In the United States, 82% of individuals hospitalized with e-cigarette or vaping product use–associated lung injury (EVALI) reported using tetrahydrocannabinol (THC)-containing products, and the additive vitamin E acetate has also been strongly linked to this outbreak, according to a study published in the Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report. Although other chemicals may be responsible for injuries in some cases, the CDC recommends refraining from use of THC-containing vaping or e-cigarette products.
Organizations including the CDC and the Food and Drug Administration (FDA) have been investigating the nationwide outbreak of EVALI since August 2019. The current report provides an update on patient demographics, patient-reported substance use, and hospitalization dates, as well as e-cigarette or vaping-related emergency department (ED) visits analyzed through the National Syndromic Surveillance Program (NSSP).
Of the 2668 hospitalized EVALI cases reported to the CDC in all 50 states, the District of Columbia, the US Virgin Islands, and Puerto Rico as of January 2020, 66% were men, the median age was 24 years (range, 13-85 years), and 76% were younger than 35 years . Most of these patients (73%) were non-Hispanic white, and 15% were Hispanic. Of the 2022 patients with available information on substance use, 82% (n=1650) reported using any THC-containing e-cigarette or vaping product, including 33% (n=669) who exclusively used THC-containing products. A total of 57% (n=1162) reported using any nicotine-containing product, including 14% (n=274) who exclusively used nicotine-containing products.
The CDC recommends that the public not use THC-containing vaping or e-cigarette products, especially those acquired from informal sources such as family, friends, and dealers, either online or in person. However, reason for concern still exists regarding use of nicotine-containing products because a small percentage of patients with EVALI reported exclusive use of nicotine products. Additionally, a strong link has been found between vitamin E acetate and the EVALI outbreak, with the additive being detected in both FDA and state laboratory-tested product samples, as well as in patient lung fluid samples from geographically diverse states as tested by the CDC.
Nevertheless, insufficient evidence exists to rule out the possible contribution of other chemicals of concern in some EVALI cases, especially in consumers who did not report using THC-containing products. Further research into the causes of these cases is warranted.
NSSP data shows that from August 11 to September 8, 2019, the number of possible EVALI-related ED visits sharply increased by a mean of 26 visits per million each week (95%; CI, 18-33) peaking at 116 per million during the week of September 8, 2019, then decreasing by an average of approximately 4 per million ED visits weekly (95% CI, 4-5) thereafter, until reaching 35 per million during the week of January 5, 2020. This rate remains higher than the 23 per million ED visits seen in the week of August 18, 2019. The decline in the number of cases is likely multifactorial, due to greater public awareness, the removal of vitamin E acetate from many products, and a reduction in the supply of informally sourced THC products due to action of enforcement agencies.
Study investigators concluded, “The identification of EVALI as a new clinical syndrome highlights a need for further studies. Understanding the long-term health consequences of EVALI will require long-term patient follow-up. It is not known whether additives other than vitamin E acetate in e-cigarette, or vaping, products might cause similar lung injury. In addition, ongoing surveillance for lung injury associated with e-cigarette, or vaping, product use needs to continue to detect possible increases in lung injury if new additives (eg, a harmful diluent other than vitamin E acetate) are added to these products in the future.”
Krishnasamy VP, Hallowell BD, Ko JY, et al; Lung Injury Response Epidemiology/Surveillance Task Force. Update: characteristics of a nationwide outbreak of e-cigarette, or vaping, product use-associated lung injury — United States, August 2019-January 2020. MMWR Morb Mortal Wkly Rep. 2020;69(3):90-94.