What Is EVALI (E-Cigarette or Vaping-Associated Lung Injury)?

Disclaimer: Results are not guaranteed*** and may vary from person to person***.

EVALIReviewed by Dr. Michael Kessler, DC—Just before the COVID-19 pandemic rocked the world, a smaller and more localized epidemic was taking shape. EVALI, or e-cigarette or vaping-associated lung injury, was affecting a young and otherwise healthy demographic.

Vaping and COVID-19 may seem unrelated, but EVALI, caused by e-cigarettes, may leave users with increased susceptibility to the virus and its severe symptoms.

EVALI was identified in the fall of 2019, when an unfamiliar lung-related illness was causing mass hospitalizations. It was quickly recognized as a vaping-associated lung illness, likely being caused by vitamin E acetate, an additive in THC (tetrahydrocannabinol) vape products.

THC is the psychoactive compound in marijuana that gets people “high.” THC on its own will not cause EVALI.

The connection with COVID-19 is that both conditions affect the respiratory system, while the process of vaping can offer added risk to users.

What Is EVALI?

EVALI is an acronym for e-cigarette or vaping associated lung injury, a term coined in late 2019 to replace VAPI, or vaping-associated pulmonary injury. The new name was in response to a significant uptick in vape-related lung conditions.

Much like COVID-19, researchers are still learning a lot about the illness and exactly what is causing it, how to treat it, and what the mechanisms are behind it. But they have identified a very strong relationship in studying this THC-vaping lung disease.

Symptoms of EVALI include:

  • Shortness of breath
  • Difficulty breathing
  • Chest pain
  • Gastrointestinal sickness

The reason for the surge in cases is likely related to increased usage among youth. In 2012, the number of middle and high school students who vaped was less than three percent. Those numbers have since climbed to more than 20%.

EVALI Causes

Vaping is often viewed as a safe alternative to smoking. But, although it is clearly an alternative, it is by no means safe. Doctors have long cautioned people about the safety of vaping, suggesting that the practice was too new to understand. The picture is now becoming clearer.

E-cigarettes don’t create smoke. The concern with these devices, outside of addiction, are the ingredients and interactions that may occur when they are heated and introduced into the lungs. It’s important to know how they work:

First, a sensor heats a small amount of liquid upon each draw of the e-cigarette. Then the liquid turns into vapor that is inhaled. That vapor is then absorbed into the bloodstream, and the remaining aerosol (vapor) is exhaled.

The liquid is typically flavored, and features either nicotine, like a tobacco cigarette, or THC, like a marijuana cigarette.

Vaping can cause serious harm to your lungs. These products feature chemicals and particles that are linked to conditions such as:

  • Lung disease
  • Asthma
  • Lung inflammation
  • Chronic obstructive pulmonary disease (COPD)
  • Lung damage
  • Heart disease
  • Popcorn lung (bronchiolitis obliterans)
  • Lipoid pneumonia (lipids enter the lungs)
  • Collapsed lung

Officials believe that EVALI is caused by the vitamin E acetate in vape products with THC.

Vitamin E acetate is an oil used to thicken or dilute vaping liquids, and specifically to condense THC in vapes. That said, it can be found in tobacco vape products, albeit much less frequently.

A CDC report compared lung fluid from healthy people and those with EVALI. Vitamin E acetate was found in none of the healthy samples, while it was present in 48 of 51 participants with EVALI.

Below are some quick facts on EVALI and vitamin E acetate:

  • Scientists have found it difficult to pinpoint an exact cause because product brands and ingredients vary.
  • “Dank Vapes,” a THC-containing product, is most commonly associated with EVALI.
  • Exclusive use of THC vape products boosts vapers’ risk of developing EVALI.
  • Vitamin E acetate is closely associated with EVALI. As a topical or nutritional supplement, vitamin E is safe.
  • Vitamin E acetate is an oil derivative used as a thickening agent in vape products, and about half of the products associated with EVALI.
  • Other chemical ingredients that may lead to EVALI include:
    • Triglycerides
    • Plant oils
    • Petroleum distillates
    • Diluent terpenes

THC and Vitamin E Acetate

As mentioned, THC and other forms of vitamin E are not dangerous on their own. But when the oil agent vitamin E acetate is added to THC as a thickener for vape products, it creates a dangerous situation.

Vitamin E acetate is quite sticky, and there is evidence to suggest it may adhere to lung tissue and stay there. It is yet to be seen for how long. Singling out vitamin E acetate in relation to THC products is rather simple: THC is known to leave the lungs very quickly, yet it remains when vitamin E acetate is present.

Of course, not every case of EVALI is associated with vitamin E acetate, but a remarkably high percentage of cases are.

Some research indicates that the vitamin E acetate leaves a layer of oil over membranes in the lungs that are essential for stability and expansion, ultimately impairing the breathing process.

