Given the increasing numbers of adolescents and young adults who report using inhaled tobacco products such as e-cigarettes, these findings reinforce the need for family physicians to discuss the harms of tobacco use – particularly e-cigarette use -- with young patients, especially in the context of risk for contracting COVID-19.
For FPs, "The big take-home message is that not smoking (or) vaping is even more important with novel coronavirus out there," said Douglas Kamerow, M.D., M.P.H., senior scholar in residence at the AAFP's Robert Graham Center for Policy Studies in Family Medicine and Primary Care and a long-time public health policy expert who has written at length on the role of family medicine in the pandemic. Kamerow added that FPs need to stress to patients that tobacco use is dangerous regardless of how patients use it.
The CDC reported that as of Sept. 3, more than 6 million Americans have been infected with SARS-CoV-2, the virus responsible for COVID-19, and more than 185,000 have died from the disease. For those who survive, evidence indicates that the disease can cause long-term respiratory problems in some patients.
From May 6-14, 2020, the study authors conducted a national cross-sectional survey of adolescents and young adults ages 13-24. The survey collected information on use of inhaled tobacco products such as cigarettes and e-cigarettes; self-reported COVID-19 symptoms, testing and diagnosis; body mass index; and a variety of demographic information. A total of 4,351 participants completed the survey.
Analysis of the responses showed statistically significant associations between recent tobacco use and COVID-19. For example, compared with those who had never used inhaled tobacco products, adolescents and young adults who used both cigarettes and e-cigarettes in the previous 30 days were 6.84 times as likely to receive a positive diagnosis of COVID-19.
Adolescents and young adults who reported dual use of cigarettes and e-cigarettes in the previous 30 days also were 4.69 times as likely to self-report COVID-19-related symptoms and 9.16 times as likely to have taken a COVID-19 test.
Use of either type of inhaled tobacco product also was associated with COVID-19 symptoms, testing and diagnosis, although not to the same degree as dual use. Compared with never-users, those who were past 30-day users of e-cigarettes only were 1.91 times more likely to receive a positive diagnosis for COVID-19, 1.43 times more likely to report having COVID-19 related symptoms and 2.55 times more likely to undergo testing. For those who used only cigarettes, those odds ratios were 1.53, 1.15 and 1.16, respectively.
The authors acknowledged that their research identified only an association between use of inhaled tobacco products and COVID-19 – not a causal relationship -- and noted that the study was based on participant self-reporting. Nevertheless, they said that their findings "show that e-cigarette use and dual use of e-cigarettes and cigarettes are significant underlying risk factors for COVID-19 that has previously not been shown."
The authors added that the findings provide timely evidence that youth who use inhaled tobacco products are at greater risk for COVID-19, which indicates a need for additional screening and education. They encouraged health care professionals to ask all youth, including those infected with COVID-19, about cigarette and e-cigarette use. They also suggested the findings could be an opportunity for parents, schools and community-based organizations to direct youth to learn about the effects of inhaled tobacco products on the respiratory and immune systems.
Kamerow offered the following advice when counseling young patients: "Always ask if they smoke or vape or chew. It's not enough to ask if they smoke."
As for reducing the risks of COVID-19, Kamerow recommended that youth wear face masks and practice social distancing and that they be urged to avoid going to large gatherings such as parties.
The Academy has a wealth of resources available to assist members in helping patients to quit using tobacco. The AAFP also has a number of clinical resources and patient education materials available for members to provide guidance throughout the COVID-19 pandemic.