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TABLE. Number of patients with lung injury associated with e-cigarette use, or vaping (n = 771), by demographic and substance use characteristics — United States, 2019 Characteristic No. (%) Demographic (n = 771)* Sex Male 531 (68.9) Female 234 (30.4) Missing 6 (0.8) Age group (yrs) <18 125 (16.2) 18–24 293 (38.0) 25–34 184 (23.9) 35–44 93 (12.1) ≥45 42 (5.5) Missing 34 (4.4) Substances used in e-cigarette, or vaping, products (n = 514)† THC-containing products Yes 395 (76.9) No 96 (18.7) Unknown/Missing 23 (4.5) Nicotine-containing products Yes 292 (56.8) No 173(33.7) Unknown/Missing 49 (9.5) Cannabidiol (CBD) Yes 89 (17.3) No 265 (51.6) Unknown/Missing 160 (31.1) Synthetic cannabinoids Yes 4 (0.8) No 289 (56.2) Unknown/Missing 221 (43.0) Flavored e-liquids§ Yes 102 (19.8) No 132 (25.7) Unknown/Missing 280 (54.5) Abbreviation: THC = tetrahydrocannabinol. * Patients for whom basic demographic information was submitted to CDC. † Patients for whom information was available on use of either nicotine-containing or THC-containing substances. § Flavored products that contain water, food-grade flavoring, propylene glycol, vegetable glycerin, nicotine, THC, or CBD.

FIGURE 2. Dates of symptom onset (n = 590) and hospital admission (n = 674) among patients with lung injury associated with e-cigarette use, or vaping — United States, March 31–September 21, 2019

FIGURE 1. Number of cases of lung injury associated with e-cigarette use, or vaping (n = 805) — United States, including two territories, 2019* Abbreviations: DC = District of Columbia, PR = Puerto Rico; VI = U.S. Virgin Islands. *As of September 24, 2019, 1–9 cases had been reported by 23 states and one territory; 10–29 cases had been reported by 14 states; 30–49 cases had been reported by five states; 50–99 cases had been reported by four states, and 0 cases had been reported by four states and DC. Additional cases being investigated are not reflected on this map.

