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There have been 14 cases reported in Arizona. No deaths have been reported in Arizona. There have been 2,051 cases reported by 49 states (all except Alaska), the District of Columbia, and the U.S. Virgin Islands. There have been 39 deaths confirmed in 24 states and the District of Columbia. https://www.azdhs.gov/prevention/tobacco-chronic-disease/vape-outbreak/index.php

Vape-Related Pulmonary Illnesses As of November 13, 2019, the Alabama Department of Public Health (ADPH) has 10 cases of lung disease associated with e-cigarette product use, or vaping. Please see the breakdown of current cases in Alabama below: Total Reports Confirmed Probable Not a Case 33 5* 5 23 *1 Deceased http://alabamapublichealth.gov/tobacco/ecigs.html

Vacaville woman dead in California’s fourth vaping-related death, officials believe BY VINCENT MOLESKI NOVEMBER 13, 2019 06:16 PM A Vacaville woman died last week in what investigators believe is California’s fourth vaping-related death amid a rash of e-cigarette health concerns. Amanda Margot Arconti was treated in a hospital in Novato, where she later died after coming down with an illness, the Marin County Sheriff’s Office said in a news release. Arconti, who has family in Novato, is believed to have used e-cigarettes prior to her death, and Marin County health officials believe her death may have been connected to vaping. A county health officer told KRON4 that Arconti, 45, was previously healthy but came into the hospital experiencing chest pain and trouble breathing, resulting in her death within hours. A postmortem examination and toxicology tests are scheduled for Thursday in order to identify a definitive cause of death, according to the Sheriff’s Office. In a news release issued after Arconti’s death, the California Department of Public Health warned state residents to refrain from all forms of vaping, regardless of the substance or source of e-cigarette products. “It is tragic that yet another person has died from this cause in California and people continue to fall ill. We are working closely with the U.S. Food and Drug Administration, CDC, other state health departments and local health departments across California, investigating every case and testing products, and we’ll continue until this vaping associated outbreak is over,” CDPH director Dr. Sonia Angell said in a prepared statement. “Until that time, we urge everyone to stop vaping, especially products from informal sources.” Since August, the CDPH has received reports of 161 people with a history of vaping being hospitalized for severe breathing trouble and lung damage, while four people, including Arconti, have died. The CDPH said Vitamin E acetate has been identified as a potentially harmful agent present in e-cigarette products that may result in breathing problems and lung damage, but no definitive cause has been determined and no ingredients have been ruled out. https://amp.sacbee.com/news/local/health-and-medicine/article237341414.html?__twitter_impression=true

San Francisco Bay Area records its first death linked to vaping By Amy Graff, SFGATE Published 9:34 am PST, Wednesday, November 13, 2019 A Marin County woman has died due to complications related to vaping, health officials said Wednesday. This is the first death recorded in the San Francisco Bay Area associated with e-cigarette use. The victim was in her 40s and took up vaping six months ago. She was reportedly healthy before developing acute lung disease. “With sadness, we report that there has been a death in our community suspected to be caused by severe lung injury associated with vaping,” Marin County Public Health Officer Dr. Matt Willis said in a statement. More than 2,000 Americans who vape have gotten sick with lung damage since March, many of them teenagers and young adults, and at least 40 people have died. Four of those deaths have been in California. The California Department of Public Health has asked everyone to avoid vaping, no matter the substance or source, until investigations are complete. https://www.sfgate.com/bayarea/article/California-vaping-death-Marin-County-e-cigarette-14831940.php?utm_campaign=CMS Sharing Tools (Desktop)&utm_source=t.co&utm_medium=referral

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Since June 2019, CDPH has received reports that 161 people in California who have a history of vaping were hospitalized for severe breathing problems and lung damage, and four people have died. https://www.cdph.ca.gov/Programs/CCDPHP/Pages/Vaping-Health-Advisory.aspx

Teen receives double lung transplant after vaping-related illness CDC says vitamin E acetate could be to blame By Jen Christensen, CNN Posted: 7:43 PM, November 12, 2019Updated: 7:43 PM, November 12, 2019 Getty Images Shares: 14 (CNN) - Doctors at Henry Ford Health System in Detroit performed what they believe is the United States' first double lung transplant on a patient whose lungs were damaged after vaping, according to the hospital. The male patient, who turned 17 while recovering at the hospital, wants to remain anonymous for now, but was described as a high school athlete who likes to sail, play video games and hang out with friends. RELATED CONTENT Juul laying off 650 people in $1 billion cost-cutting plan Double lung transplant needed after vaping related injury Vitamin E acetate may be to blame for vaping illnesses, CDC says He was admitted to the hospital on September 5 with what looked like pneumonia. The transplant took place on October 15. The procedure was successful and doctors said he is doing "very well" and his recovery is "excellent." "It is a senseless disease process," Dr. Hassan Nemeh, the thoracic surgeon on the transplant team, said at a press conference Tuesday. Nemeh is the surgical director of thoracic organ transplant at Henry Ford Hospital. "Our teenage patient would have faced certain death if it weren't for the lung transplant." Nemeh said the extensive damage he saw in the boy's lungs was like "nothing I have ever seen before," in the nearly 20 years he has been doing transplant work. "This is an evil I haven't faced before." A letter from the boy's family, read during the press conference, said: "Our family could never have imagined being at the center of the largest adolescent public health crisis to face our country in decades. Within a very short period of time our lives have been forever changed." The boy has a good prognosis, but his recovery was described by doctors as a long and "rough" one that will take months. Now off a ventilator, the boy has had to work with a physical therapy team to walk again and regain his strength. The number of vaping-related injuries has climbed to at least 2,051 as of November 5, according to the US Centers for Disease Control and Prevention. So far, states have reported 40 deaths. "We believe we are seeing the tip of the iceberg, said Dr. Lisa Allenspach, the medical director of the Henry Ford lung transplant program. "Making sure that our teens understand the danger of vaping is of paramount importance." The CDC has been working closely with local health departments and the US Food and Drug Administration to pinpoint what exactly is causing these severe vaping-related illnesses. It doesn't appear that any one product is to blame, although many cases seem to be linked to products bought "off the street" or from other "informal sources," such as a family or friend, rather than from a vaping store, according to the CDC. The doctors in this case declined to say how long the teen had been vaping, nor did they say what vaping products he had been using. THC has been present in most of the samples of vaping products that the FDA has tested so far, and most of the patients who have gotten sick said they had used THC products in the past. On Friday, the CDC said Vitamin E acetate, an additive sometimes used in THC and other vaping products, may be to blame for the national outbreak, but said additional factors may be to blame. The CDC also is trying to figure out what the risk factors may be, if there are any, among those who have gotten sick. In the wake of these injuries, some states and cities have placed limits on sales of vaping products. Many of these actions are now being challenged in court. Some stores, including Walgreens and Walmart, have stopped selling vaping products. In September, President Donald Trump promised to take action. His administration has looked at a possible flavor ban, but so far nothing has happened. Until the public health investigation is complete, public health departments are saying to refrain from vaping. Dr. Nicholas Yeldo, the anesthesiologist on the teen's transplant team, hopes this case will serve as a reminder about exactly how serious these vaping illnesses are. "Without the heroic measures that were taken in this case, this young patient would have died, there is no doubt about it. So I beg of you, this was not just the unlucky one," Yeldo said. "This is happening way, way too much for us to turn our heads to this."

