Public health experts draft recommendations to help prevent vaping product use-associated lung injury

About four years ago, federal health officials reported a scary new epidemic linked to e-cigarette use that caused a life-threatening and potentially irreversible lung condition. The condition – called e-cigarette or vaping product use-related lung injury (EVALI) – was initially linked to the inclusion of vitamin E acetate (VEA) in e-liquids used in vape cartridges. It was originally found in marijuana vape products that were unregulated.

Jason Rose, MD, MBA, associate professor of medicine and associate dean for innovation and physician science development at the University of Maryland School of Medicine (UMSOM), co-led a workshop through the American Thoracic Society that brought together public health experts from across the country on EVALI. Will discuss investigation findings and research and draft recommendations to help prevent future epidemics. Their analysis was published in a new report in the January 2023 issue Annals of the American Thoracic Society.

We are trying to raise awareness about this as a growing public health concern. We have identified and managed the VEA problem, but it is likely that new substances and contaminants will appear in e-liquid formulations that could induce lung injury in the future.”


Jason Rose, MD, MBA, Associate Professor of Medicine and Associate Dean for Innovation and Physician Science Development at the University of Maryland School of Medicine

E-cigarette use has increased over the years as some adults use these nicotine products to quit smoking. What has been concerning, however, is the increase in vaping among teenagers and young adults who are using these products for recreational purposes. In a federally funded 2019 survey, 22 percent of college students said they had vaped nicotine in the past month, more than double the percentage who reported vaping in a 2017 survey. According to the National Institute on Drug Abuse, the percentage of college students who said they had used marijuana in the past 30 days increased from 5 percent in 2017 to 14 percent in 2019. Similar rates and similar rate increases were seen among young adults who were not attending college.

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According to the new analysis, the 2019 EVALI epidemic caused 2,807 hospitalizations and 68 deaths in the United States before VEA was detected and removed from e-cigarette products. Symptoms of EVALI mimic those of an acute respiratory illness with symptoms such as coughing, shortness of breath, chest pain, and in some cases coughing up blood. Gastrointestinal symptoms, fever, fatigue, or rapid weight loss were also associated with EVALI.

At its core, EVALI is a serious disease that primarily affects the lungs and results in substantial hospitalizations and deaths in a relatively young and otherwise healthy population across the United States. This epidemic is largely caused by the unregulated and rapidly evolving nature of the e-cigarette industry and certainly highlights the need for continued action by both researchers and government agencies.”


Meghan Rebuli, PhD, study co-leader, assistant professor, Department of Pediatrics, UNC School of Medicine

Early in the pandemic, the Centers for Disease Control and Prevention (CDC) took samples of e-cigarettes from Evaly patients to identify what they were inhaling into their respiratory systems. Tetrahydrocannabinol (THC) – the psychoactive ingredient in cannabis – and vitamin E acetate were found in most samples; This led the CDC to conclude that vitamin E acetate was likely responsible for causing Evali. Vitamin E acetate, however, was not found in all vaping products linked to EVALI cases, which raises the question of whether other ingredients may also be causing the lung condition, according to Dr. Rose.

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The workshop panel issued several public health recommendations to prevent such outbreaks in the future. First and foremost, the panel emphasized the need for scientists to more fully understand EVALI’s processes. Further studies are needed, for example, to evaluate the role of various compounds in vaping products in the development of lung disease. This step will require further research and testing of e-liquid formulations to determine their toxicity (based on dose and delivery via inhalation) with the goal of classifying the ingredients to create safety standards. The workshop panel suggested less restrictive regulations on the study of marijuana — currently considered a controlled substance by the federal government — to allow for more robust studies of THC in vaping products.

Health care providers need to be better educated to quickly recognize the signs and symptoms of EVALI and identify new outbreaks. Just as important, however, is the need to inform consumers through public health messages of the potential dangers of vaping products that are largely unregulated and have unknown health risks.”


Mark T. Gladwin, MD, UMSOM dean, vice president for medical affairs, University of Maryland, Baltimore, and John Z. and Akiko K. Bowers Distinguished Professor

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