Vitamin E acetate was associated with EVALI (E-cigarette, or Vaping, products use Associated Lung Injury), reported on Nov 20th, 2019 by Centers of Disease Control (CDC).
Vitamin E is a fat-soluble vitamin. It is present in many foods, such as almonds, sunflower seeds and vegetable oils. Vitamin E is an antioxidant, and is important for normal function of many organs 1. Many of us take multivitamin pills containing vitamin E or use skin lotions containing vitamin E.
So how could vitamin E possibly cause EVALI?
EVALI officially gained its name earlier in 2019, after its outbreak in Wisconsin was reported 2. All reported cases involved use of E-cigarettes, or vaping products, within the past 90 days.
An E-cigarette is usually a battery-driven device that heats up liquid, and generate aerosol for users to inhale. Use of E-cigarettes is called vaping.
Although many E-cigarettes contain nicotine, some of them are nicotine-free, and some contain THC (tetrahydrocannabinol) or CBD (cannabidiol) oils. THC from marijuana is the chemical that gives users the sense of “high”.
As of Nov 20, 2019, 2,290 cases of EVALI and 47 deaths have been reported in the US. Age of the patients ranges from 13-78, with 77% under 35 years old.
It is unknown. Investigation is ongoing. Recent research has pointed to a few chemicals.
Vitamin E acetate – Lung fluid samples of 29 patients from 10 states were recently tested for possible chemicals from vaping products. Vitamin E was detected in all samples.
THC – THC was detected in 82% of above lung fluid samples from patients. Previously THC was considered a possible cause of EVALI, as 86% of patients used THC-containing products 3.
Nicotine – Nicotine was found in 60% of above lung fluid samples from patients, consistent with the rate of patients who use nicotine-containing products.
Other chemicals – Current research has not ruled out any other chemicals. CDC is still investigating those. It is possible more than one chemical causes EVALI.
We don’t know. Vitamin E is safe if we ingest it or apply it onto our skin.
Some earlier studies showed that, at higher than physiological concentration, vitamin E modifies properties of saturated phospholipids4,5. Researchers thus speculate that inhaled vitamin E may damage the inner surface of lung alveoli in a similar way 3,6.
How did vitamin E get into E-cigarettes? It is used as an additive in many E-cigarettes and often as a thickening agent in THC-containing products. While researching for this article, I wondered what has prompted manufacturers to choose vitamin E as an additive, and how E-cigarette production has been regulated? This will be a topic on another day.
Examination of patient lung tissue from biopsy or autopsy under microscope revealed acute lung injury and diffuse alveoli damage 7.
Pathologists also observed lipid-like material in lung fluids and inside macrophages cells, which might be related to oil products inhaled during vaping 8. However, some experts disagreed, arguing that other insults to lungs, such as infection, could result in similar pathological changes.
Patients have described a broad range of symptoms. Majority of patients had cough and short of breath. Some felt chest pain, feverish and chills. Gastrointestinal complains are also common, including nausea, vomiting, diarrhea and stomachache.
Many of these symptoms are unspecific, overlapping with those of other diseases such as pneumonia. The upcoming flu season will possibly add additional challenge to diagnosis of EVALI.
According to the latest guideline, EVALI is diagnosed based on vaping history, clinical features and results of selected tests. Other causes of pulmonary diseases such as viral and bacterial infections need to be ruled out.
There is no definite cure for EVALI yet, as the cause is unknown. Current treatment includes corticosteroids, supportive care and close follow-up.
No vitamin E acetate should be added to any vaping products;
Do not use any THC-containing vaping product;
Avoid vaping products from informal sources;
Vaping products should never be used by youth or pregnant women.
CDC continues to post weekly updates. Hopefully new research will uncover the real cause of EVALI and guide its prevention and treatment.
1. Burton GW, Joyce A, Ingold KU. Is vitamin E the only lipid-soluble, chain-breaking antioxidant in human blood plasma and erythrocyte membranes? Arch Biochem Biophys 1983;221(1):281–90.
2. Layden JE, Ghinai I, Pray I, et al. Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin — Preliminary Report. New England Journal of Medicine 2019;0(0):null.
3. Blount BC, Karwowski MP, Morel-Espinosa M, et al. 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. MMWR Morb Mortal Wkly Rep 2019;68(45):1040–1.
4. Massey JB, She HS, Pownall HJ. Interaction of vitamin E with saturated phospholipid bilayers. Biochem Biophys Res Commun 1982;106(3):842–7.
5. Kamal MA, Raghunathan VA. Modulated phases of phospholipid bilayers induced by tocopherols. Biochim Biophys Acta 2012;1818(11):2486–93.
6. Casals C, Cañadas O. Role of lipid ordered/disordered phase coexistence in pulmonary surfactant function. Biochim Biophys Acta 2012;1818(11):2550–62.
7. Henry TS, Kanne JP, Kligerman SJ. Imaging of Vaping-Associated Lung Disease. N Engl J Med 2019;381(15):1486–7.
8. More on the Pathology of Vaping-Associated Lung Injury. The New England Journal of Medicine 2019;4.
I received my MD from PUMC in Beijing China and my Ph.D. in Biochemistry from Stony Brook University on Long Island. Over the years, I have worked in the fields of genetic research and clinical medicine in different parts of the US, including PA, MO, CT, FL, NY and MI. My research has been published in multiple scientific journals. Currently I live in Ann Arbor, MI with my husband and our children and Mango the orange tabby. I love hiking, running, baking, cooking and biking.