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The exact mechanism of vitamin E acetatemediated pulmonary toxicity is unknown, but it is thought to interfere with pulmonary surfactant function.[11] One study found vitamin E acetate and tetrahydrocannabinol in the bronchoalveolar lavage fluid in 94% of EVALI patients;[10] other studies found 77% to 84% of EVALI patients reported using tetrahydrocannabinol-based products.[10,49,51] It is important to note that vitamin E acetate is present mainly in tetrahydrocannabinol-containing e-liquids purchased on the black market, not in nicotine-containing e-liquids purchased through licensed businesses.[12] Therefore, the risk of EVALI is likely low among users of commercially available nicotine-only e-liquids