By Ian Sliney – Epidemiologist
Forty-seven years later I still remember my first cigarette, and I was addicted to nicotine from the first puff. I smoked regularly for twenty years, then following multiple attempts, I kicked the habit cold-turkey after a doctor in Nairobi misread a chest x-ray and warned me I may have a Broncho-carcinoma. Luckily he was wrong.
I managed to stay away from nicotine for another twenty years. Then, in early October 2014, I Ied an Ebola response team into Monrovia at the height of the West African Ebola epidemic. As we waded through the hypochlorite baths at the airport, rinsed our hands in Clorox at the entrance to the terminal, and had our temperatures taken by public health nurses in full bio-hazard suits, my friend and colleague Christophe, ex-Médecins Sans Frontières and lifelong smoker, pulled out a pack of Marlboro Lights, shrugged his shoulders and said, “Peu importe, t’es foutu” (Either way, you’re screwed).
The cigarettes damped down the ever-present fear for the five weeks we spent in Liberia. And afterwards, as we waited out our 21-day quarantine, nurses from the Virginia department of health monitored us both twice daily. On November 21, I received my letter saying I was cleared to re-enter society. It is still on my fridge to this day, a reminder that I had cheated death yet again.
I quit smoking a year later while I was living in Geneva. I’d tried nicotine patches, but I developed an allergic reaction to the adhesive, so they did not work for me. I took up vaping a few months later, and slowly worked my way back to being fit again, regularly running between five and ten kilometres every day. A couple of years later, I finally decided it was time to quit vaping too, and so on October 3 last year, I left my vaping device in the USA when I went to Cameroon for a two-month consultancy as interim director of a large HIV-AIDS supply chain program.
It was a relief to be free of nicotine at last. And as all addicts do, I vowed never to give in to temptation again.
But ironically, life has a funny way of sneaking up on you when you think everything’s okay and everything’s going right…..
But then a pandemic was declared, and the Governor of Virginia issued an executive stay at home order. So I signed up as a Medical Reserve Corps volunteer and put my experience and energy into setting up community networks to run errands for those at risk in our neighbourhood. Ironically, I was also exposed to an index case, and I was one of the first beneficiaries of the program I had set up as once again I waited out another quarantine.
A month later, with almost 900,000 cases and 50,000 COVID-19 deaths in the USA, my daily time series analyses of the incident cases in the Hopkins GitHub dataset shows me that in the county where I live, we are still a few weeks away from flattening the curve – as the President encourages us to drink Clorox and shine ultraviolet light up our noses.
I’ve hardly been out of my condominium for the past month, and the stress and strain are beginning to take their toll. I live alone, and while the two months of isolation in my hotel in Yaoundé proved to be useful training for the isolation I am now obliged to enjoy here at home, I am more afraid for my life here than I ever was in Monrovia. I’ve tried to stay abreast of the emerging literature on risk factors because I’m in the demographic that may – or may not – have a viral sword of Damocles hanging over my head. I am male and take ACE inhibitors for my hypertension.
A few days ago, I noticed that my anxiety was slowly creeping up on me. I was mindful that I had started picking my fingernails again, a pernicious habit from my childhood that I had overcome with the many years of CBT that accompanied a very troubled divorce some fifteen years ago. I began to dream that I was smoking again, influenced I think by the recent literature from France suggesting that nicotine may in fact have a protective action against SARS COV-2 infection and its very unpleasant sequelae.
And then this morning, I found myself faced with an incredibly difficult decision. I want to live through this pandemic, but we have learned that there are potentially many hundreds of thousands if not millions of asymptomatic super spreaders. We have learned that while we may have begun to flatten the curve, the potential for an exponential resurgence of cases is very real, and that I am going to get infected sooner or later. But I don’t want to die just yet. My children live the other side of the continent in San Francisco. I want to be still able to hold them, and my grandchildren in my arms and hug and kiss them as all parents do.
But that could be lethal for me, and even for my son-in-law who beat Acute Lymphoblastic Leukemia about ten years go. So, what should I do to try once again to beat the odds?
I’ve been following the debate in the literature about the potential of various drugs to interact with ACE2 cell surface receptors and their level of cellular expression, as well as our emerging understanding of the special affinity of SARS COV2 for those same receptors.
A few days ago, my brother in law shared some information with me emanating from a group of vaping experts. It suggested that smoking might actually be protective against COVID-19. One of these experts had noted that a community of Hasidic Jews in New York had all been infected, but that the only fatality was a non-smoker. All the other community members either smoked or vaped.
There seemed to be a very strong negative association between exposure to smoking or vaping and COVID-19 disease. Could it be that nicotine can block the ACE2 receptors in the nasal and pulmonary mucosa and prevent SARS COV-2 infection?
And then there is a preliminary study by CDC showing higher percentages of ICU admission amongst those with pre-existing conditions. It showed that for current smokers (13.7% of the general population), only 2.1% of hospital admissions and 1.3% of ICU admissions reported current smoking. For previous smokers (22% of the general population) a similar pattern was observed, at only 4.3% of hospital admission and 7.2% of ICU admissions
To me these two studies beg a series of questions:
Is the pattern seen amongst the Hasidic community a reflection of their genetics and culture?
Does any history of smoking protect against severe COVID-19 disease? Knowing the severe damage caused by cigarette smoke, that does seem implausible.
Or are the CDC results flawed because of the low rates of completion (5.8%) of case reports?
Or is the issue more nuanced, and related to exposure to nicotine and its effect upon the Renin-Angiotensin system?
Or could it be that formers smokers are now vaping and the propylene glycol in vape juice could be exerting an effect? After all, it used to be employed as a hospital disinfectant.
How can we tease these factors out? Isn’t it time to go back to the data, mine it for all it is worth and try to find out?
Both retrospectively and prospectively, we can apply incredibly powerful multivariate methods to see if there is any evidence that nicotine, or propylene glycol, or any other discernible and biologically plausible factor is associated with improved COVID-19 survival odds.
I used the word powerful here deliberately. The White House likes that word. But they need to apply it more intelligently, and less politically. Lives are at stake. As are Clorox and vape juice sales.
But who is going to do this? That’s a bit of a play on words too because in Geneva, the public health powers (especially the WHO) are as political as they are in Washington. Are they ever going to support an epidemiologist who wants to find out if vaping may be protective against SARS COV-2 It is very disappointing to realise that as far as this issue is concerned, they are likely to conduct themselves no better than the White House.
Unfortunately, it’s still every man for himself, and at a time when science must rule, we just have to make intelligent guesses and move forwards. So, this morning I made my very personal decision. I’m not proud of it. I’m actually annoyed at myself for making it. I went out to my neighborhood Seven Eleven about an hour ago, wearing my N95 mask, and as well as buying some milk for my coffee, I reluctantly bought a vaping device.
Then I sat down, filled myself with caffeine and nicotine, and feeling a little calmer than yesterday, I asked myself if I had made the right decision?
Who has the courage to toss ignorance and partisan politics into the garbage and find out?