A chest X-ray taken of a early victim of EVALI in Utah Image : AP

In a new report out Monday, health officials from the Centers for Disease Control and Prevention (CDC) have acknowledged that the wave of lung illness cases and deaths linked to vaping has a main bad guy: Products that contain THC sold on the black market. But to the disappointment of some experts, the agency is still recommending that people avoid using any e-cigarette or vaping products, regardless of their drug contents or whether they’re sold legally.




The report is the latest update to what’s become a coordinated investigation by the CDC, FDA, and state health agencies into the condition, now officially dubbed “e-cigarette, or vaping, product use associated lung injury,” or EVALI. According to the report, there have been 1,604 cases of EVALI in 49 states reported to the CDC as of mid October. There have also been 34 deaths across 24 states.


Sufferers of EVALI have experienced a range of severe respiratory and gastrointestinal symptoms, including trouble breathing and vomiting, with most people needing hospitalization. At this point, though, there is no concrete diagnostic test for EVALI. People have been diagnosed with it if they have a recent history of vaping and other potential causes for their symptoms such as infection have been ruled out. The median age of victims is 24, but the median age of those dead is 45.

The clear link between THC containing products and EVALI has been apparent since nearly the beginning, when cases were first reported in Wisconsin this August. And health officials in some states have been more overt in making a connection between the majority or all of their cases and THC products sold on the black market. CDC officials on the other hand have been more cautious in their wording, often only going as far as to state that THC products may play a role.

The latest findings underscore just how big that role really is. Out of the 867 cases with available product information, 86 percent of victims reported using THC products in the three months prior to their symptoms starting. That includes 34 percent who used THC products exclusively. By contrast, only 11 percent of EVALI cases have been linked to the exclusive use of nicotine products, as have three deaths.

The authors of the report also allude to the link between EVALI and illicit THC products, noting that patients seem to have “typically obtained their THC-containing e-cigarette, or vaping, products through informal sources, such as friends or illicit in-person and online dealers.” Despite this reality, they still offer a broad warning about vaping in general.


“[B]ecause 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,” they wrote.

But Angela Janis, a Wisconsin psychiatrist who has worked with patients who use medical cannabis, is one of many outside experts who are starting to have problems with the federal government’s approach to EVALI, including the CDC.


“I’ve had issue with their use of the terms vaping and e-cigarettes. The nomenclature they use seems to be intentionally confusing,” she told Gizmodo. “Generally, vaping is a delivery method, and e-cigarettes are colloquially known to be those vaping devices used for delivering nicotine, a sub-set of vaping rather than a synonym. The use of the terms synonymously purposefully conflates the two, but I think this leads to more confusion.”

It’s true that we still don’t understand why people are becoming so acutely sick from vaping, though it seems very likely that THC itself isn’t to blame. Some reports have tied the use of Vitamin E oil often found in illicit THC products to EVALI, since many victims have had a form of pneumonia known to be caused by inhaling oil. But not everyone’s lungs have been damaged in the same way, nor has Vitamin E been found in all of the implicated products.


It has become abundantly clear that illicit THC products are behind the vast majority of cases, though. And because some people may be reluctant to admit their use of these products, especially if they live in states where cannabis is still illegal, the percentage of cases linked to them may be even higher. People who use legally bought THC products, meanwhile, are left wondering just how much danger they’re in.

“I understand they want to make the guidance as far-reaching as possible with the current unknowns, but providing clearer data on this can help to guide some of these difficult conversations on risks vs benefits, especially in the populations of those using THC containing vapes for medical purposes,” Janis said.


Some drug policy experts have also criticized the actions taken so far by the federal and state governments i n the name of keeping people safe from EVALI. States such as New York and Utah have tried to pass bans on stores selling flavored nicotine products—though these have faced legal challenges—and the federal government is weighing its own version. In Massachusetts, all vaping products have been banned, period, until January 2020. Flavored products have definitely popularized vaping among teens, and there are real questions about whether the e-cigarette industry as a whole should have been better regulated long before 2019. But there’s no clear connection between these products and EVALI, and the bans could very well push some people to the black market.

“What we are seeing play out right now is a real life drama of how various substances are criminalized without justified reasoning and reliable research to do so,” Matt Sutton of the non-profit Drug Policy Alliance told Gizmodo. “Given that all evidence points to the substances in question being purchased off the street and not from legitimate licensed retailers, any bans that are put in place will only negatively impact the safest sources. Unfortunately, many lawmakers have purported the facts and taken advantage of these deaths to run a propaganda campaign aimed at banning vaping, given growing concerns around youth vaping.”


Even if a minority of EVALI cases do ultimately end up being caused by conventional e-cigarettes, the public still isn’t getting the inf ormation they need right now, according to Janis.

“I have not heard of any of these cases connected to large e-cig manufacturers like Juul. If they are implicated, that needs to be shared with all consumers. However, if not, that should also be shared, as many people are using e-cigs as a harm reduction tool,” she said. “I have been continually disappointed by the lack of acknowledgement of this in their vape messaging.”


In more recent months, the CDC has said that current e-cigarette users shouldn’t switch back to tobacco cigarettes out of fear of EVALI, following anecdotal reports of people doing just that. But as long as health officials are being vague about what’s really happening out there, people may very well start to tune out all their warnings.