Teen receives double lung transplant after vaping-related illness CDC says vitamin E acetate could be to blame By Jen Christensen, CNN Posted: 7:43 PM, November 12, 2019Updated: 7:43 PM, November 12, 2019 https://www.news4jax.com/health/teen-receives-double-lung-transplant-after-vapingrelated-illness

Tonight 9 PM ET Dr. Henry NIman PhDAt Last A Major Factor Killing Vapers Is IdentifiedVaping And Vitamin E Acetate MMWR Early ReleaseVaping Lung Damage Risk Factors Illinois - MMWR

Dr. Henry NIman PhDAt Last A Major Factor Killing Vapers Is IdentifiedVaping And Vitamin E Acetate MMWR Early ReleaseVaping Lung Damage Risk Factors Illinois - MMWR

Tonight at 9 PM ET Dr. Henry NIman PhDAt Last A Major Factor Killing Vapers Is IdentifiedVaping And Vitamin E Acetate MMWR Early ReleaseVaping Lung Damage Risk Factors Illinois - MMWR

Updated November 8, 2019, at 1:00 PM EST What is New Recent CDC laboratory testing of bronchoalveolar lavage (BAL) fluid samples (or samples of fluid collected from the lungs) from 29 patients with EVALI submitted to CDC from 10 states found vitamin E acetate in all of the BAL fluid samples. Vitamin E acetate is used as an additive in the production of e-cigarette, or vaping, products. This is the first time that we have detected a potential chemical of concern in biologic samples from patients with these lung injuries. CDC continues to recommend that people should not use e-cigarette, or vaping, products that contain THC, particularly from informal sources like friends, or family, or in-person or online dealers. We will continue to provide updates as more data become available. What We Know New Laboratory Findings: Analyses of bronchoalveolar lavage (BAL) fluid samples (or samples of fluid collected from the lungs) of patients with e-cigarette, or vaping, product use associated lung injury identified vitamin E acetate, an additive in some THC-containing products. Recent CDC laboratory test results of BAL samples from 29 patients submitted to CDC from 10 states identified vitamin E acetate in all BAL fluid samples. THC was identified in 82% of the samples and nicotine was identified in 62% of the samples. CDC tested for a range of other chemicals that might be found in e-cigarette, or vaping, products, including plant oils, petroleum distillates like mineral oil, MCT oil, and terpenes (which are compounds found in or added to THC products). None of these potential chemicals of concern were detected in the BAL fluid samples tested. This is the first time that we have detected a potential chemical of concern in biologic samples from patients with these lung injuries. These findings provide direct evidence of vitamin E acetate at the primary site of injury within the lungs. These findings complement the ongoing work of FDAexternal icon and some state public health laboratories to characterize e-liquid exposures and inform the ongoing multistate outbreak. About the Outbreak: As of November 5, 2019, 2,051* cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have been reported to CDC from 49 states (all except Alaska), the District of Columbia, and 1 U.S. territory. Thirty-nine deaths have been confirmed in 24 states and the District of Columbia (as of November 5, 2019). Latest outbreak information is updated every Thursday. CDC continues to work closely with FDA, states, public health partners, and clinicians on this investigation. About Patient Exposure: All EVALI patients have reported a history of using e-cigarette, or vaping, products. THC is present in most of the samples tested by FDA to date, and most patients report a history of using THC-containing products. The latest national and state findings suggest products containing THC, particularly from informal sources like friends, or family, or in-person or online dealers, are linked to most of the cases and play a major role in the outbreak. What We Don't Know No one compound or ingredient has emerged as the cause of these illnesses to date; and it may be that there is more than one cause of this outbreak. Many different substances and product sources are still under investigation. While it appears that vitamin E acetate is associated with EVALI, evidence is not yet sufficient to rule out contribution of other chemicals of concern to EVALI. What CDC Recommends CDC recommends that you do not use e-cigarette, or vaping, products that contain THC. CDC also recommends that people should not: Buy any type of e-cigarette, or vaping, products, particularly those containing THC, off the street. Modify or add any substances to e-cigarette, or vaping, products that are not intended by the manufacturer, including products purchased through retail establishments. Since the specific compound or ingredient causing lung injury are not yet known, the only way to assure that you are not at risk while the investigation continues is to consider refraining from use of all e-cigarette, or vaping, products. Adults using e-cigarettes to quit smoking should not go back to smoking; they should weigh all risks and benefits and consider utilizing FDA-approved nicotine replacement therapiesexternal icon.. If people continue to use an e-cigarette, or vaping, product, carefully monitor yourself for symptoms and see a healthcare provider immediately if you develop symptoms like those reported in this outbreak. Irrespective of the ongoing investigation: E-cigarette, or vaping, products should never be used by youths, young adults, or women who are pregnant. Adults who do not currently use tobacco products should not start using e-cigarette, or vaping, products. There is no safe tobacco product. All tobacco products, including e-cigarettes, carry a risk. THC use has been associated with a wide range of health effects, particularly with prolonged heavy use. The best way to avoid potentially harmful effects is to not use THC, including through e-cigarette, or vaping, products. Persons with marijuana use disorder should seek evidence-based treatment by a health care provider. Top of Page Key Facts about Use of E-Cigarette, or Vaping, Products Electronic cigarettes — or e-cigarettes — are also called vapes, e-hookahs, vape pens, tank systems, mods, and electronic nicotine delivery systems (ENDS). Using an e-cigarette product is commonly called vaping. E-cigarettes work by heating a liquid to produce an aerosol that users inhale into their lungs. The liquid can contain: nicotine, tetrahydrocannabinol (THC) and cannabinoid (CBD) oils, and other substances and additives. THC is the psychoactive mind-altering compound of marijuana that produces the “high”. Key Facts about Vitamin E Acetate Vitamin E is a vitamin found in many foods, including vegetable oils, cereals, meat, fruits, and vegetables. It is also available as a dietary supplement and in many cosmetic products, like skin creams. Vitamin E acetate usually does not cause harm when ingested as a vitamin supplement or applied to the skin. However, previous research suggests when vitamin E acetate is inhaled, it may interfere with normal lung functioning. Vitamin E acetate is used as an additive in the production of e-cigarette, or vaping, products, because it resembles THC oil. Vitamin E acetate is also used as a thickening ingredient in e-liquids. If you have questions about CDC’s investigation into the lung injuries associated with use of e-cigarette, or vaping, products, contact CDC-INFO or call 1-800-232-4636. Latest Outbreak Information Updated every Thursday This complex investigation spans almost all states, involves over 2,000 patients, and a wide variety of brands and substances and e-cigarette, or vaping, products. As of November 5, 2019, 2,051* cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have been reported to CDC from 49 states (all except Alaska), the District of Columbia, and 1 U.S. territory. Thirty nine deaths in 24 states and the District of Columbia: Alabama, California (3), Connecticut, Delaware, District of Columbia, Florida, Georgia (3), Illinois (3), Indiana (3), Kansas (2), Massachusetts (2), Michigan, Minnesota (3), Mississippi, Missouri, Montana, Nebraska, New Jersey, New York, Oregon (2), Pennsylvania, Tennessee (2), Texas, Utah, and Virginia. The median age of deceased patients was 53 years and ranged from 17 to 75 years (as of November 5, 2019). More deaths are under investigation. Among 1,378 patients with data on sex (as of October 15, 2019): 70% of patients are male. Among 1,364 patients with data on age (as of October 15, 2019): The median age of patients is 24 years and ages range from 13 to 75 years. 79% of patients are under 35 years old. By age group category: 14% of patients are under 18 years old; 40% of patients are 18 to 24 years old; 25% of patients are 25 to 34 years old; and 21% of patients are 35 years or older. Among 867 patients with information on substances used in e-cigarette, or vaping, products in the 3 months prior to symptom onset** (as of October 15, 2019): About 86% reported using THC-containing products; 34% reported exclusive use of THC-containing products. About 64% reported using nicotine-containing products; 11% reported exclusive use of nicotine-containing products. Number of Lung Injury Cases Reported to CDC as of November 5, 2019 Dates of symptom onset and hospital admission for patients with lung injury associated with e-cigarette use, or vaping — United States, March 31-November 2, 2019 Top of Page What CDC is Doing Public Health Response: CDC’s Lung Injury response efforts are committed to: Identify and define the risk factors and the source for lung disease associated with e-cigarette product use, or vaping. Detect and track confirmed and probable cases in the US. Communicate actionable recommendations to state, local, and clinical audiences. Establish lab procedures that can assist with the public heath investigation and patient care. Partnerships: CDC is working 24/7 to identify the cause or causes of this outbreak through partnerships with states and other federal agencies. CDC continues to work closely with FDA, states, public health partners, and clinicians on this investigation by providing consultation and technical assistance to states on communication, health alerts, public outreach, and surveillance. CDC has activated the Emergency Operations Center (EOC) to coordinate activities and provide assistance to states, public health partners and clinicians around the nation. CDC worked with states to create primary and out-of-hospital case definitions to classify confirmed and probable cases in a consistent way. States are in the process of classifying patients. CDC will report numbers of confirmed and probable lung injury cases once states have finalized their classification of cases. By invitation, CDC has deployed Epidemic Intelligence Service (EIS) officers and other CDC staff to support states. Media and Communication: CDC is maintaining an outbreak webpage with key messages and weekly updates on case counts, deaths, and resources. CDC is holding congressional briefings, media telebriefings, and regular calls with health departments, clinicians to provide timely updates. Laboratory Testing: CDC is currently testing bronchoalveolar lavage (BAL) fluid samples and other samples. CDC is testing pathologic specimens, including lung biopsy or autopsy specimens, associated with patients. CDC is offering aerosol emission testing of case-associated product samples from e-cigarette, or vaping, products and e-liquids. Analysis of aerosol emissions will augment FDA’s ongoing work to characterize e-liquid and will improve our understanding of exposure among case-patients associated with the Lung Injury outbreak. CDC is coordinating e-cigarette, or vaping, product analysis with FDA. Results may provide insight into the nature of the chemical exposure(s) contributing to this outbreak. CDC developed guidance documents to assist public health laboratories, healthcare providers, pathologists, and others with specimen collection, storage, and submission to CDC for testing. For more information and resources visit For the Public, For Healthcare Providers and For State and Local Health Departments as well as our Publications and Resources page. * The increase in lung injury cases from last week represents both new patients and recent reporting of previously-identified patients to CDC. ** Based on complete reports received. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html

