ENDS EVALI VALI THCVALI

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Studies, Surveys, Papers, and Case Studies

  • Sometimes it's necessary to view the PDF version to access the full study.
  • EVALI / VALI / THCVALI was originally blamed by some experts on the use of nicotine vapor products. It was proven that it was caused by illicit THC (marijuana / cannabis) cartridges, not nicotine products. It appears that most of the cases were caused by Vitamin E, which was used as a cutting and thickening agent to lower manufacturing costs and to make the products appear to be high quality. On this page, we will chronicle the studies and media covering the truth about the cause of this illness that caused several deaths in the United States.
  • If you'd prefer someone else to add a study to a topic, there is a subject section called "Suggested studies to add to this page". You may put the link in that section for one of the regular page editors to address.
  • PAGE EDITORS - Please only add Studies, Surveys, Papers in this format to keep page consistent for all viewers.
    • Topic
    • Year (list new to old) Name of Study (In link format to the study)
    • Note here if animal study (leave blank if not)
    • Brief Summary
    • Link to PDF Version
    • Citation
    • Acknowledgements (funded by, helped by)
    • Keywords
    • Other


"EVALI"

2022: United States public health officials need to correct e-cigarette health misinformation

2022: End Vape Misinformation, Tobacco Control Experts Urge Surgeon General

2021: Request by 75 experts to CDC to rename EVALI

This letter is signed by seventy-five multidisciplinary experts, as well as other key stakeholders in the fight to reduce tobacco-related disease and death. This includes seven individuals who have served as president of the Society for Research on Nicotine and Tobacco. Drawing from our collective expertise, we write to petition the Centers for Disease Control and Prevention to rename “E-cigarette or Vaping Product Use-Associated Lung Injury” (EVALI).

Studies / Papers

2022: Exposure to Negative News Stories About Vaping, and Harm Perceptions of Vaping, Among Youth in England, Canada, and the United States Before and After the Outbreak of E-cigarette or Vaping-Associated Lung Injury (‘EVALI’)

  • Between 2017 and February–March 2020, youth exposure to negative news stories, and perceptions of vaping harms, increased, and increases were exacerbated during and immediately after ‘EVALI’. By August 2020, exposure to negative news stories returned to 2019 levels, while perceptions of harm were sustained.


2021: The outbreak of lung injuries often known as "EVALI" was nothing to do with nicotine vaping

An examination of the evidence shows that EVALI cannot have been caused by nicotine vaping. The characteristics of the lung injury outbreak are consistent with localised supply chain contamination. The contaminant has been identified and is known to be Vitamin E Acetate. This had been used as a thickener or cutting agent in illicit Tetrahydrocannabinol (THC) cannabis vape pens. This agent cannot be mixed with nicotine vaping liquids and would serve no useful purpose if it could be. No other cause or causal agent has been identified that would both implicate nicotine liquids and be consistent with the geographical and temporal pattern of the lung injury outbreak.


2020 - July 22: NEWS THAT TAKES YOUR BREATH AWAY: RISK PERCEPTIONS DURING AN OUTBREAK OF VAPING-RELATED LUNG INJURIES

The increase in e-cigarette risk perceptions might discourage adult smokers from using e-cigarettes as a way to quit smoking, despite evidence from a clinical trial that ecigarettes are a more effective cessation method than FDA-approved products such as the nicotine patch. Our econometric results suggest that the immediate impact of the first information shock was to increase the fraction of respondents who perceived e-cigarettes as more harmful than smoking by about 16 percentage points. More targeted advice about the risks of THC e-cigarettes (vs nicotine products) might have more effectively reduced the use of those products, potentially preventing EVALI cases.

  • PDF Version
  • Citation: Dave, D., Dench, D., Kenkel, D. et al. News that takes your breath away: risk perceptions during an outbreak of vaping-related lung injuries. J Risk Uncertain 60, 281–307 (2020). https://doi.org/10.1007/s11166-020-09329-2
  • Acknowledgement: Dhaval Dave acknowledges support through grant R01DA039968 from the National Institute on Drug Abuse. The authors are grateful to Cornell University and the Health Thought Leadership Network at Bentley University for funding the data collection.


2020: Sparking the Discussion about Vaping and Anesthesia: Comment

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.

2020: Analysis of Cannabinoid-Containing Fluids in Illicit Vaping Cartridges Recovered from Pulmonary Injury Patients: Identification of Vitamin E Acetate as a Major Diluent

As of December 12, 2019, the Wadsworth Center has analyzed 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 analyzed, 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.

