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Unanswered questions regarding vaping lung disease (EVALI)

By Dr. V. A. Gyarmathy and Dr. G. Z. Xantus

Although the electronic cigarette or vaping product-use associated lung injury (EVALI) epidemic in the US seems to have stopped, various epidemiological and medical questions remain open. We have come to a shocking conclusion after discussing the following topics:

Background – the EVALI epidemic

In the summer of 2019, the Centers for Disease Control and Prevention (CDC) declared an emergency in the United States of electronic cigarette or vaping product-use associated lung injury (EVALI).

The numbers were the highest in September of 2019, when almost 1,000 patients were admitted to the hospital and almost 120 people per one million visited the emergency room because of e-cigarettes. By February of 2020, over 2,800 patients were hospitalized and 68 people died.

EVALI patients typically vaped multiple products: 82% used any THC and 33% used only THC, and 57% used any nicotine and 14% used only nicotine. The CDC claimed to have established a link between Vitamin E acetate (VEA) and EVALI, especially in connection with THC containing products, and recommended the people refrain from vaping and that VEA should not be added to vaping liquids.

Watch this 5:03 minute video by MedCram: “Vaping / E-Cigarette Associated Lung Injury: CDC Update & Vitamin E Acetate”

By the beginning of February 2020, however, the EVALI epidemic was considered to be over. The CDC attributed the end of the epidemic to – among other things – the removal of VEA from vape juices.

Questions related to the EVALI epidemic

Although the EVALI epidemic in the US seems to have stopped, various epidemiological and medical questions remain open.

  • First, how come there were no known EVALI cases outside the United States?
  • Second, did the epidemic really stop because VEA was removed from all vaping products, or was the association between VEA and the EVALI outbreak in the US only an ecological fallacy?
  • Third, although hospitalizations due to EVALI dwindled to just a couple of cases by January of 2020, why are vaping-related emergency room visits still showing an increasing trend?

In this review, we are attempting to address these three questions.

Question one: how come there were virtually no known EVALI cases outside the United States?

Contradiction: worldwide availability of vaping products

Vaping has become increasingly popular all over the world. There are no commercial restrictions on devices or fluids, and they are freely accessible in online stores like Amazon and Ali Express, not to mention other online retailers.

Still, one of the most striking characteristics of the EVALI epidemic was that only the United States reported a severe upsurge in cases. There were only 17 cases in Canada, two in Thailand, and one in Mexico, but the latter one was somebody form the US who happened to be diagnosed in Mexico. In addition, the 3 cases in Brazil reported that they had used vape juices from the United States.

Maybe biased reporting?

Is this an issue of disease reporting characteristic of the United States but not of other countries? There is no major difference in the disease surveillance systems of the United States and, for example, that of the United Kingdom and Australia. As such, the EVALI outbreak is probably not the product of differential reporting due to differences in the reporting systems.

Local or cultural differences?

In addition, even within the United States, the EVALI outbreak did now show a clear geographic pattern that would have reflected local legislative patterns of cannabis decriminalization.

Could it be cultural differences? Users often tweak vaping devices to change manufacturers’ settings. This tweaking obviously has an effect on the physical and chemical characteristics of vaped juices. It is difficult to imagine that it is only Americans that tweak and no other nations, especially given the busy social media contacts of cannabis and e-cigarette aficionados.

Alternatively, vaping juices that caused EVALI might have contained bad quality unregulated THC products, which appeared in the United States as a result of a sudden legalization wave across states and the following “green rush”.

Watch this 2:38 minute video: “UC Davis Study Raises Mold Worries For Medical Cannabis Users”

Question two: is the association between Vitamin E acetate and the EVALI outbreak in the US just a fallacy?

Biased Vitamin E acetate studies

In September of 2019, the CDC found a link between EVALI and Vitamin E acetate. They established this link based on a small report from a forensic laboratory. This report was not only small and unrepresentative of the entire United States, but also analyzed vape juices in general and not from those patients that succumbed to EVALI.