References Moritz ED, Zapata LB, Lekiachvili A, et al.; Lung Injury Response Epidemiology/Surveillance Group; Lung Injury Response Epidemiology/Surveillance Task Force. Update: characteristics of patients in a national outbreak of e-cigarette, or vaping, product use associated lung injuries. MMWR Morb Mortal Wkly Rep 2019;68:985–9. CrossRefexternal icon PubMedexternal icon Ritchel M. New York State suspects vitamin E may have played a role in vaping illnesses. New York Times. September 5, 2019. https://www.nytimes.com/2019/09/05/health/vaping-illness-lung-vitamin-e.html?smid=nytcore-ios-shareexternal icon Ritchel M, Grady D. What you need to know about vaping-related lung illness. New York Times. September 11, 2019. https://www.nytimes.com/2019/09/07/health/vaping-lung-illness.html?smid=nytcore-ios-shareexternal icon Downs D. Amid vape pen lung disease deaths: what exactly is vitamin E oil? Seattle, WA: Leafly; 2019. https://www.leafly.com/news/health/vape-pen-lung-disease-vitamin-e-oil-explainedexternal icon Kamal MA, Raghunathan VA. Modulated phases of phospholipid bilayers induced by tocopherols. Biochim Biophys Acta 2012;1818:2486–93. CrossRefexternal icon PubMedexternal icon Massey JB, She HS, Pownall HJ. Interaction of vitamin E with saturated phospholipid bilayers. Biochem Biophys Res Commun 1982;106:842–7. CrossRefexternal icon PubMedexternal icon Casals C, Cañadas O. Role of lipid ordered/disordered phase coexistence in pulmonary surfactant function. Biochim Biophys Acta 2012;1818:2550–62. CrossRefexternal icon PubMedexternal icon Siegel DA, Jatlaoui TC, Koumans EH, et al.; Lung Injury Response Clinical Working Group; Lung Injury Response Epidemiology/Surveillance Group. 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. MMWR Morb Mortal Wkly Rep 2019;68:919–27. CrossRefexternal icon PubMedexternal icon CDC. Outbreak of lung injury associated with the use of e-cigarette, or vaping, products. Atlanta, GA: US Department of Health and Human Services, CDC; 2019. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#what-cdc-recommends

