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All authors have made a significant contribution to this article from
concept to implementation and publication.
Abstract
Health crises have become a popular topic of discussion. In the wave of
the ongoing pandemic, experts have suggested the role of vaping and
other tobacco product use exemplifying the vulnerability of the
population to contract the COVID-19. We discuss some of the events that
led up to these conclusions and also offer a unique insight into another
form of tobacco use that is potentially propagating its spread
especially in the South Asian region – chewed tobacco. Both of these
have been a perennial issue that head and neck cancer surgeons have been
dealing with. Governments and Head and Neck cancer care providers now
have an opportunity to deal with a common enemy in the midst of this
pandemic.
Commentary
In these anxious times most people resort to unhealthy, self soothing
habits from a bag of potato chips to binging chocolates. But fictitious
“stress busters” known to cause head neck cancers have been identified
by experts that are making populations vulnerable to contract the severe
acute respiratory syndrome related-coronavirus-2 (SARS-CoV-2) infection
– tobacco use and vaping. Since the novel coronavirus attacks the
lungs, it would be logical for most users to taper, or better stop, the
use of such products and not escalate them. (1) Yet the youth continues
to use these devices finding ways to circumvent laws and without
realizing its implication on the larger society. (2)
The initial reputation of Electronic Nicotine Delivery System (ENDS), or
more colloquially called “vaping”, of being harmless began to change
in mid 2019, when the reports of mysterious and life-threatening lung
injuries related to vaping began to emerge across the globe.(3) The
terrifying part was not the lack of diagnosis, etiology or treatment of
the so-called EVALI (e-cigarette, or vaping, product use associated lung
injury) but the demographic of the patients presenting these symptoms.
The Center for Disease Control (CDC) reported that a typical EVALI
patient was a 18-24 year-old male with a history of e-cigarette use.(4)
This profile comprised of nearly 5 million middle and high school
American students who had used e-cigarettes in the past 30 days,
including 10.5% of middle school students and 27.5% of high school
students.(4) After realizing an alarming 78% increase in e-cigarette
use among high school students in a single year, the U.S. Surgeon
General called the use of ENDS an “epidemic”, issuing a call for
action against the use of e-cigarettes.(5) Emergency room visits started
increasing in August 2019 and peaked in September with mostly young men
and boys. In a matter of about two months, the rate of hospital
admissions related to EVALI skyrocketed by more than ten times with an
unknown number of non-hospitalized cases out there. To add to this, the
death toll also started to rise with reports emerging from across ten
states.(4,6) Today EVALI remains a diagnosis of exclusion because no
specific test or marker exists for its diagnosis.
A similar rampant development is now plaguing our planet with COVID-19
infecting more than a 180 countries – nearly two million confirmed
cases and causing over a million deaths. (7) The only difference is that
this was not by choice! Similar to vaping and tobacco use, this ongoing
“pandemic” has affected people across races and cultures in high-,
middle- and low- income countries alike. The acute respiratory illness
in a patient with a history of e-cigarette/vaping use and
tetrahydrocannabinol (THC) exposure could be caused by a viral or EVALI
etiology.(4) This cannot be distinguished from influenza and other virus
related diseases by signs and symptoms at presentation. A Chinese study
has also found that among infected patients, a history of smoking could
increased the likelihood of progression of the pneumonia like symptoms
by up to 14 times.(8) The WHO states that COVID-19 can spread through
small droplets from the nose or mouth, which are spread when an infected
person coughs or exhales. These droplets settle on objects around us and
can survive for few hours or up to several days. Others can be infected
by the Coronavirus by touching these objects or surfaces followed by
touching their eyes, nose or mouth.(7) By virtue of their design, these
products are brought to the mouth and face to inhale from repeatedly. At
the same time, many users have increased cough or expectoration that is
a recipe for increased transmission rates in society. To add to the
numerous public health lawsuits against the vaping industry, they are
now defending an allegation of willfully shipping over one million
contaminated pods this year without notifying customers.(1)
Smokeless tobacco (SLT) could also be aiding the spread of and
increasing the susceptibility towards COVID-19. The chewed form is often
held in the mouth until the “kick” sets in, and then spat out along
with saliva. This mixture is a harbinger of multiple pathogens, now
including the SARS-CoV-2. With a historical precedence of imposing bans
on public spitting to successfully curb the tuberculosis epidemic, many
countries, provinces and cities continue such policies for controlling
other communicable diseases.(9) Currently just eleven countries of the
South East Asian region account for 90% of the global consumption of
SLT, with a majority in India and Bangladesh.(10) SLT users often deface
public places by spitting, commonly in low- and middle-income countries.
What is worrisome is that 64% of people who live in sprawling tiny
tenements and urban slums are in Asia. Places like these could become a
petri dish for communicable infections like COVID-19, where SLT use is
part of popular culture.
Just like other tobacco products, SLT use also is linked to a higher
prevalence respiratory symptoms, heart disease and cancers, all of which
are strongly associated with COVID-19.(11,12)
To strengthen containment measures, few state have issued advisories
underscoring the exacerbation of the risk of spreading COVID-19,
particularly among the young people that smoke and vape.(13) Health
experts are urging administrations to ban all tobacco and vaping
products.(14) States in India have also banned the manufacture and
distribution of smokeless tobacco products during these trying times.
Head and Neck cancer care providers and governments of the world now
have an opportunity to deal with a common enemy in the midst of this
pandemic- tobacco and vaping.(15)
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