August 11, 2020

Stanton A. Glantz, PhD

Vaping linked to COVID-19 risk in teens and young adults

There have been several reports, mostly in non-peer reviewed preprints, reporting lower levels of COVID-19 infections among smokers than nonsmokers. This is a surprising finding because, based on what we know about the effects of smoking and vaping on immune function of the respiratory system, one would expect that smoking and vaping would increase risks of COVID infection.

A big problem with all the studies to date has been that they have been based on people who were tested, rather than samples drawn from the population as a whole.  Because of limited availability of tests in many places, the resulting samples are biased toward people who may already have symptoms.

Shivani Mathur Gaiha and Bonnie Halpern-Felsher from Stanford and Jing Cheng from UCSF have addressed this problem by doing a study that used a population-based sample of youth and young adults, “Association between youth smoking, electronic cigarette use and Coronavirus Disease 2019,” that was just published in Journal of Adolescent Health.  They found vaping and dual use of cigarettes and e-cigarettes (the most common use pattern) was associated with increasing likelihood of experiencing symptoms, getting tested and being diagnosed with COVID.

These findings are particularly important as the case mix of people getting COVID is moving to younger people, perhaps reflecting increased exposures due to reduced social distancing and a lack of understanding about factors exacerbating COVID-related risk in this age group.

The FDA needs to pay attention to these findings as it considers the premarket approval applications for e-cigarettes that are pouring into its office now. These results specifically challenge FDA’s assumption that e-cigarettes are safer than cigarettes. They also highlight the fact that there are immediate serious adverse effects of e-cigarettes that cost a lot of money (both in terms of direct health costs and general social disruption to the economy), something that the FDA needs to consider in its regulatory impact analysis (cost-benefit analysis) of approving e-cigarettes.

Because flavors are an important reason kids use e-cigarettes, these findings also support the need for bans on all flavors – including menthol – in e-cigarettes as part of comprehensive flavor ban legislation that is being considered all over the country and world.

Here is Stanford’s press release on the paper:

Vaping is linked to a substantially increased risk of COVID-19 among teenagers and young adults, according to a new study led by researchers at the Stanford University School of Medicine [and UCSF]. 

The study, which will be published online Aug. 11 in the Journal of Adolescent Health, is the first to examine connections between youth vaping and COVID-19 using U.S. population-based data collected during the pandemic.

Among young people who were tested for the virus that causes COVID-19, the research found that those who vaped were five to seven times more likely to be infected than those who did not use e-cigarettes. 

“Teens and young adults need to know that if you use e-cigarettes, you are likely at immediate risk of COVID-19 because you are damaging your lungs,” said the study’s senior author, Bonnie Halpern-Felsher, PhD, professor of pediatrics.  

‘Not just a small increase in risk’

“Young people may believe their age protects them from contracting the virus or that they will not experience symptoms of COVID-19, but the data show this isn’t true among those who vape,” said the study’s lead author, postdoctoral scholar Shivani Mathur Gaiha, PhD.

“This study tells us pretty clearly that youth who are using vapes or are dual-using [e-cigarettes and cigarettes] are at elevated risk, and it’s not just a small increase in risk; it’s a big one,” Gaiha said.

Data were collected via online surveys conducted in May. Surveys were completed by 4,351 participants ages 13 to 24 who lived in all 50 U.S. states, the District of Columbia and three U.S. territories. The researchers recruited a sample of participants that was evenly divided between those who had used e-cigarettes and those who had never used nicotine products. The sample also included approximately equal numbers of people in different age groups (adolescent, young adult and adult), races and genders.    

Participants answered questions about whether they had ever used vaping devices or combustible cigarettes, as well as whether they had vaped or smoked in the past 30 days. They were asked if they had experienced COVID-19 symptoms, received a test for COVID-19 or received a positive diagnosis of COVID-19 after being tested.

Results adjusted for confounding factors

The results were adjusted for confounding factors such as age, sex, LGBTQ status, race/ethnicity, mother’s level of education, body mass index, compliance with shelter-in-place orders, rate of COVID-19 diagnosis in the states where the participants were residing, and state and regional trends in e-cigarette use.

Young people who had used both cigarettes and e-cigarettes in the previous 30 days were almost five times as likely to experience COVID-19 symptoms, such as coughing, fever, tiredness and difficulty breathing as those who never smoked or vaped. This may explain why they were also more likely to receive COVID-19 testing, said Halpern-Felsher, especially given that in May, many regions limited COVID-19 testing to people with symptoms. Depending on which nicotine products they used and how recently they had used them, young people who vaped or smoked, or both, were 2.6 to nine times more likely to receive COVID-19 tests than nonusers.

Among the participants who were tested for COVID-19, those who had ever used e-cigarettes were five times more likely to be diagnosed with COVID-19 than nonusers. Those who had used both e-cigarettes and conventional cigarettes in the previous 30 days were 6.8 times more likely to be diagnosed with the disease. The researchers did not find a connection between COVID-19 diagnosis and smoking conventional cigarettes alone, perhaps because the prevalent pattern among youth is to use both vaping devices and traditional cigarettes. Other research has shown that nearly all nicotine-using youth vape, and some also smoke cigarettes, but very few use cigarettes only, Halpern-Felsher said.

‘Now is the time’

In line with other recent COVID-19 research, the study found that lower socioeconomic status and Hispanic or multiracial ethnicity were linked to a higher risk of being diagnosed with the disease.

In addition to warning teenagers and young adults about the dangers of vaping, the researchers hope their findings will prompt the Food and Drug Administration to further tighten regulations governing how vaping products are sold to young people.

“Now is the time,” Halpern-Felsher said. “We need the FDA to hurry up and regulate these products. And we need to tell everyone: If you are a vaper, you are putting yourself at risk for COVID-19 and other lung disease.”

[Jing Cheng] of the University of California, San Francisco also contributed to the research, which was funded by the Taube Research Faculty Scholar Endowment; the National Heart, Lung and Blood Institute (grant U54 HL147127); and the Food and Drug Administration Center for Tobacco Product

Here is the abstract of the paper:

Purpose: Assess whether youth cigarette and e-cigarette use are associated with COVID-19 symptoms, testing and diagnosis.

Methods: An online national survey of 13-24 year olds was conducted in May 2020 (n=4351). Multivariable logistic regression assessed relationships among COVID-19-related symptoms, testing and diagnosis and cigarettes only, e-cigarettes only and dual use, socio-demographic factors, obesity, and complying with shelter-in-place.

Results:  COVID-19 diagnosis was 5 times more likely among ever-users of e-cigarettes only [95%CI 1.82,13.96], 7 times more likely among ever-dual-users [95%CI 1.98,24.55] and 6.8 times more likely among past 30-day dual users [95%CI 2.40, 19.55]. Testing was 9 times more likely among past 30-day dual-users [95%CI 5.43, 15.47] and 2.6 times more likely among past 30-day e-cigarette only users [95%CI 1.33, 4.87]. Symptoms were 4.9 times more likely among past 30-day dual users [95%CI 3.07, 7.16].

Conclusion:  COVID-19 is associated with youth use of e-cigarettes only and dual use of e-cigarettes and cigarettes, suggesting the need for screening and education.


The full citation is:  Gaiha SM, Cheng J, Halpern-Felsher B.  Association between youth smoking, electronic cigarette use and Coronavirus Disease 2019.  Journal of Adolescent Health 2020; epub ahead of print 11 Aug 2020.  It is available here.

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