CDC, the Food and Drug Administration (FDA), state and local health departments, and multiple public health and clinical partners are investigating a national outbreak of e-cigarette, or vaping, product use–associated lung injury (EVALI). Based on data collected as of October 15, 2019, 86% of 867 EVALI patients reported using tetrahydrocannabinol (THC)-containing products in the 3 months preceding symptom onset (1). Analyses of THC-containing product samples by FDA and state public health laboratories have identified potentially harmful constituents in these products, such as vitamin E acetate, medium chain triglyceride oil (MCT oil), and other lipids (2,3) (personal communication, D.T. Heitkemper, FDA Forensic Chemistry Center, November 2019). Vitamin E acetate, in particular, might be used as an additive in the production of e-cigarette, or vaping, products; it also can be used as a thickening agent in THC products (4). Inhalation of vitamin E acetate might impair lung function (5–7). Bronchoscopy and bronchoalveolar lavage† (BAL) can be part of the clinical and diagnostic workup of EVALI patients. The decision to perform this procedure is made by the clinical team on a case-by-case basis (8). During August–October 2019, BAL fluid specimens were collected by clinical teams caring for hospitalized EVALI patients. Public health laboratories and health departments from 10 states (California, Connecticut, Hawaii, Illinois, Maryland, Michigan, Minnesota, Texas, Utah, and Wisconsin) coordinated the submission of residual BAL fluid specimens from 29 patients to CDC. To better characterize exposure among EVALI patients, CDC developed and validated isotope dilution mass spectrometry methods to analyze specific toxicants of concern and active compounds in case-associated BAL fluid.§ These CDC analytic methods can identify vitamin E acetate, MCT oil (medium chain triglycerides), plant oils (long chain triglycerides), petroleum distillates (including mineral oil), diluent terpenes, cannabinoids, and nicotine in BAL fluid. The quality of case-associated BAL specimens was assessed by measuring dipalmitoylphosphatidylcholine (DPPC), the principal phospholipid in naturally-occurring lung surfactant: the presence of acceptable levels of DPPC confirms that the lavage procedure recovered adequate pulmonary epithelial fluid. When specimen volume was insufficient to perform all planned analyses, analysis of vitamin E acetate and cannabinoids was prioritized. Among the 27 BAL fluid specimens with sufficient volume for testing, all had measurable levels of DPPC. Overall, 21 (72%) patients with available specimens were male, and their median age was 23 years (range = 16–67 years), which is consistent with the sex and age patterns of EVALI patients reported to CDC to date (1). Two of the patients died. Vitamin E acetate was detected in all 29 patient BAL samples. Among 23 patients for whom self-reported THC use information was available, 20 reported using THC-containing products. THC or its metabolites were detected in 23 of 28 patient BAL samples, including in those of three patients who said they did not use THC products. Nicotine metabolites were detected in 16 of 26 patient BAL specimens. Results for plant oils, MCT oil, petroleum distillates, and diluent terpenes were all below analyte-specific levels of detection (typically in the low ng/mL range). This is the first reported identification of a potential toxicant of concern (vitamin E acetate) in biologic specimens obtained from EVALI patients. These findings provide direct evidence of vitamin E acetate at the primary site of injury among EVALI patients and are consistent with FDA product testing and media reports of state public health laboratory testing documenting vitamin E acetate in product samples used by EVALI patients (2,3) (Personal communication, D.T. Heitkemper, FDA Forensic Chemistry Center, November 2019). Other diluents and additives of concern (e.g., plant oils, MCT oil, petroleum distillates, and diluent terpenes) were notably not detected in BAL fluid specimens from EVALI patients. Although vitamin E acetate was detected in all specimens in this analysis of a convenience sample of 29 EVALI case-associated BAL specimens, additional studies are needed, including comparison with BAL fluid specimens from healthy volunteers and animal studies using controlled exposures to establish whether a causal link exists between this exposure and EVALI. Based on these data from 29 patients, it appears that vitamin E acetate is associated with EVALI; however, it is possible that more than one compound or ingredient could be a cause of lung injury, and evidence is not yet sufficient to rule out contribution of other toxicants to EVALI. These findings reinforce CDC’s recommendation that persons should not use e-cigarette, or vaping, products containing THC, especially those obtained from informal sources such as friends or family, or those from the illicit market, where product ingredients are unknown or can be highly variable (9). Until the relationship of vitamin E acetate and lung health is better characterized, it is important that vitamin E acetate not be added to e-cigarette, or vaping, products. CDC will continue to update guidance, as appropriate, as new data become available from this outbreak investigation. Top Corresponding author: Benjamin C. Blount, [email protected], 770-488-7894.

Evaluation of Bronchoalveolar Lavage Fluid from Patients in an Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injury — 10 States, August–October 2019 Early Release / November 8, 2019 / 68 Benjamin C. Blount, PhD1*; Mateusz P. Karwowski, MD1*; Maria Morel-Espinosa, PhD1; Jon Rees, PhD1; Connie Sosnoff, MA1; Elizabeth Cowan, PhD1; Michael Gardner, MS1; Lanqing Wang, PhD1; Liza Valentin-Blasini, PhD1; Lalith Silva, PhD1; Víctor R. De Jesús, PhD1; Zsuzsanna Kuklenyik, PhD1; Cliff Watson, PhD1; Tiffany Seyler, PhD1; Baoyun Xia, PhD1; David Chambers, PhD1; Peter Briss, MD2; Brian A. King, PhD3; Lisa Delaney, MS4; Christopher M. Jones, PharmD, DrPH5; Grant T. Baldwin, PhD6; John R. Barr, PhD1; Jerry Thomas, MD1; James L. Pirkle, MD, PhD1 1Division of Laboratory Sciences, National Center for Environmental Health, CDC; 2Office of the Director, National Center for Chronic Disease Prevention and Health Promotion, CDC; 3Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC; 4Office of the Director, National Institute for Occupational Safety and Health, CDC; 5Office of Strategy and Innovation, National Center for Injury Prevention and Control, CDC; 6Division of Overdose Prevention, National Center for Injury Prevention and Control, CDC. Top * These two authors contributed equally. † Bronchoalveolar lavage, performed in the evaluation of lung disease, involves instillation of sterile saline into a subsegment of the lung, followed by suction and collection of the fluid for analysis. § CDC has not yet published these validated isotope dilution mass spectrometry methods.

