Coordinated Confusion

Experts say the spread of misinformation about vapor has a negative effect on public health.

By Timothy S. Donahue

It can be confusing for even the experts. During the pandemic, the vapor industry has struggled under conflicting reports about whether vaping makes you more susceptible to catching Covid-19. Several media stories have speculated that vaping could make having the illness even more severe (see “Up in the Air,” page 16). Anti-tobacco groups quickly began to claim smoking and vaping could even help spread the disease although no studies have found this to be true.

In the U.S., these news stories have prompted politicians to demand that the U.S. Food and Drug Administration (FDA) temporarily ban e-cigarettes. Several states are either considering or have passed vaping regulation as part of their coronavirus response. Globally, the World Health Organization (WHO) has accused the tobacco (and vapor) industry of creating doubt about the risks of nicotine and tobacco product and Covid-19. One country, South Africa, went as far as to ban tobacco products altogether as part of its coronavirus lockdown.

The controversy grew in April and May as researchers noted a remarkable underrepresentation of smokers among Covid-19 patients who had been admitted to the hospital. “This has led some scientists to hypothesize that there may be some protective effect from nicotine specifically to do with coronavirus,” said Guy Bentley, director of Consumer Freedom Research at the Reason Foundation, a libertarian think tank. Currently, clinical trials are underway investigating the effects of nicotine patches in France and now in Wales.

During a webinar held by the Reason Foundation in mid-May, a panel of harm reduction experts weighed in on the supportive new research as well as the misinformation being disseminated and the impact these factors have on both the vapor industry and overall public health.

Sally Satel, resident scholar at the American Enterprise Institute, an influential right-wing think tank, noted that every observational study concerning Covid-19 has seen that smokers are underrepresented in patients who are admitted to the hospital. These included thousands of patients in more than two dozen studies from several countries, including Italy, France, China and the United States. She also said that many of these studies have not been peer-reviewed, and concerns about data collection exist. “Nevertheless, they’re exciting, and they are especially exciting … because they are so counterintuitive,” said Satel.

Satel pointed to one study conducted by Konstantinos Farsalinos, a cardiologist and research fellow at the Onassis Cardiac Surgery Center in Athens, Greece. Farsalinos found that across 13 studies from China, only 6.5 percent of all hospitalized patients with Covid-19 were smokers whereas 26 percent of the population smokes cigarettes. If smoking made no difference, you would expect a 26 percent representation, according to Satel. “If smoking was harmful [relating to Covid-19] you certainly wouldn’t expect lesser representation,” she said. “So that was very eye-catching. This pattern has since been found in many of the studies. They’re all in the same ballpark … a U.S. study found [the same] … A French study also found similar results.”

Satel explains that the research has shown two ways nicotine could have an impact on Covid-19 with one being more plausible. The first theory is, very basically, that nicotine blocks the entry of the virus into receptor cells. The more plausible theory, however, is that nicotine has a suppressing effect on the cytokine pathway, says Satel. The immune system depends on cytokine signaling to keep the human body healthy.

“Now, cytokines are chemicals produced by white cells in the body or the infection-fighting cells. And specifically, in this case, a macrophage is one of those cells, and macrophages literally eat viruses,” explains Satel. “Anyway, briefly, there is a receptor on the macrophage called the citicoline receptor or a neuronal type, and nicotine also can attach to that receptor and influence the release of those cytokines, and the mechanism of that is called a cytokine storm.”

WHO is to blame?

Tobacco may also be potentially part of a Covid-19 cure. British American Tobacco (BAT) researchers announced in May that BAT’s potential Covid-19 vaccine was moving to human trials after it generated a positive immune response in preclinical trials. The vaccine candidate uses proteins from tobacco leaves. Yet rather than welcoming BAT’s effort to help tackle the pandemic, the WHO cautioned health authorities against engaging with the tobacco industry.

Many experts believe that even if BAT is successful in creating a vaccine, organizations such as the WHO would ignore the science and possibly put lives at risk. It would not be the first time, explains Tim Andrews, executive director for the Taxpayers Protection Alliance, a group that monitors federal spending. He says the WHO has a long history of hostility to alternative nicotine products.

Andrews says that the WHO’s failures “have cost millions of lives,” not just because of the Covid-19 issues but because its track record of trying to prevent the acceptance of reduced-risk tobacco health alternatives has led to more people smoking and more people dying from combustible cigarettes. “The more I looked over the last few years, the more horrified I was by how [the WHO’s] actions are actively harming and not helping public health,” said Andrews.

Since the electronic nicotine-delivery system (ENDS) came to market, the WHO has attempted to block its advance at every turn. As early as 2008, the WHO has stated that it “does not consider [ENDS] to be a legitimate therapy for smokers trying to quit.” Andrews said that as studies started to show that vapor products were “95 percent safer than combustible cigarettes” and ENDS products became accepted by Public Health England (PHE), the WHO had to make a choice: admit failure and accept ENDS as part of tobacco harm reduction plans or ignore science.

“Unfortunately, they have doubled down on their position contrary to all available evidence. And in fact, not only are they now … working towards further restrictions on e-cigarettes, they’re actually going out spreading deliberate misinformation,” says Andrews. “And it seems the more evidence [that] is coming out on the fact that they’re an effective harm reduction tool, the more the WHO is going to try … to call on countries to do large-scale campaigns against them.”

As an example of WHO dishonesty, Andrews pointed to a large-scale social media campaign started by the health body in January suggesting that ENDS can cause lung injuries and increase the risk of heart disease. According to Andrews, there is not a shred of evidence for either claim.

