Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products

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CDC, the U.S. Food and Drug Administration (FDA), state and local health departments, and other clinical and public health partners are investigating a multistate outbreak of e-cigarette, or vaping, product use associated lung injury (EVALI).

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Updated November 14, 2019, at 1:00 PM EST

What is New

CDC has identified vitamin E acetate as a chemical of concern among people with e-cigarette, or vaping, product use associated lung injury (EVALI). Recent CDC laboratory testing of bronchoalveolar lavage (BAL) fluid samples (fluid samples collected from the lungs) from 29 patients with EVALI submitted to CDC from 10 states found vitamin E acetate in all of the samples. Vitamin E acetate might be used as an additive, most notably as a thickening agent in THC-containing e-cigarette, or vaping, products.

CDC recommends that people should not use e-cigarette, or vaping, products that contain THC, particularly from informal sources like friends, or family, or in-person or online dealers. Until the relationship of vitamin E acetate and lung health is better understood, vitamin E acetate should not be added to e-cigarette, or vaping, products.  In addition, people should not add any substance to e-cigarette or vaping products that are not intended by the manufacturer, including products purchased through retail establishments. CDC will continue to update guidance, as appropriate, as new data become available from this outbreak investigation.

What We Know

New Laboratory Findings:

  • 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 identified vitamin E acetate, an additive in some THC-containing products.
  • Recent 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 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:

  • As of November 13, 2019, 2,172* cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have been reported to CDC from 49 states (all except Alaska), the District of Columbia, and 2 U.S. territories (Puerto Rico and U.S. Virgin Islands).
    • Forty-two deaths have been confirmed in 24 states and the District of Columbia (as of November 13, 2019).
    • Latest outbreak information is updated every Thursday.
    • CDC continues to work closely with FDA, states, public health partners, and clinicians on this investigation.

About Patient Exposure:

  • All EVALI patients have reported a history of using e-cigarette, or vaping, products.
    • Vitamin E 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 e-cigarette, or vaping, products.
    • The latest national and state findings suggest products containing THC, particularly from informal sources like friends, or family, or in-person or online dealers, are linked to most of the cases and play a major role in the outbreak.
What We Don't Know
  • While it appears that vitamin E acetate is associated with EVALI, evidence is not yet sufficient to rule out contribution of other chemicals of concern to EVALI.  Many different substances and product sources are still under investigation, and it may be that there is more than one cause of this outbreak.
What CDC Recommends
  • CDC recommends that you do not use THC-containing e-cigarette, or vaping, products.
  • CDC also recommends that people should not:
    • Buy any type of e-cigarette, or vaping, products, particularly those containing THC from informal sources like friends, or family, or in-person or online dealers.
    • Modify or add any substances such as vitamin E acetate to e-cigarette, or vaping, products that are not intended by the manufacturer, including products purchased through retail establishments.
  • Since the specific cause or causes of lung injury are not yet known, the only way to assure that you are not at risk while the investigation continues is to consider refraining from use of all e-cigarette, or vaping, products.
  • Adults using e-cigarettes to quit smoking should not go back to smoking; they should weigh all risks and benefits and consider utilizing FDA-approved nicotine replacement therapiesexternal icon.
  • 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.
  • Irrespective 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 with marijuana use disorder should seek evidence-based treatment by a health care provider.
Key Facts about Use of E-Cigarette, or Vaping, Products
  • Electronic cigarettes — or e-cigarettes — are also called vapes, e-hookahs, vape pens, tank systems, mods, and electronic nicotine delivery systems (ENDS).
  • Using an e-cigarette product is commonly called vaping.
  • E-cigarettes work by heating a liquid to produce an aerosol that users inhale into their lungs.
  • The liquid can contain: nicotine, tetrahydrocannabinol (THC) and cannabinoid (CBD) oils, and other substances and additives. THC is the psychoactive mind-altering compound of marijuana that produces the “high”.
Key Facts about Vitamin E Acetate
  • Vitamin E acetate might be used as an additive, most notably as a thickening agent in THC-containing e-cigarette, or vaping, products.
  • Vitamin E is a vitamin found in many foods, including vegetable oils, cereals, meat, fruits, and vegetables. It is also available as a dietary supplement and in many cosmetic products, like skin creams.
  • Vitamin E acetate usually does not cause harm when ingested as a vitamin supplement or applied to the skin. However, previous research suggests when vitamin E acetate is inhaled, it may interfere with normal lung functioning.

