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2019 Lung Injury in Illinois Cases* Individuals needing more investigation Deaths ** 166 42 3 Updated October 31, 2019 *Case means evidence of respiratory illness, with no other cause identified, and report vaping in the last 90 days. ** Death included in the number of cases Cases in Chicago and Bureau, Cass, Champaign, Coles, Cook, DeKalb, DeWitt, DuPage, Fulton, Henry, Kane, Kendall, Knox, Lake, LaSalle, Macoupin, Madison, Marion, McHenry, McLean, Peoria, Perry, Rock Island, Sangamon, St. Clair, Tazewell, Vermilion, Wabash, Whiteside, Will, Winnebago, and Woodford counties. Ages - 13-75 years. Median age - 22 years. http://www.dph.illinois.gov/topics-services/prevention-wellness/tobacco/e-cigarettes-and-vapes

What We Know About the Outbreak: As of October 29, 2019, 1,888* cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have been reported to CDC from 49 states (all except Alaska), the District of Columbia, and 1 U.S. territory. Thirty-seven deaths have been confirmed in 24 states (as of October 29, 2019). Latest outbreak information is updated every Thursday. About Patient Exposure: All EVALI patients have reported a history of using e-cigarette, or vaping, products. THC is present in most of the samples tested by FDA to date, and most patients report a history of using THC-containing products. The latest national and state findings suggest products containing THC, particularly those obtained off the street or from other informal sources (e.g. friends, family members, illicit dealers), are linked to most of the cases and play a major role in the outbreak. What We Don't Know At this time, FDA and CDC have not identified the cause or causes of the lung injuries in these cases, and the only commonality among all cases is that patients report the use of e-cigarette, or vaping, products. No one compound or ingredient has emerged as the cause of these illnesses to date; and it may be that there is more than one cause of this outbreak. Many different substances and product sources are still under investigation. What CDC Recommends CDC recommends that you do not use e-cigarette, or vaping, products that contain THC. CDC also recommends that people should not: Buy any type of e-cigarette, or vaping, products, particularly those containing THC, off the street. Modify or add any substances to e-cigarette, or vaping, products that are not intended by the manufacturer, including products purchased through retail establishments. Since the specific compound or ingredient causing lung injury are not yet known, the only way to assure that you are not at risk while the investigation continues is to consider refraining from use of all e-cigarette, or vaping, products. If you are an adult using e-cigarettes, or vaping, products, to quit smoking, do not return to smoking cigarettes. Adults addicted to nicotine using e-cigarettes should weigh all risks and benefits and consider utilizing FDA-approved nicotine replacement therapiesexternal icon. If people continue to use an e-cigarette, or vaping, product, carefully monitor yourself for symptoms and see a healthcare provider immediately if you develop symptoms like those reported in this outbreak. Irrespective of the ongoing investigation: E-cigarette, or vaping, products should never be used by youths, young adults, or women who are pregnant. Adults who do not currently use tobacco products should not start using e-cigarette, or vaping, products. There is no safe tobacco product. All tobacco products, including e-cigarettes, carry a risk. THC use has been associated with a wide range of health effects, particularly with prolonged heavy use. The best way to avoid potentially harmful effects is to not use THC, including through e-cigarette, or vaping, products. Persons with marijuana use disorder should seek evidence-based treatment by a health care provider. CDC will continue to update guidance, as appropriate, as new data emerges from this complex outbreak. If you have questions about CDC’s investigation into the lung injuries associated with use of e-cigarette, or vaping, products, contact CDC-INFO or call 1-800-232-4636. Top of Page Key Facts about Use of E-Cigarette, or Vaping, Products Electronic cigarettes — or e-cigarettes — are also called vapes, e-hookahs, vape pens, tank systems, mods, and electronic nicotine delivery systems (ENDS). Using an e-cigarette product is commonly called vaping. E-cigarettes work by heating a liquid to produce an aerosol that users inhale into their lungs. The liquid can contain: nicotine, tetrahydrocannabinol (THC) and cannabinoid (CBD) oils, and other substances and additives. THC is the psychoactive mind-altering compound of marijuana that produces the “high”. Top of Page Latest Outbreak Information Updated every Thursday This complex investigation spans almost all states, involves over a thousand patients, and a wide variety of brands and substances and e-cigarette, or vaping, products. Case counts continue to increase and new cases are being reported, which makes it more difficult to determine the cause or causes of this outbreak. As of October 29, 2019, 1,888* cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have been reported to CDC from 49 states (all except Alaska), the District of Columbia, and 1 U.S. territory. Thirty seven deaths in 24 states and the District of Columbia: Alabama, California (3), Connecticut, Delaware, Florida, Georgia (3), Illinois (2), Indiana (3), Kansas (2), Massachusetts, Michigan, Minnesota (3), Mississippi, Missouri, Montana, Nebraska, New Jersey, New York, Oregon (2), Pennsylvania, Tennessee (2), Texas, Utah, and Virginia. The median age of deceased patients was 53 years and ranged from 17 to 75 years (as of October 29, 2019). More deaths are under investigation. Among 1,378 patients with data on sex (as of October 15, 2019): 70% of patients are male. Among 1,364 patients with data on age (as of October 15, 2019): The median age of patients is 24 years and ages range from 13 to 75 years. 79% of patients are under 35 years old. By age group category: 14% of patients are under 18 years old; 40% of patients are 18 to 24 years old; 25% of patients are 25 to 34 years old; and 21% of patients are 35 years or older. Among 867 patients with information on substances used in e-cigarette, or vaping, products in the 3 months prior to symptom onset** (as of October 15, 2019): About 86% reported using THC-containing products; 34% reported exclusive use of THC-containing products. About 64% reported using nicotine-containing products; 11% reported exclusive use of nicotine-containing products. See CDC’s Lung Injury cases map and bar chart of dates of symptoms onset and hospital admission for Patients with e-cigarette, or vaping, product use associated lung injury (EVALI) for more details. Top of Page What CDC is Doing Public Health Response: CDC’s Lung Injury response efforts are committed to: Identify and define the risk factors and the source for lung disease associated with e-cigarette product use, or vaping. Detect and track confirmed and probable cases in the US. Communicate actionable recommendations to state, local, and clinical audiences. Establish lab procedures that can assist with the public heath investigation and patient care. Partnerships: CDC is working 24/7 to identify the cause or causes of this outbreak through partnerships with states and other federal agencies. CDC continues to work closely with FDA, states, public health partners, and clinicians on this investigation by providing consultation and technical assistance to states on communication, health alerts, public outreach, and surveillance. CDC has activated the Emergency Operations Center (EOC) to coordinate activities and provide assistance to states, public health partners and clinicians around the nation. CDC worked with states to create primary and out-of-hospital case definitions to classify confirmed and probable cases in a consistent way. States are in the process of classifying patients. We expect that states and clinicians may look back for past lung injury cases based on CDC’s case definition CDC will report numbers of confirmed and probable lung injury cases once states have finalized their classification of cases. By invitation, CDC has deployed Epidemic Intelligence Service (EIS) officers and other CDC staff to support states. Media and Communication: CDC is maintaining an outbreak webpage with key messages and weekly updates on case counts, deaths, and resources. CDC is holding congressional briefings, media telebriefings, and regular calls with health departments, clinicians to provide timely updates. Laboratory Testing: CDC is expanding the range of available laboratory testing. CDC is currently testing bronchoalveolar lavage (BAL) fluid samples, as well as blood or urine samples paired to BAL fluid samples. CDC is testing pathologic specimens, including lung biopsy or autopsy specimens, associated with patients. CDC is offering aerosol emission testing of case-associated product samples from e-cigarette, or vaping, products and e-liquids. Analysis of aerosol emissions will augment FDA’s ongoing work to characterize e-liquid and will improve our understanding of exposure among case-patients associated with the Lung Injury outbreak. CDC is coordinating e-cigarette, or vaping, product analysis with FDA. Results may provide insight into the nature of the chemical exposure(s) contributing to this outbreak. CDC developed guidance documents for were created to assist public health laboratories, healthcare providers, and pathologists, and others, with specimen collection, storage, and submission. For more information and resources visit For the Public, For Healthcare Providers and For State and Local Health Departments as well as our Publications and Resources page. * The increase in lung injury cases from last week represents both new patients and recent reporting of previously-identified patients to CDC. ** Based on complete reports received. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html

