Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients With Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury

United States, October 2019

David A. Siegel, MD; Tara C. Jatlaoui, MD; Emily H. Koumans, MD; Emily A. Kiernan, DO; Mark Layer, MD; Jordan E. Cates, PhD; Anne Kimball, MD; David N. Weissman, MD; Emily E. Petersen, MD; Sarah Reagan-Steiner, MD; Shana Godfred-Cato, DO; Danielle Moulia, MPH; Erin Moritz, PhD; Jonathan D. Lehnert, MPH; Jane Mitchko, MEd; Joel London, MPH; Sherif R. Zaki, MD; Brian A. King, PhD; Christopher M. Jones, PharmD, DrPH; Anita Patel, PharmD; Dana Meaney Delman, MD; Ram Koppaka, MD, PhD


Morbidity and Mortality Weekly Report. 2019;68(41):919-927. 

In This Article

Clinical Care and Public Health Recommendations

Reporting cases to state, local, territorial, or tribal health departments is critical for accurate surveillance of EVALI. Reporting cases and obtaining and sending products, devices, and clinical and pathologic specimens for testing, can help health departments and CDC determine the cause or causes of these lung injuries.*** CDC is developing International Classification of Diseases, Tenth Edition, Clinical Modification coding guidance for health care encounters related to EVALI. Updates, when available, can be found at https://www.cdc.gov/lunginjury (Box 3).

Public Health Recommendations

At this time, FDA and CDC have not identified the cause or causes of the lung injuries among EVALI cases, and the only commonality among all cases is that patients report the use of e-cigarette, or vaping, products. This outbreak might have more than one cause, and many different substances and product sources are still under investigation. To date, national and state data suggest that products containing THC, particularly those obtained off the street or from other informal sources (e.g., friends, family members, or illicit dealers), are linked to most of the cases and play a major role in the outbreak.[11,12] Therefore, CDC recommends that persons should not use e-cigarette, or vaping, products that contain THC. Persons should not buy any type of e-cigarette, or vaping, products, particularly those containing THC, off the street. Persons should not modify or add any substances to e-cigarette, or vaping, products that are not intended by the manufacturer, including products purchased through retail establishments.

Given that the exclusive use of nicotine-containing products has been reported by a small percentage of persons with EVALI, and that many persons with EVALI report combined use of THC- and nicotine-containing products, the possibility that nicotine-containing products play a role in this outbreak cannot be excluded. Therefore, at present, CDC continues to recommend that persons consider refraining from using e-cigarette, or vaping, products that contain nicotine. If adults are using e-cigarette, or vaping, products to quit cigarette smoking, they should not return to smoking cigarettes; they should use evidence-based treatments, including health care provider counseling and FDA-approved medications.††† If persons continue to use these products, they should carefully monitor themselves for symptoms and see a health care provider immediately if symptoms develop. Irrespective of the ongoing investigation, e-cigarette, or vaping, products should never be used by youths, young adults, or women who are pregnant. There is no safe tobacco product, and the use of any tobacco products, including e-cigarettes, carries a risk. Therefore, persons who do not currently use tobacco products should not start using e-cigarette, or vaping, products.

This investigation is ongoing. CDC will continue to work in collaboration with FDA and state and local partners to investigate cases and to update guidance, as appropriate, as new data emerges from this complex outbreak.