Seven months and more than a million deaths into the pandemic, scientists around the globe still don’t understand why some people infected with coronavirus get extremely ill and die, while others survive. The sheer range of outcomes for people who get COVID-19—from asymptomatic, to mild symptoms, to moderate disease leading to months-long complications, to death—has infectious disease doctors baffled. In a desperate race against time, researchers are rushing through work to better understand the disease, to find treatments and ultimately to develop an effective vaccine.
But how do we determine whether all this new research is actually useful, unbiased and of high quality? And how do we prevent the spread of misinformation due to overinterpreted, low-quality research findings or outright biased research? Leading medical researchers have begun sounding the alarm on the “pandemic of bad science” threatening our understanding of COVID-19 and potentially putting people at risk (case in point: hydroxychloroquine).
Do we know enough to conclude anything about the relationship between COVID-19 and nicotine? Experts say no.
Inevitably, this bias and bad science has found its way into the debate on tobacco harm reduction by positing a tenuous link between vaping nicotine and COVID-19. The researchers driving this hypothesis are cynically using the pandemic as a golden opportunity to “prove” e-cigarettes damage the lungs. This singular focus on finding harms is inexcusable, and is a wasteful diversion of scientific resources that could be put into eradicating the coronavirus and traditional tobacco smoking—saving millions of lives in the process.
Do we know enough to conclude anything about the relationship between COVID-19 and nicotine? Experts in nicotine and tobacco science, including an editor of the journal Nicotine and Tobacco Research, say no, pointing to the reality that much of the research produced during the pandemic has come from large databases or hospital data which rely on opportunistic, non-random samples of patients.
Because these “observational” data are not systematically collected, they are susceptible to various biases that can produce misleading results. For example, many of the early studies from China published in leading medical journals found that patients above the age of 70 were not being diagnosed with COVID-19. Interpreted at face value, these studies could suggest that COVID-19 is less likely among older adults.
But we now know, from many more studies in much larger samples, that the opposite is true: Older adults are significantly more likely to develop the most severe complications associated with the virus, including death. This example—likely the result of selection bias in the early Chinese studies (a common issue with observational studies)—highlights the risk of blindly accepting research findings without properly accounting for the quality of the research.
However, despite the clear limitations of observational research, the mainstream media continue to highlight similar studies that associate vaping nicotine with COVID-19. This fits a pre-established agenda: Journalists have long used anecdotal or flawed research to perpetuate a vaping panic through news of nicotine poisonings, “popcorn lung,” explosions, heart attacks and last year’s misnamed E-cigarette or Vaping Product-Use Associated Lung Injury (EVALI) outbreak.
A recent New York Times article, “Vaping Links to Covid Risk Are Becoming Clear,” is the latest example. The author, Katherine J. Wu, holds a PhD in microbiology and immunobiology. As a scientist, she should know that leading scientists have argued for increased access to vaped nicotine due to its lower risk compared with smoking and resulting potential to saving lives.
But Wu only interviews American pulmonologists who assert that vaping is harmful and damages the lungs. According to one doctor she quotes, nicotine vaping products, “do just about everything bad you can think of.”
There are also serious problems with the studies Wu cites to support her argument. Of 27 linked references included in the article, only one was a study that looked at the connection between vaping and COVID-19. That study, by Dr. Bonnie Halpern-Felsher, is a small, online survey conducted one week in early May 2020 that happens to be at the center of a scientific controversy. Many scientists have noted its flaws and some (including one of the authors of this article) wrote the editor of the publishing journal—noting “the implausible conclusions reached by the authors” and calling for the paper’s retraction.
Her reporting uses a worst-case-scenario strategy found in other articles linking vaping nicotine with negative outcomes.
Wu also fails to mention studies that indicate the opposite of her conclusions—that nicotine might have protective effects against the virus and could function as a COVID-19 treatment.
Her reporting uses a worst-case-scenario strategy found in other articles linking vaping nicotine with negative outcomes—which tend to profile people who are heavily dependent on vaped nicotine or have experienced horrifying injuries due to rare battery explosions or EVALI.
James Ippolito and Janna Moein check those boxes for Wu. Ippolito, a 26-year-old army veteran, is described as being “hooked” on vaping nicotine for six years. He says, “I vape every day, all day long.” Of Moein, 22, Wu writes, “he was blowing through several THC-laced cartridges a week—more, he said, than most people can handle.”
