The Name We Choose for What Happened
How a respiratory crisis became a problem of public health framing, and why evidence alone failed to correct it.
I ~ The Lung and the Void
In late July 2019, a man in his early twenties was admitted to a hospital in southeastern Wisconsin with an oxygen saturation below 85 percent. A level consistent with acute respiratory failure. He was an athlete. He didn’t smoke. He had no known history of lung disease. He was coughing up blood. He breathed with the visible effort of someone trying to pull air through a thick liquid.
The CT scan showed diffuse ground-glass opacities with whitish patches scattered across the lungs, as if an oily substance had reached the alveoli and altered their surface.
“It looked like a chemical burn,” a pulmonologist involved in the early cases would later say, speaking on condition of anonymity.
The young man had not been in a fire. He didn’t work in a factory. There was no known occupational exposure. Only one clue remained in the medical records, still uncertain: recent use of vaping products.
In the days that followed, more patients began to arrive.
First in southeastern Wisconsin, then in other parts of the state. Young. Healthy. Similar symptoms: shortness of breath, fever, nausea, and bilateral lung infiltrates. No explanation seemed sufficient.
Before it came to resemble a generalized crisis, it was something more elemental: there was not yet a clinical category capable of saying, with any certainty, what was happening.
II ~ The Moment Something Comes Into Being
In Milwaukee, physicians at the Children’s Hospital of Wisconsin were beginning to notice something that did not yet have a name. The cases had not arrived all at once. They came in sequence over the course of weeks, as isolated episodes of acute respiratory failure in previously healthy adolescents, until they gradually began to fit into the same pattern. As the medical records accumulated, the similarities between them no longer seemed coincidental.
In July 2019, eight adolescents were hospitalized with severe lung injuries after reporting recent use of vaping products. The imaging findings were consistent: ground-glass opacities, diffuse inflammation, and signs of an insult that did not match any known infectious pattern.
Pulmonologists and radiologists at the hospital, among them Lynn D’Andrea and Michael Gutzeit, began comparing the cases. Not only the symptoms, but the trajectories: young patients with no relevant medical history, rapid deterioration, and the need for intensive respiratory support.
Among the cases documented during that period, a significant proportion evolved more severely: progressive respiratory failure, admission to intensive care units, invasive mechanical ventilation, and, in refractory situations, the use of extracorporeal membrane oxygenation: an extreme measure reserved for patients whose lungs can no longer sustain the oxygen exchange required for life.
What had initially seemed like a series of isolated incidents began to take shape. It was not yet an explanation. But it was already a pattern.
III ~ The Moment the Crisis Becomes Public
On July 25, 2019, the Milwaukee Journal Sentinel published a digital report on eight Wisconsin teenagers hospitalized with severe lung injuries after recent use of vaping products. The article spoke of suspicion. It did not assert causality. But in moments like this, caution rarely lasts as long as the speed of its circulation.
The next day, at 11:19 a.m., the story changed scale.
In a report by Susan Scutti, CNN stated that “eight teenagers were hospitalized with severely damaged lungs,” bringing to national attention a clinical alert that, until then, had remained local: “We suspect these injuries were caused by vaping,” said Michael Gutzeit, medical director at the Children’s Hospital of Wisconsin.
What, in Wisconsin, had still been an unsettling cluster of cases under investigation began to circulate nationally as a sign of a broader public health crisis. The question was no longer only clinical. It had become public:
Is vaping the cause?
The outbreak did not begin there. Bodies had already been falling ill before that. But it was there that it came to exist, for the American public, as a recognizable phenomenon. From that moment on, the country was no longer just observing cases; it was observing a pattern.
And with the pattern came a demand as immediate as it was imperfect: to give it a name.
IV ~ The Bristol Lab
As the crisis expanded in public discourse, its material epicenter lay elsewhere.
It was not a hospital. It was a residential home.
In Bristol, Wisconsin, amid trimmed lawns and pale brick facades, two brothers — Tyler and Jacob Huffhines — were running a home-based operation producing thousands of THC cartridges a day.
