated that 11 patients (14.1%) had deteriorated, and 67 patients (85.9%) had improved/stabilized. The patients in the progression group were significantly older than those in the disease improvement/stabilization group (66 [51, 70] vs. 37 [32, 41] years, U = 4.932, P = 0.001). The progression group had a significantly higher proportion of patients with a history of smoking than the improvement/stabilization group (27.3% vs. 3.0%, χ² = 9.291, P = 0.018). For all the 78 patients, fever was the most common initial symptom, and the maximum body temperature at admission was significantly higher in the progression group than in the improvement/stabilization group (38.2 [37.8, 38.6] vs. 37.5 [37.0, 38.4]°C, U = 2.057, P = 0.027). Moreover, the proportion of patients with respiratory failure (54.5% vs. 20.9%, χ² = 5.611, P = 0.028) and respiratory rate (34 [18, 48] vs. 24 [16, 60] breaths/min, U = 4.030, P = 0.004) were significantly higher in the progression group than in the improvement/stabilization group. C-reactive protein was significantly elevated in the progression group compared to the improvement/stabilization group (38.9 [14.3, 64.8] vs. 10.6 [1.9, 33.1] mg/L, U = 1.315, P = 0.024). Albumin was significantly lower in the progression group than in the improvement/stabilization group (36.62 ± 6.60 vs. 41.27 ± 4.55 g/L, U = 2.843, P = 0.006). Patients in the progression group were more likely to receive high-level respiratory support than in the improvement/stabilization group (χ² = 16.01, P = 0.001). Multivariate logistic analysis indicated that age (odds ratio [OR], 8.546; 95% confidence interval [CI]: 1.628–44.864; P = 0.011), history of smoking (OR, 14.285; 95% CI: 1.577–25.000; P = 0.018), maximum body temperature at admission (OR, 8.999; 95% CI: 1.036–78.147, P = 0.046), respiratory failure (OR, 8.772, 95% CI: 1.942–40.000; P = 0.016), albumin (OR, 7.353, 95% CI: 1.098–50.000; P = 0.003), and C-reactive protein (OR, 10.530; 95% CI: 1.224−34.701, P = 0.028) were risk factors for disease progression.

Conclusions:

Several factors that led to the progression of COVID-19 pneumonia were identified, including age, history of smoking, maximum body temperature on admission, respiratory failure, albumin, C-reactive protein. These results can be used to further enhance the ability of management of COVID-19 pneumonia.

© 2020 by Lippincott Williams & Wilkins, Inc.

New York State Academy of Family Physicians

For Immediate Release

March 22, 2020

Contact: Vito F. Grasso, MPA

Executive Vice President

(518) 489-8945/ vito@nysafp.org

Statement by NYSAFP on Link Between Tobacco Use and COVID-19 Call for a Ban on the Sale of All Tobacco/Vaping Products During Pandemic Period

Barbara Keber, MD President

“As our State and Country struggle to respond to the rapidly evolving and escalating COVID-19 pandemic affecting our residents and straining our healthcare system, mounting evidence demonstrates the link between tobacco use and increased risk for progressive COVID-19. NYSAFP calls for an immediate ban on the sale of all tobacco and vaping/e-cigarette products by Executive Order to protect New Yorkers and lessen the impact and progression of this serious virus on those who contract it.”

“A recently published study (https://pubmed.ncbi.nlm.nih.gov/32118640/ compared COVID-19 patients with disease progression to those who’s health improved or were stabilized. The study found that the progression group had a significantly higher proportion of patients with a history of smoking/tobacco use than the improvement/stabilization group, suggesting patients who use tobacco are 14 times as likely to have COVID-19 progression requiring more extensive treatment and hospitalization than those who do not. Additionally, people with COVID-19 are highly contagious and with sustained progression continue to infect others. The increased risk is an alarming finding which must be immediately addressed in our COVID-19 response.”

“The American Academy of Family Physicians recently developed guidance stating that people who smoke or use vapes or e-cigarettes have a significantly higher risk of contracting respiratory infections like coronavirus. People with decreased lung function caused by smoking or vaping are more likely to develop serious complications caused by infections.”

“Now more than ever, it is critical for the State and medical community to take actions to prevent our youth from ever using these highly addictive, deadly products and to help our patients to reduce their risks through FDA-approved cessation and telehealth during this pandemic.”

“NYSAFP has been an active supporter of legislation to end the sale of all flavored tobacco including flavored e-cigarettes given that nearly one in three high schoolers are now using a flavored vape product in New York. This proposal must be enacted immediately in the final budget being negotiated. Further, given the clear evidence of elevated risk of COVID-19 and tobacco use, NYSAFP calls for a ban on the sale of all tobacco/vaping products during the pandemic period. Bold, swift actions must be taken to protect our residents and we must follow the science which supports our call for a ban.”

The NYSAFP is the New York chapter of the American Academy of Family Physicians. NYSAFP represents more than 6,000 family physicians and medical students throughout the state and provides advocacy, education and information for its members. For more information, please visit www.nysafp.org.