CDC, States Update Number of Cases of Lung Injury Associated with use of E-cigarette, or Vaping, Products Media Advisory For Immediate Release: Thursday, October 31, 2019 Contact: Media Relations (404) 639-3286 CDC today announced the updated number of confirmed and probable lung injury cases and deaths associated with the use of e-cigarette, or vaping, products. Patients with Lung Injury As of October 29, 2019, 1,888 confirmed and probable lung injury cases associated with use of e-cigarette, or vaping, products were reported by 49 states (all except Alaska), the District of Columbia, and the U.S. Virgin Islands. Data on age, sex, and substances used in e-cigarette, or vaping, products was updated in the MMWR report released on Monday, October 28, 2019. Deaths 37 deaths have been confirmed in 24 states and the District of Columbia: Alabama, California (3), Connecticut, Delaware, Florida, Georgia (3), Illinois (2), Indiana (3), Kansas (2), Massachusetts, Michigan, Minnesota (3), Mississippi, Missouri, Montana, Nebraska, New Jersey, New York, Oregon (2), Pennsylvania, Tennessee (2), Texas, Utah, and Virginia. For updates on this investigation, visit: www.cdc.gov/lunginjury. For information about the collection of e-cigarette, or vaping, products, including e-liquids, associated with confirmed or probable cases for possible testing by FDA, contact: [email protected]. For information about collection and submission of clinical specimens for possible testing by CDC, see CDC’s Healthcare Provider web page. For information about collection and submission of e-cigarette, or vaping, products, including e-liquids, associated with confirmed or probable cases for possible aerosol emissions testing by CDC, contact: [email protected]. Clinicians and health officials who have questions about this outbreak can contact: [email protected]. All others, including the general public, who have questions about this outbreak can contact CDC-INFO at 800-232-4636, or visit wwwn.cdc.gov/dcs/ContactUs/Form.

