Is There a Relationship Between E-Cigarette Use and Positive COVID-19 Diagnosis in Adults with Asthma, Aged 18-30?

  1. Title
    • Is there a relationship between e-cigarette use and positive COVID-19 diagnosis in adults with asthma aged 18-30?
  2. Background
    • COVID-19, a respiratory disease caused by a novel coronavirus SARS-CoV-2, has changed life for people across the world, especially in the United States. The COVID-19 pandemic started in 2020 and the virus has evolved into 5 variants. Risk factors for COVID-19 include individuals who are immunocompromised, of old age, pregnant, have diabetes, and those with preexisting chronic respiratory conditions (Majmundar, Allem, Cruz, & Unger, 2020). Another risk factor includes lifestyle choices such as smoking and e-cigarette or vape use.
    • E-cigarette and vaping use can also cause an acute respiratory illness known as e-cigarette/vaping product use-associated lung injury (EVALI) (Callahan, Lanspa, & Blagev, 2021). As of February 2020, reported EVALI cases were more than 2800, and 68 patients had died (Callahan, Lanspa, & Blagev, 2021).
    • Interestingly, researchers have discovered that allergic asthma may be a protective factor against COVID-19, due to interleukin-13 (IL-13) (Morrison, et al., 2022). IL-13 is a cytokine that protects against SARS-CoV-2 viral and cell shedding and was shown to affect viral entry, replication, and cell-to-cell transmission (Morrison, et al., 2022). Furthermore, due to asthma being a potential protective factor, it is of interest to investigate the relationship between e-cigarette use and COVID-19 in young adults with asthma.
  3. Key study question
    • Is there a potential link between e-cigarette use and COVID-19 in young adults with asthma?
  4. Method
    • To investigate the relationship between e-cigarette use and positive COVID-19 diagnosis in young adults with asthma, data was collected from the 2020 and 2021 National Health Interview Survey (NHIS). The dependency variable COVID-19 diagnosis was determined by asking survey participants if “a doctor or other health professional ever told you that you had or likely had coronavirus or COVID-19” (National Center for Health Statistics, 2022). Only yes or no responses were used from this variable.
    •             The independent variable of interest, E-cigarette use, was recorded as current, used, but not current user, and never used. The age range for individuals in this study was from 18-30 because the prevalence of adults who had ever used an e-cigarette was highest among those aged 18-24 (National Center for Health Statistics, 2020). Only adults aged 18-30 who reported that they still had asthma were included. Other participant demographics were included such as urban-rural location, sex, and education level. Another variable included looked at weakened immune system due to health conditions and yes or no answers were included. Participants were asked if they had ever been told they had Chronic Obstructive Pulmonary Disease (COPD), emphysema, or chronic bronchitis where only yes or no answers were included. Lastly, participants were asked if they reported their general health status to be excellent, very good, good, fair, or poor.
    •             A Chi-square test was performed to compare positive and negative COVID-19 diagnoses across participant characteristics. Multiple logistic regression was then performed to investigate the relationship between e-cigarette use and co-variates (urban-rural, sex, education, weakened immune system, chronic respiratory disease other than asthma, and general health status) to positive COVID-19 diagnosis. An alpha level of 0.05 was used to assess the statistical significance.
  5. Findings
    • A total of 77 (15.8%) of the 487 participants observed from both surveys were classified as having a positive COVID-19 diagnosis. Figure 1 shows the patient characteristics across those with positive and negative COVID-19 diagnoses. The weakened immune system status, e-cigarette user status, and educational level were significant variables related to diagnosis. 10 (30.3%) out of 33 participants with a weakened immune system reported a positive COVID compared to 67 (14.8%) out of 454 without a weakened immune system who reported a positive COVID diagnosis. 14 (29.8%) of current e-cig users, 21 (16.03%) of former but not current users, and 42 (13.6%) of those who have never used reported a positive COVID diagnosis. 33 (22.9%) of 144 high school grads, 20 (14.5%) of 138 with some college and no degree, 1 (5.3%) of 19 with an occupational, technical, or vocational associated degree, 8 (19.1%) of 42 with an academic associate degree, and 15 (10.4%) of 144 with a bachelor’s degree reported a positive diagnosis.
