Characteristics of Patients in a National Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injuries

United States, October 2019

Erin D. Moritz, PhD; Lauren B. Zapata, PhD; Akaki Lekiachvili, MD; Emily Glidden, MPH; Francis B. Annor, PhD; Angela K. Werner, PhD; Emily N. Ussery, PhD; Michelle M. Hughes, PhD; Anne Kimball, MD; Carla L. DeSisto, PhD; Brandon Kenemer, MPH; Mays Shamout, MD; Macarena C. Garcia, DrPH; Sarah Reagan-Steiner, MD; Emily E. Petersen, MD; Emily H. Koumans, MD; Matthew D. Ritchey, DPT; Brian A. King, PhD; Christopher M. Jones, DrPH; Peter A. Briss, MD; Lisa Delaney, MS; Anita Patel, PharmD; Kara D. Polen, MPH; Katie Sives, MPH; Dana Meaney-Delman, MD; Kevin Chatham-Stephens, MD; Lung Injury Response Epidemiology/Surveillance Group


Morbidity and Mortality Weekly Report. 2019;68(43):985-989. 

In This Article


Cases of EVALI continue to be reported to CDC as part of this national outbreak. Similar to previous reports at the national and state levels,[1–4] most patients reported use of THC-containing products in the 3 months before symptom onset. Patients were predominantly aged <35 years, non-Hispanic white, and male. Patients with EVALI who died were older than patients who survived. Illnesses and deaths occurred across an age spectrum, from adolescents to older adults. Approximately half of cases, and two deaths, occurred in patients aged <25 years. Older adults were disproportionately represented among patients who died; only 2% of cases, but nearly 25% of deaths, occurred in patients aged >65 years. Further, any use of THC-containing products was reported for 86% of patients who survived and 84% of patients who died; exclusive use of THC-containing products was reported for 63% of EVALI patients who died and for 33% who survived.

Findings from this report, which is the largest analysis of EVALI patients to date, suggest that this outbreak continues to primarily affect young persons, highlighting the need to communicate the dangers of e-cigarette, or vaping, use particularly among youths and young adults. Although 2% of all EVALI patients were aged 65–75 years, 24% of deaths were in this age group; relevant tailored and targeted messaging might also be needed for this age group. Consistent with previously published reports,[1–4] the data presented here suggest that THC-containing products are playing an important role in this outbreak. Further, reports from Illinois, Utah, and Wisconsin suggest that patients have typically obtained their THC-containing e-cigarette, or vaping, products through informal sources, such as friends or illicit in-person and online dealers, although local and regional differences in illicit THC supply and production might exist.[3,4]

The findings in this report are subject to at least three limitations. First, data on substances used in e-cigarette, or vaping, products were self-reported or reported by proxies and might be subject to recall bias, as well as social desirability bias because nonmedical marijuana is illegal in many states. Therefore, underreporting might have occurred, particularly for patients who died and others whose information was provided by a proxy. Second, data on some variables, such as race/ethnicity, were missing for many patients, and conclusions based on these data might not be generalizable to the entire patient population. Finally, these data might be subject to misclassification of substance use for multiple reasons. Patients likely did not know the content of the e-cigarette, or vaping, products they used, and methods used to collect substance use data varied across states.

To date, no single compound or ingredient has emerged as the cause of EVALI, and there might be more than one cause. Because most patients report using THC-containing products before the onset of symptoms, 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 and 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. In addition, because the specific compound or ingredient causing lung injury is not yet known, and while the investigation continues, persons should consider refraining from use of all e-cigarette, or vaping, products. E-cigarette, or vaping, products should never be used by youths, young adults, or women who are pregnant. Moreover, persons who do not currently use tobacco products should not start using e-cigarette, or vaping, products.[2,5]