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Severe Lung Injury Associated With Use of e-Cigarette, or Vaping, Products

Key Points


What are the clinical characteristics and vaping exposures among patients hospitalized with e-cigarette, or vaping, product use–associated lung injury (EVALI) in California?


Of 160 patients included in this case series, 74% were younger than 35 years, 46% required admission to intensive care units, and 29% required mechanical ventilation. Of 86 patients interviewed, 83% reported using tetrahydrocannabinol (THC)-containing products, most of which were acquired from informal sources; vitamin E or vitamin E acetate was present in 84% of THC-containing products tested from 24 patients.


Use of THC-containing products and vitamin E acetate appear to be associated with the EVALI outbreak, but additional investigation is needed to determine the cause(s).



Since August 2019, more than 2700 patients have been hospitalized with e-cigarette, or vaping, product use–associated lung injury (EVALI) across the United States. This report describes the outbreak in California, a state with one of the highest case counts and with a legal adult-use (recreational) cannabis market.


To present clinical characteristics and vaping product exposures of patients with EVALI in California.

Design, Setting, and Participants

Case series describing epidemiologic and laboratory data from 160 hospitalized patients with EVALI reported to the California Department of Public Health by local health departments, who received reports from treating clinicians, from August 7 through November 8, 2019.


Standardized patient interviews were conducted to assess vaping products used, frequency of use, and method of product acquisition. Vaping products provided by a subset of patients were tested for active ingredients and other substances.

Main Outcomes and Measures

Demographic and clinical characteristics, level of care, and outcomes of hospitalization were obtained from medical record review.


Among 160 patients with EVALI, 99 (62%) were male, and the median age was 27 years (range, 14-70 years). Of 156 patients with data available, 71 (46%) were admitted to an intensive care unit, and 46 (29%) required mechanical ventilation. Four in-hospital deaths occurred. Of 86 patients interviewed, 71 (83%) reported vaping tetrahydrocannabinol (THC)-containing products, 36 (43%) cannabidiol (CBD)-containing products, and 39 (47%) nicotine-containing products. Sixty-five of 87 (75%) THC-containing products were reported as obtained from informal sources, such as friends, acquaintances, or unlicensed retailers. Of 87 vaping products tested from 24 patients, 49 (56%) contained THC. Vitamin E or vitamin E acetate was found in 41 (84%) of the THC-containing products and no nicotine products.

Conclusions and Relevance

Patients’ clinical outcomes and vaping behaviors, including predominant use of THC-containing products from informal sources, are similar to those reported by other states, despite California’s legal recreational cannabis market. While most THC products tested contained vitamin E or vitamin E acetate, other underlying cause(s) of injury remain possible. The California Department of Public Health recommends that individuals refrain from using any vaping or e-cigarette products, particularly THC-containing products from informal sources, while this investigation is ongoing.

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