    • After performing a multiple logistic regression and fitting the model, immune system status, e-cig user status, and educational levels are important predictors in the probability of reporting a positive diagnosis. The best-fitting model had an AUC value of 0.659 and a Hosmer and Lemeshow Goodness-of-Fit Test statistic of 0.9115. An analysis of Figure 2 indicates the odds for a participant in the survey to report a positive diagnosis. Those with a weakened immune system due to a health condition are 2.57 [95% CL 1.13-5.81] times more likely to be diagnosed with COVID. Current e-cig users are 2.82 [95% CL 1.36-5.84] times more likely than those who have never used to report a positive diagnosis. High school graduates are 2.63 [95% CL 1.34-5.15] times more likely than those with a bachelor’s degree to report a positive diagnosis.
    • In addition to the odds ratios from the model, the interaction between e-cigarette user status and weakened immune system status was investigated. The odd ratios are shown in Figure 3 in the appendix The odds ratio for a current e-cig user compared to someone who has never used e-cigarettes, both with weakened immune systems due to a health condition, was 1.0 [95% CL 0.08-11.93]. The odds ratio for current users compared to those who never used, both with normal immune systems, was 2.95 [95% CL 1.41-6.17]. E-cig users were just as likely to have a positive COVID diagnosis as those who have never smoked when they both had weakened immune systems. E-cig users were almost three times more likely to have a positive COVID diagnosis compared to those who never used when they both had normal, healthy immune systems.
  6. Public health significance
    • In the past 2 years, we have learned about COVID-19 and its risk factors. A few months before COVID-19 spread around the world, researchers were documenting and looking into the mysterious illness, now referred to as EVALI from e-cigarettes and vapes. In addition to risk factors, a study found that allergic asthma is a protective factor against COVID-19. Gaining an improved understanding of how e-cigarette use can damage the respiratory system and make individuals vulnerable to COVID-19 could reveal more effective public health interventions. We found that e-cigarette user status was a potential risk factor for a positive COVID diagnosis, which is in line with current literature.
    • Public health officials should recognize that vaping and e-cig use is still high among young adults (Callahan, Lanspa, & Blagev, 2021). Public health officials should also note that pandemic-exacerbated psychiatric disease may fuel even higher rates of e-cigarette use (Callahan, Lanspa, & Blagev, 2021). Increased use of e-cigarettes can cause EVALI which can be severe and life-threatening and increase the risk for COVID infection (Adhikari, Koritala, Gotur, Malayala, & Jain, 2021).
    • There are limitations to this study. The data from the 2020 NHIS had a more detailed section with multiple variables on asthma diagnosis and medication use. In the 2021 NHIS, that section was omitted, leaving only questions regarding asthma diagnosis. Another limitation is the type of asthma was never specified. There is no way to determine if the asthma is allergic asthma. The study is also limited due to a small sample size.
    • However, the study does point to an area that requires further investigation which can be undertaken by experimental studies. EVALI is an illness that has been overshadowed by COVID which necessitates additional research. The protective factor that interleukin-13 plays in allergic asthma should be further investigated among those who have the condition. More clinical and experimental studies are necessary to explore the relationship between e-cigarette use, allergic asthma, and COVID-19.
  7. Competencies
    • Apply appropriate descriptive and inferential statistical methods to analyze pattern of disease and identify the risk for diseases/health conditions.
      • Answer epidemiologic questions by conducting univariable, bivariable, and multivariable data analysis.
      • Apply common statistical methods for inference and draw appropriate conclusions from epidemiologic data.
      • Describe and apply ideal methodological alternatives to commonly used statistical methods when assumptions are not met.
      • Work through a data analysis case from the beginning to the end utilizing the latest state-of-the-art statistical methods.
    • Use computer software effectively to retrieve, manage, visualize, and analyze public health data.
      • Apply basic informatics techniques in the description and summary of public health characteristics.
      • Apply data extraction techniques to retrieve data and to convert them into a format suitable to use in a computer software.
      • Apply computer software to perform data management and data exploration to assess problematic data distributions and outliers in the variables of interest.
      • Analyze data to produce summary statistics of the major variables numerically and graphically, as appropriate.
    • Present public health data in the outline of scientific reports and presentations including the appropriate tables and figures.
      • Summarize results of statistical analysis into tables, graphs, and written presentation.
      • Interpret statistical findings and develop written scientific reports based on statistical analyses for both public health professionals and educated lay audiences.
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