Patients with Lung Injury As of October 29, 2019, 1,888 confirmed and probable lung injury cases associated with use of e-cigarette, or vaping, products were reported by 49 states (all except Alaska), the District of Columbia, and the U.S. Virgin Islands. Data on age, sex, and substances used in e-cigarette, or vaping, products was updated in the MMWR report released on Monday, October 28, 2019. Deaths 37 deaths have been confirmed in 24 states and the District of Columbia: Alabama, California (3), Connecticut, Delaware, Florida, Georgia (3), Illinois (2), Indiana (3), Kansas (2), Massachusetts, Michigan, Minnesota (3), Mississippi, Missouri, Montana, Nebraska, New Jersey, New York, Oregon (2), Pennsylvania, Tennessee (2), Texas, Utah, and Virginia. https://www.cdc.gov/media/releases/2019/a1031-lung-injury-cases.html

As of October 30, 2019, there have been 70 cases including, 1 reported death, associated with this outbreak in Virginia. Region Confirmed Probable Total Central Region 2 1 3 Eastern Region 10 9 19 Northern Region 16 14 30 Northwest Region 3 8 11 Southwest Region 5 2 7 Total 36 34 70 These case counts are based on the September 18, 2019 CDC case definition. http://www.vdh.virginia.gov/vdhlivewell/vaping/

As of 10/31/2019, 66 cases have been reported in individuals in North Carolina ranging in age from 13 to 72 years. (Note: We plan to update case counts by 4:00 pm on Thursdays.) https://www.tobaccopreventionandcontrol.ncdhhs.gov/ecigs/

Confirmed or probable cases: 93Confirmed deaths: 3Cases under review: 41Updated Thursday, 31-Oct-2019 09:29:49 CDT https://www.health.state.mn.us/diseases/lunginjuries/index.html

As of 10/25/2019, the Michigan Department of Health and Human Services has identified 44 (24 confirmed and 20 probable) cases of severe lung disease associated with vaping. The department is investigating an additional six possible cases that have been reported by health care providers. Starting the week of October 26, 2019, case counts will be updated once a week on Fridays rather than every weekday. https://www.michigan.gov/mdhhs/0,5885,7-339-71550_5104_53072---,00.html

Confirmed or probable cases: 91 Confirmed deaths: 3 Cases under review: 42 Updated Wednesday, 30-Oct-2019 09:29:55 CDT Case numbers by county https://www.health.state.mn.us/diseases/lunginjuries/index.html

The Maryland Department of Health is investigating cases of individuals who have developed severe lung illness with no clear infectious cause after using e-cigarettes, or “vaping.” Similar cases have been reported in other states across the United States and are described on the CDC Webpage. Cases of Vaping-Associated Lung Injury (as of October 29, 2019): 43 https://phpa.health.maryland.gov/OEHFP/EH/Pages/VapingIllness.aspx

Since June 2019, CDPH has received reports that 144 people in California who have a history of vaping were hospitalized for severe breathing problems and lung damage, and three people have died. https://www.cdph.ca.gov/Programs/CCDPHP/Pages/Vaping-Health-Advisory.aspx

PRESS RELEASE Press Release Department of Public Health announces the state’s second death from a vaping-associated lung injury FOR IMMEDIATE RELEASE: 10/30/2019 Department of Public Health BOSTON — A second person has died of a vaping-associated lung injury, the Massachusetts Department of Public Health (DPH) announced today. The patient, a woman in her 40s from Middlesex County who vaped nicotine, is among more than 200 suspected vaping-associated lung injury patients that have been reported to DPH since September when Massachusetts began requiring clinicians to immediately report any unexplained lung injury in a patient with a history of vaping to the department. Earlier this month, DPH reported the state’s first death from a vaping-associated lung injury, a woman in her 60s from Hampshire County who also vaped nicotine. ``I am deeply saddened to learn about the death of a second patient from this lung injury,’’ said Public Health Commissioner Monica Bharel, MD, MPH. ``While we continue to work with our federal partners to investigate the cause of these vaping-associated lung injuries, we cannot at this time attribute a single substance or product to this outbreak of illness.” Governor Baker declared a public health emergency on September 24 and temporarily banned the sale of vaping products and devices, in response to the growing number of cases of severe lung injuries associated with the use of e-cigarettes and cannabis and nicotine vaping products in Massachusetts and nationally. Since the state began mandating the reporting of vaping-associated lung injuries on September 11, DPH has received 204 reports from clinicians of suspected vaping-associated lung injuries. Of those 204 reports, 20 confirmed and 41 probable cases have been reported to the US Centers for Disease Control and Prevention (CDC). DPH will report this second confirmed death from a vaping-associated lung injury to the CDC next week. Clinicians are asked to report any individual experiencing otherwise unexplained progressive symptoms of shortness of breath, fatigue, chest pain, cough, or weight loss, of any severity, and an abnormal chest imaging study, who also reports vaping within the 90 days prior to the onset of symptoms. Of the 61 Massachusetts cases that have been reported to the CDC, 27 are male and 34 are female. A majority of the cases– 51 percent – are under the age of 30. Thirty percent of the people vaped only nicotine, 39 percent vaped only tetrahydrocannabinol (THC), an ingredient found in marijuana, while 25 percent reported vaping nicotine and THC. DPH’s new online dashboard provides detailed information on vaping cases that DPH has reported to the CDC and is updated each Wednesday. As a result of the vaping ban, the Commonwealth has implemented a statewide standing order for over-the-counter nicotine replacement products that allow people to access products like gum, lozenges, and patches as a covered benefit through their insurance without requiring an individual prescription. Individuals who are vaping are encouraged to call the Massachusetts Smokers’ Helpline at 1-800-QUIT-NOW or visit makingsmokinghistory.org or Mass.gov/QuitVaping to connect to treatment. https://www.mass.gov/news/department-of-public-health-announces-the-states-second-death-from-a-vaping-associated-lung