This is the first reported identification of a potential toxicant of concern (vitamin E acetate) in biologic specimens obtained from EVALI patients. These findings provide direct evidence of vitamin E acetate at the primary site of injury among EVALI patients and are consistent with FDA product testing and media reports of state public health laboratory testing documenting vitamin E acetate in product samples used by EVALI patients (2,3) (Personal communication, D.T. Heitkemper, FDA Forensic Chemistry Center, November 2019). Other diluents and additives of concern (e.g., plant oils, MCT oil, petroleum distillates, and diluent terpenes) were notably not detected in BAL fluid specimens from EVALI patients. https://www.cdc.gov/mmwr/volumes/68/wr/mm6845e2.htm?s_cid=mm6845e2_w

References CDC. Outbreak of lung injury associated with e-cigarette use, or vaping. Atlanta, GA: US Department of Health and Human Services, CDC; 2019. https://www.cdc.gov/lunginjury Moritz ED, Zapata LB, Lekiachvili A, et al.; Lung Injury Response Epidemiology/Surveillance Group; Lung Injury Response Epidemiology/Surveillance Task Force. Update: characteristics of patients in a national outbreak of e-cigarette, or vaping, product use–associated lung injuries—United States, October 2019. MMWR Morb Mortal Wkly Rep 2019;68:985–9. CrossRefexternal icon PubMedexternal icon Ghinai I, Pray IW, Navon L, et al. E-cigarette product use, or vaping, among persons with associated lung injury—Illinois and Wisconsin, April–September 2019. MMWR Morb Mortal Wkly Rep 2019;68:865–9. CrossRefexternal icon PubMedexternal icon Illinois Department of Public Health. E-cigarettes and vapes. Springfield, IL: Illinois Department of Public Health; 2019. http://www.dph.illinois.gov/topics-services/prevention-wellness/tobacco/e-cigarettes-and-vapesexternal icon Kirkham C, Dastin J. Explainer: one possible culprit in vaping lung illnesses—“Dank Vapes.” Washington, DC: Reuters; 2019. https://www.reuters.com/article/us-health-vaping-industry-explainer-idUSKCN1VY2ETexternal icon US Department of Health and Human Services. Surgeon General’s advisory on e-cigarette use among youth. Washington, DC: US Department of Health and Human Services, CDC; 2018. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/surgeon-general-advisory/index.html Schauer GL, King BA, Bunnell RE, Promoff G, McAfee TA. Toking, vaping, and eating for health or fun: marijuana use patterns in adults, U.S., 2014. Am J Prev Med 2016;50:1–8. CrossRefexternal icon PubMedexternal icon

TABLE 3. Characteristics of e-cigarette, or vaping, product use behaviors among adult* EVALI patients and survey respondents†,§ who reported using tetrahydrocannabinol (THC)-containing products — Illinois, July–October 2019 Characteristic No./Total no. (%) Odds ratio (95% CI)¶ P-value¶ Adjusted odds ratio (95% CI)** P-value EVALI patients (n = 66) Survey respondents (n = 519) Sex Men 49/66 (74) 341/519 (66) 1.6 (0.8–2.7) 0.17 1.6 (0.9–3.0) 0.11 Women 17/66 (26) 178/519 (34) reference —†† —†† —†† Age group (yrs) 18–29 54/66 (82) 222/519 (43) 6.0 (3.1–11.5) <0.0001 —** —** 30–44 12/66 (18) 297/519 (57) reference —†† —†† —†† Race/Ethnicity All other racial/ethnic groups§§ 23/66 (35) 87/519 (17) 2.9 (1.7–5.2) 0.0001 —** —** Unknown 6/66 (9) 22/519 (4) 3.0 (1.2–7.9) 0.03 —** —** White, non-Hispanic 37/66 (56) 410/519 (79) reference —†† —†† —†† E-cigarette, or vaping, use behavior Any nicotine-containing products 45/66 (68) 237/361 (66) 1.1 (0.6–2.0) 0.69 1.1 (0.6–1.9) 0.87 Only nicotine-containing products 10/45 (22) 0/237 (0) —¶¶ —¶¶ —¶¶ —¶¶ Any nicotine-containing product <1x/day,***,††† 5/42 (12) 16/232 (7) 1.8 (0.5–5.6) 0.34 1.4 (0.5–4.2) 0.57 Any nicotine-containing product >5x/day*** 27/42 (64) 178/232 (77) 0.5 (0.3–1.1) 0.09 0.8 (0.4–1.7) 0.57 Any THC-containing products¶¶ 56/66 (85) 519/519 (100) —¶¶ —¶¶ —¶¶ —¶¶ Only THC-containing products 21/56 (38) 124/519 (24) 1.9 (1.1–3.4) 0.03 2.0 (1.1–3.6) 0.03 Any THC-containing product <1x/day*** 7/49 (14) 122/403 (30) 0.4 (0.2–0.9) 0.02 0.4 (0.2–1.0) 0.04 Any THC-containing product >5x/day*** 19/49 (39) 76/403 (19) 2.7 (1.5–5.1) 0.001 3.1 (1.6–6.0) 0.0009 Dank Vapes§§§ 45/53 (85) 140/391 (36) 10.1 (4.6–22.0) <0.0001 8.5 (3.8–19.0) <0.0001 Obtained any THC-containing product informally¶¶¶ 48/50 (96) 251/378 (66) 12.1 (2.9–50.8) <0.0001 9.2 (2.2–39.4) 0.003 Both THC- and nicotine-containing products 35/66 (53) 237/361 (66) 0.59 (0.3–1.0) 0.05 0.56 (0.3–1.0) 0.05 Abbreviations: CI = confidence interval; EVALI = E-cigarette, or vaping, product use–associated lung injury; THC = tetrahydrocannabinol. * Online survey responses were collected during September 17–October 8, 2019. Survey respondents were asked about e-cigarette, or vaping, product use in the 3 months preceding survey completion; EVALI patients were asked about e-cigarette, or vaping, product use in the 3 months preceding symptom onset. † Aged 18–44 years. § Only survey respondents who resided in one of the 28 Illinois counties with any reported outbreak-associated EVALI cases during July 31-October 15, 2019 were included in this analysis. ¶ Calculated using Pearson’s chi-square test. ** Adjusted for race/ethnicity and age group. Each adjusted odds ratio used the age group ≥30 years and non-Hispanic white as the reference group. Therefore, adjusted odd ratios for age groups and race/ethnicity are not presented. †† Values were not calculated for reference cells. §§ Includes survey respondents who identified as Hispanic, non-Hispanic black, and non-Hispanic other. ¶¶ Only survey respondents who reported using THC-containing e-cigarette, or vaping, products in the past 3 months were included in this analysis, therefore, odds ratios were not calculated for this e-cigarette, or vaping, use behavior. *** Frequency of use was reported by individual product. If any e-cigarette, or vaping, product was reported as being used more than five times a day, the survey respondent or case were classified as using that class of product (e.g., nicotine- or THC-containing) more than five times/day. The same criteria were used to classify product use frequency as less than one time/day). ††† Because of small cell size, Fisher’s exact test was used to calculate the 95% CI and p-value for the unadjusted odds ratio. §§§ Dank Vapes are a class of largely counterfeit THC-containing products of unknown provenance that are marketed under a common name and distributed through informal sources. ¶¶¶ Obtaining any THC-containing e-cigarette, or vaping, products from informal sources (a dealer, off the street, or from a friend) was compared with obtaining any THC-containing products from a formal source (store or licensed dispensary). Because online sources might be formal (e.g., a licensed dispensary) or informal, persons who reported online purchases were excluded from this analysis. No EVALI patients and <1% of public survey respondents reported online purchases.

