MILWAUKEE — Before COVID-19 took the spotlight, Wisconsin was preoccupied with a different public health crisis affecting people’s lungs.

As e-cigarette use was soaring among young people, a set of mysterious — and sometimes deadly — lung illnesses linked with vaping raised alarms. Milwaukee officials urged everyone in the city to stop vaping immediately; state health officials called teen vaping an “epidemic.”

But soon, that public health scare was outscared — by a pandemic that infected hundreds of thousands of Wisconsinites.

“People aren't thinking about smoking and vaping right now,” said UW-Madison’s Dr. Megan Piper, associate director of research at the Center for Tobacco Research and Intervention. “People are thinking about the pandemic.”

Still, some Wisconsinites have been working to make sure that vaping education and research don’t disappear, even if they’re no longer the biggest public health problem at hand. 

And the pandemic has only added to the list of questions about vaping — like how lockdowns will affect trends in e-cigarette use, and whether vaping history puts people at a greater risk of an infection like COVID-19.

"Everything in the healthcare system became highly focused on treating COVID," Piper said. But moving forward, she said, "I'm hopeful that cigarettes and e-cigarette use will be back on the preventive health agenda."


The state of vaping

As the pandemic was getting underway, e-cigarette use was actually starting to dip among young people, said Lindsey Boehm, a recently graduated nursing student at UW-Eau Claire. Boehm has been working with nursing professor Lorraine Smith on a project to educate young people about vaping risks.

After several years of uptick, 2020 saw a decline in how many middle and high schoolers reported vaping in the past 30 days, according to the National Youth Tobacco Survey. Around 20% of high schoolers reported vaping in that latest survey, compared to around 28% the year before.

“That really dangerous growth that we were concerned about among adolescents has really gone down,” Piper said.

Federal measures like raising the age for buying tobacco products, including e-cigarettes, and banning many flavored vape products probably played into this decline, the researchers said. But with COVID-19 upending young people’s lives and school years, there are still a lot of questions about how those trends will hold up.

For adolescents, peer pressure is a huge factor, Smith pointed out. And a lot of e-cigarette use among young people is about getting together and being social, Piper added.

Franklin High School junior Bella Le said she’s seen at her school how vaping can become a social norm. Le is a part of her local FACT group, which helps educate teens about the risks of tobacco and other related products.

“People just think that it's part of the high school experience, that you're supposed to try out alcohol and tobacco products and vaping,” Le said.

With many schools turning to virtual classes or hybrid models during the pandemic, Smith and Piper said those social factors may not have packed the same punch. 

On the other hand, though, many people use e-cigarettes and other substances to cope with anxiety and other mental health challenges, Boehm pointed out. Across the U.S., substance use rose during the early days of the pandemic, along with other mental health struggles, according to CDC research.

“Stress leads to an automatic response of reaching for a cigarette, reaching for a vape if you are dependent,” Piper said. With the increased levels of stress, loneliness and boredom during the pandemic — and the disappearance of other rewarding activities, like gathering with loved ones — “you're just looking to anything to help make you feel a little bit better during the day,” she said.


An added risk?

In scientific terms, it’s still early to draw conclusions, the researchers stressed. But some preliminary research has found that vaping may increase COVID-19 risk.

A study from Stanford University surveyed thousands of young people aged 13 to 24 who had gotten coronavirus tests. Out of this group, people who reported that they’d used vape products before were five times as likely to test positive, compared to those who said they’d never vaped.

There are two main theories about how vaping might lead to a higher risk of catching COVID-19, Boehm said.

The behavior itself might be an issue: Someone who is vaping is, of course, not wearing a mask. And young people tend to share devices, Boehm said, which could also lead to more spread.

Plus, though vaping products don’t contain the same toxins as traditional cigarettes, they still affect the body — and could potentially leave it more vulnerable to infection.

“As we say, while e-cigarettes are less harmful than combustibles, they are not harmless,” Piper said.

E-cigarette use is still a relatively new trend, Piper pointed out, so we don’t have a lot of information about how it affects the body in the long term. 

But some studies have proposed that vaping could affect blood vessels in the brain, or lead to more expression of the ACE2 receptor — which the coronavirus uses to latch onto cells. And other research has found that nicotine can suppress parts of the immune system.

Cigarette smoking has more clearly been linked with worse COVID-19 outcomes, with a Cleveland Clinic study finding heavy smokers were around two times more likely to be hospitalized or die after a coronavirus infection.

Though the exact links still need more study, Le said the focus on health — and especially lung health — during the pandemic may have discouraged people from picking up vape products.

“It was just a wake-up call for people to focus on their health, and how one little thing can change their lifestyles,” Le said.


On the ‘back burner’

Even as these questions have been raised, a lot of research on smoking and vaping has stalled, Piper said, making it difficult to track trends and develop new treatments. And for Boehm, Smith and Le, the work of educating and connecting with the community has moved largely online during the pandemic. 

Instead of going into schools in person, Boehm and Smith have been connecting with young people via virtual sessions. Le’s FACT group has turned to a lot of social media outreach instead of organizing events in the community.

While the online format has allowed their program to reach new audiences — like young people in a juvenile detention center — Smith said it’s felt like vaping has really been on the “back burner” in terms of public health priorities. 

Le said she’s looking forward to connecting with people and sharing information face-to-face again in the future.

“I hope that we'll be able to have more outreach opportunities with the students, because I feel like it has a bigger impact on the community,” Le said. “There's only so much that you can do on social media.”

Coming out of the pandemic, there will still be many questions about how the past year has affected vaping and smoking trends, Piper said. And, of course, other pre-existing gaps — like understanding exactly how vaping affects the body in the long term — still need to be filled, Smith said.

Moving forward, finding nuance in messaging about vaping will be key, Piper said. 

While “the healthiest thing is to not be inhaling anything other than air,” she said, vaping can play an important role in helping people who are trying to quit much-more-dangerous combustible cigarettes. (Smoking-related diseases kill almost 500,000 Americans each year, she pointed out — which almost rivals the first-year toll from COVID-19.)

Keeping young people from developing a habit, while also giving smokers the option to switch, is a delicate balance, she said.

“E-cigarettes have a place in helping smokers switch to a less harmful product,” Piper said. “E-cigarettes have no business being in the hands of adolescents, because of the risk for addiction potential, the other problems that can cause with brain development.”

Among those young people, there’s still work to be done to make sure people understand the risks of vaping, Le said. A lot of high schoolers take the attitude of “I’ll still do whatever I want, because it’s my life,” she said — without fully thinking about the health consequences.

Boehm, who was born and raised in Eau Claire, said that building those connections with young people in her hometown has been rewarding work.

“The thing that makes me the most interested [in this work] is just empowering young people to make good decisions about their health, especially here in my community,” Boehm said. “I think that teenagers and adolescents need a little support with decision-making, and they need to be empowered with knowledge about vaping so they can make better decisions about their health.”

The Wisconsin Tobacco Quit Line offers free help to quit smoking, vaping or other tobacco use. You can call 800-QUIT-NOW, text READY to 200-400 or chat online.