Before coronavirus, pulmonologists, pediatricians and parents were busy battling a different nationwide health crisis: the “epidemic” of teen vaping. Last year, over five million high school and middle school students reported using e-cigarettes, inhaling mysterious nicotine-filled juices with little sense of the long-term effects.
So when an unfamiliar virus began sending scores of patients to the hospital with failing lungs, doctors wondered whether there would be consequences for the newly addicted generation.
On Tuesday, researchers at the Stanford University School of Medicine published a study which may confirm the fears of parents and doctors across the nation. Vaping is not just a small risk for coronavirus. Among teens and young adults who were tested, those who had used e-cigs were five to seven times more likely to be infected than non-users.
“We were surprised,” said Dr. Bonnie Halpern-Felsher, professor of pediatrics at Stanford University and the study’s senior author. “We expected to maybe see some relationship .... but certainly not at the odds ratios and the significance that we're seeing it here.”
The study is the first national population-based look at connections between vaping and coronavirus in young people, based on surveys of over 4,351 participants ages 13 to 24 from all 50 U.S. states, the District of Columbia and three U.S. territories. Among tested participants, young people who had ever used e-cigs were five times more likely to be diagnosed with coronavirus, while those who had used both e-cigs and regular cigarettes within the previous 30 days were 6.8 times as likely to be diagnosed with the disease.
“This is yet another piece showing that e-cigarettes are harmful to our health, period,” said Halpern-Felsher.
There could be several reasons for vapers’ heightened transmission risk. E-cigarettes can damage lungs and alter the immune system, making each coronavirus exposure more likely to trigger an infection, experts say. It is also possible that the aerosol emitted from e-cigarettes could have droplets containing coronavirus, Halpern-Felsher said, which could then be spread to another person or re-inhaled into one’s lungs. Many vaping social norms — hand-to-mouth contact, passing e-cigs between friends — are also high-risk pandemic behavior. It’s hard to exhale a cloud of smoke with a mask on.
More research is needed to understand the medical relationship between coronavirus and vaping, experts say. But the risk is clear, even when variables like race, sex, state COVID-19 rates and compliance with shelter-in-place orders are taken into account. The researchers say they hope these findings will prompt regulators to toughen regulations on these devices. Vaping is no longer just a personal risk, the study shows, but also a public health risk.
“Using e-cigs is sort of like the anti-mask,” said Dr. Jonathan Winickoff, professor of pediatrics at Harvard Medical School and MassGeneral Hospital for Children. “If we can control vaping in youth, we’ve gone part of the way in helping curb the pandemic.”
Widespread concern for teen vapers
Sophia Beerel, one of Winickoff’s patients, was 14 when she took her first hit of an e-cigarette — a candy-sweet head rush with no warnings and seemingly few consequences. It started with an impulsive hit of a classmate’s device during a science class bathroom break.
“I knew it was more than water,” said Beerel, now 16. “I knew it was a type of juice. I wasn't aware to the extent of how much nicotine was in it. I didn't even know what nicotine was at that point.”
“I was like, whatever… better than cigarettes,” she continued. “That's what people were saying.”
So began a multi-year battle with nicotine addiction. She ignored her parents’ “nicotine talk” and lit candles at home to mask the smell of her exhales. At 15, she tried to quit and felt sick with withdrawal symptoms like jitters, nerves and shakes. It was only when she lost her luggage stocked with pods during a five-week vacation that she was forced to quit cold turkey.
Beerel says she has mostly stopped using e-cigarettes, down from a pack of pods roughly every 10 days (equivalent to about four packs of cigarettes) to an occasional nostalgic hit. But when the pandemic began, Beerel wondered if her old habit was going to put her at additional risk.
“I think it's scary for everyone,” said Beerel. “I did have thoughts like how much of my lungs are compromised.”
It troubles Winickoff, her doctor, as well. Over the past few years, Winickoff has seen kids he began treating as babies turn to e-cigarettes — teenagers who lose their breath after a flight of stairs, athletes who have lost the stamina to play sports and many, many photos of damaged lungs. But he says he has never been more worried about teen tobacco use than right now.
