To the Editors:
A recent analysis by Gaiha et al. concluded that “e-cigarette use and dual use of e-cigarettes and cigarettes are significant underlying risk factors for COVID-19” [
[1]
]. The article deviated from standard reporting practices in several ways.First, the authors classified tobacco use as never (referent), ever, and past 30-day use of cigarettes only, e-cigarettes only, and both products. However, Table 1 presented the participant characteristics only for never and ever e-cigarette use; cigarette smoking was absent. This table is not useful because it does not provide information relating tobacco exposures to outcomes in Table 2.
Second, the authors did not disclose the crucial raw numbers of exposed participants who had COVID-19-related symptoms, COVID-19 tests, and COVID-19 diagnoses. As a result, it is very difficult to interpret the results. We offer an example.
Gaiha et al. reported that “COVID-19 diagnosis was five times more likely among ever-users of e-cigarettes only (95% confidence interval [CI]: 1.82–13.96), seven times more likely among ever-dual-users (95% CI: 1.98–24.55), and 6.8 times more likely among past 30-day dual-users (95% CI: 2.40–19.55)” [
[1]
]. These adjusted odds ratios are promoted in a Stanford Medicine webpage [[2]
].Going smoke-free or vape-free: Reducing your risks for COVID-19. Stanford Medicine Tobacco Prevention Toolkit.
http://med.stanford.edu/tobaccopreventiontoolkit/COVID-19.html
Date accessed: August 20, 2020
Using a standard epidemiologic technique, we estimated the number of exposed cases for each of the adjusted odds ratio in the previous paragraph. They are n = 5, n = 3, and n = 5, respectively. We asked the authors to provide actual numbers. They declined.
The authors’ claims have already prompted national policy recommendations by members of Congress [
[3]
,[4]
]. They are obligated to publish a complete table of all participant characteristics that are unweighted so that the study can be adequately evaluated.Third, the senior author, who is an editorial board member of the Journal of Adolescent Health, may have breached its policy on conflicts of interest. On July 22, 2019, she filed an affidavit with a federal district court in a lawsuit against an e-cigarette manufacturer, in which she said, “We cannot wait. We must act immediately. The courts have moved swiftly before to ban other drugs or devices that have harmed human health. The courts must similarly act swiftly now to ban Juuls in order to prevent more youth from a lifetime of addiction” [
[5]
]. According to guidance from the International Committee of Medical Journal Editors [[6]
], her activity in the lawsuit is “directly or topically related” to her article in the journal and should have been disclosed.Funding Sources
The authors were supported by unrestricted grants from tobacco manufacturers to the University of Louisville and by the Kentucky Research Challenge Trust Fund. The sponsors had no knowledge of this work and therefore had no input or other influence in the design, analysis, interpretation of results, or in the preparation of and decision to submit the letter.
References
- Association between youth smoking, electronic cigarette use, and COVID-19.J Adolesc Health. 2020; 67: 519-523
- Going smoke-free or vape-free: Reducing your risks for COVID-19. Stanford Medicine Tobacco Prevention Toolkit.(Available at:)http://med.stanford.edu/tobaccopreventiontoolkit/COVID-19.htmlDate accessed: August 20, 2020
- Citing a dubious study, this congressman wants the FDA to ban e-cigarettes as a COVID-19 hazard.(Reason, August 17, 2020, Available at:)
- Letter to the Honorable Alex Azar II, Secretary, U.S. Department of Health and Human Services, August 20, 2020.(Available at:) (Accessed September 16, 2020)
- Public health emergency that needs action now: Epidemic youth use of Juul. Federal District Court, Middle District of Florida.(Case 8:19-cv-00884-MSS-AAS. Publicly Available at:) (Accessed September 16, 2020)
- Disclosure of financial and non-financial relationships and activities, and conflicts of interest.(Available at:) (Accessed September 16, 2020)
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- Association Between Youth Smoking, Electronic Cigarette Use, and COVID-19Journal of Adolescent HealthVol. 67Issue 4