Discussion E-cigarettes were introduced to the U.S. market in 2007 (1). In 2018, 20.8% of high school students reported current e-cigarette use (5). E-cigarette use is markedly lower among U.S. adults than among youths; in 2018, only 3.2% of adults currently used e-cigarettes, with higher prevalences among persons aged 18–24 years (7.6%) and 25–34 years (5.4%) than among older age groups (6). Approximately three fourths of patients in this investigation were aged <35 years. In the general U.S. adult population, current e-cigarette use is slightly higher among males than females for both adults and youths (6); in the present investigation, approximately seven in 10 cases occurred in males. In this investigation, 62% of patients were aged 18–34 years; this is consistent with the age group with highest reported prevalence of marijuana use in the preceding 30 days in the United States (7). THC-containing and nicotine-containing products were the most commonly reported substances used in e-cigarettes, or vaping products, by patients. Specific data on use of THC in e-cigarettes, or vaping products, in the general population is limited; among U.S. middle and high school students in 2016 who had ever used an e-cigarette, 30.6% reported using THC in an e-cigarette (33.3% among males and 27.2% among females) (8). Among adults who reported using marijuana in 2014, 9.9% reported consuming it via a vaporizer or other electronic device (11.5% among men and 7.8% among women) (9). In a recent study of college students, approximately 75% of those who had used substances other than nicotine in e-cigarettes reported using marijuana or THC-containing products in an e-cigarette (10). Because information about substance use in this investigation was self-reported, the information is not available for some cases because of the time required for completing and reporting patient interviews, inability to conduct interviews (e.g., patient refusal, loss to follow-up, persons who were too ill or died before they could be interviewed) and missing data for certain variables (e.g., patient refusal to answer certain questions). In addition, patients might not always know what substances they use or might be hesitant to reveal use of substances that are not legal in their state. Continued monitoring of patient case counts and characteristics, as well as substances used with e-cigarette, or vaping, products, is critical to informing the ongoing investigation and helping to identify the cause. CDC and state health departments continue to collect and analyze epidemiologic data to better understand what types of devices and products patients are using (e.g., cartridges and e-liquids), the source of products or location where they were obtained, and the patterns (e.g., duration and frequency) of specific product use. Given the vast number of chemicals used in e-cigarette, or vaping, products, it is important to link epidemiologic data with findings from laboratory analyses of products and clinical specimens from patients. Federal, state, and private laboratories are working to collect and analyze products obtained from patients with lung injury associated with e-cigarette use, or vaping. In addition, CDC, clinical, and public health laboratories are collecting clinical specimens for future targeted analyses of substances identified in product samples. The specific chemical exposure(s) causing this outbreak is unknown at this time. National data to date show that most lung injury patients with data on substance use report using THC-containing products with or without nicotine-containing products, although some patients report using only nicotine-containing products. While this investigation is ongoing, CDC recommends that persons consider refraining from using e-cigarette, or vaping, products, particularly those containing THC. Persons who continue to use e-cigarettes or vaping products should carefully monitor themselves and seek medical attention immediately if they have symptoms consistent with those described in this outbreak.§ Regardless of the investigation, e-cigarettes, or vaping products, should never be used by youths, young adults, pregnant women, or by adults who do not currently use tobacco products (2). Adults who use e-cigarettes because they have quit smoking should not return to smoking combustible cigarettes. In addition, persons who use e-cigarettes or vaping products should not get them from informal sources or off the street and should not modify e-cigarette, or vaping, devices or add any substances that are not intended by the manufacturer. Both THC-containing and nicotine-containing e-cigarette, or vaping, products purchased legally within states might also contain harmful substances (1); it is difficult for consumers to know what is in these products, and full ingredient lists are typically not available. 