2020: Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI

The FDA detected no vitamin E acetate in 197 case-associated nicotine products analyzed 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.

2020: Association of vaping‐related lung injuries with rates of e‐cigarette and cannabis use across US states

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.

2019 - December 20: Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI

  • Updated February 20, 2020
  • Among the case patients for whom laboratory or epidemiologic data were available, 47 of 50 (94%) had detectable tetrahydrocannabinol (THC) or its metabolites in BAL fluid or had reported vaping THC products in the 90 days before the onset of illness.
  • Vitamin E acetate was associated with EVALI in a convenience sample of 51 patients in 16 states across the United States.
  • PDF Version
  • Citation: See Study
  • Acknowledgement: Supported by a grant (P50CA180908) from the National Cancer Institute and a grant (P30CA016058) from the FDA Center for Tobacco Products; and by Ohio State University Pelotonia Intramural Research.


2019: Vaping and lung disease in the US: PHE’s advice

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.

Expert Testimony

2021: Testimony in Netherlands pertaining to a potential flavour / flavor ban: Regulation of e-cigarette flavours – a response

  • Signed by 24 experts from around the world
  • Covers 12 key points including EVALI


Media

2019 - October 29: US vaping deaths linked to THC - not nicotine

  • A series of vaping deaths in the US have been linked to THC, the illegal psychoactive compound in cannabis, and not legal nicotine.


Suggestions to add to this page

2023: Over 1 year later: smokers’ EVALI awareness, knowledge and perceived impact on e-cigarette interest

2022: Analysis of state portrayals of the risks of e-cigarette use and the cause of the EVALI outbreak

2021: Vitamin E Acetate is not Soluble in Nicotine E-liquids

2021: Lessons Learned From the E-cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) Outbreak Response, Minnesota, 2019-2020

2019 and Beyond: The CDC, the FDA, and others: EVALI

  • Article: The CDC’s EVALI screwup
    • Making a mistake is one thing. Failing to correct it is worse.
    • But there is no evidence–none at all— that anyone got sick with EVALI from using e-cigarettes.
  • Twitter thread by Mike Pesko about the letter to the CDC requesting them to change the name of EVALI, and the CDC's refusal to do so. This letter was signed by 75 international tobacco control / public health experts.
  • Paper: Vitamin E Acetate is not Soluble in Nicotine E-liquids
    • Vitamin E acetate is not soluble in formulations of nicotine e-liquids and if mixed into a nicotine e-liquid will form a visibly distinct layer. Therefore, it is unlikely that nicotine-only e-cig users will be exposed to vitamin E acetate.
  • Paper: The outbreak of lung injuries often known as "EVALI" was nothing to do with nicotine vaping
    • An examination of the evidence shows that EVALI cannot have been caused by nicotine vaping. The characteristics of the lung injury outbreak are consistent with localised supply chain contamination. The contaminant has been identified and is known to be Vitamin E Acetate. This had been used as a thickener or cutting agent in illicit Tetrahydrocannabinol (THC) cannabis vape pens. This agent cannot be mixed with nicotine vaping liquids and would serve no useful purpose if it could be.
  • Article: E-Cigarettes Increasingly Blamed for Lung Illnesses, as Evidence Points Elsewhere
    • CDC identified THC vapes with vitamin E acetate as culprit, but 66% of adults blame e-cigarettes for vaping deaths
  • Tweets by Scott Gottlieb, MD
    • An e-cigarette is an FDA regulated electronic nicotine delivery system (ENDS). It delivers nicotine. What CDC seems to be trying to refer to here are illegal vapes or “dabs” that contain THC. We develop precise regulatory nomenclature for a reason. It helps differentiate products
    • CDC should reconsider the name it ascribed to these illnesses (EVALI) now that it seems to be definitively linked to THC vapes and dabs. By not speaking with precision it could leave a false impression as to the clear causal relationship between the tragic illnesses and THC vapes
    • The public health risk is that kids using these illegal and dangerous THC products may not know that the CDC warnings relate to the THC products they’re using; since the CDC is not using a precise nomenclature to more clearly describe the THC vapes and dabs
  • Tweet by Scott Gottlieb MD
    • My point is simply if you know a THC product hurt someone, don’t call it an e-cigarette, call it a THC vape or THC vaping product. Nomenclature matters in helping consumers properly identify which products are causing which kinds of risks. That’s why we develop naming systems.

More Information

See the following Safer Nicotine Wiki pages

  • Myth Busting
  • Click on the category link below for more studies and media by topic on ENDS.