Allison Inserro

The coronavirus disease 2019 (COVID-19) pandemic began in the United States just as the CDC and FDA were tracking 

 associated with vaping and e-cigarettes. On Tuesday, a new study said it is the first to show that e-cigarette use, vaping, and smoking traditional cigarettes by US teenagers and young adults is associated with a greater likelihood of contracting COVID-19.

But vaping had stronger effects than combustible cigarettes on all aspects of COVID-19, from showing symptoms to getting tested to having the disease.

Researchers at the Stanford University School of Medicine published their findings in the 

. The authors said the findings bring new urgency to efforts by policy makers, school officials, community leaders, and others to educate the public about the link between smoking and COVID-19. They also urged more regulation of the e-cigarette industry.

"The FDA should eliminate the sale and marketing of all e-cigs right now. There is too much concern over their health impact and on youth use to keep them on the market," said Bonnie Halpern-Felsher, PhD, FSAHM, a professor of pediatrics and research director in the Division of Adolescent Medicine at Stanford University, in an email to 

The findings were based on an online national survey of 4351 adolescents and young adults aged 13 to 24. The survey was conducted in May 2020 in all 50 states, the District of Columbia, and 3 US territories. The investigators recruited participants who were evenly divided between those who had used e-cigarettes and those who had never used nicotine. Different age groups, races, and genders were divided equally, and information about sociodemographic factors, obesity, and complying with shelter-in-place orders were also collected.

The researchers asked whether the participants had ever used vaping devices or combustible cigarettes, as well as whether they had vaped or smoked in the past 30 days. They were also asked if they had experienced COVID-19 symptoms, received a test for COVID-19, or received a positive diagnosis of COVID-19 after being tested.

Results showed that those who vaped were 5 to 7 times more likely to be infected than those who did not use e-cigarettes: e-cigarette-only users (95% CI, 1.82-13.96), users of both methods (95% CI, 1.98-24.55), and 6.8 times more likely among past 30-day dual-users (95% CI, 2.40-19.55).

Getting tested was 9 times more likely among past 30-day dual-users (95% CI, 5.43-15.47) and 2.6 times more likely among past 30-day e-cigarette only users (95% CI, 1.33-4.87).

Those who had smoked via either method in the past 30-days were 4.7 times more likely to show COVID-19 symptoms (95% CI, 3.07-7.16).

Halper-Felsher said pulmonologists are still seeing cases of 

e-cigarette, or vaping, product use-associated lung injury (EVALI)

, which came to light last summer after teens and young adults started showing up in emergency departments across the country with a mysterious lung illness. It was later determined, based on reports, that the products contained tetrahydrocannabinol, or THC, and vitamin E acetate.

The last report, made as COVID-19 began community transmission, said that 2807 individual were sicked by February 18, 2020. Of those, 68 people died. 

The last regulatory action the FDA took on e-cigarettes came in January, but Halpern-Felsher said it does not go far enough.

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The authors said the findings bring new urgency to efforts by policy makers, school officials, community leaders, and others to educate the public about the link between smoking and coronavirus disease 2019 (COVID-19). 

Vaping a Risk Factor for COVID-19 in Teens, Young Adults 

A community-based cognitive behavioral therapy (CBT) program using peer support in low-income, rural Alabama, aimed primarily at Black individuals with diabetes, was effective in reducing 

 intensity and improving functioning, according to a recent paper.

Pain associated with diabetes is complex, but about 50% to 70% of adults with diabetes suffer from chronic pain, the authors said. It may stem from diabetic polyneuropathy (up to 30%) of patients, or from musculoskeletal pain (up to 80%) or from comorbid osteoarthritis.

However, unlike white patients, Black patients, and especially patients in rural areas, have difficulty finding nonpharmacological pain relief. But uncontrolled pain can interfere with self-functioning, like the ability to exercise or maintain a healthy diet, which is critical in diabetes management. Glycemic control may worsen, the authors said, if chronic pain, diabetes, sleep disorders and depression sets in.

In addition, drug therapy for pain, whether opioids, acetaminophen, or nonsteroidal anti‐inflammatory drugs (NSAIDS), may not be suitable or sufficient for patients with diabetes due to risk of overdose, substance use disorder, or renal or liver side effects.

Between 2013 to 2015, a trial called Living Healthy took place in rural Alabama. Researchers recruited 230 patients with diabetes from 8 counties; all had reported pain in the past month. Because of the small, tight-knit nature of these communities, it was not possible to randomize the participants; 96 individuals were placed in the intervention group and 99 were placed in the control arm. 