“This is a dangerous convergence of two different crises — the epidemic of youth e-cigarette use combined with the pandemic of COVID-19,” said Winickoff.
The Stanford study sheds new light on just how problematic the mix could be. Participants who used cigarettes and e-cigarettes in the previous 30 days were also almost five times more likely to experience COVID-19 symptoms like coughing, fever, tiredness and difficulty breathing.
“I think our findings have a very strong message to health care providers, parents, and teens,” Halpern-Felsher said. “If you are vaping and smoking, this is yet another sign that these products are hurting your body and your lungs.”
An FDA spokesperson could not comment on the specifics of the study but said the agency will review it. In a statement, the spokesperson noted that people who smoke cigarettes may be at increased risk of infection and worse outcomes due to COVID-19. They said it is not yet known whether the same is true for e-cigarettes.
“E-cigarette use can expose the lungs to toxic chemicals, but whether those exposures increase the risk of COVID-19 or the severity of COVID-19 outcomes is not known,” the spokesperson said. “However, many e-cigarette users are current or former smokers, and cigarette smoking increases the risk of respiratory infections, including pneumonia. Irrespective of COVID-19, e-cigarettes should never be used by youth, young adults, and pregnant women or adults who do not currently use tobacco products.”
The Stanford study did not analyze a possible connection between COVID-19 diagnosis and use of conventional cigarettes for study participants. This may be because most nicotine-using youth either use e-cigs only or both e-cigs and traditional cigarettes, according to Halpern-Felsher, but few use conventional cigarettes alone.
‘A one-two punch’
The Stanford study focuses mainly on transmission, but experts’ concerns regarding e-cigs extend beyond that. A July study from the University of San Francisco suggests smoking, including e-cigarettes, doubles young adults’ risk of getting seriously sick with coronavirus — the “most prevalent factor” in young adults’ medical vulnerability for severe COVID-19 illness.
It’s a factor that Colin Finnerty, 21, can’t get out of his head. In March, Finnerty became one of the first people in his county to come down with coronavirus, he said. Doctors identified a small pneumonia infection in his bottom left lung, he said, and it spread to both sides in just two days. He spent six days on oxygen in the hospital, isolated, worried he was going to die.
“Being a 21-year-old, I should not be spending six days in the hospital for lung complications,” Finnerty said. “I was told so much that, statistically, I was in the clear. But I learned very shortly that was wrong.”
Finnerty looks nothing like the prototypical coronavirus patient. He is generally healthy, works at a ski resort and spends his free time swimming, skateboarding and snowboarding. But he has also been addicted to vaping since he was 17. For over three years, he was vaping from the second he woke up to the second he went to bed, he said.
Data is lacking on the medical connection between coronavirus and vaping. But Finnerty still worries that his e-cigarette addiction may have turned his coronavirus diagnosis into a battle for his life.
“It's just weird to think that maybe if I hadn't bought that first [e-cigarette] ... then maybe it wouldn't have happened,” said Finnerty. “Or at least not happened as brutally as it ended up happening,”
Existing research suggests that a smoker’s lungs are especially ripe for coronavirus infection, according to Winickoff. Smoking can paralyze the lungs’ cilia — little hair-like fibers that sweep away mucus and pathogens — making them less effective as guards against dangerous infections. It can also make it easier for coronavirus to bind in the lung, Winickoff said, so a smaller dose of virus is more likely to cause an infection.
“For smokers, it essentially takes less virus to cause disease,” Winickoff said. “And in general, the higher the viral load, the bigger the problems…. So it’s really a one-two punch there.”
E-cigarettes can also weaken the immune system and appear to cause underlying conditions like asthma which may make it harder to fight the virus. And tobacco and nicotine are just the beginning, some worry. No one is systematically checking what’s inside many of these devices, a large portion of which now come from factories overseas. Experts have found substances like carcinogens, heavy metals, herbicides, toxic chemicals and chemicals known to cause heart and lung disease.
The Centers for Disease Control told NBC News it does not currently list e-cigarette use as a medical condition that increases risk for severe COVID-19 infection.
