Update on E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI)

What is EVALI?

EVALI (e-cigarette or vaping product use-associated lung injury) is an inflammatory process in the lungs that is caused by an inhaled substance. EVALI symptoms can differ from patient to patient because of a wide variety of ingredients in the liquid that produces the vapor. EVALI can cause pneumonia, emphysema (damage to tiny air sacs in the lungs), or fibrinous pneumonitis (an inflammatory reaction of the lungs).

About E-Cigarette and Vaping Products

E-cigarettes are also called vapes, vape pens, mods, e-hookahs, tank systems, mods, and electronic nicotine delivery systems (ENDS). Using an e-cigarette is called vaping. A vaping device contains a cartridge filled with liquid and a battery that heats the liquid, which the user inhales, then exhales as an aerosol (“vapor”). The liquid can contain nicotine, cannabinoid (CBD), tetrahydrocannabinol (THC, the psychoactive substance in marijuana), flavorings, and additives.

What Causes EVALI?

Experts have found it hard to determine the exact cause of EVALI because there are thousands of vaping products, all with different ingredients. Because of this variability, the symptoms of EVALI can vary widely.

Here’s what we do know:

• The Centers for Disease Control and Prevention (CDC) has identified a strong connection between EVALI and THC, especially in counterfeit products or those bought “on the street” — from friends or in-person or online dealers. People who exclusively use THC products are at increased risk for EVALI, but it’s not yet known if those who don’t use THC products personally have been exposed to it from other vapers or if other ingredients are responsible for their lung injury.
• There is also a strong link between vitamin E acetate and EVALI. Vitamin E is found in many foods and is considered safe for use as a dietary supplement and in skin products. Vitamin E acetate, however, is an oil derivative that is added as a thickener to some vaping products. It is a component of many counterfeit brands. Vitamin E acetate has been found in the lung fluids of EVALI patients, while it is not found in patients who don’t have EVALI. Previous research has shown that vitamin E acetate interferes with normal lung functioning when inhaled.
• Many other chemical components have been found in bronchoscopy specimens in some EVALI patients but not all. There is currently not enough evidence to determine if any of these could be contributors, either with or without THC.

EVALI Statistics

The CDC stopped issuing EVALI updates as of February 18, 2020, because of the slowing of EVALI cases since September 2019 and the identification of vitamin E acetate as a primary cause. The following figures are correct as of that date.

• A total of 2,807 hospitalized cases and deaths have been reported to the CDC from all 50 states, the District of Columbia, the U.S. Virgin Islands, and Puerto Rico.
• There have been 68 deaths, with the following distribution: Alabama, California (4), Connecticut, Delaware, District of Columbia, Florida (2), Georgia (6), Illinois (5), Indiana (6), Kansas (2), Kentucky, Louisiana (2), Massachusetts (5), Michigan (3), Minnesota (3), Mississippi, Missouri (2), Montana, Nebraska, New Jersey, New York (4), Oregon (2), Pennsylvania, Rhode Island, South Carolina, Tennessee (2), Texas (4), Utah, Virginia and Washington (2).
• The median age at death was 49.5 years, with a range of 15 to 75 years.
• Of 2668 hospitalizations or deaths (as of January 14):
• 66% were male.
• The median age was 24 years, with a range of 13 to 85 years.
• By age group:
• 15% of patients were under 18 years of age.
• 37% of patients were 18 to 24 years of age.
• 24% of patients were 25 to 34 years of age.
• 24% of patients were 35 years or older.
• Of the 2,022 hospitalized who had data on substance use (as of January 14, 2020):
• 82% reported using THC-containing products. Of those, 33% reported using THC-containing products exclusively.
• 57% reported using nicotine-containing products. Of those, 14% reported exclusive use of nicotine-containing products.
• 50% of EVALI patients who reported using products containing THC provided data on product source (as of January 7, 2020):
• 78% reported getting products only from informal sources (dealers, online, family/friends, or other sources).
• 16% reported buying vaping products only from commercial sources (vape or smoke shops, stores, pop-up shops, recreational and/or medical dispensaries).
• 6% reported acquiring products from both sources — commercial and informal.
• 54% of EVALI patients who reported using products containing nicotine provided data on product source (as of January 7, 2020):
• 69% reported purchasing products from commercial sources only.
• 17% reported getting products from informal sources only.
• 15% reported acquiring products from both sources — commercial and informal.
• Emergency department (ED) visits increased sharply in August 2019 and peaked in September. Since that time, ED visits have gradually decreased. Reasons for the decline may include increased public awareness of the risk, removal of vitamin E acetate from some vaping products, and law enforcement attention to illicit products.
• A study published on February 20, 2020, analyzed samples from 51 EVALI cases and 99 comparison samples from patients without EVALI.
• Researchers used bronchoalveolar lavage to test for vitamin E acetate, medium-chain triglyceride (MCT) oil, plant oils, coconut oil, diluent terpenes, and petroleum distillates. They found vitamin E acetate in 48 of the 51 samples (94%) and THC in 47 of the 51 samples (94%).
• Other than coconut oil and limonene (1 EVALI patient each), they found no vitamin E acetate in samples from patients without EVALI.

CDC Recommendations

• People should not use any e-cigarette or vaping product containing vitamin E acetate. People should not add any substances to vaping products, including products bought from retail sources.
• Youths, young adults, and pregnant women should never use vaping products containing nicotine or THC.
• Adults who don’t smoke tobacco should not begin using vaping products.
• Adults who use e-cigarettes as a substitute for smoking cigarettes should not return to smoking. They should consider using an FDA-approved smoking cessation product. If they continue to use e-cigarettes, they should completely stop smoking cigarettes and not use both products at the same time. They should contact their healthcare provider for help quitting smoking or if they are concerned about EVALI.
• The use of THC has been linked with a wide range of health issues, especially with frequent or long-term use. The best way to avoid any potentially harmful effects is to avoid vaping products that contain THC.
• People who experience significant impairment or distress from ongoing cannabis use should seek treatment by a healthcare professional.