E-cigarette vaping associated acute lung injury (EVALI): state of science and future research needs

Antonella Marrocco, Dilpreet Singh, David C. Christiani, Philip Demokritou

Research output: Contribution to journalReview articlepeer-review

2 Scopus citations


“E-Cigarette (e-cig) Vaping-Associated Acute Lung Injury” (EVALI) has been linked to vitamin-E-acetate (VEA) and Δ-9-tetrahydrocannabinol (THC), due to their presence in patients’ e-cigs and biological samples. Lacking standardized methodologies for patients’ data collection and comprehensive physicochemical/toxicological studies using real-world-vapor exposures, very little data are available, thus the underlying pathophysiological mechanism of EVALI is still unknown. This review aims to provide a comprehensive and critical appraisal of existing literature on clinical/epidemiological features and physicochemical-toxicological characterization of vaping emissions associated with EVALI. The literature review of 161 medical case reports revealed that the predominant demographic pattern was healthy white male, adolescent, or young adult, vaping illicit/informal THC-containing e-cigs. The main histopathologic pattern consisted of diffuse alveolar damage with bilateral ground-glass-opacities at chest radiograph/CT, and increased number of macrophages or neutrophils and foamy-macrophages in the bronchoalveolar lavage. The chemical analysis of THC/VEA e-cig vapors showed a chemical difference between THC/VEA and the single THC or VEA. The chemical characterization of vapors from counterfeit THC-based e-cigs or in-house-prepared e-liquids using either cannabidiol (CBD), VEA, or medium-chain triglycerides (MCT), identified many toxicants, such as carbonyls, volatile organic compounds, terpenes, silicon compounds, hydrocarbons, heavy metals, pesticides and various industrial/manufacturing/automotive-related chemicals. There is very scarce published toxicological data on emissions from THC/VEA e-liquids. However, CBD, MCT, and VEA emissions exert varying degrees of cytotoxicity, inflammation, and lung damage, depending on puffing topography and cell line. Major knowledge gaps were identified, including the need for more systematic-standardized epidemiological surveys, comprehensive physicochemical characterization of real-world e-cig emissions, and mechanistic studies linking emission properties to specific toxicological outcomes.

Original languageEnglish (US)
Pages (from-to)188-220
Number of pages33
JournalCritical Reviews in Toxicology
Issue number3
StatePublished - 2022
Externally publishedYes

All Science Journal Classification (ASJC) codes

  • Toxicology


  • acute lung injury
  • acute respiratory distress syndrome (ARDS)
  • counterfeit cartridges
  • e-cigarettes
  • pneumonia
  • vaping
  • vitamin E acetate (VEA)
  • Δ-9-tetrahydrocannabinol (THC)


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