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, devices. Persons with marijuana use disorder should seek evidence-based treatment by a health care provider. This investigation is ongoing. CDC will continue to work in collaboration with FDA and state and local partners to investigate cases and advise and alert the public on the investigation as additional information becomes available. Top Lung Injury Response Epidemiology/Surveillance Group Jennifer Adjemian, Center for Surveillance, Epidemiology, and Laboratory Services, CDC; Minal Amin, National Center for Immunization and Respiratory Diseases, CDC; Jose Aponte, Center for Surveillance, Epidemiology, and Laboratory Services, CDC; Vaughn Barry, Epidemic Intelligence Service, National Center for Injury Prevention and Control, CDC; Diane Browning, Northrop Grumman; Jordan Cates, Epidemic Intelligence Service, National Center for Immunization and Respiratory Diseases, CDC; Gyan Chandra, National Center for Chronic Disease Prevention and Health Promotion, CDC; Karen Chang, Epidemic Intelligence Service, National Center for Chronic Disease Prevention and Health Promotion, CDC; Katelyn Chiang, National Center for Chronic Disease Prevention and Health Promotion, CDC; Jennifer Chevinsky, Epidemic Intelligence Service, National Center for Chronic Disease Prevention and Health Promotion, CDC; Augustina Delaney, G2S Corporation; Angela Dunn, Utah Department of Health; Molly Evans, National Center for Injury Prevention and Control, CDC; Victoria Fields, Epidemic Intelligence Service, National Center on Birth Defects and Developmental Disabilities CDC; Aaron Fleischauer, North Carolina Department of Health and Human Services Center for Preparedness and Response, CDC; Macarena Garcia, Center for Surveillance, Epidemiology, and Laboratory Services, CDC; Caitlin Green, National Center on Birth Defects and Developmental Disabilities, CDC; Arianna Hanchey, National Center for Environmental Health, CDC; Kathleen Hartnett, Center for Surveillance, Epidemiology, and Laboratory Services, CDC; Brooke Hoots, National Center for Injury Prevention and Control, CDC; Asad Islam, Center for Surveillance, Epidemiology, and Laboratory Services, CDC; Charlotte Kaboré, National Center for Chronic Disease Prevention and Health Promotion, CDC; Vikram Krishnasamy, National Center for Injury Prevention and Control, CDC; Mohammed Lamtahri, Center for Surveillance, Epidemiology, and Laboratory Services, CDC; Jennifer Layden, Illinois Department of Public Health; Dana Meany-Delman, National Center on Birth Defects and Developmental Disabilities; Jonathan Meiman, Wisconsin Department of Health Services; Christina Mikosz, National Center for Injury Prevention and Control, CDC; Maureen Miller, Epidemic Intelligence Service, National Center for Chronic Disease Prevention and Health Promotion, CDC; Yousra Mohamoud, National Center for Chronic Disease Prevention and Health Promotion, CDC; Erin Moritz, National Center for Environmental Health, CDC; Varsha Neelam, National Center on Birth Defects and Developmental Disabilities, CDC; David Nitschke, Center for Surveillance, Epidemiology, and Laboratory Services, CDC; Kevin O’Laughlin, Epidemic Intelligence Service, National Center for Emerging and Zoonotic Infectious Diseases, CDC; Samantha Olson, , G2S Corporation; Tia Rogers, Epidemic Intelligence Service, National Center for Injury Prevention and Control, CDC; Nicki Roth, Eagle Medical Services; Phil Salvatore, Epidemic Intelligence Service, National Center for Injury Prevention and Control, CDC; Alana Vivolo-Kantor, National Center for Injury Prevention and Control, CDC; Angela Werner, National Center for Environmental Health, CDC; Jason Wilken, California Department of Public Health, Center for Preparedness and Response, CDC Council of State and Territorial Epidemiologist Vaping-Associated Pulmonary Injury Task Force. Top Corresponding author: Cria G. Perrine; [email protected]. Top 1National Center for Chronic Disease Prevention and Health Promotion, CDC; 2National Center for Injury Prevention and Control, CDC; 3National Center for Environmental Health, CDC; 4Epidemic Intelligence Service, CDC; 5New Mexico Department of Health; 6Minnesota Department of Health; 7Illinois Department of Public Health; 8California Department of Public Health; 9Utah Department of Health; 10Wisconsin Department of Health Services; 11North Carolina Department of Health and Human Services; 12National Center for Immunization and Respiratory Diseases, CDC. Top All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed. Top * https://www.cdc.gov/tobacco/basic_information/e-cigarettes/assets/2019-Lung-Injury-Surveillance-Case-Definition-508.pdfpdf icon. † CDC determined the intent of this project to be public health practice for disease and injury control; thus, the activity is not research involving human subjects and Institutional Review Board approval was not required (OMB No. 0920–1011). § https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/need-to-know/index.html. ¶ http://nationalacademies.org/hmd/reports/2017/health-effects-of-cannabis-and-cannabinoids.aspxexternal icon.

