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Study: Adult-Use Legalization Markets Not Tied to Vaping-Related Lung Illness

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States with well-established legal markets permitting adult-use [cannabis] sales experienced far fewer incidences of the vaping-related lung illness EVALI (e-cigarette or vaping product use-associated lung injury) as did jurisdictions where adult-use was prohibited, according to data published in the journal Addiction.

According to the study’s corresponding press release: “A negative relationship between EVALI prevalence and rates of pre-outbreak vaping and [cannabis] use suggests that well-established markets may have crowded-out use of riskier, informally sourced e-liquids. Indeed, the five earliest states to legalize recreational [cannabis] — Alaska, California, Colorado, Oregon and Washington — all had less than one EVALI case per 100,000 residents aged 12 to 64. None of the highest EVALI-prevalence states — Utah, North Dakota, Minnesota, Delaware and Indiana — allowed recreational [cannabis] use.”

Commenting on the findings, NORML Deputy Director Paul Armentano said, “These results come as little surprise. In jurisdictions where cannabis is legally regulated, consumers gravitate toward the above-ground retail marketplace where they can access lab-tested products manufactured by licensed businesses.”

He added, “Just like alcohol prohibition gave rise to the illicit production of dangerous ‘bathtub gin,’ [cannabis] prohibition provides bad actors, not licensed businesses, the opportunity to fulfill consumers’ demand – sometimes with tragic results.”

A prior analysis, published in April in the Journal of the American Medical Association (JAMA) Network Open similarly reported, “[EVALI cases] were concentrated in states where consumers do not have legal access to recreational [cannabis] dispensaries. … One possible inference from our results is that the presence of legal markets for [cannabis] has helped mitigate or may be protective against EVALI.”

According to the US Centers for Disease Control and Prevention, nearly 3,000 people sought hospitalization because of the illness, which peaked last September, and nearly 70 people died as a result of it. Late last year, the CDC publicly identified vitamin E acetate – a diluting agent sometimes present in counterfeit, unregulated vape pen products – as a primarily “culprit” in the outbreak. Earlier this year, the agency reiterated: “Vitamin E acetate is strongly linked to the EVALI outbreak. Vitamin E acetate has been found in product samples tested by FDA and state laboratories and in patients’ lung fluid samples tested by CDC from geographically diverse states. Vitamin E acetate has not been found in the lung fluid of people that do not have EVALI.”

The abstract of the study, “Association of vaping-related lung injuries with rates of e-cigarettes and cannabis use across US states,” appears online here. The study’s accompanying press release is online here.


NORML advocates for changes in public policy so that the responsible possession and use of [cannabis] by adults is no longer subject to criminal penalties. NORML further advocates for a regulated commercial cannabis market so that activities involving the for-profit production and retail sale of cannabis and cannabis products are safe, transparent, consumer-friendly, and are subject to state and/or local licensure. Finally, NORML advocates for additional changes in legal and regulatory policies so that those who use [cannabis] responsibly are no longer face either social stigma or workplace discrimination, and so that those with past criminal records for [cannabis]-related violations have the opportunity to have their records automatically expunged.

Find out more at and read our Fact Sheets on the most common misconceptions and myths regarding reform efforts around the country


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