How Many Cases are There in Louisiana Substance/Exposure Outbreak Cases Deaths Age Range Median Age Nicotine Nicotine & THC THC 29 0 17-71 28 21% 58% 21% 29 cases of EVALI were reported to Louisiana health officials between August and October of 2019. Those cases were reported from throughout the state with the ages ranging from 17-71. There have been no deaths in Louisiana associated with this illness. http://ldh.la.gov/index.cfm/page/3724

Massachusetts reports 2nd vaping-related death The second resident to die was a woman in her 40s from Middlesex County. WGBH-FM, 10:48 AM BOSTON (AP) — Massachusetts health officials say a second state resident has died from a vaping-related lung illness. Marylou Sudders, secretary of Health and Human Services, told WGBH-FM on Wednesday that the second resident was a woman in her 40s from Middlesex County. The state previously said a woman in her 60s from Hampshire County died of a vaping-related illness. No additional information was released. Sudders says both deaths were attributed to the use of nicotine vaping products. She says the state has had 204 suspected cases of vaping-related pulmonary illnesses, 61 of which were reported to the U.S. Centers for Disease Control and Prevention as confirmed or probable. https://www.boston.com/news/health/2019/10/30/massachusetts-2nd-vaping-death

The Promise and Peril of Vaping, Part 1: A Mystery in Nebraska Hosted by Michael Barbaro, produced by Alexandra Leigh Young, and edited by M.J. Davis Lin and Wendy Dorr How one man’s death is changing our understanding of vaping and its consequences. Monday, October 28th, 2019 Kathleen Fimple You will see the animals on the wall. So, there’s a rainbow trout and an antelope and a deer above the fireplace. So, yeah. Kathleen Fimple You guys can sit — Kathleen Fimple That room’s a mess, but we could pull some things off — Kathleen Fimple My daughter made this. Kathleen Fimple That’s what we used for the funeral. Kathleen Fimple He played guitar, so we’ve got guitar picks, and “Grandma’s Feather Bed” was a song we all liked to sing together. Kathleen Fimple There’s a shotgun shell, there’s the antler — this knife has an antler. Kathleen Fimple He was a Scout leader. Kathleen Fimple Those were from the casket spray. Kathleen Fimple He was a lifelong smoker. Julie Bosman What did he smoke? Kathleen Fimple Marlboros. Julie Bosman Not the lights, the — Kathleen Fimple Oh, no. No, no. Julie Bosman How did he feel about his smoking? Was he like, “Ugh, I hate this,” or, “I love it, and I don’t want to quit.” Or how — Kathleen Fimple I love it, and I don’t want to quit. And also, a lot of denial, especially early on. My grandpa lived to be, whatever, 80-something, and he smoked. Kathleen Fimple Eventually, I think he reconciled that, yes, smoking was bad, and it could cause cancer. Kathleen Fimple In his 30s, while we were first married, he quit several times briefly. Kathleen Fimple He’d stop for a month or two, and then, yeah. Dulcia Steffen So that he would see her face every time he pulled out a cigarette. I was like, O.K., I’ve tried all the little tactics. Kathleen Fimple We’d go to church, and he sing a line, and then he’d stop, and then he’d have to pick it up later because he’d have to catch his breath in between. And he used to whistle all the time — he couldn’t whistle anymore. Kathleen Fimple I think that was when he started vaping. Julie Bosman Do you know how he got the idea? Kathleen Fimple No. We both, I had kind of seen advertisements for it and things, but it was his idea, and he bought one and came home with it. Julie Bosman Do you know which brand? Kathleen Fimple Mistics. Dulcia Steffen Then he had blu, and then he went to Juul. Kathleen Fimple And he only went to Juul less than a year ago. Kathleen Fimple There was a cough, cold going around — Kathleen Fimple And it probably, in some ways, was less obvious to us because he had a smoker’s cough. So he coughed, but it was also obvious that this was worse. Kathleen Fimple That’s probably why he went, though, in April, just because you kept pushing him. Dulcia Steffen Yeah. Kathleen Fimple Dr. Simon said, “You have pneumonia, and you’re going to the hospital.” Dulcia Steffen His hands were like ice. Kathleen Fimple They were starting to turn blue. Dulcia Steffen He couldn’t blink, and his mouth was propped open, and he wasn’t breathing very often. And his last breath I could tell because there was just a slight twitch in his neck. Kathleen Fimple I was in a meeting when the Department of Health called. Kathleen Fimple He asked about any exposure in the past to moldy wood, or wood chips, to asbestos, to pesticides. Then they asked about symptoms. Kathleen Fimple Did he lose weight, was he coughing? Kathleen Fimple I said, I don’t know why vaping — I mean, yes, he vaped, but I don’t think it’s from vaping. They said he had pneumonia. Lifelong smoker, C.O.P.D. — Dulcia Steffen It was a straight replacement for cigarettes. Kathleen Fimple Yeah. Dulcia Steffen Yeah, and part of it was habit. Years and years of habit, when you get in the vehicle, you light up a cigarette. So when he’d get in the vehicle and start to drive, he would vape. Kathleen Fimple I knew it wasn’t the perfect solution, but again, figured it was better. Julie Bosman Right. Kathleen Fimple For him, and for us. Julie Bosman Did you ever