Vaping raises COVID risk, but don’t ban it
In August 2019, health officials sounded an alarm at reports of a mysterious lung illness. Young and otherwise healthy people were visiting emergency rooms across the country with such symptoms as shortness of breath, chest pain, coughing, fatigue, nausea and vomiting. COVID-19 was still months away. This was EVALI, an acronym for electronic vaping-related lung illness.
Vaping devices heat nicotine along with chemical solvents and flavors to create an inhalable steam. They had been marketed as a safer alternative to combustible cigarettes but were facing increasing scrutiny due to their surging popularity with teens and young adults. EVALI provided evidence of vaping’s immediate risks and accelerated calls from public health officials and parents to restrict or completely ban the sale of some vaping products. As of Feb. 18, 2020, the Centers for Disease Control and Prevention had documented more than 2,807 cases and 68 deaths related to vaping products. The CDC has since stopped reporting these numbers; EVALI cases had started to decline before being eclipsed by the pandemic.
When COVID-19 first hit, smoking and vaping were identified almost immediately as risk factors for heightened vulnerability to the disease. This claim initially was based more on intuition than evidence; that a habit known to damage the lungs could increase susceptibility to a disease that attacks the lungs seemed a safe bet.
Growing data appear to support this hypothesis. A U.K. study with over 2.4 million participants found that smoking increases one’s risk of developing more severe COVID-19 symptoms. A recent survey of more than 4,300 U.S. residents between the ages of 13 and 24 found that, after controlling for factors such as age, sex, race, and compliance with stay-home orders, respondents who reported dual use of combustible and electronic cigarettes in the past thirty days, the commonly accepted indicator of regular use, were 6.8 times more likely than dual abstainers to report receiving a positive COVID-19 diagnosis, and 4.7 times more likely to report symptoms of the disease. Similarly, past-month dual users were more than 4 times more likely than cigarette-only users and vape-only users to show COVID-related symptoms and more than 3 times more likely to test positive for the virus.
It is not yet clear why dual use may increase the odds of COVID infection, but there are plausible clues. Dual use may indicate a greater propensity for risk-taking, possibly manifested in less social distancing. Both smoking and vaping adversely affect lung function and may reduce resistance to the virus, and dual users are likely inhaling larger volumes of harmful substances than those who stick to one product. Also, dual users are likely to touch their mouths and faces with their fingers often, and young e-cig users frequently share devices. Both behaviors increase the likelihood of infection.
The defense of vaping has never been that it is harmless, but that it is less harmful than smoking. Even if vaping does increase susceptibility to COVID-19, it is arguably still safer than traditional smoking, a habit linked to 480,000 deaths in the U.S. each year. Vaping reduces or eliminates the tars and smoke that contribute to various cancers, and thousands of adults say that vaping has helped them quit smoking. Still, concern over possible links between vaping and COVID-19 has again generated calls to severely restrict or even ban vaping altogether. There are no comparable calls to ban cigarettes.
We understand the impulse toward prohibition, but we caution against it.
Full or partial prohibition of vaping products is unlikely to reduce use significantly, but it is likely to have undesirable consequences. Like the war on drugs, vape bans will expand the black market and unregulated vape products will increase health risks for consumers. In New York, New Jersey and Massachusetts, where flavors have been banned and taxes increased, an illegal trade is blossoming. Punishment for illicit vape use will generate consequences that outweigh the risks of vaping and will disproportionately affect youth and marginalized groups.
Vaping can be discouraged but not eliminated. The link between COVID-19 and vaping (and smoking) needs to be at the forefront of public messaging intended to discourage use. Like the effective anti-smoking campaigns launched decades ago, vaping reduction efforts must frame vaping as undesirable and uncool — focusing, for example, on the inconveniences and anxieties that accompany nicotine addiction and the longterm damage and death that COVID-19 can cause. Public health campaigns should be geared toward people who are most likely to use and become addicted and who are vulnerable to COVID-19. Health care providers should also take a proactive role in counseling patients to reduce nicotine use, something many fail to do. Regulations should focus on product manufacturers and sellers by restricting advertising and levying fines against companies that intentionally market to youth.
While we cannot know how long COVID-19 will seriously threaten our lives and livelihoods, we can be confident that vaping is here to stay for the foreseeable future. Policies need to reflect that reality and treat the goal of reducing vaping as the long game that it is.