Updated: August 2022
What is EVALI?
EVALI stands for E-cigarette, or Vaping, product use-Associated Lung Injury. It refers to a severe, sometimes fatal, respiratory illness. Symptoms include shortness of breath and chest pains.
EVALI was first recorded in 2019, when a sudden spate of respiratory illnesses broke out in the USA, leading to 68 deaths by February 2020.
In this post I look at the causes of EVALI and the impact on vaping. Please note this article has been updated after a new study by Dr Colin Mendelsohn (see further reading), who also kindly checked this article for accuracy.
Does nicotine vaping cause EVALI?
Almost certainly not.
Vaping had been legal and popular around the world for over a decade before EVALI broke out, yet had not been linked to respiratory illness. Even when the disease broke out, it was almost entirely confined to the USA.
The real culprit was Vitamin E Acetate. Research by the CDC found that patients with EVALI had Vitamin E Acetate in their lung tissue. Vitamin E Acetate is a cutting agent that was used in black market THC (cannabis) vaping oils in the US at the time. VEA is not soluble in nicotine e-liquid.
14% of EVALI patients claimed they had not used illegal cannabis products. However, as Professor Polosa pointed out at the time, US cannabis users faced criminal prosecution and the loss of healthcare (at the time they needed it most) if they admitted to using illegal products containing THC. Indeed, some of the people who had EVALI but denied using THC products later changed their story and admitted to using illegal cannabis, leading one doctor to state:
“It may turn out there are only two kinds of people who get this disease: those who vape THC and those who won’t admit it…”
What’s more, EVALI was almost entirely confined to the United States. Isolated incidents abroad have been found, but at least one of these examples is linked to travel from the USA, while others were likely misdiagnosed. Furthermore, as Vitamin E acetate was eliminated from the illicit supply chain for THC products, incidents of EVALI declined rapidly.
The evidence that Vitamin E Acetate, rather than nicotine vaping, was the cause of EVALI led 75 multi-disciplinary experts to call for the name of the disease to be changed, stating in the letter:
“...we have concerns that EVALI currently 1) stigmatizes nicotine e-cigarette use, which the CDC itself has recognized offer potential public health benefits (see below) and 2) does not communicate the risks of lung injury from adulterants such as Vitamin E Acetate.”
What was the impact of EVALI on vaping?
The consequences of the disease, its naming and its poor handling were severe.
The first is the confusion it could cause amongst cannabis users. The name EVALI links the disease to vaping and e-cigarettes - not to cannabis use. By incorrectly linking EVALI to nicotine vaping, there’s a real danger that illicit cannabis users would fail to make the connection between the products they were using and the disease it could cause.
Secondly, it caused a severe loss of confidence in vaping in the USA, which continued after the EVALI crisis had abated. Indeed, one US manufacturer told me he had seen vape shop sales fall by 50%. It also created a change in perceptions outside the US and in the UK.
Indeed, Action on Health and Smoking noted that there had been a significant increase in the number of people who believed vaping was harmful in 2020. They argued this was likely due to EVALI and the poor reporting it received:
“While the cause of this outbreak has since been identified as vitamin E acetate used to adulterate cannabis-containing e-liquids the media coverage of the initial outbreak was far more prominent than the subsequent explanation or the fact that both vitamin E acetate and THC containing liquids are banned under UK rules.”
Vaping may not be 100% safe, but it is around 95% less harmful than smoking. The problem for nicotine users is that their choice is often between smoking and vaping. If the perception is that vaping nicotine is as or more dangerous than smoking, some vapers will revert to smoking, while smokers who would have switched to vaping will continue to smoke.
Finally, EVALI has been used to call for/as a reason for further regulations and/or bans. For example, the FDA said that it would ban most flavoured e-cigarettes in response to EVALI, despite the fact that flavours help people stop smoking and, as indeed EVALI itself demonstrated, that bans can cause dangerous products to be sold.
What should UK vapers do?
First, it’s worth noting the strict contrast between the products that caused the issue and nicotine vaping devices sold in the UK. The issue in North America was caused by illegal, contaminated cannabis oils. In contrast, the UK has strict regulations around legal nicotine devices which control the ingredients that go into e-liquid and require both e-liquid and devices to undergo emissions testing.
Submitted products and submitting companies are listed on the MHRA website, and the MHRA operates a yellow card system to capture issues exactly like this one. Yet despite the fact that there are millions of vapers in the UK at the time of EVALI, and the system had been operating for several years, only a handful of respiratory issues had been linked to vaping. Of these cases, some are not causally related (i.e. they are likely to be linked to issues other than vaping.)
However, it is also possible to buy illegal devices, often under the counter at convenience stores. We don’t know what’s in the e-liquid in these devices, but if companies are prepared to smuggle them into the UK, it’s unlikely they go through the same emissions testing and ingredient control as regulated e-liquid. So if you are a vaper, do make sure you buy from reputable sources only.