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E-Cigarette or Vaping Product Use-Associated Lung Injury (EVALI): An Update

Key points:

  • E-cigarettes and vapes contain substances linked to EVALI.

  • EVALI can present as a wide array of symptoms.

  • EVALI can be difficult to diagnose.

An illustration of lungs.

Before COVID-19 swept the nation – and the world – the respiratory condition identified and named EVALI in 2019 garnered attention and action by the Centers for Disease Control and Prevention (CDC), as a national outbreak of cases first appeared in the United States. Unfortunately, EVALI – short for e-cigarette or vaping product use-associated lung injury – has not disappeared; in fact, much still needs to be learned about this illness.

What is EVALI?

EVALI is a serious illness that can develop from inhaling the aerosol of e-cigarettes and vaping products. It has primarily impacted young adults. Symptoms can include cough, shortness of breath, chest pain, and coughing up blood. Individuals with EVALI may also have gastrointestinal symptoms like abdominal pain, nausea, vomiting and diarrhea, to other symptoms, such as fatigue, fever, chills or rapid weight loss.

Particularly troubling are emerging long-term studies indicating that a significant proportion of those diagnosed with EVALI experience long-term adverse effects beyond respiratory limitations, such as cognitive impairment, symptoms of depression, anxiety, post-traumatic stress, and more.

What specifically causes EVALI?

Pinpointing the causes of EVALI is difficult. Initially, the CDC took e-cigarette samples to identify what EVALI patients were breathing into their respiratory symptoms. Tetrahydrocannabinol (THC), the psychoactive ingredient in marijuana, and vitamin E acetate were found in most samples. Although vitamin E is safe for skin application and ingestion through cosmetics, foods and supplements, inhaling it can harm the lungs. However, vitamin E acetate wasn’t found in all the EVALI-associated products. This likely suggests that other substances in e-cigarettes can cause EVALI.

How is EVALI diagnosed?

A doctor looking at an x-ray.

EVALI can be challenging for health professionals to diagnose since its symptoms can either mimic those of other respiratory or be nonspecific. There is no simple blood test. Instead, there is reliance upon symptoms, absence of other lung infections, irregularities found on lung X-rays or scans, and recent use of e-cigarettes or vaping products. It is crucial to have thorough and candid conversations with adolescents and young adults about how often and what type of vaping devices and e-cigarettes they use. Not knowing this can raise the chances of EVALI being undiagnosed.

How common is EVALI?

The CDC stopped EVALI data collection in February 2020. As of that date, there were 2,807 hospitalized EVALI cases in the United States, including 68 deaths, 15% of which were in people under 18.

Reporting of probable and confirmed EVALI cases has now shifted to individual state health departments. However, inconsistent reporting, stoppage of reporting cases at a national level, and lack of attention to EVALI highlight a need for improvement in reporting.

The bottom line

Further research regarding EVALI is needed to help increase understanding and ultimately prevent future cases. Meanwhile, highlighting the risks and harms of e-cigarettes and vaping devices to youth must continue. By Linda Antinoro Reviewed by Cindy Bistany, DHSc References

1. Centers for Disease Control and Prevention. (2020, February 25). Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products. Retrieved from

2. UNC Health (2023, January 3) UNC Researchers Tackle the E-Cigarette or Vaping Product Use-associated Lung Injury (EVALI) Epidemic. Retrieved from

3. Abdallah B, Lee H, Weerakoon SM, Messiah SE, Harrell MB, Rao DR. Clinical manifestations of EVALI in adolescents before and during the COVID-19 pandemic. Pediatr Pulmonol. 2023 Mar;58(3):949-958. doi: 10.1002/ppul.26283. Epub 2022 Dec 28. PMID: 36530031; PMCID: PMC9878061.

4. Zulfiqar H, Sankari A, Rahman O. Vaping Associated Pulmonary Injury. [Updated 2022 Nov 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:

5. Rebuli ME, Rose JJ, Noël A, Croft DP, Benowitz NL, Cohen AH, Goniewicz ML, Larsen BT, Leigh N, McGraw MD, Melzer AC, Penn AL, Rahman I, Upson D, Crotty Alexander LE, Ewart G, Jaspers I, Jordt SE, Kligerman S, Loughlin CE, McConnell R, Neptune ER, Nguyen TB, Pinkerton KE, Witek TJ Jr. The E-cigarette or Vaping Product Use-Associated Lung Injury Epidemic: Pathogenesis, Management, and Future Directions: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc. 2023 Jan;20(1):1-17. doi: 10.1513/AnnalsATS.202209-796ST. PMID: 36584985; PMCID: PMC9819258.

6. Blagev DP, Callahan SJ, Harris D, Collingridge DS, Hopkins RO, Eve JR, et al. prospectively assessed long-term outcomes of patients with e-cigarette or vaping-associated lung injury (EVALI). Ann Am Thorac Soc. 9 May 2022;

7. Shipra Rai, Sanaya Hormozdyaran, Joseph Burns, John B. Amodio, Annabelle I. Quizon; Diagnosis of EVALI in Adolescents During the COVID-19 Pandemic: A Case Series. Hosp Pediatr May 2022; 12 (5): 538–543.


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