CDC Laboratory Findings Reported November 8, 2019:

• Analyses of bronchoalveolar lavage (BAL) fluid samples (fluid samples collected from the lungs) of patients with e-cigarette, or vaping, product use-associated lung injury (EVALI) identified vitamin E acetate, an additive in some THC-containing e-cigarette, or vaping, products.
• CDC laboratory test results of BAL fluid samples from 29 patients submitted to CDC from 10 states found vitamin E acetate in all of the samples.
  • THC was identified in 82% of the samples and nicotine was identified in 62% of the samples.
  • CDC tested for a range of other chemicals that might be found in e-cigarette, or vaping, products, including plant oils, petroleum distillates like mineral oil, MCT (medium chain triglyceride) oil, and terpenes (which are compounds found in or added to THC products). None of these chemicals of concern were detected in the BAL fluid samples tested.
  • This is the first time that we have detected a chemical of concern in biologic samples from patients with these lung injuries. These findings provide direct evidence of vitamin E acetate at the primary site of injury within the lungs.
  • These findings complement the ongoing work of FDAexternal icon and some state public health laboratories to characterize e-liquid exposures and inform the ongoing multistate outbreak.

About the Outbreak:

• CDC is only reporting hospitalized EVALI cases and EVALI deaths regardless of hospitalization status. CDC has removed nonhospitalized cases from previously reported case counts. See Public Health Reporting for more information.
• As of December 17, 2019, a total of 2,506 hospitalized EVALI cases have been reported to CDC from all 50 states, the District of Columbia, and two U.S. territories (Puerto Rico and U.S. Virgin Islands).
  • Fifty-four deaths have been confirmed in 27 states and the District of Columbia (as of December 17, 2019).
• Although the number of reported cases appears to be declining, states are still reporting new hospitalized EVALI cases to CDC on a weekly basis and should remain vigilant with EVALI case finding and reporting.

About Patient Exposure:

• All EVALI patients have reported a history of using e-cigarette, or vaping, products.
  • Vitamin E acetate has been identified as a chemical of concern among people with e-cigarette, or vaping, product use-associated lung injury (EVALI).
  • THC is present in most of the samples tested by FDA to date, and most patients report a history of using THC-containing products.
  • The latest national and state findings suggest THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, family, or in-person or online dealers, are linked to most of the cases and play a major role in the outbreak.
• CDC has analyzed national data on use of THC-containing product brands by EVALI patients.
  • Overall, 152 different THC-containing product brands were reported by EVALI patients.
  • Dank Vapes, a class of largely counterfeit THC-containing products of unknown origin, was the most commonly reported product brand used by patients nationwide, although there are regional differences. While Dank Vapes was most commonly reported in the Northeast and South, TKO and Smart Cart brands were more commonly reported by patients in the West and Rove was more common in the Midwest.
  • The data further support that EVALI is associated with THC-containing products and that it is not likely associated with a single THC-containing product brand.

What We Don’t Know

• While it appears that vitamin E acetate is associated with EVALI, there are many different substances and product sources that are being investigated, and there may be more than one cause.

What CDC Recommends

• CDC and FDA recommend that people should not use THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, family, or in-person or online sellers.
• Vitamin E acetate should not be added to e-cigarette, or vaping, products. Additionally, people should not add any other substances not intended by the manufacturer to products, including products purchased through retail establishments.
• While it appears that vitamin E acetate is associated with EVALI, there are many different substances and product sources that are being investigated, and there may be more than one cause. Therefore, the best way for people to ensure that they are not at risk while the investigation continues is to consider refraining from the use of all e-cigarette, or vaping, products.
• Adults using e-cigarettes or vaping products as an alternative to cigarettes should not go back to smoking; they should weigh all available information and consider utilizing FDA-approved cessation medicationsexternal icon. They should contact their healthcare provider if they need help quitting tobacco products, including e-cigarettes.
• Adults who continue to use an e-cigarette, or vaping, product should carefully monitor themselves for symptoms and see a healthcare provider immediately if they develop symptoms like those reported in this outbreak.

If you are an adult trying to quit smoking:

• Contact a healthcare provider for help quitting tobacco products, including e-cigarettes.
• Use evidence-based treatments, including counseling and FDA-approved cessation medicationsexternal icon.

If you are concerned about your health after using an e-cigarette, or vaping, product, contact your healthcare provider, or local poison control center at 1-800-222-1222.

Adults with ongoing cannabis (marijuana) use that leads to significant impairment or distress should seek out evidence-based behavioral treatment.

• Effective treatments are available, and recovery is possible. A number of therapy-based treatments such as cognitive-behavioral therapy, contingency management, motivational enhancement therapy, and multi-dimensional family therapy have been shown to be effective.
• Visit Substance Abuse and Mental Health Services Administration’s Treatment Locatorexternal icon to locate treatment in your area or call 1-800-662-HELP (4357).

For adults currently using marijuana/THC-containing e-cigarette, or vaping, products for medical use: We do not know if there are different health effects of using different forms of marijuana, such as smoking, vaping, and edibles, or whether transitioning from one form to another might reduce harm. Talk with your healthcare provider about other available treatment options for the conditions.

• Regardless of the ongoing investigation:
  • E-cigarette, or vaping, products should never be used by youths, young adults, or women who are pregnant.
  • Adults who do not currently use tobacco products should not start using e-cigarette, or vaping, products. There is no safe tobacco product. All tobacco products, including e-cigarettes, carry a risk.
  • THC use has been associated with a wide range of health effects, particularly with prolonged frequent use. The best way to avoid potentially harmful effects is to not use THC-containing e-cigarette, or vaping, products. Persons engaging in ongoing cannabis (marijuana) use that leads to significant impairment or distress should seek evidence-based treatment by a healthcare provider.