If you have questions about CDC’s investigation into the lung injuries associated with use of e-cigarette, or vaping, products, contact CDC-INFO or call 1-800-232-4636.

Latest Outbreak Information

Updated every Thursday

  • This complex investigation spans almost all states, involves over 2,000 patients, and a wide variety of brands and substances and e-cigarette, or vaping, products.
  • As of November 13, 2019, 2,172* cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have been reported to CDC from 49 states (all except Alaska), the District of Columbia, and 2 U.S. territories (Puerto Rico and U.S. Virgin Islands).
    • Forty-two deaths have been confirmed in 24 states and the District of Columbia (as of November 13, 2019).
      • The median age of deceased patients was 52 years and ranged from 17 to 75 years (as of November 13, 2019).
    •  More deaths are under investigation.
  • Among 1,378 patients with data on sex (as of October 15, 2019):
    • 70% of patients are male.
  • Among 1,364 patients with data on age (as of October 15, 2019):
    • The median age of patients is 24 years and ages range from 13 to 75 years.
    • 79% of patients are under 35 years old.
    • By age group category:
      • 14% of patients are under 18 years old;
      • 40% of patients are 18 to 24 years old;
      • 25% of patients are 25 to 34 years old; and
      • 21% of patients are 35 years or older.
  • Among 867 patients with information on substances used in e-cigarette, or vaping, products in the 3 months prior to symptom onset** (as of October 15, 2019):
    • About 86% reported using THC-containing products; 34% reported exclusive use of THC-containing products.
    • About 64% reported using nicotine-containing products; 11% reported exclusive use of nicotine-containing products.
Number of Lung Injury Cases Reported to CDC as of November 13, 2019

Dates of symptom onset and hospital admission for patients with lung injury associated with e-cigarette use, or vaping — United States, March 31–November 9, 2019
What CDC is Doing

Public Health Response:

  • CDC’s Lung Injury response efforts are committed to:
    • Identify and define the risk factors and the source for lung disease associated with e-cigarette product use, or vaping.
    • Detect and track confirmed and probable cases in the US.
    • Communicate actionable recommendations to state, local, and clinical audiences.
    • Establish lab procedures that can assist with the public heath investigation and patient care.

Partnerships:

  • CDC is working 24/7 to identify the cause or causes of this outbreak.
  • CDC continues to work closely with FDA, states, public health partners, and clinicians on this investigation by providing consultation and technical assistance to states on communication, health alerts, public outreach, and surveillance.
  • CDC has activated the Emergency Operations Center (EOC) to coordinate activities and provide assistance to states, public health partners and clinicians around the nation.
  • CDC worked with states to create primary and out-of-hospital case definitions to classify confirmed and probable cases in a consistent way. States are in the process of classifying patients.
    • CDC will report numbers of confirmed and probable lung injury cases once states have finalized their classification of cases.
  • By invitation, CDC has deployed Epidemic Intelligence Service (EIS) officers and other CDC staff to support states.

Media and Communication:

  • CDC is maintaining an outbreak webpage with key messages and weekly updates on case counts, deaths, and resources.
  • CDC is holding congressional briefings, media telebriefings, and regular calls with health departments, clinicians to provide timely updates.

Laboratory Testing:

  • CDC is currently testing bronchoalveolar lavage (BAL) fluid samples and other samples.
  • CDC is testing pathologic specimens, including lung biopsy or autopsy specimens, associated with patients.
  • CDC is offering aerosol emission testing of case-associated product samples from e-cigarette, or vaping, products and e-liquids. Analysis of aerosol emissions will augment FDA’s ongoing work to characterize e-liquid and will improve our understanding of exposure among case-patients associated with the Lung Injury outbreak. CDC is coordinating e-cigarette, or vaping, product analysis with FDA.
  • Results may provide insight into the nature of the chemical exposure(s) contributing to this outbreak.
  • CDC developed guidance documents to assist public health laboratories, healthcare providers, pathologists, and others with specimen collection, storage, and submission to CDC for testing.
  • For more information and resources visit For the Public, For Healthcare Providers and For State and Local Health Departments as well as our Publications and Resources page.

* The increase in lung injury cases from last week represents both new patients and recent reporting of previously-identified patients to CDC.

** Based on complete reports received.