The US Centres for Disease Control and Prevention (CDC), the US Food and Drug Administration (FDA), state and local health departments, and other clinical and public health partners are investigating a national outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI). Laboratory data show that vitamin E acetate, an additive in some THC-containing e-cigarette, or vaping, products, is closely associated with EVALI.
A recent study analysed samples from 51 EVALI cases from 16 states and a comparison group of samples from 99 healthy people for vitamin E acetate, plant oils, medium chain triglyceride (MCT) oil, coconut oil, petroleum distillates, and diluent terpenes. Vitamin E acetate was identified in bronchoalveolar lavage (BAL) fluid samples (fluid samples collected from the lungs) from 48 of the 51 EVALI patients, but not in the BAL fluid from the healthy comparison group.
No other toxicants were found in BAL fluid from either group, except for coconut oil and limonene (1 EVALI patient each).
This study built upon a previously released CDC report using a large number of BAL fluid samples from EVALI patients, and added healthy controls, and yielded the same finding. These findings complement the ongoing work of the FDA and some state public health laboratories to characterise e-liquid exposures and inform the ongoing multistate outbreak.
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.
The 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 utilising FDA-approved cessation medication. 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.
Abstract
Background: The causative agents for the current national outbreak of electronic-cigarette, or vaping, product use–associated lung injury (EVALI) have not been established. Detection of toxicants in bronchoalveolar-lavage (BAL) fluid from patients with EVALI can provide direct information on exposure within the lung.
Methods: BAL fluids were collected from 51 patients with EVALI in 16 states and from 99 healthy participants who were part of an ongoing study of smoking involving nonsmokers, exclusive users of e-cigarettes or vaping products, and exclusive cigarette smokers that was initiated in 2015. Using the BAL fluid, we performed isotope dilution mass spectrometry to measure several priority toxicants: vitamin E acetate, plant oils, medium-chain triglyceride oil, coconut oil, petroleum distillates, and diluent terpenes.
Results: State and local health departments assigned EVALI case status as confirmed for 25 patients and as probable for 26 patients. Vitamin E acetate was identified in BAL fluid obtained from 48 of 51 case patients (94%) in 16 states but not in such fluid obtained from the healthy comparator group. No other priority toxicants were found in BAL fluid from the case patients or the comparator group, except for coconut oil and limonene, which were found in 1 patient each. 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. Nicotine or its metabolites were detected in 30 of 47 of the case patients (64%).
Conclusions: Vitamin E acetate was associated with EVALI in a convenience sample of 51 patients in 16 states across the United States.
Authors
Benjamin C Blount, Mateusz P Karwowski, Peter G Shields, Maria Morel-Espinosa, Liza Valentin-Blasini, Michael Gardner, Martha Braselton, Christina R Brosius, Kevin T Caron, David Chambers, Joseph Corstvet, Elizabeth Cowan, Víctor R De Jesús, Paul Espinosa,
Carolina Fernandez, Cory Holder, Zsuzsanna Kuklenyik, Jennifer D Kusovschi, Cody Newman, Gregory B Reis, Jon Rees, Chris Reese, Lalith Silva, Tiffany Seyler, Min-Ae Song, Connie Sosnoff, CR Spitzer, Denise Tevis, Lanqing Wang, Cliff Watson, Mark D Wewers, Baoyun Xia, Douglas T Heitkemper, Isaac Ghinai, Jennifer Layden, Peter Briss, Brian A King, Lisa J Delaney, Christopher M Jones, Grant T Baldwin, Anita Patel, Dana Meaney-Delman, Dale Rose, Vikram Krishnasamy, John R Barr, Jerry Thomas, James L Pirkle
[link url="https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html"]US Centres for Disease Control and Prevention material[/link]
[link url="https://www.nejm.org/doi/full/10.1056/NEJMoa1916433"]New England Journal of Medicine abstract[/link]