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E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI)

  • The term for the lung disease that can develop due to vaping
  • Symptoms include shortness of breath, cough, and chest pain
  • Treatments include steroids and antibiotics
  • Involves Pediatric Pulmonology, Allergy, Immunology & Sleep Medicine, Emergency Medicine


EVALI is the name given by the Centers for Disease Control and Prevention (CDC) to the dangerous, newly identified lung disease linked to vaping. The name EVALI is an acronym that stands for e-cigarette or vaping product use-associated lung injury.  

The illness was first recognized by the CDC in August 2019 after health department officials across the country began to work together to study cases of severe, sometimes fatal, lung infections that arose suddenly in otherwise healthy individuals. The number of people who needed to be hospitalized after experiencing symptoms ranging from shortness of breath to fever quickly rose in many states around the U.S. As more details emerged, doctors and researchers discovered that patients shared at least one common risk: all reported they had recently used e-cigarette or vaping products.

Even though the agency announced that vitamin E acetate appears associated with this vaping-related illness, federal investigators have not yet identified a single ingredient (though there could be several) that causes EVALI. It’s therefore unclear how the condition develops or why, in the most severe and life-threatening cases, it causes the lungs to stop functioning altogether.   

However, CDC and Food and Drug Administration (FDA) officials urge everyone to avoid e-cigarette or vaping products that contain tetrahydrocannabinol, or THC (a high-inducing chemical derived from marijuana). THC has been detected in most of the EVALI case samples tested by the FDA so far, according to the CDC. In additional guidance, the FDA cautioned people against adding additional substances to vaping products and to not use products obtained off the street. To completely avoid one’s risk of developing EVALI, the CDC states, “consider refraining from use of all e-cigarette, or vaping, products.”

Because there are also other associated health risks with e-cigarettes, both agencies emphasize that vaping products should never be used by youth or women who are pregnant. 

Vaping involves using a device—categorically called e-cigarettes, but also known as vape pens, mods, or tanks—that heats up a small amount of liquid, turning it into a vapor that can be inhaled. Most vape liquids—also called e-juice or e-liquid and sold in cartridges, pods, or custom containers—contain substances such as propylene glycol and glycerol as base ingredients that create the vapor. 

Besides those base ingredients, many of the more popular vaping devices contain nicotine and artificial flavors. Researchers who have analyzed commercial vaping liquid samples have also detected potentially harmful acetals that form when flavoring chemicals mix with the base ingredients. 

Meanwhile, health officials investigating EVALI cases have found that many patients used vaping liquid that contained additional compounds, such as THC, cannabinoid (CBD) oil, and vitamin E oil.

“The latest national and state findings suggest products containing THC, particularly those obtained off the street or from other informal sources (e.g. friends, family members, illicit dealers), are linked to most of the cases and play a major role in the outbreak,” according to a statement released by the CDC. 

The outbreak of EVALI cases has occurred against a backdrop of an ongoing vaping epidemic among youth. At Yale Medicine, most pediatricians have started asking middle- and high school-age patients about their exposure to and habits related to vaping, in addition to the common screening questions about other substances that can derail physical and mental health, like alcohol and cigarettes. One goal is to educate youth about the dangers of vaping; another is to identify patients who might be at higher risk for developing related problems.

“I screen all of my patients, any child over age 12, since [vaping] can exacerbate underlying conditions like asthma,” says Yale Medicine pediatric pulmonologist Pnina Weiss, MD.

What is EVALI?

EVALI stands for e-cigarette or vaping product use-associated lung injury. The term was recently coined by the CDC in response to a multi-state outbreak of severe lung illness that was first identified in August 2019 and is associated with using e-cigarette and vaping products. It was previously known as VAPI (vaping associated pulmonary illness). 

What are the symptoms of EVALI?

Diagnosing EVALI can be challenging because the symptoms of this lung condition are similar to those in other respiratory illnesses, like pneumonia and even the seasonal flu virus. They include:

  • Shortness of breath
  • Cough
  • Chest pain
  • Fever and chills
  • Diarrhea, nausea, and vomiting
  • Tachycardia (rapid heartbeat)
  • Tachypnea (rapid and shallow breathing) 

What are the causes of EVALI?

Health officials continue to investigate which ingredient(s) may be causing EVALI. The high-inducing chemical derived from marijuana, called THC, has been linked to many of the documented cases, according to the CDC. 

In the meantime, a study found that people who use only e-cigarettes increase their risk of developing lung disease by about 30% compared with nonusers. At the same time, the risk of being diagnosed with lung disease—which includes chronic bronchitis, emphysema, asthma, or chronic obstructive pulmonary disease (COPD)—was highest among adults who smoke cigarettes and vape, according to the researchers, who tracked study participants over three years.

What are the risk factors of EVALI?

The only identified risk factor of EVALI is current or previous use of an e-cigarette or vaping device. 

How is EVALI diagnosed?

There is no single test yet for EVALI—it is what’s known as a “diagnosis of exclusion,” which means that a doctor will conduct tests to rule out other potential diseases and conditions. “It can look exactly like bacterial or viral pneumonia,” Dr. Weiss says.

 A diagnosis of EVALI may be made if the following criteria are met:

  • The patient reports use of an e-cigarette (vaping) or dabbing (inhaling concentrated marijuana in the form of wax or oil) during the 90 days before symptoms are first noticed.
  • A chest X-ray or CT scan shows hazy-looking spots (called opacities) in the lungs. This contrasts with a clear black space in healthy lungs.
  • No other type of lung infection is detected, which means tests for viruses and bacterial infections come back negative. 

What is the treatment for EVALI?

The treatment options for EVALI are currently based on expert recommendations, explains Dr. Weiss. The condition is so new that doctors and researchers do not have access to long-term studies, which could show if a particular treatment approach works better than another one.

Treatment of EVALI depends on the severity of the illness. Patients who are extremely ill and unable to breathe on their own may need to be placed on a ventilator, a machine that exchanges air for them. Those that are less severe may need supplemental oxygen.

The primary medication treatments are:

  • Corticosteroids. A type of medication that reduces inflammation in the lungs.
  • Antibiotics. It is recommended that these be given while test results are being finalized as it’s difficult to distinguish EVALI from bacterial infections.
  • Antivirals. These can be considered, especially during influenza season. 

What is the outlook for someone with EVALI?

Because the illness is so new, there is no way to predict how patients will fare after being released from the hospital following treatment. Dr. Weiss says that some have become ill again after steroid treatment is stopped, so follow-up care is vital. 

 “We recommend that patients see a pulmonologist within one to two weeks after being discharged to undergo testing of lung function and pulse oximetry [level of oxygen in the blood],” she says.

Because of the lack of long-term data and the fact that patients have died from EVALI, the prognosis for those affected remains uncertain. Researchers are working hard to learn as much as possible about the illness, its causes, and the odds for making a full recovery.

How is Yale Medicine unique in its approach to EVALI?

“Yale physicians have been at the forefront in identifying EVALI cases,” Dr. Weiss says. She explains that even before CDC guidelines on treating the illness were released, Yale doctors were successfully treating patients with a combination of antibiotics and steroids. Doctors at Yale Medicine also collaborate with researchers in the fields of tobacco and addiction medicine to provide care for patients with EVALI.