Fact-check #01
EVALI: the missing cause
In 2020, the CDC identified the cause of the lung injury outbreak in the United States. Five years later, Brazil’s official guidance still doesn’t mention it.
What the source says
CDC, United States
Final outbreak update, February 2020
“Vitamin E acetate is strongly linked to the EVALI outbreak.”
THC
Most cases involved THC-containing products, “particularly from informal sources”.
78%
of patients got their products only from informal sources.
Don’t go back to smoking
The CDC’s final advice to adults who switched from cigarettes to nicotine vapes.
What was said in Brazil
Five official documents. None mentions THC or vitamin E.
Jun 2025
Joint Technical Note 233/2025
Ministry of Health, INCA and Anvisa
The official guidance for reporting EVALI in the country. Its example clinical case is a patient who used cannabis and a liquid with nicotine and CBD. The injury is attributed to the e-cigarette.
THC OR VITAMIN E: NOT MENTIONED
Feb 2024
Position letter
Brazilian Thoracic Society (SBPT)
Describes EVALI as a disease of e-cigarettes. The same letter calls the idea that vaping helps people quit a “myth”, without citing any cessation studies.
THC OR VITAMIN E: NOT MENTIONED
Dec 2023
Vote 459/2023
Anvisa Board of Directors
Cites “2,807 hospitalisations and 68 deaths” when describing the US e-cigarette “epidemic”, linking to the very CDC page that points to vitamin E.
THC OR VITAMIN E: NOT MENTIONED
Nov 2023
Letter 12/2023
Brazilian Society of Clinical Oncology, attached to the vote
Cites “acute harms already known (e.g. EVALI)” to oppose vaping, even as a way to quit smoking.
THC OR VITAMIN E: NOT MENTIONED
Oct 2023
Technical Note 58/2023
Ministry of Health, cited in the vote
“Some recent studies indicate that the use of [e-cigarettes] may increase the risk of heart disease and lung disorders, such as [...] EVALI.”
THC OR VITAMIN E: NOT MENTIONED
Quotes from Brazilian documents are free translations from Portuguese.
Why this matters
At the start of the outbreak, in 2019, the confusion was understandable. The CDC investigated every product and even advised people to stop using all e-cigarettes until the cause was found. Within months, the investigation had an answer: vitamin E acetate, used to dilute THC oil in illicit-market cartridges.
And even at the height of the outbreak, the United States did not ban nicotine vapes. It tightened the rules: a minimum age of 21 (Dec 2019), restrictions on flavoured cartridges (Jan 2020) and pre-market authorisation for each product.
What is not understandable is Brazil, in 2025, still holding on to the doubts of 2019. The mistake has two costs. It treats as a risk the product that helps smokers get off cigarettes. And it leaves THC users without a warning: they need to know the danger was in the adulterant from an uncontrolled market, not in the plant.
The lesson of EVALI is the same as that of vaping: unregulated markets make people sick. Getting the diagnosis wrong means getting the policy wrong.
What we are not saying
We are not saying Brazil’s diagnostic criteria are wrong: the CDC case definition also considers e-cigarette use in the previous 90 days. And we are not blaming THC. Cannabis use deserves a responsible debate, which is already happening in Brazil, however hard-fought. The problem is leaving out the cause and, with it, pointing public policy in the wrong direction.
Sources
CDC — Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products (Feb 2020) Joint Technical Note 233/2025 — Ministry of Health, INCA and Anvisa (in Portuguese) SBPT — Position on electronic smoking devices (Feb 2024, in Portuguese)Anvisa — Vote 459/2023, case 25351.911221/2019-74 (includes SBOC Letter 12/2023 and Ministry of Health Technical Note 58/2023)
FDA — enforcement policy on flavoured cartridges (Jan 2020), via ASCO Post