TABLE 2. E-cigarette, or vaping, product use behaviors among survey respondents aged ≥18 years who used e-cigarettes during the 3 months preceding the survey (N = 4,631), by age group and sex — Illinois, July–October 2019* E-cigarette, or vaping, use behavior 18–34 years (n = 1,874) ≥35 years (n = 2,757) All ages No./Total no. (%) P-value† No./Total no. (%) P-value† No./Total no. (%) P-value† Men (n = 1,283) Women (n = 591) Men (n = 1,752) Women (n = 1,005) Men (n = 3,035) Women (n = 1,596) Any nicotine-containing products 964/1,020 (95) 414/459 (90) 0.002 1,448/1,511 (96) 815/863 (94) 0.12 2,412/2,531 (95) 1,229/1,322 (93) 0.003 Only nicotine-containing products 809/964 (84) 342/414 (83) 0.55 1,309/1,448 (90) 762/815 (94) 0.01 2,118/2,412 (88) 1,104/1,229 (90) 0.07 Any nicotine-containing product <1x/day§ 21/956 (2) 19/407(5) 0.01 17/1,428 (1) 10/800 (1) 0.90 36/2,382 (2) 24/1,202 (2) 0.28 Any nicotine-containing product >5x/day§ 780/956 (82) 309/407 (76) 0.02 1,271/1,428 (89) 663/800 (83) <0.0001 2,051/2,384 (86) 972/1,207 (82) <0.0001 Any THC-containing products 321/1,243 (26) 174/564 (31) 0.03 282/1,716 (16) 153/989 (15) 0.51 603/2,959 (20) 327/1,553 (21) 0.59 Only THC-containing products 56/321 (17) 45/174 (26) 0.03 63/282 (22) 48/153 (31) 0.04 119/603 (20) 93/327 (28) 0.003 Any THC-containing product <1x/day§ 64/255 (25) 44/123 (36) 0.03 74/220 (34) 36/110 (33) 0.87 138/475 (29) 80/233 (34) 0.15 Any THC-containing product >5x/day§ 64/255 (25) 16/123 (13) 0.007 40/220 (18) 24/110 (22) 0.43 104/475 (22) 40/233 (17) 0.14 Dank Vapes¶ 102/240 (42) 51/126 (40) 0.71 53/223 (24) 19/105 (18) 0.25 155/463 (33) 70/231 (30) 0.40 Obtained any THC-containing product informally** 172/240 (72) 82/120 (68) 0.51 118/210 (56) 42/107 (39) 0.004 290/450 (64) 124/227 (55) 0.01 Both THC- and nicotine-containing products 155/1,020 (15) 72/459 (16) 0.81 138/1,510 (9) 53/863 (6) 0.01 293/2,530 (12) 125/1,322 (9) 0.04 Abbreviations: CI = confidence interval; THC = tetrahydrocannabinol. * Online survey responses were collected during September 17–October 8, 2019. † Calculated using Pearson’s chi-square test. § Frequency of use was reported by individual product. If any e-cigarette, or vaping, product was reported as being used more than five times a day, the survey respondent was classified as using that class of product (nicotine- or THC-containing) more than five times/day. The same criteria were used to classify product use as less than one time/day. ¶ Dank Vapes are a class of largely counterfeit THC-containing products of unknown provenance that are marketed under a common name and distributed through informal sources. ** Obtaining any THC-containing e-cigarette, or vaping, products from informal sources (a dealer, off the street, or from a friend) was compared with obtaining any THC-containing products from a formal source (store or licensed dispensary). Because online sources might be formal (e.g., a licensed dispensary) or informal, persons who reported online purchases were excluded from this analysis. Fewer than 1% of public survey respondents reported online purchases.

TABLE 1. E-cigarette, or vaping, and combustible product use among survey respondents aged ≥18 years who used e-cigarettes during the 3 months preceding the survey (N = 4,631), by age group, sex, and race/ethnicity — Illinois, July–October 2019* Characteristic No./Total no. (%) E-cigarette, or vaping, product use Combustible product use All respondents THC-containing only† Nicotine-containing only† Both THC- and nicotine-containing† Any nicotine-containing Any THC-containing Marijuana Cigarettes Age group (yrs) 18–24 29/443 (7) 306/443 (69) 108/443 (24) 414/443 (93) 206/571 (36) 264/592 (45) 56/592 (9) 601 (13) 25–34 72/1,036 (7) 845/1,036 (82) 119/1,036 (11) 964/1,036 (93) 289/1,236 (23) 353/1,256 (28) 83/1,256 (7) 1,273 (27) 35–44 54/1,238 (4) 1,053/1,238 (85) 131/1,238 (11) 1,185/1,239 (96) 264/1,422 (19) 309/1,437 (21) 77/1,437 (5) 1,457 (31) ≥45 57/1,135 (5) 1,018/1,135 (90) 60/1,135 (5) 1,078/1,135 (95) 171/1,283 (13) 193/1,291 (15) 93/1,290 (7) 1,300 (28) Sex Men 119/2,530 (5) 2,118/2,530 (84) 293/2,530 (12) 2,412/2,531 (95) 603/2,959 (20) 740/3,002 (25) 163/3,002 (5) 3,035 (66) Women 93/1,322 (7) 1,104/1,322 (84) 125/1,322 (9) 1,229/1,322 (93) 327/1,553 (21) 379/1,574 (24) 146/1,573 (9) 1,596 (34) Race/Ethnicity§,¶ White 165/3,304 (5) 2,789/3,304 (84) 350/3,304 (11) 3,140/3,305 (95) 757/3,836 (20) 919/3,885 (24) 252/3,884 (6) 3,932 (89) Black 6/60 (10) 42/60 (70) 12/60 (20) 54/60 (90) 24/74 (32) 26/78 (33) 10/78 (13) 79 (2) Other 12/149 (8) 119/149 (80) 18/149 (12) 137/149 (92) 47/183 (26) 57/187 (30) 13/187 (7) 188 (4) Hispanic 22/181 (12) 135/181 (75) 24/181 (13) 159/181 (88) 63/215 (29) 67/219 (31) 18/219 (8) 221 (5) All respondents 212/3,852 (5) 3,222/3,852 (84) 418/3,852 (11) 3,641/3,853 (94) 930/4,512 (21) 1,119/4,576 (24) 309/4,575 (7) 4,631 Abbreviation: THC = tetrahydrocannabinol. * Online survey responses were collected during September 17–October 8, 2019. † Only survey respondents who answered both the question about use of THC-containing e-cigarette products (n = 4,512) and the question about nicotine-containing e-cigarette products (n = 3,853) were used to calculate these mutually exclusive categories. § Whites, blacks, and persons of other races were non-Hispanic; Hispanic persons could be of any race. ¶ Race/ethnicity data was missing for 211 survey respondents.

