In late 2019, otherwise healthy young people started arriving in emergency departments unable to breathe. Most pages about EVALI now file it as closed history. That's half right — the outbreak did end, but it ended for a narrower reason than people assume.
Key Takeaways
- EVALI is a severe lung injury linked to vaping, identified in a 2019–2020 US outbreak
- Final figures: 2,807 hospitalizations and 68 deaths as of 18 February 2020
- Vitamin E acetate in informally sourced THC vapes was strongly linked as the cause
- The outbreak ended because that additive became rarer — not because unregulated vapes became safe
What EVALI Is
E-cigarette or vaping product use-associated lung injury: a severe inflammatory injury to the lungs following vaping [1]. Imaging showed widespread inflammation across both lungs, and many patients required intensive care and mechanical ventilation [2].
What made it alarming was who it affected. Not people with existing lung disease, but healthy adolescents and young adults, deteriorating over days.
What Caused It
Investigation converged on vitamin E acetate, used as a thickening and cutting agent in informally sourced THC vaping products [1].
The reason it was used is the reason it was dangerous. Vitamin E acetate is genuinely harmless swallowed or applied to skin — it's a common ingredient in supplements and cosmetics — and it thickened cannabis oil convincingly, which made diluted product look potent. But a substance being safe to eat says nothing about whether it's safe to heat and inhale. Lungs are not a digestive tract, and "food-grade" was never a claim about inhalation.
Symptoms
Shortness of breath, cough, and chest pain, usually developing over days to weeks. Fever, chills, and fatigue are common — and so are nausea, vomiting, and diarrhea, which is worth flagging because those gastrointestinal symptoms often came first and led people to assume they had a stomach bug while their lungs were being injured.
Anyone with worsening breathlessness or chest pain who has been vaping should seek medical care and say so explicitly. It changes what clinicians look for.
Is EVALI Still a Risk?
Not at outbreak scale. Cases fell sharply through 2020 as vitamin E acetate became less common in the illicit supply and public warnings spread, and the CDC stopped collecting counts in February 2020 [3].
But note carefully what changed and what didn't. One adulterant became less common. The system that put it there — unregulated products, undisclosed additives, no testing, no accountability — is unchanged. Vitamin E acetate wasn't the disease; it was the specific thing that happened to be in the supply that year.
The durable lesson is about informal supply generally rather than one chemical: when nobody can tell you what's in a cartridge, that gap is the risk, and it's still there.
If vaping has become hard to stop
Plenty of people who intended to vape occasionally find they can't get through a day without it. That's dependence rather than a discipline problem, and nicotine in particular produces it quickly — especially in adolescents [4].
Where vaping is doing a job — managing anxiety, stress, or a low mood that was there first — treating both together is what holds; removing the substance alone usually doesn't. Our work centers on co-occurring mental health conditions alongside substance use. If you're a parent worried about a teenager, our Families & Loved Ones team can help you approach it.
Seek urgent medical care for worsening shortness of breath, chest pain, or bluish lips — and tell clinicians about any vaping, including what was in it if you know. If this brings up thoughts of suicide or self-harm, call or text 988, the Suicide & Crisis Lifeline.
FAQs
- What is EVALI?
- EVALI stands for e-cigarette or vaping product use-associated lung injury — a severe, sometimes fatal inflammatory lung injury identified during a US outbreak in 2019 and 2020. It caused breathing difficulty, low blood oxygen, and widespread lung inflammation, in many cases in previously healthy young people.
- How many people were affected by EVALI?
- The outbreak produced 2,807 hospitalizations and 68 deaths reported to the CDC as of 18 February 2020, when case counts had fallen enough that the agency stopped collecting them. Those are final outbreak figures, not current ones.
- What caused EVALI?
- Vitamin E acetate was strongly linked as the primary culprit. It was used as a thickening or cutting agent in informally sourced THC vaping products. It is harmless to swallow or apply to skin, which is part of why it was used — but inhaled into the lungs it behaves very differently.
- Is EVALI still happening?
- Not at outbreak scale. Cases fell sharply through 2020 as vitamin E acetate became less common in the informal supply and awareness rose. But the underlying situation — unregulated vaping products containing undisclosed additives — was never resolved, so severe lung injury from informally sourced vapes remains possible.
- What are the symptoms of EVALI?
- Shortness of breath, cough, and chest pain, often with fever, chills, nausea, vomiting, diarrhea, and fatigue. The gastrointestinal symptoms are notable because they can precede breathing problems and lead people to assume it is a stomach illness. Symptoms typically develop over days to weeks rather than suddenly.
- Is vaping nicotine safe if EVALI was about THC products?
- EVALI was overwhelmingly associated with THC-containing products from informal sources, but that is a statement about one specific outbreak, not a safety endorsement of nicotine vaping. Nicotine vaping carries its own established risks, including strong dependence potential — particularly in adolescents.
- Does insurance cover treatment for substance use and co-occurring conditions?
- Most major plans cover medically necessary treatment for substance use and mental health conditions together. You can verify coverage for free in a few minutes.
Sources
- Rebuli ME, et al. Annals of the American Thoracic Society (2023), NIH/PMC. The E-cigarette or Vaping Product Use-Associated Lung Injury Epidemic: Pathogenesis, Management, and Future Directions.
- Kligerman S, et al. Chest (2021), NIH/PMC. CT Findings and Patterns of e-Cigarette or Vaping Product Use-Associated Lung Injury.
- Wiens T, et al. Public Health Reports (2021), NIH/PMC. Lessons Learned From the EVALI Outbreak Response, Minnesota, 2019–2020.
- National Institute on Drug Abuse (NIDA). Tobacco, Nicotine, and Vaping.
This article is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment.
Written by
Executive Director
Dominic Perry is a Licensed Clinical Social Worker (LCSW), Licensed Clinical Alcohol and Drug Counselor (LCADC), Master Addiction Counselor (MAC), and DOT Substance Abuse Professional (SAP) with approximately eight years of experience in behavioral health and substance use treatment. Dominic began his work with Virtue as a therapist at the Corbett residential facility before progressing into leadership, and now serves as Executive Director of Virtue Recovery Center – Outpatient in Las Vegas. He earned his Bachelor of Social Work from UNLV and his Master of Social Work from the University of Nevada Reno.
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