A new study suggests that vaping reduces inflammatory biomarkers when to compared to someone who smokes combustible cigarettes. “While vaping inflammatory biomarkers were elevated compared to nonusers, those differences were not statistically significant,” the study’s authors state.
“There was also no significant difference in the elevation of biomarkers between the exclusive smokers and dual smokers – the additive effect of e-cigarettes was low if present at all.”
The research, reported in the journal Circulation, used the U.S. For Disease Control and Prevention (CDC) and the U.S Food and Drug Administration’s (FDA) Population Assessment of Tobacco and Health (PATH) that has been released yearly since 2013.
The dataset is from this first cycle using data of participants’ smoking habits along with blood samples. The researchers looked specifically at metabolites, biomarkers, of inflammation and oxidative stress – the culprits felt to underlie tobacco’s harmful effects. In addition to the usual demographic data, there was specific information on the use or nonuse of tobacco, vaping, and cigarette smoking.
Results reflect findings for adults age 18 or older, where data on biomarkers and tobacco use were available, which was 7130 participants. This included 58.6 percent neither smoked nor used e-cigarettes (nonusers); 29.6 percent smoked exclusively; 1.9 percent vaped exclusively and 9.9 percent smoked and vaped (dual users).
“Exclusive and dual smokers had the highest inflammatory and oxidative stress biomarkers relative to nonusers,” the researchers note. “Exclusive vapers had ‘significantly lower levels’ except for C-reactive protein (than smokers).”
The research concluded that e-cigarettes appear to have little impact on inflammatory biomarkers, certainly not as great as smoking tobacco. This research “highlight(s) the importance of completely replacing cigarette smoking with e-cigarettes or quitting the use of both products for cigarette smokers to derive potential health benefits,” the report states.
AS recently reported, data from the 2020 National Youth Tobacco Survey (NYTS) found that 1.8 million fewer U.S. youth are currently using e-cigarettes compared to last year. The NYTS, conducted by the U.S. Food and Drug Administration (FDA) and the U.S. Centers for Disease Control and Prevention (CDC), data shows an alarming increase in the number of youth who use disposable e-cigarettes.
Compared to 2019, the number of youth using e-cigarettes is down 1.8 million. However, the number of youth using disposable e-cigarettes has risen: 26.5 percent of high school users are using disposables, up from 2.4 percent in 2019, and 15.2 percent of middle school users are using disposables, up from 3 percent last year.
The FDA did not include disposable products when it announced its flavor ban for closed-pod systems in February of this year. The 2020 NYTS showed that more than 8 out of 10 youth e-cigarette users report use of flavored products and the majority of those used a disposbale product.
The study states that almost 40 percent of high school users are using an e-cigarette on 20 or more days out of the month and almost a quarter of them use e-cigarettes every day.
Last week, the FDA issued warning letters notifying three companies who sell or distribute unauthorized ENDS products to remove those products from the market. The regulatory agency issued a warning letter to XL Vape LLC (doing business as Stig Inc.), warning the company to remove their disposable e-cigarettes from the market because they do not have the required premarket authorization.
The additional warning letters were issued to Flavour Warehouse LTD (doing business as Vampire Vape) and Pretty Women UK LTD (T/A Coil2oil and Mad Kingdom Liquids) for illegally marketing unauthorized menthol-flavored e-liquids. “The labeling and/or advertising of these products also features cartoon images, such as vampires and kings, that are commonly marketed and/or appeal to youth,” according to the FDA.
The overall use of e-cigarettes by youth dropped from 28 percent to 20 percent among high schoolers, according to the latest data. The U.S. Food and Drug Administration (FDA) and the U.S. Centers for Disease Control and Prevention (CDC) released the 2020 National Youth Tobacco Survey (NYTS), which show 1.8 million fewer U.S. youth are currently using e-cigarettes compared to 2019.
“After two years of disturbing increases in youth e-cigarette use, we are encouraged by the overall significant decline reported in 2020,” the FDA stated in a release. “This is good news; however, the FDA remains very concerned about the 3.6 million U.S. youth who currently use e-cigarettes and we acknowledge there is work that still needs to be done to curb youth use.”
