E-cigarette and Vaping-associated Lung Injury (EVALI): A Systematic Review of Forensic Pathology and Toxicological Perspectives

Abstract

E-cigarette and vaping-associated lung injury (EVALI) has emerged as a significant public health concern, leading to severe respiratory complications and fatalities worldwide. This systematic review analyses the medico-legal implications of vaping-related deaths, emphasizing postmortem toxicology, autopsy findings, and medico-legal challenges. A comprehensive literature search was conducted across multiple databases, including PubMed, Scopus, Web of Science, Embase, and Google Scholar, to identify relevant studies from 2010 onward. A total of 280 studies were identified, of which 11 met the inclusion criteria, covering 156 cases across multiple countries. The findings indicate that tetrahydrocannabinol (THC) and nicotine exposure vary geographically, with vitamin E acetate being a primary suspect in EVALI-related toxicity. Autopsy results commonly reveal bilateral lung opacities, diffuse alveolar damage, and lipid-laden macrophages, often leading to misdiagnoses such as COVID-19 pneumonia. Forensic investigations face challenges in establishing standardized diagnostic criteria, determining the exact cause of death, and addressing regulatory gaps in e-cigarette formulations. Despite corticosteroid therapy and vaping cessation being the mainstay of treatment, fatalities still occur, underscoring the need for stringent regulatory policies and improved forensic assessment techniques. This review highlights the importance of postmortem toxicology in differentiating vaping-related deaths from other pulmonary conditions, providing critical insights for forensic pathologists, toxicologists, and policymakers. Medico-legal experts must adopt a standardized investigative protocol to accurately document and analyze EVALI-related cases to guide future public health planning. The protocol for this systematic review was registered prospectively with International Prospective Register of Systematic Reviews (PROSPERO) (CRD420251041017).