Electronic cigarettes (e-cigarettes), also called vapes, e-hookas, vape pens, tank systems, mods, and electronic nicotine delivery systems (ENDS), are electronic devices that produce an aerosol by heating a liquid typically containing nicotine, flavorings, and other additives; users inhale this aerosol into their lungs (1). E-cigarettes also can be used to deliver tetrahydrocannabinol (THC), the principal psychoactive component of cannabis (1). Use of e-cigarettes is commonly called vaping. Lung injury associated with e-cigarette use, or vaping, has recently been reported in most states (2–4). CDC, the Food and Drug Administration (FDA), state and local health departments, and others are investigating this outbreak. This report provides data on patterns of the outbreak and characteristics of patients, including sex, age, and selected substances used in e-cigarette, or vaping, products reported to CDC as part of this ongoing multistate investigation. As of September 24, 2019, 46 state health departments and one territorial health department had reported 805 patients with cases of lung injury associated with use of e-cigarette, or vaping, products to CDC. Sixty-nine percent of patients were males, and the median age was 23 years (range = 13–72 years). To date, 12 deaths have been confirmed in 10 states. Among 514 patients with information on substances used in e-cigarettes, or vaping products, in the 30 days preceding symptom onset, 76.9% reported using THC-containing products, and 56.8% reported using nicotine-containing products; 36.0% reported exclusive use of THC-containing products, and 16.0% reported exclusive use of nicotine-containing products. The specific chemical exposure(s) causing the outbreak is currently unknown. While this investigation is ongoing, CDC recommends that persons consider refraining from using e-cigarette, or vaping, products, particularly those containing THC. CDC will continue to work in collaboration with FDA and state and local partners to investigate cases and advise and alert the public on the investigation as additional information becomes available. State health departments, the Council of State and Territorial Epidemiologists (CSTE), and CDC have developed definitions for confirmed and probable cases* and medical chart abstraction and case interview forms. The case definition, forms, and instructions for reporting cases were disseminated to all state health departments in late August 2019. Patients with cases of lung injury associated with e-cigarette use, or vaping, had 1) a history of e-cigarette use, vaping, or dabbing (vaping concentrated marijuana) within 90 days before symptom onset; 2) imaging studies showing lung injury; 3) absence of evidence of infection (confirmed cases) or infection not thought to be the sole cause of the lung injury or infectious disease testing not performed (probable cases); and 4) absence of alternative plausible diagnoses. Most states are reporting case counts to CDC as case status is determined; however, it can take up to several weeks to complete and submit information from medical chart abstraction and interviews. Additional time might be required after the information is submitted to CDC to clean and standardize data submitted in different formats. This report summarizes patterns of the lung injury outbreak and characteristics of cases reported to CDC, including demographic characteristics and selected substances used by patients.† As of September 24, 2019, 805 cases of lung injury from 46 states and one territory had been reported to CDC (Figure 1). Among the 805 cases reported, basic patient data (i.e., demographics and dates of symptom onset and hospitalization) were received for 771 (96%) patients. Ninety-one percent of patients were hospitalized. Median duration between symptom onset and hospitalization was 6 days (range = 0–158 days) (Figure 2). Although some cases occurred during April–June 2019, the number of cases began increasing in early July. The decline in reporting of onset dates and hospitalizations in the most recent 3–4 weeks is the result, in part, of a lag in reporting; there is no evidence that occurrence of lung injury cases is declining. Sixty-nine percent of patients were male (Table). Median age was 23 years (range = 13–72 years); 61.9% were aged 18–34 years, and 16.2% were aged <18 years. Among the 12 deaths reported to CDC, 58% occurred in men, and the median age was 50 years (range = 27–71 years). Among a subset of 514 patients (63.8%) for whom information on substances used in e-cigarettes, or vaping, products was available, 395 (76.9%) reported using THC-containing products, and 292 (56.8%) reported using nicotine-containing products in the 30 days preceding symptom onset; 210 patients (40.9%) reported using both THC-containing and nicotine-containing products, 185 (36.0%) reported exclusive use of THC-containing products, and 82 (16.0%) reported exclusive use of nicotine-containing products.

