Stanford Professor Bonnie Halpern-Felsher
Professor Bonnie Halpern-Felsher, director of Fellowship Research, Department of Pediatrics at Stanford University

In recent years, e-cigarette use among adolescents has skyrocketed. Some have even called it an epidemic. 

Between 2017 and 2018 alone, there was a 10 percent rise in adolescent vaping, according to a 2020 article by Drs. Kristen Jones and Gary A. Salzman published in Missouri Medicine. The increase equates to about 1.3 million teens. 

Studies have shown that e-cigarettes are highly addictive and are harmful to the lungs. 

Now new research by Professor Bonnie Halpern-Felsher, director of Fellowship Research, Department of Pediatrics at Stanford University, suggests that vaping is a significant underlying risk factor for COVID-19. 

Halpern-Felsher and fellow researchers from the University of California published their findings in August 2020 in the Journal of Adolescent Health. They conducted a national online survey of 4,351 adolescents and young adults aged 13 to 24 and looked at the relationship between e-cigarettes and dual use of e-cigarettes and cigarettes and COVID-19 symptoms, testing and diagnosis.

Study results included:

  • E-cigarette users were 5 times more likely to get a COVID-19 diagnosis.
  • Dual users of e-cigarettes and cigarettes were 7 times more likely to get a COVID-19 diagnosis.
  • Past 30-day dual users were 6.8 times more likely to have a COVID-19 diagnosis.
  • Past 30-day dual users were 9 times more likely to have COVID-19 testing.
  • Past 30-day e-cigarette only users were 2.6 times more likely to have COVID-19 testing.
  • COVID-19 symptoms were 4.7 times more likely in past 30-day dual users.

In this Q&A, Halpern-Felsher explains why these findings are significant and what they mean for consumer safety. She reiterates the health risks of e-cigarette use and gives parents tips on how to talk to their children about the dangers of vaping. 

Q: What was the most striking thing that you found after all the data came in from the study?

A: I’ve been doing a lot of research on teens and e-cigarettes for years and tobacco for 25 years. The intent of the original study was to look at the products that youth are using and to get an update on what are they using. What are their patterns of use? What are their flavors? Things like that. COVID came around just when my first author and I were going to field the study. So we then added the questions on COVID not knowing at all what we were going to find. We thought that there would be some relationship because we know e-cigarettes harm your lungs as do cigarettes. We expected to see some relationship, but we certainly did not expect it to be five to seven times more likely [to be diagnosed with COVID-19] depending on the patterns of use. 

Q: What can consumers take away from the data that you gathered?

A: I think there’s a simple message, which is that e-cigarettes are harmful products. And for teenagers and parents to think that these are not harmful is incorrect. That’s one thing to know. Because we do know that e-cigarettes cause lung damage and seem to be changing your immune system and therefore potentially making it more likely for you to become sick from COVID. Granted, we looked at symptoms, but we didn’t get to look at severity or hospitalization. 

The other thing is that we may simply be finding an exposure. So teens, even though about half of them were sheltering in place, they were maybe in their backyard with their friends, sharing their device. You share, you increase your exposure. Your hand to mouth, you know you touch a doorknob, you touch the e-cigarette device and then you touch your mouth, which we know is something you shouldn’t be doing during COVID-19. 

So what we may be finding is simply exposure difference. It may also be that the virus is transported through the droplets in the aerosol. Either you are breathing it deeper yourself and rather than just breathing normal air you are taking in deep puffs, or you are standing next to somebody who’s vaping, and that is causing the cloud around you. We can’t test the mechanism in the study. It’s more of an epidemiological study to show what’s happening here.

Q: So the study doesn’t prove causation. 

A: No.

Q: You talked about how this data can help make people — schools, community-based organizations and policymakers — more aware. I think about parents, mostly. What tips do you have for parents who want to talk to their children about vaping? 

A: We want parents to raise the issue with their children. The way I always think of it is: Here’s yet another study coming out that shows there is a relationship between e-cigarettes and some harm. 

We’ve seen other studies looking at seizures or asthma, and bronchitis. With EVALI it is still questionable whether it is THC, e-cigarette or nicotine. Although there are certainly teenagers and adults who have been hospitalized with EVALI who say they’ve only used nicotine e-cigarettes, so it’s hard to know.

But here’s just one more study in this list that really shows that e-cigarettes are definitely harmful. Exactly why, we don’t know. We can piece it together from other literature, the harms on the lungs and the immune system. But we don’t really know specifically. So that’s what I want them to do — here’s one more study. And what I always tell parents is now is not the time. I mean we are always going to be angry as parents, but now is not the time to be angry with them. Now is the time to talk to them. If they are not using, reinforce that and tell them that’s great. And reinforce the peer-pressure issues that teens are facing and whatever might be driving them to use. 

If they are using — and certainly you aren’t going to find that out from the first conversation because when you say to a teen ‘Are you using?’ they certainly aren’t going to tell you yet — but you raise the issue with them, and generally if you wait for a few conversations, it’s going to come out. But you just make a very safe environment for teenagers to tell you if they are using and then you try to get them help rather than just be angry with them because that’s not going to solve the problem. 

So that’s what I hope parents will do with this information.

Q: When you say “getting help,” are you also saying it’s OK to reach out to a professional counselor who might help with this issue?

Exactly. A physician, a counselor. Unfortunately, we don’t have any FDA-approved nicotine replacement therapy for anybody under the age of 18. Nor do we really have studies to tell us how much nicotine to give an e-cigarette user to help them, particularly a teenager. But there are plenty of doctors who are prescribing nicotine replacement therapy for people under 18. And it seems to be having some good success. So going and talking to a healthcare professional or therapist, rehab, getting some help would be very good because a lot of teenagers are addicted. There was a recent study published showing that about — I think it was 25 percent — of teens who are using e-cigarettes would like to quit. 

There’s not enough research, and it shows that we don’t really have a solution. But it doesn’t stop people from trying to work with teenagers and using what we know from cigarettes, nicotine replacement and cognitive behavioral therapy, things like that. 

Q: What would you want the public to know about what you found in your research? 

A: I would just tell the public look, we don’t know why, whether it’s exposure or direct health impact, but clearly these e-cigarettes and cigarettes are harmful. And the reason why we found dual use is that most teenagers in the U.S. start with e-cigarettes and then some of them move onto cigarettes, so our predominant pattern is dual use. This doesn’t mean that they went from cigarettes to e-cigarettes. Other research shows that teens initiate with e-cigarettes, they do not initiate with cigarettes. And then they are more likely to go on and use cigarettes subsequently. 

Also, know that we didn’t look at the number of times in the past 30 days. We just looked at presence or absence. So it could be that the majority of people who used in the past 30 days could be using cigarettes a lot and only using e-cigarettes once in a while. We’re going to go back and look at the data.