There was nothing improvised about it.
Inside the house, investigators found a highly organized assembly line: glass jars filled with dark, viscous oil; boxes containing tens of thousands of empty cartridges; packaging bearing counterfeit brands — Dank Vapes, Dabwoods, Chronic Sour Patch — ready to circulate as legitimate products. The cartridges were distributed through social media and local intermediaries, quickly moving through the informal circuits that already sustained the illicit cannabis market in the United States.
The scale was industrial: 31,200 filled cartridges; 98,000 empty cartridges; 1,616 ounces of THC oil.
The logic, simple. Pure THC distillate was expensive. Thick. Valued precisely for that density, which functioned for the consumer as a visible sign of potency. To increase volume without altering that appearance, it had to be diluted — without appearing diluted.
It was at this point that an economic logic met chemistry.
The solution did not come from a clandestine lab, but from a mundane input of American industry: vitamin E acetate. Produced at scale by companies such as DSM and BASF for the cosmetics, supplement, and pharmaceutical sectors, the compound circulated through industrial supply chains in volumes sufficient to supply not only factories, but also the parallel circuits orbiting the illicit THC market.
Within that illicit context, its function was ideal. Thick, inexpensive, and visually indistinguishable from cannabis oil, vitamin E acetate allowed the concentrate to be diluted while preserving the appearance of quality. In large batches, it could be easily incorporated into the liquid, reducing costs and expanding profit margins.
Within that market logic, it may have seemed like a smart solution. From a pulmonary standpoint, it was a disaster.
Harmless when ingested or applied to the skin, the compound had never been intended for inhalation. When heated and inhaled, it could adhere to lung tissue, interfere with alveolar function, and impair the oxygen exchange on which the body depends to remain alive.
What, at that moment, still seemed like a technical detail — a formulation choice, an adjustment of viscosity — was, without anyone knowing it, the signature of the crime.
There was, however, an obstacle that was not chemical, but social.
Many of the hospitalized patients were minors.
In Wisconsin in 2019, the use and possession of THC by individuals under 21 was treated as possession of a Schedule I controlled substance, punishable by up to six months in jail and a fine of up to $1,000 for a first offense. Repeat offenses could be charged as felonies. And when there was evidence of distribution, penalties could extend to years in prison, aggravated in cases involving minors or proximity to schools.
In that context, silence was not just shame. It was also a calculation.
Stigma, fear of family, fear of school, fear of the police. Everything conspired against the accuracy of the reports. Some patients withheld THC use. Others may simply not have known what was inside the cartridge purchased from a friend, an intermediary, or through social media.
Scott Aberegg, a pulmonologist at the University of Utah Health, would later summarize the problem with brutal candor. There were perhaps only two kinds of people who developed that illness: those who used THC, and those who did not admit it.
The statement was harsh. It was also a clue. Science was trying to narrow down the cause; the accounts, shaped by fear, illegality, and uncertainty, slowed that narrowing. And in the meantime, public language remained wider than the evidence.
V ~ The Broad Word
While the material cause of the outbreak remained invisible, public language moved ahead. By August, the crisis seemed to be everywhere. Headlines repeated the same formula of alarm and imprecision: “mysterious vaping illness,” “vaping-related lung injury.”
The word did more than describe. It organized fear.
“Vaping” — a broad, imprecise term, functional under uncertainty — came to name the phenomenon. Everything fit within it: regulated nicotine devices, illicit THC cartridges, industrial products, and homemade mixtures.
The effect was subtle, but profound. Distinct cases, with potentially different origins, came to be perceived as manifestations of the same problem. The scale appeared to expand: dozens of states, perhaps beyond the borders of the United States. The category was broad enough to sustain that expansion and the moral panic.
Later, a working paper from the National Bureau of Economic Research would describe that moment as an information shock. It was not exactly misinformation. It was something more subtle and, in some respects, more powerful: information that was true, but aggregated too early and too broadly.
