Health economist Michael Pesko is asking the Centers for Disease Control and Prevention a question it should have answered years ago: Why is the agency still using a deeply misleading name for a health condition?
In an April 4 letter to CDC Acting Director Jay Bhattacharya, Dr. Pesko, professor of economics at the University of Missouri, urged the agency to reconsider the term “E-cigarette, or Vaping, Product Use-Associated Lung Injury,” or EVALI.
The term was adopted during a highly publicized spate of cases in 2019, which the CDC and other health authorities rapidly implied were caused by nicotine vapes. This sparked alarm in the United States and around the world—causing many people to revert from vaping to smoking, and leading to global policy ramifications that reverberate to this day.
Never mind that evidence soon indicated a different culprit; the damage to tobacco harm reduction was done.
“EVALI” still lumps together fundamentally different products in ways that mislead clinicians, the public and people who smoke.
Pesko wrote that the evidence points overwhelmingly to vitamin E acetate in unregulated, adulterated THC vaping products—not standard nicotine e-liquids—yet “EVALI” still lumps together fundamentally different products in ways that mislead clinicians, the public and people who smoke who might otherwise switch to less harmful alternatives.
It is vital that public health language should not spread confusion. Inaccurate terminology fosters public mistrust of our health organizations. Language shapes clinical assumptions, media framing, regulation and personal decisions. When the name of an outbreak points people toward the wrong product category, the misunderstanding can persist for years after the science has moved on.
The CDC has been asked this question before.
In August 2021, Pesko and a group of distinguished colleagues led a petition signed by 75 multidisciplinary experts, including seven former presidents of the Society for Research on Nicotine and Tobacco, asking the CDC to retire the term EVALI. The signers argued that the name was “ineffective and misleading” because, in ordinary language, “e-cigarette” refers to nicotine vaping. They warned that the term was driving misperceptions, stigmatizing nicotine vaping and confusing both the public and health professionals.
The CDC refused.
The 2019 outbreak was time-limited and geographically concentrated. That pattern is consistent with a poisoning event—not with an inherent property of nicotine vaping products.
In its September 22, 2021 response, the agency acknowledged that most cases were linked to THC-containing products from informal sources and that vitamin E acetate was strongly linked to the outbreak. But it still declined to rename EVALI, pointing to residual uncertainty and to reports that 14 percent of patients said they had exclusively used nicotine-containing products. But such self-reports warrant caution, especially in places where cannabis use remains banned, giving people a clear incentive not to disclose it.
The CDC’s decision may have sounded cautious. In practice, it has been costly.
The central facts have been clear for years. The 2019 outbreak was time-limited, geographically concentrated and strongly associated with a contaminated THC supply chain. It peaked in September 2019 and faded rapidly by early 2020. That pattern is consistent with a poisoning event—not with an inherent property of nicotine vaping products that had already been used for years.
Tobacco harm reduction expert Clive Bates put the logic bluntly in 2021: The evidence indicates that nicotine vaping was not the cause of the outbreak. Vitamin E acetate was the identified contaminant. It served an economic purpose in unregulated THC oils. It is not soluble in the propylene glycol and vegetable glycerin base used in nicotine e-liquids. And no parallel change in nicotine products explains why the outbreak rose and fell when it did.
That conclusion also fits what careful reporting uncovered in real time.
Polling showed that after the outbreak and the flood of media coverage, two-thirds of respondents associated the deaths with “e-cigarettes such as JUUL.”
Early in the crisis, investigators and journalists followed a trail through illicit-market THC cartridges, thickening agents, counterfeit packaging and fly-by-night brands like Dank Vapes. Reporting from Leafly, Inverse, Columbia Journalism Review and Filter documented how unregulated THC carts are often filled using tainted additives to mimic purity and stretch profits. New thickening agents had entered this market in late 2018. Vitamin E acetate emerged as a prime suspect because it was widespread, newly popular, cheap and found in the products used by sick patients.
Meanwhile, the very term EVALI nudged the public toward the wrong conclusion.
The 2021 experts’ letter cited polling showing that, after the outbreak and the flood of media coverage, two-thirds of respondents associated the deaths with “e-cigarettes such as JUUL,” while only 28 percent associated them with “marijuana or THC e-cigarettes.” That is not a harmless misunderstanding. It is a failure of risk communication. When the CDC’s label points people toward nicotine vaping, many people will never make it to the fine print.
Worse, as Pesko and the other experts warned, the confusion appears to have had behavioral consequences.
A 2021 article summarizing new evidence reported that the EVALI scare was associated with a sharp drop in nicotine vape sales and an immediate rise in cigarette consumption in both Massachusetts and around the US.
The damage did not stop there.
Once a misleading name takes hold, it spreads through hospital coding, state data systems and clinical practices. The misnamed EVALI outbreak heightened health care provider wariness, and later coding changes made it easier to tag visits as a “vaping-related disorder” without distinguishing the substance involved. Old panic can then live on in new datasets, where nicotine, THC, smoking and unrelated illness blur together.
The CDC cannot undo the frightened headlines from 2019. It cannot persuade every person who went back to cigarettes. But it can stop repeating the mistake.
The 75 experts proposed one replacement, ATHCVALI: Adulterated THC Vaping Associated Lung Injury. Whether or not that is the perfect substitute is almost beside the point. The larger issue is that the current label remains anchored to the confusion of the outbreak’s earliest days, not to the evidence.
Pesko’s new letter takes a restrained approach. It does not demand a specific acronym. It simply asks the CDC to revisit its terminology in light of the evidence and the real-world consequences of continued conflation.
The CDC should do exactly that. It should clearly state, without hedging, that the 2019–2020 outbreak was driven by adulterated THC vaping products, especially those contaminated with vitamin E acetate.
The CDC cannot undo the frightened headlines from 2019. It cannot reopen the vape shops that went under because of the panic. It cannot persuade every person who went back to cigarettes because they were falsely told, directly or by implication, that nicotine vaping had caused a wave of damaged lungs and death.
But it can stop repeating the mistake.
Photograph (cropped) by Reed Mansour via Flickr/Creative Commons 2.0
The Influence Foundation, which operates Filter, has received unrestricted grants from Juul Labs, Inc. Filter‘s Editorial Independence Policy applies.