The CDC said it does not comment on externally led studies, such as the new Stanford study, but is currently collecting its own data on vaping and COVID-19.
“As more data on tobacco-related indicators are reported, including smoking status and e-cigarette use, CDC will continue to release these findings to help inform evidence-based recommendations for the general public, clinicians, and health departments,” the agency said in a statement to NBC News.
'I honestly think the FDA has taken its eye off the ball'
A fivefold increase in coronavirus susceptibility is a scary statistic for young e-cigarette users, but experts say it should also be troubling to regulators. Over one in four high school students reported current e-cigarette use in last year’s National Youth Tobacco Survey. If schools reopen and teen vaping goes unchecked, transmission rates could increase, affecting teachers, parents and the community at large.
The results of the Stanford study underscore the need to clamp down on teen e-cigarette use, according to Halpern-Felsher.
“I honestly think that the FDA has taken its eye off the ball, really even before the pandemic,” Halpern-Felsher said.
Halpern-Felsher is not alone in this sentiment; regulation of e-cigarettes has been too slow and too limited for many advocates. This January, the FDA issued a ban on most flavored cartridges, including popular “gateway” flavors like mint and mango. But the ban gave exceptions to certain products, such as menthol and tobacco cartridges, flavored “open tank” e-juice and disposable e-cigarettes.
A new cast of brands has already grown in these loopholes. Throughout the pandemic, there have remained a rainbow assortment of workarounds for addicted youth, in flavors like cotton candy, banana and green apple candy.
In July, the FDA sent warning letters notifying 10 companies to pull flavored disposables and youth-appealing e-liquids from the market. In a statement to NBC News, an FDA spokesperson said its top priority “remains protecting youth from products that pose the greatest risk for initiation or use by minors.”
“The FDA continues to prioritize enforcement against e-cigarette products, specifically those most appealing and accessible to youth,” the agency spokesperson said. “We are concerned about the popularity of these products among youth and want to make clear to all tobacco product manufacturers and retailers that, even during the ongoing COVID-19 pandemic, the FDA is keeping a close watch on the marketplace and will hold companies accountable."
But existing actions have not gone far enough, according to Halpern-Felsher.
“The cigarette market, it’s the Wild Wild West,” Halpern-Felsher said. “As soon as you get one product off the market, the next one comes on. … We need to stop the whack a mole, we need to regulate and stop the entire market of e-cigarettes.”
Rep. Raja Krishnamoorthi, D-Ill., who chairs the Subcommittee on Economic and Consumer policy, sent a letter to the FDA on Tuesday, citing the new Stanford study. He previously wrote the agency in April regarding the potential of e-cigarettes to exacerbate the coronavirus pandemic, but the FDA then declined to act, citing lack of conclusive evidence on the topic.
“Today, we have the evidence that the FDA was waiting for, and it can no longer deny the danger e-cigarettes pose during the coronavirus crisis,” wrote Krishnamoorthi. “[I]t is evident that the youth vaping epidemic has combined forces with the coronavirus pandemic, creating a much deadlier foe that demands FDA action.”
So far, patchwork regulation has shaken companies, but not addicts. E-cigarette brands may rise and fall, but the number of teen e-cigarette users has only risen in recent years.
While Beerel and Finnerty feel compelled to speak out against e-cigarettes, they both have struggled to ditch the habit completely. Finnerty, who says he has been diagnosed with PTSD after getting out of the hospital, urged others to take all possible steps to avoid his situation, including avoiding e-cigarettes.
“Easier said than done,” said Finnerty. “But I just hope that people consider that they are putting themselves at a much greater risk.”
Coronavirus is the latest in a long list of risks incurred by teen vapers. But the results of the Stanford study feel especially shocking, Beerel said. It’s not a distant risk. It’s not a small risk. And for teenagers living with parents and interacting with the community, it’s not just a personal risk either.
“It makes me at least really thankful that I haven’t gotten it yet, and a little bit concerned for both myself and my peers,” said Beerel. “Because COVID-19 is a nasty disease...it's already so contagious. To think that it can be even more contagious based on vaping is really just shocking and scary.”