Characteristics of a Multistate Outbreak of Lung Injury Associated with E-cigarette Use, or Vaping — United States, 2019 Early Release / September 27, 2019 / 68 Cria G. Perrine, PhD1; Cassandra M. Pickens, PhD2; Tegan K. Boehmer, PhD3; Brian A. King, PhD1; Christopher M. Jones, DrPH2; Carla L. DeSisto, PhD1,4; Lindsey M. Duca, PhD1,4; Akaki Lekiachvili, MD1; Brandon Kenemer, MPH1; Mays Shamout, MD1,4; Michael G. Landen, MD5; Ruth Lynfield, MD6; Isaac Ghinai, MBBS4,7; Amy Heinzerling, MD4,8; Nathaniel Lewis, PhD4,9; Ian W. Pray, PhD4,10; Lauren J. Tanz, ScD4,11; Anita Patel, PharmD12; Peter A. Briss, MD1; Lung Injury Response Epidemiology/Surveillance Group (View author affiliations) View suggested citation Summary What is already known about this topic? Lung injury associated with e-cigarette use, or vaping, has recently been reported in most states. CDC, the Food and Drug Administration, and others are investigating this outbreak. What is added by this report? Among 805 cases reported as of September 24, 2019, 69% were in males; 62% of patients were aged 18–34 years. Among patients with data on substances used in e-cigarettes, or vaping products, tetrahydrocannabinol (THC)-containing product use was reported by 76.9% (36.0% reported exclusive THC-product use); 56.8% reported nicotine-containing product use (16.0% reported exclusive nicotine-product use). What are the implications for public health practice? The cause of the outbreak is unknown. While this investigation is ongoing, CDC recommends that persons consider refraining from using e-cigarette, or vaping, products, particularly those containing THC.