The authors estimated that, during the initial EVALI shock, the share of respondents who came to view e-cigarettes as more harmful than conventional cigarettes increased by about 16 percentage points. Before the outbreak, roughly 9 percent of American adults held that view; during the crisis, it rose to approximately 31 percent.
When the CDC later refined its communication and began emphasizing the role of THC and informal sources, the correction was only partial. The initial impression survived the revision of the evidence.
Language had already done what the evidence could not yet do: it had provided an outline. And with that outline, it fixed a vector of fear.
VI ~ The Name
In October 2019, the CDC formalized that still unstable unity. On the 11th, while reporting 1,299 cases and 26 deaths, Principal Deputy Director Anne Schuchat announced in a press telebriefing that the official term would be “EVALI”: E-cigarette or Vaping Product Use-Associated Lung Injury. By the end of the month, the numbers had risen to 1,604 cases and 34 deaths.
The gesture was administrative. It seemed prudent. Technical. Comprehensive. And it was. But it was also doing something else.
Names like this do not merely describe phenomena. They organize the field of what appears plausible and, in doing so, distribute fear, responsibility, and attention. In choosing a word, an authority also chooses a semantic protagonist, a path of interpretation, a field of possible responsibility.
In public health, the first name is rarely the last word of science.
But it is often the word that remains.
The process that led to the choice of the term remains, to a large extent, outside the public record.
VII ~ The Detective Finds the Weapon
As the name consolidated, the investigation advanced. In partnership with state authorities and the FDA, CDC laboratories began analyzing fluid collected directly from patients’ lungs.
The results were difficult to ignore. Vitamin E acetate appeared consistently in the cases. It did not appear in healthy controls. At the same time, another pattern became clear: most patients had used THC-containing products, often obtained from informal sources.
The investigation, published in the New England Journal of Medicine, presented compelling data. Among 51 EVALI patients across 16 states, 48 had vitamin E acetate detected in their lungs. Among 99 healthy participants in the comparison group — including exclusive users of nicotine e-cigarettes — none showed the substance. Among cases with available laboratory or epidemiological data, 47 of 50 had detectable THC, THC metabolites, or reported use of THC-containing products in the 90 days prior to illness.
The hypothesis narrowed. It was not vaporization itself. It was what, exactly, was being vaporized — and where it came from. It was a clear answer to the scientific question. Not to the question already circulating in the public.
The substance that solved a market problem — viscosity — revealed itself in the lung as an agent of chemical asphyxiation.
The weapon had been identified.
It was not the one that had been named.
VIII ~ The Map That Didn’t Add Up
There was an even simpler clue — one that, at the time, was largely overlooked by the corporate press. By 2019, nicotine vaping had already been a global phenomenon for years: millions of users, diverse markets both legal and illicit, and distinct regulatory regimes across the world.
If nicotine vaping were the intrinsic causal agent behind that surge in lung injuries, similar outbreaks should have appeared in other countries.
They did not.
By October 2019, some health authorities were already pointing to a pattern incompatible with the use of regulated nicotine products.
Public Health England issued a statement that read almost like a geopolitical correction to the American language.
The outbreak, the statement said, did not appear to be associated with the long-term use of nicotine e-cigarettes. If it were, the pattern would be different: demographic, clinical, geographic. It would be broader, more distributed, more consistent with the global geography of use.
The statement added something even more delicate: an indiscriminate response could amplify the misunderstanding already circulating about the relative safety of e-cigarettes, and push former smokers back toward conventional cigarettes.
The difference between Atlanta and London was not, at its core, one of data.
It was one of framing.
IX ~ The Shock
The evidence advanced.
The perception did not.
At the peak of the crisis, the share of people who came to view e-cigarettes as more harmful than conventional cigarettes rose sharply. The shift was rapid and persistent.
In October 2019, a survey by the Kaiser Family Foundation found that only about 30 percent of respondents believed e-cigarettes were safer than combustible cigarettes. The clinical crisis was still unfolding. The mental reclassification of risk was already underway.