Discussion Since the introduction of e-cigarettes into the United States in 2007, use of these devices has increased rapidly, particularly among youths (6). Although initially created for use with nicotine-containing products, e-cigarettes are also used to aerosolize THC (7). In this survey of Illinois residents who used e-cigarette, or vaping, products and did not have EVALI, use of THC-containing products was less prevalent (21%) than was use of nicotine-containing products (94%); however, a higher proportion of survey respondents aged <35 years reported using THC-containing products, consistent with the observed age distribution of EVALI patients in this outbreak both in Illinois and nationally (1,2). Two thirds of survey respondents were men, reflecting the sex distribution of outbreak-associated EVALI patients, in Illinois and nationally (1,2). Among persons aged 18–34 years, the prevalence of frequent daily use of both nicotine-containing and THC-containing e-cigarette, or vaping, products was higher among men than among women. These findings suggest that e-cigarette, or vaping, product use behaviors among younger adults, especially men, might place them at higher risk for developing EVALI associated with this outbreak. A much higher proportion of adult EVALI patients reported use of THC-containing e-cigarette, or vaping, products (85%) than did adults who use e-cigarette, or vaping, products and have not developed lung injury (21%). When e-cigarette, or vaping, product use among EVALI patients aged 18–44 years was compared with that of a subset of survey respondents aged 18–44 years who reported use of THC-containing products, a number of significant differences were found. Specifically, patients with EVALI had higher odds of reporting exclusive use of THC-containing products, as well as reporting frequent use of these products, obtaining them through informal sources, and using a counterfeit THC-containing product marketed as Dank Vapes. Because the comparative analysis was restricted to survey respondents who reported using THC-containing e-cigarette, or vaping products, the calculated ORs comparing THC-containing product use behaviors between EVALI patients and survey respondents are likely conservative. The findings in this report are subject to at least six limitations. First, the survey was restricted to persons aged ≥18 years and findings might not be representative of younger persons; 15% of EVALI patients in Illinois during July–October 2019 were aged <18 years. Second, survey respondents were self-selected and might not be representative of the overall population of persons who use e-cigarette, or vaping, products in Illinois. To address this potential for bias, the comparative analysis was restricted to survey respondents in the same age group, geographic areas of residence, and with similar types of product use as those of EVALI patients and was adjusted for higher survey response rates among whites and older adults. Third, only 58% of Illinois EVALI patients aged 18–44 years have been interviewed; this nonresponse rate might introduce selection bias, although the characteristics of interviewed patients were similar to those of all reported EVALI patients. Fourth, EVALI patients who reported exclusive use of nicotine-containing products were also included in the comparative analysis with the subset of survey respondents who reported use of THC-containing products. Including these EVALI patients might have introduced bias, however, the prevalence of using nicotine-containing products was similar among the two groups. In addition, because analysis of product use behaviors was limited to only those persons who reported using a specific product (e.g., THC product use behaviors were only compared among EVALI patients and survey respondents who reported using THC-containing products) the inclusion of these EVALI patients did not affect the analysis of THC-containing product use behaviors. Fifth, although a similar survey instrument was used with EVALI patients and online survey respondents, most EVALI patients were interviewed by public health staff members via telephone. Differences in data collection methodology might have affected reporting of product use behaviors by EVALI patients compared with that of anonymous online survey respondents. Finally, these data were only collected from Illinois residents. Illinois has a comprehensive medical marijuana program in place but has not yet implemented sales of marijuana for recreational use; the legal purchase of tobacco products is restricted to persons aged ≥21 years. E-cigarette, or vaping, product use behaviors likely vary by jurisdictional policies that control access to these products; this might limit the generalizability of the results in this report. This is the first report to analyze e-cigarette, or vaping, product use behaviors associated with increased risk of EVALI during this outbreak. The use of an anonymous public survey facilitated the rapid collection of data to inform the ongoing investigation. Differences were observed in e-cigarette, or vaping, product use behaviors between adults who use THC-containing e-cigarette, or vaping, products and patients with EVALI. The findings in this report reinforce current recommendations that persons should not use e-cigarette, or vaping, products that contain THC, or any e-cigarette, or vaping, products obtained from informal sources such as off the street, from a dealer, or from a friend. In addition, because the specific compound or ingredient causing lung injury is not yet known, CDC continues to recommend that persons consider refraining from use of all e-cigarette, or vaping, products while the outbreak investigation continues (1). Top Acknowledgments Staff members and leadership of the Illinois Department of Public Health; local health department staff members; public survey respondents; all interviewed lung injury patients. Top Corresponding author: Livia Navon, [email protected], 312-814-3020.

