E-cigarette or Vaping Associated Lung Injury


Vaping and lung disease in the US: PHE’s advice

John Newton
Published online: 29 Oct 2019

Dr Dana Meaney-Delman, head of the CDC team investigating the outbreak has reported that “We’ve narrowed this clearly to THC-containing products that are associated with most patients who are experiencing lung injury. The specific substance or substances we have not identified yet”.

We need to be clear about what this outbreak is and is not. It is not a problem linked to long-term use of regulated nicotine vaping products. If it were, we would expect to see a very different demographic profile affected, more typical of long term vapers.

PHE has not changed its advice on nicotine containing e-cigarettes: Smokers should consider switching completely and vapers should stop smoking.

The evidence still shows that vaping carries a small fraction of the risk of smoking. Using a nicotine-containing e-cigarette makes it much more likely someone will quit successfully than relying on willpower alone. But it’s important to use regulated e-liquids and never risk vaping home-made or illicit e-liquids or adding substances.


Sparking the Discussion about Vaping and Anesthesia: Comment

John Oyston
Published online: Oct 2020

The authors refer to an outbreak of 53 cases of e-cigarette and vaping–related lung injury, in which 84% of the cases admitted to the use of tetrahydrocannabinol products. The remaining 16% may have concealed the use of an illegal product, or not known what they were using. In those cases of e-cigarette and vaping–related lung injury where bronchoalveolar lavage was performed, 100% of the specimens were positive for vitamin E acetate, a dangerous contaminant in tetrahydrocannabinol oil.  This outbreak is troubling but it is unrelated to the use of legal nicotine-based vaping products.

Analysis of Cannabinoid-Containing Fluids in Illicit Vaping Cartridges Recovered from Pulmonary Injury Patients: Identification of Vitamin E Acetate as a Major Diluent

Bryan Duffy, Lingyun Li, Shijun Lu, Lorie Durocher, Mark Dittmar, Emily Delaney-Baldwin, Deepika Panawennage, David LeMaster, Kristen Navarette, David Spink
Published online: 20 Jan 2020

As of December 12, 2019, the Wadsworth Centre has analysed 206 vaporizer fluids from 61 NYS EVALI cases. Of these, 147 contained THC, and 59 contained nicotine. Of the 147 THC-containing fluids, 101 (69%) contained VEA. In the nicotine-containing products we analysed, we detected no unusual compounds that appeared to be of concern.

There is additional evidence of a strong association of VEA with EVALI. In the initial analyses of bronchoalveolar lavage fluids from EVALI patients, 28 of 28 fluids contained vitamin E acetate.

Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI

Benjamin C. Blount, Mateusz P. Karwowski, Peter G. Shields, Maria Morel-Espinosa, Liza Valentin-Blasini, Michael Gardner, Martha Braselton, Christina R. Brosius, Kevin T. Caron, David Chambers, Joseph Corstvet, Elizabeth Cowan, Víctor R. De Jesús, Paul Espinosa, Carolina Fernandez, Cory Holder, Zsuzsanna Kuklenyik, Jennifer D. Kusovschi, Cody Newman, Gregory B. Reis, Jon Rees, Chris Reese, Lalith Silva, Tiffany Seyler, Min-Ae Song, Connie Sosnoff, Carleen R. Spitzer, Denise Tevis, Lanqing Wang, Cliff Watson, Mark D. Wewers, Baoyun Xia, Douglas T. Heitkemper, Isaac Ghinai, Jennifer Layden, Peter Briss, Brian A. King, Lisa J. Delaney, Christopher M. Jones, Grant T. Baldwin, Anita Patel, Dana Meaney-Delman, Dale Rose, Vikram Krishnasamy, John R. Barr, Jerry Thomas, James L. Pirkle
Published online: 20 Feb 2020

The FDA detected no vitamin E acetate in 197 case-associated nicotine products analysed to date. The viscosity of vitamin E acetate makes it undesirable as an additive to nicotine solutions.

Data that have been reported to date indicate that vitamin E acetate in the supply of THC-containing products and use among patients with EVALI aligns with the timing of the 2019 EVALI outbreak. In Minnesota, 10 of 10 products seized by law enforcement during 2018, before the EVALI outbreak, did not contain vitamin E acetate, whereas 20 of 20 THC-containing products seized by law enforcement during September 2019, at the peak of the outbreak, contained vitamin E acetate.

Pure THC oil has a viscosity like that of vitamin E acetate. Cutting THC oil with vitamin E acetate has been reported to be common in the illicit market.


Dhaval M. Dave, Daniel L. Dench, Donald S. Kenkel, Alan D. Mathios, Hua Wang
Published online: Apr 2020

The  early  versions  of  the  CDC  EVALI  recommendations  were  also  consistent  with the precautionary  principle;  the  early  recommendations  broadly  advised against  the  use  of e-cigarettes  without  making  distinctions  between nicotine  and THC  products  or  distinctions between youth  and adult use.  Our  econometric  results  suggest  that  an  unintended consequence  of this  approach  was  that most  people  did not perceive  the  extra  risks  of  THC products.  

More  targeted advice  about  the  risks  of  THC  e-cigarettes  might have  more  effectively  reduced  the  use  of  those  products,  potentially  preventing  EVALI  cases.

Association of vaping‐related lung injuries with rates of e‐cigarette and cannabis use across US states

Abigail S. Friedman
Published online: 26 Oct 2020

These findings are consistent with evidence linking the EVALI outbreak to vitamin E acetate and informally purchased or modified THC e‐liquids, as opposed to use of well‐established nicotine e‐cigarettes.