When the CDC adjusted its communication in December 2019, emphasizing the role of THC and informal sources, the correction came only partially.
By February 2020, the outbreak had largely disappeared. The contaminated supply chain had been disrupted. The final toll would reach 2,807 hospitalizations and 68 deaths.
The epidemiological curve fell faster than the semantic one.
Biology solved the problem. Public language did not.
What emerged was not exactly misinformation. It was something more durable: an inference formed under uncertainty, amplified at a national scale, and later difficult to undo.
A 2022 study by Amanda Katchmar and colleagues examined state health department webpages at three distinct moments. In January 2020, when vitamin E acetate had already been identified as the primary causal link, only a minority of states with comparable data clearly identified the role of vaporized THC, and few mentioned the substance directly.
Many health agencies continued to recommend avoiding all vaping products.
The distinction, now central, was rarely made explicit. The authors concluded that much of the public messaging had not been updated to accurately reflect the risks as they were better understood at that point.
The shock spread as headlines.
The correction came as a shy update.
The clinical crisis began to recede.
The mental reclassification of risk did not.
X ~ The Scar
The most enduring effect was not in hospitals.
It was in people’s minds.
“Vaping” came to be associated with an acute, dramatic, potentially lethal event.
The EVALI outbreak did not produce only a pulmonary crisis. It also produced a mental reclassification of risk. The public did not simply hear about a disease; it learned to associate “vaping” — and, in particular, nicotine e-cigarettes — with an acute, lethal, and visually disturbing event. The shift was deep, rapid, and, by all indications, persistent.
Even as the evidence pointed to adulterated illicit THC cartridges, public perception remained focused on nicotine devices.
The target, once displaced, remained displaced.
In some cases, fear may have led users to abandon vaping as an alternative to smoking. How many people returned to cigarettes is not easy to measure. But the hypothesis does not arise in a vacuum. When two products function as substitutes, changing the perceived risk of one alters behavior toward the other.
At that point, the error is no longer merely semantic.
It begins to produce consequences.
XI ~ The Dispute Over the Name
On August 5, 2021, a group of experts asked the CDC to rename the condition. The proposal: ATHCVALI — Adulterated THC Vaping Associated Lung Injury.
The letter, signed by 75 public health experts, cited a revealing statistic: two-thirds of respondents associated the outbreak deaths with “e-cigarettes such as JUUL”; only 28 percent associated them with “marijuana or THC e-cigarettes.”
The name had already organized the field of suspicion.
The argument was straightforward. The existing term did not clarify. It obscured. It continued to associate the problem with a broader category than the evidence justified, and, in doing so, produced an etiologically loose stigma.
But there was resistance. Renaming could generate new confusion. It could be interpreted as a way to minimize risk.
The debate did not pit science against error. It pitted two forms of responsibility against each other: etiological precision and communicational stability.
Among the signatories was Michael Pesko, who would write again in 2026, urging that the change finally be made.
There is no public record of a formal CDC response to the 2021 request. This does not mean the debate did not occur. It means only that it did not surface. Internal agency documents, if they come to light, may yet show whether there was substantive discussion of renaming — who argued for retaining the term, who proposed revising it, and why the original wording prevailed.
This is not a harm that depends on explicit falsehood. A category that is too broad, named too early, and repeated for long enough is sufficient.
Even after messaging was refined, the correction remained partial.
As of April 2026, it is still possible to find headlines around the world linking lung injuries from the 2019 outbreak to nicotine e-cigarettes. The name continues to do the work that the evidence has already undone.
XII ~ The Secondary Tragedy
Every crisis has its direct victims. Some also leave an indirect trail, less visible, harder to measure. In the case of EVALI, that effect was cognitive and possibly behavioral.
The working paper from the National Bureau of Economic Research is cautious when addressing behavior, but it suggests a plausible consequence: abrupt changes in risk perception may discourage adult smokers from switching from combustible cigarettes to e-cigarettes.