The distinction, which Wu makes, that Moein vaped THC products, not nicotine, is crucial: As both the Food and Drug Administration and the CDC belatedly acknowledged, illicit THC products, primarily those tainted with Vitamin E acetate oil, drove the EVALI outbreak. It’s important to note that this additive can’t be added to nicotine vape products, because it is incompatible with water-soluble e-liquid.
Yet Wu’s reporting engages in a core feature of drug-panic discourse, ignoring a vast continuum of use to focus on extreme cases. How much THC Moein vaped each week isn’t the point; he wouldn’t have ended up in a hospital intensive care unit with a collapsed lung if the Dr. Zodiak cartridges he bought weren’t adulterated with Vitamin E acetate.
Ippolito is practising harm reduction by vaping nicotine instead of smoking. And how do you define vaping “all day long?” Wu calls him “stubborn” because he doesn’t want to stop using nicotine during the COVID-19 pandemic. But as a result of this unprecedented public health catastrophe with no end in sight, Ippolito, like lots of vapers, might not want to stop because nicotine can mitigate feelings of depression and boost attentional focus.
The anecdote and photos are related to Moein’s hospitalization for tainted THC-related EVALI, yet they are incorporated into an article about COVID-19, smoking and e-cigarettes.
Articles like Wu’s don’t rely solely on questionable or misleadingly deployed science to frighten or confuse readers, but also front-load terrifying anecdotes. Moein supplies one: “My lips were blue … They had to tape my eyes shut. I was hallucinating the entire time that the nurses were trying to kill me, that the walls were made of human skin…” A trio of photos Moein provided to the Times create more reader fear. There is an image of him in a medically induced coma with a big blue breathing tube taped to his mouth. The anecdote and photos are related to Moein’s hospitalization for tainted THC-related EVALI, yet they are incorporated into an article about COVID-19, smoking and e-cigarettes.
The author also implicitly conflates the harms of smoking and nicotine vaping, juxtaposing and treating them as interchangeable: “About 34 million adults smoke cigarettes in the United States, many of them from communities of color and low socioeconomic status—groups already known to be more vulnerable to the virus. And more than 5 million middle and high school students recently reported using vapes.”
This reporting fails to acknowledge that while adults continue to smoke the most lethal consumer product on the planet, smoking rates (and vaping) continue to decrease for young people. And it neglects the independent evidence, in the form of reviews and papers from leading researchers, that has found vaping to be vastly less harmful than smoking—a critical difference for millions who have switched.
A decade of research confirms that vaped nicotine delivers significantly less harmful chemicals and constituents, including zero delivery of carbon monoxide and several carcinogens that are delivered when someone lights a combustible tobacco cigarette. And the most rigorous type of evidence, a Cochrane Review, has just found that smoking quit rates are higher in people randomized to vaporized nicotine than to nicotine replacement therapy (NRT) or vapor products without nicotine—demonstrating, as we have known for years, that nicotine helps people stop smoking when it isn’t delivered in a cigarette.
When 1 billion people worldwide still smoke and more than 8 million a year die of it, how can you justify such omissions?
We are still disentangling the science of COVID-19, and there are many more questions than answers regarding the role of nicotine and tobacco in how this deadly virus proliferates.
It is contributing to misinformed vapers switching back to smoking.
But misrepresenting the relative harm of vaping compared to smoking—in general, and in the context of the COVID-19—has severe real-world consequences. Because it is contributing to misinformed vapers switching back to smoking—potentially represented by increases in cigarettes sales, but not e-cigarette sales, during the pandemic.
Sensationalized headlines in the mainstream media, linking vaping and COVID-19 based on junk science, are undermining public health. This disinformation and disregard of science make millions of people distrust public health messaging.
It is unconscionable that government health organizations would advise vapors to quit. Instead they should be launching a campaign to help smokers switch to vaping. Because we do know this: Cigarettes deliver over 4,000 substances, many of them known carcinogens, and those chemicals choke out the lives of 1,300 smokers every day in the US—480,000 premature deaths every year. In contrast, COVID-19, which has caused a global pandemic and unprecedented economic, political and social chaos, has caused just over 215,000 US deaths in the past nine months.
The harms of smoking, which have been publicized for close to 60 years, are undeniable. Ground zero for death and disease is the combustible cigarette. If you are a smoker struggling to stop, consider reviewing these tobacco harm reduction resources from a leading public health organization in Britain that has pulled together facts on the benefits of stopping smoking—including switching to vaping nicotine.
Photograph by Helen Redmond