The WHO campaign included statements such as, “The liquid in e-cigarettes can burn skin and rapidly cause nicotine poisoning if absorbed through the skin,” and “The liquid is also highly flammable.” Not a single thing in those sentences is true, according to Andrews. “It is completely 100 percent made up. These aren’t stupid people. They aren’t writing this out of ignorance. This is a deliberate lie. And then you can see all of these people on Twitter responding by taking vape liquid and lighting [it on] fire. It does not light on fire. It does not burn your skin if you get it on your skin. This is blatant misinformation to scare people. And what is the result of this? If people are scared of something that is 95 percent safer than smoking, they will end up sticking to combustible cigarettes, which are much more deadly for them.”

Numerous public health professionals have joined Andrews in criticizing the WHO’s approach to harm reduction. In June, an international group of independent experts with no conflicting links to the tobacco or vapor industry criticized the WHO for its “backward-looking” approach to innovation and new technology, such as vapor products. The experts say they are exasperated by the WHO’s “dogmatic hostility” toward new technology and fear the U.N. health agency will squander the opportunity to avoid millions of premature deaths that will be caused by smoking.

Iowa state Attorney General Tom Miller, who was the first to publicly release the collaborative letter, said the WHO has lost its sense of mission and purpose. “It’s as if the WHO has forgotten what it is there to do—to save lives and reduce disease,” Miller said. “We can do that by helping and encouraging consumers to switch from cigarettes to lower risk products. This means being honest about the much lower risks and by using smarter regulation to make switching more attractive.”

The group criticizing the WHO includes David Abrams of the School of Global Public Health at New York University; Tikki Pangestu, visiting professor of Lee Kuan Yew School of Public Policy at the National University of Singapore; John Britton, professor of epidemiology at the University of Nottingham; Rajesh Sharan of North-Eastern Hill University in Shillong, India; David Sweanor of the Centre for Health Law, Policy and Ethics at the University of Ottawa; and Clive Bates, director of Counterfactual Consulting.

While making no mention of tobacco control policies, U.S. President Donald Trump in late may announced the U.S. would terminate its relationship with the WHO. He said that the U.N. agency failed to adequately respond to the coronavirus because China has “total control” over the global organization. He also said Chinese officials “ignored” their reporting obligations to the WHO and pressured the WHO to mislead the world when the virus was first discovered, according to a story by The Associated Press.

United against vapor

While the WHO does carry a portion of the blame for the misinformation about vapor products, Michelle Minton, senior fellow at the Competitive Enterprise Institute, another libertarian think tank, says the problem isn’t limited to one or more organizations. She believes that public health across the board has been suppressing evidence.

“This is something I’ve been writing about for many years, and I think really what we are seeing is the worst of it expressed at the time when we need our public health institutions to be at their most effective,” said Minton.

A lot of the evidence has been coming out showing that e-cigarettes are far less harmful and extremely effective as a smoking cessation tool, according to Minton. Studies are showing that ENDS are more efficient than other available nicotine-replacement therapies. However, this is not the message disseminated by the FDA.

“In April 2019, the FDA put out a warning … that they had noticed that in 10 years, from 2009 till 2019, there were 35 seizures reported while somebody was using an e-cigarette,” explains Minton. “And given the fact that there are 70,000 people in this country or more, I believe, that have seizure disorders, and a lot of [people] also vape, it would make sense that at one point or another someone [who also vaped] might actually have a seizure. Thirty-five in 10 years is really a minuscule figure. And as far as I can tell, nothing really came of that.”

In August of 2019, a mysterious lung disease began to appear in the U.S. Then, on Sept. 29, 2019, the first case of e-cigarette or vaping-associated lung injury (EVALI) was announced. “These lung injuries, which at first were described by news reporters—who were getting their information from [the] CDC [Centers for Disease Control and Prevention] and [the] FDA—as vaping,” says Minton. “So vaping-associated pulmonary injury, which suddenly by September changed to EVALI. I even asked [the] CDC about what was the choice of the change putting e-cigarettes up front even at that time as the information [was widely known at the time] that it was linked to illicit THC vaporized products on the black market. So vaping was already too broad of a term, and then when New York started reporting that every single one of their patients admitted or tested positive for THC, and then when they went to test the THC products they were using, they all contained vitamin E acetate. That’s when [the] CDC suddenly decided to use the term ‘EVALI,’ emphasizing e-cigarettes.”

The data now shows that many of the lung injuries occurred in people who are too young to legally purchase marijuana products, according to Minton. EVALI also occurred frequently in states that didn’t have legal marijuana. The CDC waited until late-October 2020 to give that information to the public. As late as Nov. 1, the CDC still advised: “Because the specific compound or ingredient causing lung injury is not yet known, and while the investigation continues, persons should consider refraining from the use of all e-cigarette or vaping products.”

The CDC narrative is still that e-cigarettes had something to do with the EVALI outbreak. However, there continues to be zero evidence that nicotine vapor products were ever found culpable in the lung injuries, says Minton, adding that “the messaging is perfect for [the] CDC who wants to continue this [image] of vaping as an epidemic.”

Ultimately, says Minton, organizations like the WHO, FDA and CDC are losing their credibility because of the way the agencies are handling vaping and ignoring the science. “It really damaged their credibility. On the eve of a crisis, a real crisis, where we would have had or we should have been able to rely on the CDC, their credibility took a major hit,” says Minton. “So that’s what we have going on here. It’s bad all around. But, I’m an optimist, so I think that one of the best things that might be able to come out of this is that Congress and other entities take a look at our public health system and try and narrow the focus of some of these agencies, maybe reign them in a little bit, maybe bring them back to talking about actual science.”