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EVALI cases linked to illicit THC cartridges


A small cluster of e-cigarette or vaping product use–associated lung injury (EVALI) cases provides more evidence of the role of tetrahydrocannabinol (THC) and vitamin E acetate in the epidemic.

In the second half of 2019, an epidemic of e-cigarette or vaping product use–associated lung injury (EVALI) was sweeping across the United States. It led to bans on flavored products and raising the minimum age to purchase tobacco products to 21 years. A new report from the Centers for Disease Control and Prevention’s (CDC’s) Morbidity and Mortality Weekly Report further confirms that tetrahydrocannabinol (THC)–containing products and vitamin E acetate (VEA) were behind the crisis.1

The Wisconsin Department of Health Services reported 3 small EVALI patient clusters (cluster A, 2 patients; cluster B, 3 patients; and cluster C, 3 patients). The patients were aged 16 to 20 years. The clusters had been identified and investigated via analysis of bronchoalveolar lavage (BAL) liquid; laboratory analysis of vaping products; and standard and follow-up interviews. All 8 patients said they used THC–containing e-cigarettes or vaping products every day in the month before symptom onset. Cartridges were bought from local illicit dealers and each patient reported that some of the cartridges they used were labelled as “Dank Vapes.” At least 2 members of each cluster reported sharing their THC cartridges before showing symptoms. The 8 patients also reported daily use of nicotine–containing vaping products.

Vitamin E acetate implicated

Vitamin E acetate was detected in all 5 THC cartridges provided by 2 patients and in the BAL liquid of 2 different patients. Investigators concluded that THC cartridges that contained VEA and were sold illegally were responsible for these 3 clusters of EVALI. Because of this report and other reports, the CDC recommends not using e-cigarette or vaping products that contain THC, particularly products from informal sources, and also stresses that due to the strong link between VEA and EVALI, VEA should not be added to any e-cigarette or vaping product.

The report did have 4 limitations. Most data were collected roughly 4 months after the onset of initial symptoms, which means that brand names, frequency, and other information were subject to recall bias. Testing for VEA in the cartridges or BAL fluids was possible in only 4 of the 8 cases in the clusters. Three patients couldn’t be reached for further interviewing. Also, the analysis was limited to a small cluster, which isn’t representative of the overall EVALI outbreak.

The CDC cautions that e-cigarettes or vaping products should never be used by children, adolescents, young adults, or pregnant women.


1. Pray IW, Atti SK, Tomasallo C, Meiman JG. E-cigarette, or vaping, product use–associated lung injury among clusters of patients reporting shared product use-Wisconsin, 2019. MMWR Morb Mortal Wkly Rep. 2020;69(9):236-240.

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