The Association of Electronic Cigarette Use With SARS-CoV-2 Infection and COVID-19 Disease Severity

Abstract

BACKGROUND Although combustible cigarette use is an established risk factor for severe COVID-19 disease, there is conflicting evidence for the association of electronic cigarette use with SARS-CoV-2 infection and COVID-19 disease severity. METHODS Study participants were from the Kaiser Permanente Research Bank (KPRB), a biorepository that includes adult Kaiser Permanente members from across the United States. Starting in April 2020, electronic surveys were sent to KPRB members to assess the impact of the COVID-19 pandemic. These surveys collected information on self-report of SARS-CoV-2 infection and COVID-related risk factors, including electronic cigarette and combustible cigarette smoking history. We also used electronic health records data to assess COVID-19 diagnoses, positive PCR lab tests, hospitalizations, and death. We used multivariable Cox proportional hazards regression to calculate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) comparing the risk of SARS-CoV-2 infection between individuals by e-cigarette use categories (never, former, and current). Among those with SARS-CoV-2 infection, we used multivariable logistic regression to estimate adjusted odds ratios (ORs) and 95% CIs comparing the odds of hospitalization or death within 30 days of infection between individuals by e-cigarette use categories. RESULTS There were 126,475 individuals who responded to the survey and completed questions on e-cigarette and combustible cigarette use (48% response rate). Among survey respondents, 819 (1%) currently used e-cigarettes, 3,691 (3%) formerly used e-cigarettes, and 121,965 (96%) had never used e-cigarettes. After adjustment for demographic, behavioral, and clinical factors, there was no association with SARS-CoV-2 infection and former e-cigarette use (hazard ratio (HR) = 0.99; CI: 0.83–1.18) or current e-cigarette use (HR = 1.08; CI: 0.76–1.52). Among those with SARS-CoV-2 infection, there was no association with hospitalization or death within 30 days of infection and former e-cigarette use (odds ratio (OR) = 1.19; CI: 0.59–2.43) or current e-cigarette use (OR = 1.02; CI: 0.22–4.74). CONCLUSIONS Our results suggest that e-cigarette use is not associated with an increased risk of SARS-CoV-2 infection or severe COVID-19 illness.

Does Vaping Increase the Likelihood of SARS-CoV-2 Infection? Paradoxically Yes and No

“…Our finding that nicotine increased ACE2 agrees with prior studies [15][16][17][18][19][20][21][22][23][24]. To the best of our knowledge, our data are the first to show that PG/VG aerosol can increase ACE2, an important finding since these solvents are the dominant chemicals in e-liquids [2,48].…”

“…Similarly, there is some discrepancy in the EC literature regarding the influence of EC use to SARS-CoV-2 susceptibility [15][16][17][18][19][20][21][22][23]. Our study clearly shows that the presence of benzoic acid in e-liquids mitigates the enhanced infection caused by nicotine.…”

“…Because prior EC studies with humans have not segregated EC users based on whether they used acid containing ECs, the data are likely noisy, which may account for some of the contradictory reports regarding the correlation between EC use and SARS-CoV-2 infection. In two clinical studies [22, 23], all EC user data were collected into a single group without regard to the EC products used. Based on our data, it would be interesting, if possible, to reanalyze these clinical data and separate the EC users into subgroups based on their EC products (acid containing or not).…”

“…Many 4 th generation EC products use benzoic or other acids that lower aerosol pH, and these are also likely to mitigate the enhanced infection. Given the diversity of e-liquids that have been sold in the past and currently, it is not surprising that prior studies have drawn different conclusions regarding the relationship between vaping and COVID-19 [15][16][17][18][19][20][21][22][23]. Overall, these data demonstrate that individual ingredients (nicotine, PG/VG, and benzoic acid) can influence SARS-CoV-2 infection of human bronchial epithelial tissues and that benzoic acid, if present, will override the increased infection produced by nicotine and PG/VG.…”

“…While preliminary, these studies suggest that EC use may increase the likelihood of contracting COVID-19. In contrast, hospital observational studies have concluded that EC use is not associated with an increased risk for COVID-19 [23, 24].…”