think, could they be dangerous? Kathleen Fimple No. No, I — Dulcia Steffen You know, when they first marketed them, they said it was a safer alternative. We assumed it was healthier for those around him as well. Archived Recording 1 This morning, Nebraska health officials have announced the state’s first vaping-related death. Archived Recording 2 That’s right, the person was over 65, and from the Douglas County, which is the Omaha area. The individual died in May, but the State Health Department just identified it as vaping-related. Archived Recording 1 There is breaking news tonight in the nationwide vaping crisis. Another death, and new reports of possible lung disease. The C.D.C. is looking into dozens of cases. Archived Recording 2 The C.D.C. can confirm 31 cases — Archived Recording 3 200 potential cases — Archived Recording 4 380 cases — Archived Recording 5 The 450 cases span — Archived Recording 6 530 cases — Archived Recording 7 It’s unclear just what’s causing the problem. The C.D.C. says it will continue to investigate. Kathleen Fimple And it showed pneumonia in the lower lobe of one lung. But the rest of his lungs, both sides and upper and lower were filled with what they call ground glass opacity. Kathleen Fimple And I said, well, how does that — is that different from just a long-term smoker? And he said, yes. This is not what you would see in just, routine, if you will, long-term smoking. Julie Bosman Is that unthinkable? Do you have any — I mean, is that something that he might have possibly done? Kathleen Fimple I don’t think he would have even known where to go to get it. Dulcia Steffen We’ve been to Colorado since it was legalized, and he wouldn’t touch it. Kathleen Fimple He was never interested. Dulcia Steffen No. So I don’t think he would have ever considered getting it black-market, either. Julie Bosman Do you know where he bought it? Kathleen Fimple Walmart. Walgreens or Walmart. Julie Bosman Walgreens or Walmart. Kathleen Fimple I don’t think he bought them anyplace else. Dulcia Steffen He never went to any of the vape shops or anything. Kathleen Fimple Oh, never. Never. Dulcia Steffen To think that that box right there could be the sole reason he’s dead, in some ways, is like looking at a gun with a bullet. It’s just a method of death. Archived Recording (Donald Trump) Last night, the United States brought the world’s number one terrorist leader to justice. Abu Bakr al-Baghdadi is dead. Archived Recording (Donald Trump) Capturing or killing Baghdadi has been the top national security priority of my administration. Archived Recording (Donald Trump) The thug who tried so hard to intimidate others spent his last moments in utter fear, in total panic and dread, terrified of the American forces bearing down on him. Archived Recording (Donald Trump) He was a sick and depraved man, and now he’s gone. Michael Barbaro From The New York Times, I’m Michael Barbaro. This is “The Daily.” Today: When John Steffen died, his family had little doubt that a lifetime of cigarette smoking was to blame. Then, the Nebraska Department of Health got an unusual tip. Part 1 of a two-part series on the promise and the peril of vaping. It’s Monday, October 28. Michael Barbaro Julie, tell me about this trip you took to Nebraska. Julie Bosman So, a couple of weeks ago, I went to Omaha, Nebraska. Michael Barbaro Julie Bosman is a national reporter at The Times. Julie Bosman And I went to the home of Kathleen Fimple — Julie Bosman — where she lives with her dog, Bo, a little terrier. And Kathleen showed me around her house. Julie Bosman And I sat down with Kathleen and her daughter, Dulcia, and her granddaughter, and they showed me something that Dulcia had made after the death of her father, John Steffen. Julie Bosman It was a glass box. Julie Bosman And inside were mementos that represented his life. Julie Bosman So John was a very active outdoorsman. There was a turkey feather from one of his hunting expeditions. Julie Bosman There were badges and pins. Julie Bosman And there were dried flowers from his funeral spray. Michael Barbaro And how exactly did he die? Julie Bosman So, John died after a long illness. Julie Bosman So he started smoking back in the ‘60s when he was a teenager, and it was a habit that he really stuck with for most of his life. Julie Bosman So he was kind of clinging to the idea that smoking wasn’t bad. Julie Bosman He tried very, very hard to quit. Julie Bosman Sometimes he would be successful, and then he started up again. Julie Bosman And his daughter, when she had her own baby daughter, she would take little pictures of the baby and tuck them into his packs of cigarettes. Julie Bosman So, she tried everything she could, but his addiction to nicotine was decades strong. [Music] Julie Bosman But then he developed C.O.P.D., chronic obstructive pulmonary disease, which is a very common disease that many smokers develop. And in his case, it gave him a very bad cough, and it made it difficult to breathe at times. Julie Bosman He had atrial fibrillation, and sometime later, he got non-Hodgkin’s lymphoma, and had to have chemotherapy for years. Julie Bosman So, John started vaping about five years ago. Julie Bosman And he had heard about vaping as the cleaner, healthier alternative to cigarettes. So he became just as enthusiastic of a vaper as he was a smoker. So, earlier this