The 2020 NYTS data also showed an uptick in the youth use of disposable e-cigarettes. Disposable products were reportedly used by 26.5 percent of high school e-cigarette users (up from 2.4 percent in 2019) and 15.2 percent of middle school e-cigarette users (up from 3 percent in 2019).
A rise in the youth use of flavors prompted the FDA to remove all flavored prefilled pods from the market. However, consistent with 2019, prefilled pods or cartridges were the most commonly used device type in 2020, the report states. “The use of disposable e-cigarettes surged among both high school and middle school students,” the FDA statement noted.
The NYTS was released on the same day that premarket tobacco product applications (PMTAs) were due to the FDA. Companies must demonstrate that each product meets the applicable statutory criteria for receiving marketing authorization, such as whether marketing the product is appropriate for the protection of the public health.
The U.S. Centers for Disease Control and Prevention (CDC) said states no longer have to track lung-related injuries caused by marijuana-based vapor products, partly because cases have dropped.
The CDC said it stopped requiring states to report the numbers in February after it pinpointed vitamin E acetate as the culprit in THC e-cigarettes making people sick, according to wftv.com.
The CDC said it is monitoring EVALI cases and hasn’t seen an uptick nationwide. However, It said the agency will continue to provide assistance to states as needed.
EVALI (e-cigarette or vaping product use-associated lung injury) is the name given by the CDC to a lung disease linked to vaping THC vapor products.
“We know beyond reasonable doubt that vaping and other smoke-free nicotine products are very much less risky than smoking and that those who switch completely see rapid improvements in their health. Yet the WHO continues to promote the outright prohibition or extreme regulation of these products. How can it make sense to ban the much safer product when cigarettes are available everywhere?”
“[The] WHO is treating vaping products as though they are part of a ploy by Big Tobacco. But they have this 100 percent wrong. In fact, the new products are disrupting the profitable cigarette trade of the tobacco industry and driving down cigarette sales. It is exactly what we need from innovation, but [the] WHO and its private funders have lined up to oppose it with calls for prohibition. Though they don’t seem to realize it, they are siding with the cigarette interests of Big Tobacco, erecting barriers to entry to new technology and protecting the incumbent cigarette oligopoly.”
“When smoking is by far the dominant cause of disease caused by tobacco, why would the WHO use World No Tobacco Day to target one of the most effective and popular alternatives to smoking? We rarely see the vaping industry advertise to adolescents and we never see kids used in commercial vaping ads—but on World No Tobacco Day we have the absurd spectacle of [the] WHO promoting adverts with children vaping. What on Earth do they think they are doing?” – Clive Bates
“Unless it does something different and embraces innovation in tobacco policy, [the] WHO will miss the targets for reducing cancer [and] heart and lung disease by some distance. Encouraging people to switch to low-risk alternatives to smoking could make a large difference to the burden of disease by 2030 if [the] WHO got behind the idea instead of blocking it.”
“On World No Tobacco Day, the WHO should be driven by one overriding question: How do we get smoking down for the greatest number at the greatest rate? We know [the] WHO embraces harm reduction in other areas of public health, including for illicit drugs and sexual health. If [the] WHO wants to even come close to meeting its targets to reduce disease, it needs a strategy for smokers who can’t or won’t quit nicotine, and the rise of smoke-free products since 2010 makes that a practical option. [The] WHO’s ‘quit or die’ approach to smokers and opposition to harm reduction makes no sense.”
“When [the] WHO set out to build an international treaty for tobacco control from 2000, the goal was clear—it was trying to tackle the worldwide epidemic of smoking-related disease. Somewhere along the way, [the] WHO seems to have lost its sense of purpose and developed a closed mentality that is leading it to take unworkable, nonnegotiable or counterproductive positions that are not backed by sound science. It seems to have neglected its core mission, ‘the highest possible level of health for all people,’ including the 1 billion smokers globally, most of whom want to avoid disease and premature death.”
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.”
Although it may have eclipsed our memories, COVID-19 is not the first disease outbreak that the Centers for Disease Control and Prevention has faced in the last three months.
