Chronic E-Cigarette Aerosol Inhalation Alters the Immune State of the Lungs and Increases ACE2 Expression, Raising Concern for Altered Response and Susceptibility to SARS-CoV-2

Abstract

Conventional smoking is known to both increase susceptibility to infection and drive inflammation within the lungs. Recently, smokers have been found to be at higher risk of developing severe forms of coronavirus disease 2019 (COVID-19). E-cigarette aerosol inhalation (vaping) has been associated with several inflammatory lung disorders, including the recent e-cigarette or vaping product use-associated lung injury (EVALI) epidemic, and recent studies have suggested that vaping alters host susceptibility to pathogens such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). To assess the impact of vaping on lung inflammatory pathways, including the angiotensin-converting enzyme 2 (ACE2) receptor known to be involved in SARS-CoV-2 infection, mice were exposed to e-cigarette aerosols for 60 min daily for 1–6 months and underwent gene expression analysis. Hierarchical clustering revealed extensive gene expression changes occurred in the lungs of both inbred C57BL/6 mice and outbred CD1 mice, with 2,933 gene expression changes in C57BL/6 mice, and 2,818 gene expression changes in CD1 mice (>abs 1.25-fold change). Particularly, large reductions in IgA and CD4 were identified, indicating impairment of host responses to pathogens via reductions in immunoglobulins and CD4 T cells. CD177, facmr, tlr9, fcgr1, and ccr2 were also reduced, consistent with diminished host defenses via decreased neutrophils and/or monocytes in the lungs. Gene set enrichment (GSE) plots demonstrated upregulation of gene expression related to cell activation specifically in neutrophils. As neutrophils are a potential driver of acute lung injury in COVID-19, increased neutrophil activation in the lungs suggests that vapers are at higher risk of developing more severe forms of COVID-19. The receptor through which SARS-CoV-2 infects host cells, ACE2, was found to have moderate upregulation in mice exposed to unflavored vape pens, and further upregulation (six-fold) with JUUL mint aerosol exposure. No changes were found in mice exposed to unflavored Mod device-generated aerosols. These findings suggest that specific vaping devices and components of e-liquids have an effect on ACE2 expression, thus potentially increasing susceptibility to SARS-CoV-2. In addition, exposure to e-cigarette aerosols both with and without nicotine led to alterations in eicosanoid lipid profiles within the BAL. These data demonstrate that chronic, daily inhalation of e-cigarette aerosols fundamentally alters the inflammatory and immune state of the lungs. Thus, e-cigarette vapers may be at higher risk of developing infections and inflammatory disorders of the lungs.

SARS-CoV-2 Causes Lung Infection without Severe Disease in Human ACE2 Knock-In Mice

“…Indeed, single cell RNA sequencing studies estimated that only 1% to 6% of cells express ACE2 in the respiratory tract, principally in airway epithelial cells, type II pneumocytes, and nasal goblet cells ( 13 , 36 , 37 ). A large meta-analysis demonstrated an increase in the expression of ACE2 and the entry factor protease TMPRSS2 with age, in men, and with smoking ( 38 ), which correlated with findings in mice showing increased ACE2 expression with age and exposure to cigarette smoke and vaping ( 39 , 40 ). Because infection is confined largely to the airway and not lung parenchyma, the hACE2 KI mouse could provide a model of self-limited infection, mild COVID-19 disease, and possibly transmission.…”

New Insights into How JUUL™ Electronic Cigarette Aerosols and Aerosol Constituents Affect SARS-CoV-2 Infection of Human Bronchial Epithelial Cells

“…Elevated ACE2 activities were found in the bronchial-lavage fluid from EC users and smokers [20]. Full body exposures to “Mint” but not “Mango” aerosols generated from JUUL™ pods increased ACE2 levels in mouse lung [30]. Three additional lung studies found elevated ACE2 levels following treatment with aerosols containing a mixture of PG (propylene glycol)/VG (vegetable glycerol) and nicotine [31,32, 33].…”

The Complexity in the Diagnosis and Treatment of Symptoms in Electronic Cigarette Users during the COVID-19 Pandemic

“…A study by Masso-Silva et al on experimental animals revealed that e-cigarette aerosols led to changes in the lung gene expression and neutrophil activation. This was also observed with the intake of vaping mint, as the ACE-2 expression increased in animal models [61].…”