key: cord-0981225-ut9v6tk1
authors: Soule, Eric K.; Kheradmand, Farrah; Eissenberg, Thomas
title: Health practitioners should caution about misinformation and association of adverse effects of electronic cigarette use and COVID-19
date: 2020-11-25
journal: Prev Med Rep
DOI: 10.1016/j.pmedr.2020.101255
sha: 0feff8154cca168109b69d66a6a5cd5bd9bd4416
doc_id: 981225
cord_uid: ut9v6tk1

nan

COVID-19, the deadly infectious respiratory disease caused by a coronavirus (SARS-CoV-2) that reached pandemic levels in early 2020, continues to impact many around the world.

Many efforts to control COVID-19's spread have focused on preventing SARS-CoV-2 infection among those particularly vulnerable to the disease, such as people over the age of 60 and/or with underlying medical conditions. However, there may be other factors that increase SARS-CoV-2 infection and resulting morbidity and mortality, including the use of electronic cigarettes or electronic nicotine delivery systems (ENDS), also known as "vaping."

The effects of ENDS use: preclinical data.

Pre-clinical studies suggest a mechanism by which chronic ENDS use could impact COVID-19 outcomes: ENDS aerosol, independent of nicotine, disrupts alveolar surfactant homeostasis. 1 Notably, ENDS-induced disruption in surfactant homeostasis along with aberrant lung macrophage responses to viral infection increased morbidity and mortality in mice exposed to influenza. 1 Human studies also demonstrate that ENDS use is associated with life-threatening lipoid pneumonia. [2] [3] [4] [5] [6] [7] Thus, ENDS users may be at greater risk for negative outcomes associated with SARS-CoV-2 infection. Indeed, lung surfactant disruption and lung inflammation may represent a major concern regarding COVID-19 outcomes. The receptor for coronavirus is expressed on airway epithelial cells including the distal alveolar type II (AT-II) cells, a specialized type of stem cells in the lungs that make surfactant. 8 This substance helps the alveoli in the lungs stay open between breaths and is critical to normal lung function. As the inflammation from COVID-19 pneumonia progresses, it causes atelectasis (alveolar collapse), and hypoxemia, which are associated with loss of surfactant. 9 Further, previous research found that lung cell samples from patients whose cause of death was SARS-CoV infection failed to express surfactant. 10 The authors concluded that acute viral infection of AT-II cells could promote disruption of lung repair and induce acute respiratory distress syndrome (ARDS), a hallmark of novel coronavirus infection. 11 Together, these findings suggest that disruption of lung surfactant production, as ENDS aerosol exposure does in mice, may exacerbate COVID-19 health risks. Research in clinical or population settings is needed to examine the relationship between ENDS use and COVID-19 further, though recent epidemiological research suggests an association between ENDS use and COVID- 19. 12 Public perception of ENDS use and COVID-19.

Despite scientific evidence to the contrary, some ENDS users believe that ENDS use is protective against COVID-19. In a recent study that used a mixed-method approach to examine self-reports of how COVID-19 has impacted ENDS users from across the United States, 13 some ENDS users reported that they believed: i) the heat generated from their ENDS device may kill the coronavirus, ii) ENDS use may increase immune system response, and iii) ENDS use may provide a protective layer to prevent COVID-19. The extent to which these beliefs are common is uncertain, though similar messages are being spread online. Indeed, at one website related to ENDS use and COVID-19 under the heading "Will vaping protect you from bacteria and viruses?", the text reads "So, does PG [propylene glycol] stop vapers from getting sick? We still don't know. Bottom line: it might. It definitely can kill bacteria and viruses. The trick, it seems, might be hitting the microbes at just the right moment with the right amount of PG…". 14 This website refers to blogs, Twitter posts, and other media sources to support the text, and also includes references to empirical reports that appear to be related to the topic of ENDS use and COVID-19. For example, one blog post 15 that is quoted at the website includes the erroneous text: "There is no evidence on any effects of e-cigarettes on coronavirus infectivity and disease progression, and we cannot exclude the possibility that the use of propylene glycol might have some beneficial effects." This blog cites research from the 1940s examining the possible antibacterial and anti-viral properties of propylene glycol gas (as opposed to aerosol generated from ENDS devices).

However, one of the empirical reports to which the text refers is from a 1980 U.S.

Environmental Protection Agency document that predates COVID-19 by three decades and describes the effectiveness of aerosolized propylene glycol for reducing the number of airborne bacteria. The document concludes that "adequate experimental data is available to show that air sanitizers do not sterilize, disinfect, act as a germicide, or protect experimental animals from infections by airborne bacterial or viruses. Thus, claims of value in preventing or treating diseases, or providing any other health protection, whether expressed or implied, are not acceptable". 16 However, the online text continues to cite a blog and a hypothesis generated from a case study 17 in which the authors speculate that propylene glycol from ENDS use may have a beneficial antimicrobial effect. Impacts of misinformation from health professionals, researchers, and media outlets.

Further research is needed to examine what impact speculations that ENDS use may be protective for COVID-19 outcomes may have, especially when they are spread widely and rapidly online. However, recent events demonstrate how unsubstantiated suggestions regarding putative methods of reducing COVID-19 morbidity and mortality are of great concern because of their potential for influencing behavior. One example of this potential influence was documented recently when shortages of the drug hydroxychloroquine were observed after suggestions, made without supporting scientific data, that it could be used to prevent or treat Similarly, after claims that nicotine might be effective for COVID-19 prevention or treatment, limits had to be set on nicotine replacement therapy products sold in France due to a spike in demand. 19 In these two scenarios, unsubstantiated suggestions may have caused drug shortages while increasing the potential for unintended consequences among individuals who selfadministered these medications that were not proven to prevent or treat COVID-19.

Similarly, suggestions that ENDS use may be protective for COVID-19 made online, in popular media, or by researchers, have the potential to cause major negative impacts on public health. While very preliminary results, 20 based on minimal data of uncertain quality 21, 22 suggest that nicotine may play a protective role in COVID-19 based on reduced incidence of COVID-19 among cigarette smokers, much more research is needed before that hypothesis is addressed definitively. Indeed, data supporting this "smoker's paradox" are "limited and questionable." 23 Conversely, a meta-analysis and systematic review suggest that progression to severe forms of COVID-19 is more likely among smokers than non-smokers. 24, 25 There are still many unanswered questions regarding whether cigarette smoking plays a role in reduced incidence of COVID-19, and if any potential effects can be linked to nicotine or ENDS use. For example, cigarette smoking may have effects on squamous metaplasia that reduce viral binding, 20 or have other effects that are not dependent on nicotine. Furthermore, the long-term health effects of administering nicotine by inhalation of ENDS aerosol remain uncertain, 21 and current evidence suggests that chronic ENDS use increases the morbidity and mortality associated with viral infection. 1 Until more is known, health practitioners should continue to follow Centers for Disease Control guidelines regarding ENDS use. Specifically, while ENDS may benefit some cigarette smokers looking to quit smoking, ENDS are not safe for youth, young adults, pregnant women, or non-tobacco users. 22 There are currently no available data that indicate ENDS use is protective for COVID-19, and health professionals should share this message widely. 

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An unexpected consequence of electronic cigarette use

Case report of electronic cigarettes possibly associated with eosinophilic pneumonitis in a previously healthy active-duty sailor

Acute Inhalational Lung Injury Related to the Use of Electronic Nicotine Delivery System (ENDS)

Acute Lipoid Pneumonia Secondary to E-Cigarettes Use: An Unlikely Replacement for Cigarettes

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