It was as late as Feb. 25 — well after the first novel coronavirus case in the United States was reported — that CDC updated its numbers on what it called the EVALI (e-cigarette, or vaping-associated lung illness) outbreak. On that day, while COVID-19 was silently spreading throughout the country, CDC announced that this “e-cigarette”-related disease had caused 2,807 hospitalizations and claimed 68 lives. Little did we know at the time that these two events were profoundly connected.
Throughout its investigation of the first outbreak, CDC created public hysteria over the dangers of electronic cigarettes by attributing the outbreak to all vaping products, whether they contained nicotine or THC and whether they were purchased at a highly regulated vape shop or from a drug dealer on the street. The very name that CDC attached to the outbreak directly implicated electronic cigarettes, which are nicotine-delivery devices that are effective in helping adult smokers to quit smoking.
Following CDC’s lead, state health departments spread the word that using an e-cigarette to quit smoking could be life-threatening — so much so that seven states issued emergency bans on the sale of most or all electronic cigarettes.
Regulate, keep e-cigs away from youth
What the CDC failed to tell the public until nearly the end of the outbreak, and what many state health departments have still not publicly revealed, is that the lung illness outbreak was not caused by electronic cigarettes at all. Instead, it was caused by THC-containing vaping cartridges that were laden with a viscous oil — vitamin E acetate oil — that had begun to be used as a thickening agent in many black market THC vaping products shortly before the outbreak started.
Experts in the cannabis industry had the cause of the outbreak pretty much figured out by Aug. 30 and had definitively figured out the cause by Sept. 11. David Downs — the California bureau chief of Leafly.com — was almost single-handedly responsible for getting wholesale THC vape cartridge manufacturers (both licit and illicit) to stop using vitamin E acetate oil as a thickening agent. This not only led to the “eradication” of EVALI, but it has proven that e-cigarettes were never involved since the outbreak has ended but e-cigarettes continue to be sold in high volume and without any changes in their ingredients or manufacturing process.
Nevertheless, as late as Dec. 11, the Massachusetts Department of Public Health was still warning the public that: “We don’t understand what is causing these illnesses. From a public health point of view, we cannot recommend that anybody use vaping or e-cigarette products at this time.”
Sales data reported by PiperJaffray for the four weeks that ended Oct. 20 (when the Massachusetts emergency ban was in effect for 25 of the 28 days) and the four previous weeks (mostly before the ban went into effect) revealed that there was a substantial shift from vaping to smoking in the state. Nationally, there was very little difference in the rate of decline in cigarette sales between these two time periods from 2018 to 2019. The rate of decline decelerated by just 0.3 percentage points (from -7.8% to -7.5%). However, in Massachusetts, the rate of decline decelerated by a massive 5.7 percentage points (from -9.8 percent to -4.1 percent). This suggests that that many ex-smokers in Massachusetts who were reliant on e-cigarettes to stay smoke-free returned to smoking.
National data reported by Bloomberg News revealed the same pattern: the rate of decline in cigarette consumption slowed significantly because of the e-cigarette scare.
And the nation’s largest cigarette manufacturer — Altria — acknowledged in its 2019 annual report that: “Growth of the e-vapor product category and other innovative tobacco products has further contributed to reductions in cigarette consumption levels and cigarette industry sales volume and has adversely affected the growth rates of other tobacco products. Continued growth in these categories could have a material adverse impact on the business, results of operations, cash flows or financial position of Altria and its tobacco subsidiaries.”
What does this have to do with COVID-19?
It means that due to the zeal of CDC and other health agencies to condemn electronic cigarettes, cigarette smoking in the United States got a significant boost just before one of the most devastating respiratory disease outbreaks in our nation’s history. And there is strong evidence that smoking makes COVID-19 significantly worse.
Thus, the e-cigarette scare significantly worsened the health consequences of COVID-19, potentially resulting in more deaths than would have occurred if the CDC and state health agencies had simply told us the truth.
Dr. Michael Siegel is a professor in the Department of Community Health Sciences, Boston University School of Public Health, where he has conducted research on tobacco for 25 years. He wrote this for InsideSources.com.