VERMONT CASES This information is updated on Thursday each week. REPORTS CASES Number investigated 19 Confirmed 3 Probable 0 Pending classification 2 Not a case 14

Cases reported in Tennessee (as of September 26, 2019):36* *Evidence of respiratory illness, with no other cause identified, and report vaping in the last 90 days

Number of confirmed or probable cases: 51Number of people under review: 27Updated Friday, 27-Sep-2019 08:50:05 CDT

Vaping Epidemic in Kansas KDHE Update 9/27/2019: As of September 27, Kansas has had two confirmed deaths related to vaping. Kansas currently has 11 probable/confirmed vaping related cases, including the two deaths. Of the cases, 64% are male and age from 17-67 years old. 10 of the 11 were hospitalized and two remain hospitalized. Regarding the types of vaping products used, there was a combination or those reporting using only nicotine, only THC, only CBD and a combination of THC and nicotine. Due to the small numbers of those affected, KDHE is not releasing locations of those affected or information about specific cases.

2019 Respiratory Illnesses in Illinois Cases* Individuals needing more investigation Deaths ** 88 17 1 Updated September 26, 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 Anonymous Survey on Vaping Habits - Illinois Residents Are you an Illinois resident and have a few minutes to share with us some information on your vaping habits? Public health departments across the U.S. are trying to understand why people are becoming seriously ill after vaping. We are trying to understand if vaping habits are different between people who have become ill after vaping, and those who have not. Any information you provide on the survey will be anonymous. Thank you for helping the Illinois Department of Public Health. Survey Here Cases in Chicago, Bureau, Champaign, Cook, DeKalb, DuPage, Henry, Kane, Kendall, Knox, Lake, Macoupin, Madison, McHenry, Peoria, Rock Island, St. Clair, Tazewell, Vermilion, Wabash, Whiteside, Will, Winnebago, and Woodford counties. Ages - 13-46 years. Median age - 22 years. Updates will be posted by end of day on Thursdays.

Current Cases as of September 26, 2019 Confirmed 1* Probable8 8 Under Investigation 7 Total 16 * Due to a change in case definitions, some previously confirmed cases have been reclassified.

Oregon Cases Updated September 26, 2019 In Oregon, five cases have been reported, two of which resulted in death.

: CBS 17 Digital Desk Posted: Sep 26, 2019 / 12:12 PM EDT/ Updated: Sep 26, 2019 / 06:24 PM EDT GREENSBORO, N.C. (WNCN) – A person has died of a disease related to vaping, FOX8 reports. Cone Health in Greensboro confirmed to FOX8 Thursday morning its first death due to vaping. No other information about the patient was immediately available. https://www.cbs17.com/news/first-vaping-related-death-reported-in-nc/

By Helena Oliviero, The Atlanta Journal-Constitution Nine people in state hospitalized with pneumonia from e-cigarettes The Georgia Department of Public Health announced Wednesday the state’s first death from a vaping-linked illness. The state agency said the patient was a man over the age of 35 who did not live in metro Atlanta. He had a history of heavy nicotine vaping, but no history of vaping THC, which has been linked to a majority of the mysterious vaping-related lung diseases afflicting e-cigarette users. The death is one of nine confirmed cases in Georgia. The nine people were hospitalized and developed pneumonia with “no known infectious cause,” according to the agency. In Georgia, those sickened range in age from 18 to 68. The median age of the cases is 26; seven are men. The Centers for Disease Control and Prevention is working with states to investigate more than 500 cases of vaping-associated illness. There have been at least eight deaths confirmed in seven states. No specific e-cigarette device or substance has been linked to all of the cases. E-cigarettes are battery-powered devices that heat liquid, turning it into vapor for inhaling. They are an increasingly popular alternative to combustible cigarettes. Doctors are reporting cases of otherwise healthy patients, many in their late teens and 20s, showing up in emergency rooms gasping for breath and vomiting. The CDC said the outbreak does not seem to be caused by an infection but by chemical exposure, possibly a solvent mixed with nicotine or THC, the main psychoactive chemical in marijuana. But with the cause of illness still unknown, the CDC is urging people to consider refraining from using e-cigarettes. People who decide to continue vaping should not buy vaping products off the street and they should not modify or add any substances to the products. Symptoms of vaping-associated illnesses, which worsen over time, include cough, shortness of breath, fatigue, chest pain, nausea, vomiting and diarrhea. The rash of cases has heightened scrutiny of e-cigarettes, even though many health experts consider them less harmful than traditional cigarettes, which release toxins through combustion. Kevin Burns, the chief executive of Juul, the dominant e-cigarette company in the U.S., stepped down on Wednesday. Juul also announced it is suspending all broadcast, print and digital product advertising in the U.S. as it faces mounting investigations, accused of getting teenagers hooked on flavored nicotine pods. K.C. Crosthwaite, an executive from Altria, the largest U.S. tobacco company and maker of Marlboro cigarettes, replaces Burns. Altria owns a 35% stake in Juul. (Altria is expected to open during the coming weeks a new “heat-not-burn” tobacco product store at Lenox Square in Buckhead, the company’s first store ahead of a national rollout.) https://www.ajc.com/news/breaking-news/first-death-linked-mysterious-vaping-illness-confirmed-georgia/GdZmSdAdkHXQeDd7R8PxdM/