Katchmar and colleagues situate this possibility within a broader economic literature, in which e-cigarettes and combustible cigarettes are treated as substitutes. A study by Cotti and co-authors estimated that a 1 percent increase in e-cigarette prices raises cigarette sales by 1.11 percent. Another study by Saffer and colleagues found that a 10 percent increase in e-cigarette prices led to a 13 percent increase in cigarette consumption, in addition to reducing smoking cessation.
This does not prove that EVALI caused, at a measurable scale, a mass return to smoking. It is not necessary to claim as much.
What can be said, with confidence, is something at once more modest and more important: public language altered the perceived hierarchy of risks.
And when a crisis leads smokers to treat a product known to be more lethal and one presumed to be less lethal as equivalent, or even to reverse that relationship, the indirect harm ceases to be merely conceptual and begins to take practical form.
The amplified fear may have led some users to reassess vaping as an alternative to smoking — and, in some cases, to give it up. It is difficult to determine how many returned to smoking because of the outbreak.
At that point, the error ceases to be merely interpretive.
It becomes measurable harm.
XIII ~ The Name Is Infrastructure
The crisis ended.
The substance was identified.
The illicit market adjusted.
The cases disappeared.
The name remained.
And with it, a version of reality remained broader than the evidence could still sustain.
Perhaps this is the real (and short) story of EVALI. Not only that of a localized respiratory outbreak, nor only that of a communication failure under uncertainty.
But of how, in moments of uncertainty, an authority must produce intelligibility before it can produce certainty, and how that intelligibility, once set in motion, tends to outlive the very evidence that later renders it insufficient.
Perhaps because names, unlike scientific hypotheses, are not designed to disappear. They are designed to remain.
And sometimes, they remain longer than they should.
Science, in general, corrects itself.
Bureaucracy stabilizes.
Public language sediments.
And in the end, what remains is not always what happened.
It is the name we gave to what happened.
* * *
Layden, Jennifer E., et al. “Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin.” New England Journal of Medicine, 2020.
Blount, Benjamin C., et al. “Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI.” New England Journal of Medicine, 2020.
Centers for Disease Control and Prevention. Press Briefing Transcript. October 25, 2019.
Kenosha County Sheriff’s Department. “Sheriff reveals details of illegal THC vaping cartridge investigation.” September 11, 2019 (updated October 1, 2019). Kenosha County, Wisconsin.
Ghinai, Isaac, et al. “E-cigarette Product Use, or Vaping, Among Persons with Associated Lung Injury — Illinois and Wisconsin, April–September 2019.” Morbidity and Mortality Weekly Report 68, no. 39 (October 4, 2019): 865–869.
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Scutti, Susan. “8 Wisconsin teens hospitalized with severe lung damage due to vaping, doctors suspect.” CNN, July 26, 2019.
Grothaus, Michael. “‘This is an evil I haven’t faced before,’ says surgeon of vaping-disease teen who received double-lung transplant.” Fast Company, November 13, 2019.
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Kaiser Family Foundation. “Data Note: Public Views on vaping and E-Cigarettes.” October 2019.
Dave, Dhaval M., Daniel L. Dench, Donald S. Kenkel, Alan D. Mathios, and Hua Wang. “News that Takes Your Breath Away: Risk Perceptions During an Outbreak of Vaping-related Lung Injuries” National Bureau of Economic Research Working Paper No. 26977, April 2020.
Katchmar, Amanda, Paul Shafer, and Michael Siegel. “Analysis of State Portrayals of the Risks of E-Cigarette Use and the Cause of the EVALI Outbreak.” Harm Reduction Journal 19 (2022): 112.
Letter to the Centers for Disease Control and Prevention regarding renaming of EVALI to ATHCVALI, signed by 75 public health experts, August 5, 2021.
Pesko, Michael F. “Evidence-based Request to Revisit CDC Terminology for EVALI.” Letter to Jay Bhattacharya, Acting Director, Centers for Disease Control and Prevention, April 4, 2026.