year — Julie Bosman It was a cold winter, and everybody had a cold, and a cough. And John kind of got it the worst. Julie Bosman And his daughter, Dulcia, started nagging at him, and saying, Dad, you really need to go to the doctor. Julie Bosman So he did, and he was diagnosed with pneumonia. Julie Bosman And he was in the hospital for a week. And seven, eight days into his hospital stay — Julie Bosman He died of acute respiratory failure, which the doctor said was a consequence of the C.O.P.D. Michael Barbaro So essentially, he died of smoking, or smoking-related lung disease, it sounds like. Julie Bosman Yes. His wife said that he always believed that he was going to die of lung cancer. So when the doctors said that he had died, essentially, as a consequence of C.O.P.D., they had no reason to question the doctor’s conclusion. Michael Barbaro And as tragic as that is, it all kind of lines up with our understanding of what a lifetime of smoking does to a person. Julie Bosman Right. But then four months after John died, Kathleen was sitting at work one day. Julie Bosman She got a phone call from an investigator at the Nebraska Department of Health, and he asked her all kinds of questions. Julie Bosman He asked if he had had any kind of vomiting before his death. Julie Bosman And he also asked her about vaping. Julie Bosman And the investigator got off the phone with her and said he would be in touch. Michael Barbaro So Julie, what was John’s relationship to vaping? Julie Bosman Kathleen told me that when he was smoking cigarettes, he would smoke a cigarette two or three times an hour. And very quickly, he was vaping two or three times an hour. Julie Bosman It was a good way to help him get his nicotine fix. Julie Bosman And then a few days later, Kathleen spoke to the medical investigator again, and he told her that it had been confirmed. John was Nebraska’s first official vaping-related death. Michael Barbaro So Julie, what exactly is going on here? Why is an original conclusion about John’s cause of death now being re-evaluated, and, it seems, challenged? What is happening? Julie Bosman So, back in May, when John died, there really was no such thing as a vaping-related death or a vaping-related illness. But throughout the summer, all these illnesses and deaths began to be reported. And all over the country, people began to look back at cases of people who had died, people who had gotten sick, and started to think a little differently about them. And in Nebraska, the State Health Department wouldn’t have even looked at John’s death if they hadn’t received a tip. Michael Barbaro We’ll be right back. So Julie, tell me about this tip. Julie Bosman So, here’s what happened. [Music] Julie Bosman John had an old friend who he went to high school with, and they saw each other at an alumni reunion a few years ago. They sat together with their spouses at this dinner, and throughout the dinner, as she described it, John was vaping constantly. And she had never seen anyone vape before. This was in 2014, it was kind of a new thing. And she told me that she was very alarmed by what she saw. Michael Barbaro What exactly alarmed her? Julie Bosman She was concerned because he was vaping so frequently. Of course, when you smoke, you generally have to go outside and do it. But John was vaping indoors, sitting at dinner. And she also just had this kind of gut sense that there was something kind of wrong about it. And she couldn’t quite shake the feeling, even after the reunion was over and years had gone by. And she and John really didn’t keep in touch, but earlier this year, when John was sick, she had heard that he was in the hospital. And then she heard that he died in May. So she waited all summer, and she started seeing things in the news about people getting sick and dying from vaping. Julie Bosman And she told me that she kept looking in the paper, she kept looking on the news to see if John was one of those people, and that never happened. So at the end of the summer, she decided that she just couldn’t get rid of this feeling that vaping was related to his death, so she called the State Health Department. Michael Barbaro So she was the tip. Julie Bosman Yeah, so her tip gets passed along to a medical investigator, and he was the investigator who called John’s wife and spoke to her, and interviewed her about his medical history. He did a bunch of other things, too. So he spoke to the physicians who attended to John, who treated him when he was sick in the hospital in Omaha. He examined his medical records, he looked at his chest X-rays. Julie Bosman A ground glass appearance on the lungs is an injury to the lung that is typically consistent with vaping. And in some cases, it can look like there are kind of opaque white spots on the X-ray. Julie Bosman And in this case, it was a very key piece of evidence for the investigator who was looking into John’s death. Michael Barbaro And what’s the understanding of how vaping might create this kind of ground glass-looking damage in the lung? Julie Bosman So when you vape, of course, you use a device that heats liquid to a very high temperature, and turns it into a vapor that you inhale. Now, that liquid can contain THC, which is the ingredient in marijuana that gets you high, or it could contain nicotine. And doctors who are investigating all these illnesses