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E-cigarette vaping associated acute lung injury (EVALI): state of science and future research needs
Open accessAbstract
"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.
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“THC vaping has been associated with pulmonary injury due to the contaminants in electronic cigarettes and vaping pens (e-cigarette, or vaping, product use associated lung injury or EVALI) [66].”
From Cannabis, cannabinoids and health: a review of evidence on risks and medical benefits (2025) · cites this paper as [66]
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“Age distribution showed 80% of the EVALI population is under the age of 34 years, with 17% aged between 13 and 17 years of age (Marrocco et al., 2022).”
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“Our findings align with reports of diffuse alveolar damage, bilateral ground-glass opacities, and increased inflammatory cells in BAL of E-cigarette or Vaping Use-Associated Lung Injury (EVALI) patients (Marrocco et al. 2022), highlighting similarities induced by inhalation exposure.”
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Metadata
- Authors
- Marrocco, A., Singh, D., Christiani, D. C., & Demokritou, P.
- Affiliations
- Harvard University (US)
- Rutgers, The State University of New Jersey (US)
- Corresponding author
- Demokritou, Philip
- Venue
- Critical Reviews in Toxicology
- Publisher
- Informa UK Limited
- Published
- 2022-03-16
- Volume
- 52
- Issue
- 3
- Pages
- 188-220
- ISSN
- 0045-6446 (ISSN-L)
- 1040-8444
- 1547-6898
- PMC
- PMC9716650
- OpenAlex
- W4285085267
- Semantic Scholar
- 842a5e89e02049f17e45dccd4c6c470858728430
- Cited by
- 78
- References
- 271
- Citations by year
- 2026: 17 · 2025: 19 · 2024: 28 · 2023: 14
- FWCI
- 2.10
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Critical Reviews in Toxicology (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- NIH
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Smoking Behavior and Cessation
- Health Sciences › Medicine › Emergency Medicine › Poisoning and overdose treatments
- Life Sciences › Pharmacology, Toxicology and Pharmaceutics › Toxicology › Forensic Toxicology and Drug Analysis
- Keywords
- alpha-tocopherol acetate, tetrahydrocannabinol, diffuse alveolar damage, ground-glass opacities, bronchoalveolar lavage, cannabidiol, medium-chain triglycerides, cytotoxicity, lung inflammation, terpenes, heavy metals, volatile organic compounds, pathophysiology
- MeSH terms
- Vaping, Adolescent, Humans, Male, Dronabinol, Vitamin E, Acute Lung Injury, Young Adult, Electronic Nicotine Delivery Systems
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