• Amy Heinzerling, Christina Armatas, Ellora Karmarkar, Kathleen Attfield, Weihong Guo, Yun Wang, Gordon Vrdoljak, Bahman Moezzi, Dadong Xu, Jeff Wagner, Jefferson Fowles, Charity Dean, Kristin J Cummings, and Jason A Wilken.
• Center for Healthy Communities, California Department of Public Health, Richmond.
• JAMA Intern Med. 2020 Jun 1; 180 (6): 861-869.

ImportanceSince August 2019, more than 2700 patients have been hospitalized with e-cigarette, or vaping, product use-associated lung injury (EVALI) across the United States. This report describes the outbreak in California, a state with one of the highest case counts and with a legal adult-use (recreational) cannabis market.ObjectiveTo present clinical characteristics and vaping product exposures of patients with EVALI in California.Design, Setting, And ParticipantsCase series describing epidemiologic and laboratory data from 160 hospitalized patients with EVALI reported to the California Department of Public Health by local health departments, who received reports from treating clinicians, from August 7 through November 8, 2019.ExposuresStandardized patient interviews were conducted to assess vaping products used, frequency of use, and method of product acquisition. Vaping products provided by a subset of patients were tested for active ingredients and other substances.Main Outcomes And MeasuresDemographic and clinical characteristics, level of care, and outcomes of hospitalization were obtained from medical record review.ResultsAmong 160 patients with EVALI, 99 (62%) were male, and the median age was 27 years (range, 14-70 years). Of 156 patients with data available, 71 (46%) were admitted to an intensive care unit, and 46 (29%) required mechanical ventilation. Four in-hospital deaths occurred. Of 86 patients interviewed, 71 (83%) reported vaping tetrahydrocannabinol (THC)-containing products, 36 (43%) cannabidiol (CBD)-containing products, and 39 (47%) nicotine-containing products. Sixty-five of 87 (75%) THC-containing products were reported as obtained from informal sources, such as friends, acquaintances, or unlicensed retailers. Of 87 vaping products tested from 24 patients, 49 (56%) contained THC. Vitamin E or vitamin E acetate was found in 41 (84%) of the THC-containing products and no nicotine products.Conclusions And RelevancePatients' clinical outcomes and vaping behaviors, including predominant use of THC-containing products from informal sources, are similar to those reported by other states, despite California's legal recreational cannabis market. While most THC products tested contained vitamin E or vitamin E acetate, other underlying cause(s) of injury remain possible. The California Department of Public Health recommends that individuals refrain from using any vaping or e-cigarette products, particularly THC-containing products from informal sources, while this investigation is ongoing.

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