and deaths don’t know exactly what it is about vaping that is making people sick. But they have noticed that some of the people who have gotten sick, or died, have had the ground glass appearance on their lungs. Or in some cases, they’ve had damage on their lungs that resembles a chemical burn. Michael Barbaro Julie, my sense is that most of these vaping-related illnesses and the deaths that we have been reading about have been not from the well-known e-cigarette brands, but from basically counterfeit and bootleg products, right? Julie Bosman Yes. So here’s what we know about that. Of the people who have gotten sick or died from vaping in the last year, about three-quarters of them have vaped THC products. A little over half have vaped nicotine, and a lot of people do both, kind of toggle back and forth between vaping weed and vaping nicotine. But as best we can tell, John did not vape THC. When I asked his family, they kind of laughed at the idea that their 68-year-old husband and father would be procuring bootleg THC. Julie Bosman They described his vaping habits as very aboveboard. Michael Barbaro I mean, is it possible that John was vaping something like THC, but just didn’t tell his family? That no one knew? Julie Bosman His family very strongly discounts that possibility. He would have had to be doing it in secret, and they thought that that notion was rather ridiculous. Michael Barbaro So if he got sick from vaping, it was from regular old — I guess if the industry is old enough to call it this, but — traditional vaping? Julie Bosman Yes. And this really only deepens the medical mystery surrounding vaping, because so many people who have gotten sick or died from vaping have been using THC vapes, and especially vaping devices or cartridges that were bought off the street, and no one really knows where they came from. Michael Barbaro But that’s not the case with John. Julie Bosman Right. Michael Barbaro So Julie, how does John’s death, as defined and diagnosed by these medical professionals, locally and nationally, how does it change our understanding of vaping and its consequences? Julie Bosman I think that his death raises an alarming possibility. And that is that someone who apparently did not vape THC, did not buy any kind of products on the black market, could also become very sick and die from a vaping-related illness. Michael Barbaro Right. And his family told you that he took up vaping, as many people do, because he thought it was actually going to make him healthier. It was going to help him quit smoking. Julie Bosman Yeah. He thought that this would be the thing that would help him quit smoking for good, and it did. And you know, people like John Steffen are exactly the kind of person that e-cigarettes were ostensibly created for. When e-cigarettes were invented, and when companies started selling them on the mass market, they said that it was for people who wanted to quit smoking and wanted a healthier alternative. And John was exactly that person. Michael Barbaro So what’s the understanding of why so many people, not just John, but hundreds of people are getting sick from this, and maybe even dying from it? Julie Bosman Well, I would just point to cigarette smoking and when it was first introduced. Cigarette smoking really took off during World War I among American men. And it wasn’t until the 1930s when doctors began to link an increase in lung cancer rates to an increase in cigarette smoking. And it took decades after that — it wasn’t until 1964 when the surgeon general released a landmark report saying, yes, smoking does cause lung cancer. So I think what a lot of doctors out there are saying is that it is far too early to know what the long-term effects of vaping might be. Michael Barbaro In other words, the gestation period for any kind of public health problem is long, is maybe even decades. Julie Bosman Yes. And it’s very early in e-cigarettes’ life. I mean, they really didn’t enter the mainstream until the last 10 years. Michael Barbaro In which case, we would be at the beginning of whatever this is, not even the middle, and definitely nowhere near the end. Julie Bosman I think we can say for sure that the C.D.C. believes that there are many, many more cases coming, and that this is only the tip of the iceberg. [Music] Michael Barbaro Julie, does John’s family think that he would still be alive today if he hadn’t taken up vaping? Julie Bosman That’s a difficult question. It’s something that they do think about. And when they look back on his life, they know that taking up smoking as a teenager was certainly a bad decision, and continuing to smoke all those decades was something that they wish he had not done. But they thought that he made a really good decision when he switched to vaping. They didn’t worry about the health consequences of vaping. And when his daughter looked at the vaping container that was left over, sitting on the coffee table, she doesn’t see something that is harmless or something that might have helped prolong his life. She sees something very dangerous. Michael Barbaro Julie, thank you very much. Julie Bosman Thanks, Michael. Michael Barbaro We’ll be right back. Michael Barbaro That’s it for “The Daily.” I’m Michael Barbaro. See you tomorrow. https://www.nytimes.com/2019/10/28/podcasts/the-daily/vaping-dangers.html?showTranscript=1