The 195 participants with follow‐up data were aged 59 [10.4] years. Almost all (96%) were African American, 79% were women, and 80% reported pain on the day of baseline data collection.

Ten experienced, trained peer advisors from the same communities were paired with patients and delivered 8 sessions via phone over 12 weeks. Participants also received an activity book, a DVD, and a health calendar. Homework and daily self‐monitoring activities were assigned.

Before each weekly phone session, the participant watched a 15‐ to 30‐minute video related to the current lesson. Each session lasted between 30 and 60 minutes and incorporated healthy eating, physical activity, stress management, communication with health care provider, medication adherence, and social support.

As with CBT, participants were educated about identifying and replacing negative or unhealthy thoughts with positive or healthy thoughts and practicing healthy actions. Through session activities and homework, they self‐monitored mood and pain levels daily. They also used deep breathing and stress reduction techniques, and set and monitored individualized behavioral goals for healthy eating and physical activity. The intervention program ended with 2 sessions aimed at maintaining new activities and skills after the end of the program.

The control group received a peer‐delivered 8‐session general health education program about other topics, such as dementia, breast cancer, and others.

Researchers examined control‐intervention differences in changes in outcome scores from baseline to 3‐month and 12‐month follow‐up, adjusted for clustering. Outcomes included PSE (Arthritis Self‐Efficacy Scale, range 10‐100); pain intensity (McGill Pain Questionnaire, range 0‐45); and PRFL (Western Ontario and McMaster Universities Osteoarthritis Index scale, range 0‐100).

At 3 months, PSE increased more for intervention (21‐point increase) than control (5‐point increase) participants (

Pain intensity decreased for both groups.

Only those in the intervention group saw a drop in PRFL (–11 score; 

The combination of CBT approaches and peer support “may be an effective strategy for pain control among adults with diabetes, without resorting to opioids, especially in areas with limited medical resources,” concluded the authors.

Khodneva Y, Richman J, Andreae S, Cherrington A, Safford MM. Peer support intervention improves pain-related outcomes among rural adults with diabetes and chronic pain at 12-month follow-up. 

. Published online March 2, 2020. doi: 10.1111/jrh.12422. 

A community-based program helped reduce pain using cognitive behavioral therapy techniques in low-income, primarily Black individuals with coexisting pain and diabetes.

CBT-Based Peer Support Helped Reduce Pain in Rural Alabama

A recent literature review about the use of noninvasive vagus nerve stimulation (nVNS) for 

 relief from headaches adds more information about this 

 the effectiveness and safety of peripheral nerve stimulation of the cervical branch of the vagal nerve in primary headache disorders.

The authors note that primary headache disorders (migraines, cluster headaches, and tension‐type headaches) are a 

. Globally, the prevalence of tension‐type headaches is about 20.1%, migraine is approximately 14.7%, and cluster headaches about 0.1%-0.4%.

The major parasympathetic branch of the autonomic nervous system, the vagus nerve transmits or mediates sensory information to the brain.

“The mechanism of action of nVNS in the treatment of headache is largely elusive and likely multifactorial,” said the authors, writing in 

To their knowledge, this is the first meta‐analysis to probe the effectiveness of nVNS in these types of headaches, they said.

The authors searched the Medline, Embase, and CENTRAL databases and used a random‐effects model to report all outcomes where nVNS was used to treat headaches in randomized controlled trials (RCTs).

Studies were included if the population included patients diagnosed with primary headache disorders, according to the 

International Classification of Headache Disorders

 (ICHD)‐II or ICHD‐III beta version); if the intervention compared cervical nVNS with sham‐device treatment or standard care; and if outcomes were measured by a reduction in headache days or attacks, pain‐free status, pain‐relief status, abortive medication use, ≥50% responder rates, adverse events, or satisfaction.

Researchers determined study quality with the Revised Cochrane tool for assessing the risk of bias.

The literature search yielded 746 articles, and of those the authors reviewed 51. Ultimately, 7 articles in 6 clinical trials were included in the review. The 6 trials included 983 randomized patients (486 to nVNS and 497 to a control).

= 634) and 3 other trials recruited patients with cluster headache (

= 349). Females made up the majority of the migraine population, and males made up most of the cluster headache participants. The percentage of preventive medication use ranged from 28.5% to 90%.