One study found that THC was present in 82% of samples from EVALI patients. It was surely held there by vitamin E acetate.


Research suggests that vaping and COVID-19 have a close relationship, and EVALI could potentially make COVID-19 far more dangerous.

Vaping may be associated with a five to seven times greater risk of COVID-19 among U.S. teenagers and young adults.

Vaping may increase the risk of COVID-19 because it requires significant hand, face, and mouth contact. One of the biggest preventative measures against COVID-19 is keeping hands away from the face.

EVALI may also influence the outcome of COVID-19 infections. If your lungs are already battling the vaping lung disease, adding another condition that attacks your respiratory system can create a dire situation.

Tips to Quit Vaping

Quitting vaping can be very difficult. People often struggle to quit because the e-cigarettes contain enjoyable candy-like flavors, supply high doses of addictive nicotine or THC, and are easy to use and quickly become habitual.

One of the most important, and often overlooked, aspects of quitting is planning. When you have an idea of how you’re going to quit vaping, you can create a targeted plan of attack. Here are a few tips to help you create your plan:

  • Know why you’re quittingWhen you have a reason to quit, it is easier to stay grounded when temptation hits.
  • Don’t provide opportunities for cheating: Avoid all tobacco or vape-related products. Substitutes will kick you off your path.
  • Commit: Give yourself time to get ready, and start within a short timeframe.
  • Learn your triggers: It’s crucial toknow your triggersso you can avoid them.
  • Prepare for cravings and withdrawals: They will happen, so you have to learn how not to give in. Sometimes getting out for a walk, eating an apple, or distracting yourself with work or another activity can help you get through a craving.
  • Imagine yourself vape-free: Think of the saying “If you can imagine it, you can achieve it.” Focus on your goal and begin the steps to make it a reality.
  • Have a support system: Friends, parents, or professionals can all be a part of your team to help you quit e-cigarettes and vaping.

Vaping Is Not Safer Than Smoking

Vaping is trendy and, to some, tastes great. But it is not a healthy alternative to smoking. It presents its own set of risks, some of which appear to set in very quickly. The ingredients, like vitamin E acetate, are potentially very dangerous and should be avoided to reduce the risk of EVALI, especially amid the COVID-19 pandemic.

Article Sources (+)

“E-cigarette or Vaping Use-Associated Lung Injury (EVALI),” American Lung Association, 2020; https://www.lung.org/lung-health-diseases/lung-disease-lookup/evali, last accessed September 17, 2020.
Wolf, M. and Rock, L., “EVALI: New information on vaping-induced lung injury,” Harvard Medical School, April 4, 2020; https://www.health.harvard.edu/blog/evali-new-information-on-vaping-induced-lung-injury-2020040319359, last accessed September 17, 2020.
“Vaping linked to risk of covid-19 in teens and young adults, a study suggests,” The Washington Post, August 18, 2020; https://www.washingtonpost.com/health/vaping-linked-to-risk-of-covid-19-in-teens-and-young-adults-a-study-suggests/2020/08/13/76d552e2-dce2-11ea-809e-b8be57ba616e_story.html, last accessed September 17, 2020.
“Vaping: The Mechanics (infographic),” Government of Canada, August 6, 2019; https://www.canada.ca/en/services/health/publications/healthy-living/vaping-mechanics-infographic.html, last accessed September 17, 2020.
Gaiha, S., et al., “Association Between Youth Smoking, Electronic Cigarette Use, and Coronavirus Disease 2019,” Journal of Adolescent Health, Aug. 2020, 67(4):519-523; https://www.jahonline.org/article/S1054-139X(20)30399-2/fulltext, last accessed September 17, 2020.
“Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products,” Centers for Disease Control and Prevention, February 25, 2020; https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#key-facts, last accessed September 17, 2020.
Boudi, F., et al., “Vitamin E Acetate as a Plausible Cause of Acute Vaping-related Illness,” Cureus, Dec. 2019; 11(12): e6350; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6952050/, last accessed September 17, 2020.
“About Electronic Cigarettes (E-Cigarettes),” Centers for Disease Control and Prevention, September 9, 2020, https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html, last accessed September 17, 2020.
Broderick, S., “What Does Vaping Do to Your Lungs?” Johns Hopkins Medicine, 2020; https://www.hopkinsmedicine.org/health/wellness-and-prevention/what-does-vaping-do-to-your-lungs, last accessed September 17, 2020.
“How to Quit Vaping,” National Institutes of Health, 2020; https://teen.smokefree.gov/quit-vaping/how-to-quit-vaping, last accessed September 17, 2020.
Sun, L., “Contaminant found in marijuana vaping products linked to deadly lung illnesses, tests show,” The Washington Post, September 6, 2019; https://www.washingtonpost.com/health/2019/09/05/contaminant-found-vaping-products-linked-deadly-lung-illnesses-state-federal-labs-show/, last accessed September 18, 2020.