The United States is experiencing an unprecedented outbreak of e-cigarette, or vaping, product use–associated lung injury (EVALI) (1). All EVALI patients have used e-cigarette, or vaping, products, and most (≥85%) have reported using products containing tetrahydrocannabinol (THC) (2,3), the principal psychoactive component of cannabis. To examine whether e-cigarette, or vaping, product use behaviors differed between adult EVALI patients and adults who use these products but have not developed lung injury, the Illinois Department of Public Health (IDPH) conducted an online public survey during September–October 2019 targeting e-cigarette, or vaping, product users in Illinois. Among 4,631 survey respondents, 94% reported using any nicotine-containing e-cigarette, or vaping, products in the past 3 months; 21% used any THC-containing products; and 11% used both THC-containing products and nicotine-containing products. Prevalence of THC-containing product use was highest among survey respondents aged 18–24 years (36%) and decreased with increasing age. E-cigarette, or vaping, product use behaviors of 66 EVALI patients aged 18–44 years who were interviewed as part of the ongoing outbreak investigation were compared with a subset of 519 survey respondents aged 18–44 years who reported use of THC-containing e-cigarette, or vaping, products. Compared with these survey respondents, EVALI patients had higher odds of reporting exclusive use of THC-containing products (adjusted odds ratio [aOR] = 2.0, 95% confidence interval [CI] = 1.1–3.6); frequent use (more than five times per day) of these products (aOR = 3.1, 95% CI = 1.6–6.0), and obtaining these products from informal sources, such as a dealer, off the street, or from a friend (aOR = 9.2, 95% CI = 2.2–39.4). The odds of using Dank Vapes, a class of largely counterfeit THC-containing products, was also higher among EVALI patients (aOR = 8.5, 95% CI = 3.8–19.0). These findings reinforce current recommendations not to use e-cigarette, or vaping, products that contain THC and not to use any e-cigarette, or vaping, products obtained from informal sources. In addition, because the specific compound or ingredient causing lung injury is not yet known, CDC continues to recommend that persons consider refraining from use of all e-cigarette, or vaping, products while the outbreak investigation continues (1). IDPH developed an online public survey targeting Illinois adults who use e-cigarette, or vaping, products based on the structured questionnaire developed by IDPH and administered to EVALI patients as part of the ongoing outbreak investigation. The public survey included questions about the types of e-cigarette, or vaping, products survey respondents used in the past 3 months, where these products were obtained, combustible cigarette and marijuana use, and any reported illness associated with e-cigarette, or vaping, product use. The public survey link was posted on the IDPH website during September 17–October 8, 2019 and was publicized through the media, posted on IDPH social media accounts, and promoted by local health departments (4). Because of an IDPH Institutional Review Board determination, the survey was restricted to persons aged ≥18 years. To compare survey respondents with EVALI patients, a subset of respondents with similar characteristics to those of EVALI patients was selected. Data were available for 137 EVALI patients reported to IDPH; 15% (20 of 137) were aged <18 years; of adult EVALI patients, 97% (113 of 117) were aged 18–44 years (Supplementary Figure, https://stacks.cdc.gov/view/cdc/82320).* Among EVALI patients aged 18–44 years, 66 of 113 (58%) had the structured patient questionnaire administered either via telephone, by a public health staff member (53 of 66, 80%); during an in-person interview, usually by a health care provider (nine of 66, 14%); or online (four of 66; 6%) (3). Among these 66 EVALI patients, 85% reported use of THC-containing e-cigarette, or vaping, products. Based on these characteristics of EVALI patients (i.e. primarily adults aged <44 years with high THC-containing product use prevalence), survey respondents for the comparative analysis were limited to those aged 18–44 years who reported use of THC-containing e-cigarette, or vaping, products. Survey respondents were further restricted to those who resided in one of the 28 Illinois counties with any reported EVALI cases and who did not report seeking health care for illness compatible with EVALI. All interviewed EVALI adult patients aged 18–44 years were included in the comparative analysis. Survey results were summarized with descriptive statistics. P-values were assessed using Pearson’s chi-square test; for cells with small numbers, Fisher’s exact test was used. To compare EVALI patients with the subset of survey respondents that reported using THC-containing products, aORs were calculated using multivariable logistic regression models that controlled for race/ethnicity and age group. P-values <0.05 were considered statistically significant. Analyses were conducted using SAS (version 9.4; SAS Institute). Among 7,704 survey respondents, 4,631 (60%) met the study inclusion criteria (i.e., Illinois residents aged ≥18 years who completed demographic questions, reported use of e-cigarette, or vaping, products in the past 3 months, and did not have EVALI) (Supplementary Figure, https://stacks.cdc.gov/view/cdc/82320).† The median age of included respondents was 38 years (range = 18–83 years), 3,035 (66%) were men, and 3,932 (89%) identified as non-Hispanic white (white) (Table 1). Overall, 3,641 (94%) respondents reported using any nicotine-containing e-cigarette, or vaping, products in the preceding 3 months, including 3,222 (84%) who reported exclusive use of nicotine-containing products. Use of any THC-containing e-cigarette, or vaping, products was reported by 930 (21%) of survey respondents, including 212 (5%) who used such products exclusively. Use of both nicotine-containing and THC-containing products was reported by 418 (11%) survey respondents. Prevalence of THC-containing product use decreased with increasing age: 36% and 13% of respondents aged 18–24 years and ≥45 years, respectively, reported using THC-containing products. Use of nicotine-containing products was consistent across age groups (93%–96%). Among survey respondents, use of combustible marijuana (24%) was higher than that of combustible tobacco (7%). Approximately 82% of male survey respondents aged 18–34 years reported frequent (more than five times per day) use of nicotine-containing e-cigarette, or vaping, products, compared with 76% of women of the same age (Table 2). Among adults aged 18–34 years, the prevalence of frequent use of THC-containing e-cigarette, or vaping, products was twice as high among men (25%) as among women (13%). Among survey respondents who reported any use of THC-containing products, exclusive use was reported by a higher proportion of women than of men both among those aged 18–34 years (26% versus 17%) and among those aged ≥35 years (31% versus 22%). A similar proportion of male and female survey respondents aged 18–34 years obtained THC-containing products from informal sources (a dealer, friends, or on the street) (72% and 68%, respectively); however, among adults aged ≥35 years, men were more likely to report informal sources of THC-containing products (56%) than were women (39%). Among the 4,631 survey respondents, 519 (11%) met the additional age, THC-use, and county of residence criteria for the comparative analysis with the 66 interviewed EVALI patients aged 18–44 years. Significant demographic differences between EVALI patients and this subset of survey respondents were identified (Table 3). Compared with the subset of survey respondents, EVALI patients had higher odds of being aged <30 years (odds ratio [OR] = 6.0, 95% CI = 3.1–11.5) and of identifying as a racial/ethnic group other than white (OR = 2.9, 95% CI = 1.7–5.2). Among EVALI patients who used THC-containing e-cigarette, or vaping, products, the odds for frequent use of these products were significantly higher compared with the subset of THC-using survey respondents (aOR = 3.1, 95% CI = 1.6–6.0). In addition, the odds were significantly higher among EVALI patients for exclusive use of THC-containing e-cigarette, or vaping, products (aOR = 2.0, 95% CI = 1.1–3.6) and obtaining THC-containing products through informal sources versus from a licensed dispensary or store§ (aOR = 9.2, 95% CI = 2.2–39.4). Compared with the subset of survey respondents, EVALI patients also had higher odds of reporting use of Dank Vapes (aOR = 8.5, 95% CI = 3.8–19.0), a class of largely counterfeit THC-containing products of unknown provenance that are marketed under a common name and distributed through informal sources (5).

Summary What is already known about this topic? Most U.S. patients with e-cigarette, or vaping, product use–associated lung injury (EVALI) report using tetrahydrocannabinol (THC)-containing e-cigarette, or vaping, products. Product use behaviors that increase risk for EVALI are unknown. What is added by this report? Compared with survey respondents aged 18–44 years reporting using of THC-containing e-cigarette, or vaping, products, EVALI patients aged 18–44 years had higher odds of reporting exclusive and frequent use of THC-containing products and obtaining these products from informal sources, such as a dealer, off the street, or from a friend, and of using Dank Vapes, a class of largely counterfeit THC-containing products. What are the implications for public health practice? CDC recommends not using THC-containing e-cigarette, or vaping, products, or any e-cigarette, or vaping, products obtained from informal sources.