In 5 trials, the control was sham treatment with an identical device and standard care while 1 trial used only standard care. Therapy lasted from 2 to 12 weeks.

Compared with sham‐device treatment, results showed that overall, nVNS was effective at providing acute pain relief. Specifically, the outcomes were:

Pain‐free status within 30 minutes (odds ratio [OR], 2.27; 95% CI, 1.16-4.44; 

Pain‐relief status within 30 minutes (OR, 1.8; 95% CI, 1.17-2.78; 

Pain‐relief status at 60 minutes (OR, 1.93; 95% CI, 1.2-3.1; 

Reduced abortive medication use (OR, 0.61; 95% CI, 0.41-0.92; 

Pain‐free status in ≥50% of treated attacks (OR, 2.15; 95% CI, 1.27-3.66;

There were no significant differences in decreased headache days, adverse events), or satisfaction between nVNS and sham‐device treatment. Additionally, the ≥50% responder rate could not be determined.

However, some unanswered questions remain due to limited data, and larger RCTs are needed, they said.

Lai YH, Huang Y, Huang LT, Chen RM, Chen C. Cervical noninvasive vagus nerve stimulation for migraine and cluster headache: A systematic review and meta-analysis. 

. Published online March 12, 2020. doi: 10.1111/ner.13122

A recent meta-analysis looked at noninvasive vagus nerve stimulation (nVNS), a nonpharmacologic method of acute pain relief for headaches.

Vagus Nerve Stimulation Effective for Acute Headache Pain, Review Finds

The risk for multiple sclerosis (MS) is raised by up to 30% by stressful life events according to a recent study, with women more affected than men.

The researchers said it is the largest population-based case-control study about the issue. Other work has hinted that suggested that stress-related disorders carry a greater risk of autoimmune disease, but specific ties to MS are unknown.

The findings also suggest a window of opportunity to intervene, as stressful major life events that occur 5 years or less before being diagnosed with MS seems to carry the greatest risk.

The authors used data from the Epidemiological Investigation of Multiple Sclerosis, which began in 2005 in Sweden. It includes both men and women, aged 16 to 70 years, and is a case-control study aimed at probing MS genetic and environmental risk factors.

Neurologists examined newly diagnosed cases fulfilling McDonald criteria at 42 participating hospitals. Time of disease onset was defined as the year and month when the first symptoms of MS appeared, with the year set as the index year.

For each case, controls were randomly selected from the continuously updated national population register and matched by age, sex, and residential area.

In total, 3185 people with MS and 9208 controls were invited to participate; 2930 patients and 6170 controls responded (a participation rate of 92% among individuals with MS and 67% among controls).

Using a self-administrated questionnaire, participants were asked about demographic characteristics, lifestyle, and psychosocial factors. They were also asked if they experienced any 10 life events considered stressful during the prior 10 years:

Serious conflict with a spouse or partner

Serious conflict with a close relative or friend

Sickness or accident occurred to a spouse, partner, or child

To be included in the study, the stressful event had to have happened before the onset of MS symptoms.

The life events were grouped into 4 categories, given their interrelationship with each other, and this is where the researchers found that some types of stressful events affected women more than men.

Cluster 1 contained death of a close relative or friend.

Cluster 2 contained 2 events relating to family: sickness or accident of a spouse, partner or child, or death of a spouse, partner or child.

Cluster 3 contained 3 areas related to intimate or romantic relationships: marriage, divorce, and conflict with a spouse or partner.

Cluster 4 contained 4 events relating to work or social relationships: poor economy, unemployment, conflict at work, and serious conflict with a close relative or friend.

Compared with those who reported no such situations (although the majority of the study group did) the risk of MS rose as the number of total events increased (

Conflict at work or within families, marriage, and sickness or accidents of family members were more likely to affect women.

Most life events that happened before MS onset were significantly associated with an increased disease risk of 15% to 30%. 

Jiang X, Olsson T, Hillert J, Kockum I, Alfredsson L. Stressful life events are associated with the risk of multiple sclerosis. 

Published online August 2, 2020. doi:10.1111/ene.14458

Author | Allison Inserro

Articles

Vaping a Risk Factor for COVID-19 in Teens, Young Adults

CBT-Based Peer Support Helped Reduce Pain in Rural Alabama

Vagus Nerve Stimulation Effective for Acute Headache Pain, Review Finds

Do Stressful Life Events Trigger Later MS Diagnosis?