Vitamin E Acetate, EVALI, and A Higher Death Risk in Older Patients

When a few initially “isolated” cases of vaping-associated lung injury were recognized as a wider-spread phenomenon earlier this summer, epidemiologists at the US Centers for Disease Control roared into action.

That was–let us not be unambiguous–a very good thing. Soon it became apparent that the symptoms health professionals were seeing in emergency rooms before flu season was the leading edge of a blossoming outbreak.  

In weekly updates to health professionals, CDC is working to keep those on the front lines of health care up-to-date. And through aggressive reporting and data analysis led by the organization’s scientists, astonishing progress has already been made. We are learning a great deal about this syndrome–much of which may help as the government weighs proposals to ban vaping products entirely.

What are the EVALI Statistics as of November 20, 2020?

Let’s nutshell the latest clinical update for those who want to talk to their patients about the risk of EVALI in a realistic, honest, comprehensive way.

This is what we know as of Thanksgiving.

  • There have been 2,290 confirmed cases of e-cigarette, or vaping, product use associated lung injury (EVALI) in 49 states and the District of Columbia–every state but Alaska.
  • The number of cases reported each week appears to be falling, but that may be due to the fact that EVALI looks a lot like flu–and it’s flu season.
  • CDC has confirmed 49 deaths caused by EVALI in 25 states, with additional deaths under investigation; the majority of deaths associated with EVALI occurred in older patients (the average age of deceased patients was 53, in a full age range of 17 to 73).
  • Of patients with complete ingredient information on their 90-day vaping product history:
    • 83% had used THC vaping products (35% exclusively)
    • 61% used nicotine vaping products (13% exclusively)
    • 48% reported dual use (using products containing THC and nicotine)
    • 4% (interestingly–and potentially significantly, assuming these patient self-reports are reliable) reported no THC or nicotine in the products they had vaped
  • Among patients who provided sufficient data for further demographic analysis:
    • 95% were hospitalized 
    • 68% were male
    • 77% were 35 years or younger

CDC also briefed Congress on the outbreak and its efforts, (including a thorough side-trip through concerns about youth vaping and cannabis) in October.

What’s New?

The most groundbreaking news of the past month is this: Between autopsy analyses of fluids taken from the lungs of those who did not survive EVALI and FDA-laboratory analysis of hundreds of samples of vaping products, experts believe we may be narrowing the broad field of suspicious agents. 

Vitamin E acetate, used to dilute vaping oils, appears to be strongly correlated with the EVALI cases being examined by CDC. And furthermore, vaping products obtained through “grey market,” informal, online, or otherwise less-than-reputable sources appear to be more strongly correlated with cases of EVALI. (In other words: “Street vapes” are sketchy vapes.)

Certainly, third-party adulteration, tampering, and compromise of vaping products could have contributed to the peak of the outbreak; the numbers of those being hospitalized today is significantly lower than at EVALI’s peak in August. So it is difficult to dismiss the possibility that in some cases, the drive to squeeze a few more drops of profit out of vape cartridges by adding cheap diluents may have cost people their lives.

What Should We Be Telling Patients?

  • No smoking is safe smoking, and no vaping is safe vaping. 
  • Human lungs evolved to breathe clear, clean, pure Earth atmosphere. Giving your lungs more detox work is a choice to make after weighing all the evidence carefully.
  • If you choose to smoke, or vape, you are introducing hundreds of unknown chemicals into vulnerable tissues. 
  • One of those chemicals may be vitamin E–great for skin and other organs when you swallow it, possibly not so great when it’s aerosolized and inhaled.
  • We do not know what vaping will do to you, in all honesty. We are working on it as fast as we can. 
  • CDC has a web page about EVALI for consumers that is regularly updated:

For now, this is the most critical takeaway from CDC’s own site:

CDC recommends that people should not use THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, or family, or in-person or online dealers. While this investigation is ongoing, vitamin E acetate should not be added to e-cigarette, or vaping, products.

In addition, people should not add any substance to e-cigarette or vaping products that are not intended by the manufacturer, including products purchased through retail establishments.

TL;DR: Don’t vape, but if you do choose to vape, please don’t “hack” vape fluids and cartridges.

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