Total reported patients statewide: 156 (Updated: 10/29/2019) Breakdown of reported patients by region: Western New York: 36 Central New York: 14 Capital Region: 27 Northern New York: 5 Metropolitan Region (outside of NYC): 35 New York City: 36 Out of State: 3* *Patients treated at hospitals in NYS but are residents of another state. https://www.health.ny.gov/prevention/tobacco_control/campaign/e-cigarettes/

Vaping-associated Illness* Data Lable Value Confirmed and Probable Cases Total Confirmed 27 Total Probable 30 Deaths 1** Most Recent 10/16/2019 Age Range 15-70 Median Age 21 Gender 18 female, 39 male Regions of State Impacted Statewide Reports Under Investigation Total 29 Most Recent 10/24/2019 Age Range 14-75 Median Age 20 Gender 12 female, 17 male Regions of State Impacted North, Central *Chart Updated Every Tuesday **Part of Probable Cases https://www.nj.gov/health/fhs/tobacco/vaping/index.shtml

A second person has now died of vaping-related illness in Massachusetts, according to the Boston Globe. The Globe said Gov. Charlie Baker and Secretary of Health and Human Services Marylou Sudders announced the death during an interview with WGBH on Wednesday. https://www.nbcboston.com/news/local/Report-2nd-Person-in-Mass-Dies-of-Vaping-Related-Illness-564099711.html

Naomi Martin @NaomiMartin · 1m On WGBH, Baker' admin official says 2nd vaping death in MA was woman in 40s from Middlesex County who reportedly vaped nicotine, and 61 total cases of vaping-related illness in the state so far have met federal reporting criteria

The latest vaping death in Georgia involved a person with a history of vaping nicotine for a few years. The state’s health agency didn’t share more details. There have been 25 confirmed cases of the vaping-associated illness in Georgia this year.Most patients were hospitalized and required respiratory support. They have ranged in age from 18 to 68, with a median age of 33. Of those sickened, 56% are men. Symptoms, which worsen over time, include cough, shortness of breath, fatigue, chest pain, nausea, vomiting and diarrhea. https://www.google.com/amp/s/www.ajc.com/news/breaking-news/third-vaping-related-death-georgia-confirmed-total-cases-rise/ftrS8mjDILCGbH1iSjKxJM/amp.html

As of (10/29/2019) DPH has identified 25 cases of vaping-associated illness in Georgia, including 3 deaths. Other possible cases are being reviewed. Cases range in age from range in age from 18 to 68 years (the median age is 33 years), and 56% are male. Cases experienced severe respiratory symptoms including cough and shortness of breath. Cases also reported experiencing fever, fatigue, chest pain, nausea, vomiting, and diarrhea. Most cases have been hospitalized and have required respiratory support. Cases have reported vaping a variety of substances, including nicotine, THC and CBD products. Clinicians who become aware of cases similar to those described above should report them to the Georgia Poison Center at 1-800-282-5846 https://dph.georgia.gov/vapinglunginjury

Since June 2019, CDPH has received reports that 142 people in California who have a history of vaping were hospitalized for severe breathing problems and lung damage, and three people have died https://www.cdph.ca.gov/Programs/CCDPHP/Pages/Vaping-Health-Advisory.aspx

PITKIN COUNTY, Colo. (CBS4) – Pitkin County has reported a death attributed to vaping to the Colorado Department of Public Health and Environment. Another death has been linked to vaping in the state but has not been concretely identified as of yet. No details about the victim were immediately available. Pitkin County Public Health says the illness is particularly concerning in the Roaring Fork Valley. https://denver.cbslocal.com/2019/10/29/vaping-outbreak-death-colorado-pitkin-county/

Lung Injury Associated with Vaping, Texas Public Health Region Number of Cases 1 (Panhandle) 2 2/3 (North Texas) 82 4/5N (East Texas) 4 6/5S (Southeast Texas) 36 7 (Central Texas) 21 8 (South Texas) 7 9/10 (West Texas) 3 11 (Rio Grande Valley) 9 Not yet determined 1 Total 165 Figure 1: Cases of Lung Injury Associated with Vaping, Texas, as of 10/29/19 https://www.dshs.texas.gov/news/updates.shtm#vaping

Lung Injury Associated with E-Cigarette Use, or Vaping* - Florida Year Reported Cases Year-to-Date Deaths Year-to-Date 2019 78 1 Report last updated on October 29, 2019 with data from January 01, 2019 - October 26, 2019. FLHealthCharts.com is provided by the Florida Department of Health, Division of Public Health Statistics & Performance Management. Data Source: Florida Department of Health, Division of Disease Control and Health Protection, Florida Bureau of Epidemiology. http://www.flhealthcharts.com/ChartsReports/rdPage.aspx?rdReport=ChartsProfiles.LungInjuryE-CigaretteUse