In addition, another study found no Vitamin E acetate in vape juices before the outbreak only after the outbreak. The vape juice that the scientists examined were from confiscated pods. As such, they were probably not stored in accordance with strict laboratory standards, and as we know, chemicals break down in temperatures higher than 70F (20C). Is it a possibility that Vitamin E acetate degraded over time in those pre-epidemic pods, and this is why they did not contain any traceable amounts?

What is wrong with Vitamin E acetate anyway?

Even if it is indeed true that there was Vitamin E acetate only afterwards, does that really mean that evaporated Vitamin E acetate is dangerous for one’s health? According to our knowledge, there are no studies specifically assessing Vitamin E acetate vapors on human health.

The CDC noted that heightened user awareness and most probably the removal of Vitamin E acetate from vape juices lead to the end of the EVALI epidemic in the United States. In addition, the CDC also warned against counterfeit products, which apparently make up the majority of vaping products.

The primary motivation of black-market players is profits and not public health concerns. As such, it is unrealistic to expect that counterfeit producers would stop using an adulterant (Vitamin E acetate in this case) as a response to public uproar or ill health effects.

It is also possible that while THC and Vitamin E Acetate alone might not be a health hazard, but they interact at high temperatures and exert a synergistic ill effect.

Watch this 2:21 minute video by VapeMeet: “Vape News: Michigan Recalls Legal THC Vapes for Vitamin E Acetate…”

Question three: why are vaping-related emergency room visits still showing an increasing trend?

High vaping temperatures

We know little about the long-term effects of vaping. Vaping-related emergency room visits have been on the rise parallel with the increasing popularity of vaping. As such, Vitamin E acetate and/or counterfeit vape juices may (or may not) have been the reason of the EVALI outbreak. However, there is still something about vaping that makes people sick.

One reason might be repeated exposure of people who vape to metal fumes. Most vaping devices heat a metal coil to about 1800F (1000C) by means of a rechargeable 3-6 V battery. This high temperature is above the boiling point of a number of metals, including cadmium and zinc.

Watch this 9:20 minute video by Mic the Vegan: “The Mysterious Vaping Disease: Cause Discovered”

And the stuff that we do not know about…

To our knowledge, no requirements exist about the labeling of the coil alloys of vaping pens. As such, only the producers know what the coils are made up of. In addition, vape coil manufacturing probably follows cost effectiveness rather than public health concerns.

In addition to the potential melting of the metal vaping coils, new and potentially hazardous molecules might form at these high temperatures. Moreover, unknown added hazardous materials might also contribute to the risks of vaping. An analogous example is the addition of bright boat paint to tattoo inks that scientists found caused severe health reactions.

How do the health effects of smoking compare to those of vaping? To our knowledge, nobody has ever performed a scientific study contrasting tobacco-related illnesses and deaths among tobacco smokers with vaping related illnesses and deaths among vapers. It could be a very interesting assessment.


Research related to and therefore conclusions about the health effects of vaping are difficult. In vitro experiments might not adequately reflect real-life conditions due to the unregulated nature of vaping liquids as well as users potentially tweaking their vaping pens.

What is more, there is not just one type of vaping pen, but most pens are different. Therefore, even if the pens are not tweaked, there is no consensus regarding how a “typical” vaping pen works.

In addition, it is difficult to model the environment in the human lungs. Moreover, certain components in the vape juice might interact with other components and have synergistic effects that they alone would not have.

Vaping is a multidimensional issue. Quality control of vaping products, transparency considering the legality, are necessary thorough international research to understand the health aspects of vaping. Having accomplished that, proper user education is essential to prevent similar epidemics in the future and determine safe vaping and/or whether safe vaping exists.

Speaking of safe vaping, is the American only EVALI epidemic the result of an upsurge of bad quality THC products due to a sudden legalization wave in the US, and is the subsequent vilification and widespread e-cigarette and vaping ban a conspiracy by the tobacco industry to eliminate the competition? Watch this stunning investigative video by The Economist.


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