“[Vitamin E acetate] certainly seems to be the most likely culprit, but even the CDC is not willing to say that this is the only potential cause of the outbreak,” she added.

Dr Wilson and coauthors spotlighted e-cigarettes and vaping as a public health crisis even before the EVALI outbreak, in a May 2019 paper published in Pediatrics.7 “I think there may be other products that behave similarly to vitamin E acetate and we may not be able to know what all they are actually inhaling,” she said. “People mix their own fluids and use bootleg product. They make it in their basements and give it to a bunch of friends. Who knows what’s in those? In a lot of cases, we weren’t able to test patients’ vaping fluids.”

The federal government is cracking down on websites advertising THC vaping cartridges. The Food & Drug Administration (FDA) and Drug Enforcement Agency (DEA) seized 44 such websites, they announced December 20, 2019.8

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Neither agency responded to Cancer Therapy Advisor’s requests for comment on international supply chains or whether particular batches or sources of vitamin E acetate have been implicated in EVALI hospitalizations or deaths (nor did the US Department of Homeland Security, which tracks international consumer product supply chains).

Additional possible EVALI deaths are still under investigation, but deaths and the incidence rate of new diagnoses appeared to be plateauing, the CDC reported.2 EVALI patients with chronic diseases, including cardiovascular disease and diabetes, are at high risk of rehospitalization and death, prompting the CDC to urge close monitoring after patients are released from the hospital.

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“Electronic cigarettes should never be used by youth or by adults who are not currently smoking,” the IASLC policy statement cautioned.1 “Cancer treatment outcomes are worse in patients who continue to smoke, and it is critical for all physicians to support patients through shared decision making to stop smoking. Individuals who smoke, including those with cancer, should quit smoking immediately by any means possible.”

Health care providers should advise patients to stop smoking and vaping using evidence-based cessation strategies like counseling and nicotine-replacement pharmacotherapies, the IASLC policy stated.1

Patients undergoing immune checkpoint inhibition therapy against cancer should not use cannabis products, clinicians told Cancer Therapy Advisor, because of evidence that they can reduce tumor response to immunotherapy.9


  1. The International Association for the Study of Lung Cancer (IASLC). IASLC Policy Statement – electronic cigarettes. Published November 12, 2019.  Accessed February 3, 2020.
  2. US Centers for Disease Control and Prevention. Outbreak of lung injury associated with the use of E-cigarette, or vaping, products [news release]. Updated January 21, 2020. Accessed February 3, 2020.
  3. Hartnett KP, Kite-Powell A, Patel MT, et al. Syndromic surveillance for e-cigarette, or vaping, product use-associated lung injury [published online December 20, 2019]. N Engl J Med. doi: 10.1056/NEJMsr1915313
  4. US Centers for Disease Control and Prevention. Electronic cigarettes: For healthcare providers. Updated January 14, 2020. Accessed January 19, 2020.
  5. Blount BC, Karwowski MP, Shields PG, et al. Vitamin E acetate in bronchoalveolar-lavage fluid associated with EVALI [published online December 20, 2019]. N Engl J Med. doi: 10.1056/NEJMoa19164335
  6. Krishnasamy VP, Hallowell BD, Ko JY, et al. Update: Characteristics of a nationwide outbreak of e-cigarette, or vaping, product use–associated lung injury — United States, August 2019–January 2020. MMWR Morb Mortal Wkly Rep. 2020;69:90-94.
  7. Walley SC, Wilson KM, Winickoff JP, Groner J. A public health crisis: Electronic cigarettes, Vape and JUUL. Pediatrics. 2019;143(6):e20182741. doi: 10.1542/peds.2018-2741
  8. US Food and Drug Administration. FDA, DEA seize 44 websites advertising sale of illicit THC vaping cartridges to US consumers as part of Operation Vapor Lock: Federal, state, local authorities continue to investigate supply chain of products associated with lung injuries [press release]. Published December 20, 2019. Accessed January 19, 2020.
  9. Merkle, S, Tavernier SS. Cannabis use and bleomycin: An overview and case study of pulmonary toxicity. Clin J Oncol Nurs. 2018;22(4):438-443.