Breath is Precious: The Vaping Disease Killed My Mother BY MARY MARGARET DAVIS Photo courtesy of Mary Margaret Davis At first, the doctors said it was pneumonia. On the way back from the hospital two days before her death, my mother groaned between coughs, “I’m never smoking again; I’m throwing out all of my e-cigarettes and weed pens.” This was a groundbreaking statement from my mother, who, like many, had embraced vaping as an alternative to smoking with swift, open arms. Despite recent protests from loved ones, she was adamant for years that it was far healthier than her cigarette habit. Having always believed marijuana was not a dangerous drug to consume, Mom began to vape THC products in late 2018 — not long after California legalized the drug for recreational use. If I knew my mother, she would try to move mountains before she would declare she was quitting either drug. It’s easy to assume just how much pain she was in to say this. My father, a doctor who is all too familiar with the dangers of vaping, responded to her declaration of quitting by saying, “Good, Mary. There are some things that are precious, like your vision and your breath, and you just can’t hurt those things.” “Breath is precious,” my mom repeated. On Friday, Sept. 6, my father found her blue in the lips, struggling for such precious air but unable to grasp it. She had most likely suffered for hours. Her death came swiftly after. Later, X-rays revealed a white substance infiltrating her lungs, clouds as silky as the puffs of vape she would exhale. Those clouds weren’t there when she had an X-ray two days before her death; they had developed as rapidly as an unexpected thunderstorm, unleashing an onslaught of destruction on her system and ultimately killing her. Relentless. No mercy given. These X-rays confirmed what my family had feared; this wasn’t a simple case of pneumonia, this was the new vaping illness sweeping the nation with fury. The white substance in her lungs was one of many symptoms associated with this new disease. Just as many others had, she suffered from nausea, vomiting and diarrhea. Other symptoms reported are coughing, shortness of breath and chest pain. The Investigation When Mom died, my father immediately requested an autopsy to confirm our suspicions. The deputy coroner working on the night of her death said in response, “An autopsy is not in the budget unless it’s requested by the GBI [Georgia Bureau of Investigation].” “Well,” my father responded, “I think this is one that needs to be investigated.” Dad began to explain my mother’s death in the way he would repeat until it was practically ingrained in him: Mary Kerrie Davis took a trip to California in July. She vaped legal marijuana. She had a cough when she returned home. She developed what you could barely call pulmonary pneumonia, and she was an otherwise healthy woman; this is a sudden death that should be investigated. Yes, she also vaped nicotine for years. The next day, Dad turned to the local Blairsville sheriff’s office. Again my father explained her death. The deputy on duty told him, “I don’t see how her vaping in California is a crime in Union County.” Again, my father explained the vaping illness. With some pushing, the GBI performed their autopsy. Everywhere we turned, the response was the same: Where was the crime? What are the mysterious circumstances? A Georgia judge my dad had contacted for advice said, “You know, in all my years of serving, I have never seen a death related to THC.” Then turning to the world of medicine, Dad reached out to my mother’s primary care physician and close family friend. Agreeing that her death was concerning, he reached out to the Centers for Disease Control and Prevention, who in turn directed him to the Georgia Department of Health, who then advised that he file a report with poison control. We found ourselves at a standstill. No one who my father contacted, whether it be law enforcement or medical professionals, seemed to be aware of the national vaping epidemic aside from her primary care physician. On Monday, Sept. 9, we got word that Mom’s autopsy was complete, and the funeral home would pick her up the following day. At the same time, my family found incriminating messages on my mother’s phone; she had been purchasing THC cartridges illegally in Georgia. We began to search the house and came across several cartridges. The next step was obvious: these needed to be tested. My father swiftly called a GBI officer he had known for some time; he told my father he would make some calls. After this, my father called the GBI crime lab where they had taken Mom. He was put directly in contact with her medical examiner, where he expressed his concerns about vaping. Hours passed. Impatience grew. My father, deciding instead to take matter into his own hands, then called the GBI office’s tip line. He was directed to the North Georgia Drug Task Force, who immediately sent a Union County narcotics investigator to our home. The officer searched the cartridges we had accumulated, and with a shake of his head, told us, “Yeah, we’ve been having a lot of problems with this brand.” He took Mom’s phone and the bag of cartridges, and for the first time since her death, my family felt accomplished. On Tuesday, Sept. 10, the funeral home called us. “Our guy went to pick her up, but the GBI told us they wanted to keep her for further testing,” they informed my dad. “A blessing in disguise,” my dad answered. “They’re taking this seriously.” The next day, my father called the medical examiner again, curious about the extra tests they had performed. She told him that based on the phone call she received from my father from the day before, she decided to run more tests and take a few more biopsies; this came just hours after she informed the funeral home her body was ready to be cremated. This was an opportunity that we had almost missed. Several days passed. As the death toll continued to rise and Georgia began to receive reports, my mother’s death did not make headlines. On Sept. 16, the medical examiner reported to my father that it would take four months to confirm her cause of death, despite reports of vaping-related deaths growing in numbers. Many times throughout the investigation, my tired father hung his head between his hands. “It’s incredible,” he would say, voice laced with the pain of loss, “how much we have to do to get this investigated, how many dots that we have to connect for the officials. It’s incredible how much we have to do just to get the damn weed out of our house. Why wouldn’t they be sending people to talk to us? Why do we have to ask them to do it?” My mother was a middle-aged woman. At the age of 52, she was not exactly the demographic associated with the vaping disease: men with a median age of 19, according to a recent report by The Washington Post. Although adolescents do make up a large portion of e-cigarette users, 1 in 20 U.S. adults reported using e-cigarettes, according to a 2016 study. How many people, particularly middle-aged women, are dead because of this disease and haven’t been investigated? A Not-So-Sudden Rise of Side Effects The side effects of the vaping disease are not new. In a survey, users of nicotine e-cigarettes reported 405 side effects, with 326 of those being negative, according to a 2014 study titled “Vaping and Health: What Do We Know about E-Cigarettes?.” Such side effects included headaches and changes in appetite. The same study reported “various nicotine-related degradation products and other impurities in e-liquids and vapors,” although it claimed that such impurities were so small, it did not affect human health. Nicotine toxicity has been known to produce symptoms of nausea, vomiting and diarrhea. Various online forums report similar effects from vaping, dating as far back as 2012. Because vaping marijuana is a relatively new practice, researchers aren’t yet sure of its side effects. The Absence of Regulation My mother had declared she was done with vaping, yet her decision came too late. She will never see her youngest daughter graduate high school, nor her oldest graduate college. She will never see her daughters married or meet her grandchildren. Her absence, a sudden and jarring hole in my family, will be felt for decades to come. Yet I wonder if the blame is fully my mother’s. Was it her decision that was too late, or was it the absent decision of the FDA to tighten regulations on e-cigarettes and marijuana pens? The CDC reports over 450 confirmed cases related to the vaping illness, and more are likely to come as the number of those infected has more than doubled from Aug. 27 to Sept. 9. As the death toll slowly marches upward, there is little being done to further regulate nicotine and marijuana juices. Pax Labs is the mother company of Juul and was founded in 2007. It has long claimed that e-cigarettes are a healthy alternative to smoking. On the front page of the website, the company promotes users to “make the switch,” telling its audience that Juul is a “satisfying alternative” to cigarettes. For years, research behind their claims as a healthy alternative has been dangerously absent, particularly in long-term studies. The first long-term study reports a higher risk of heart attacks by five-fold, according to a 2018 study published by the National Academies of Sciences, Engineering and Medicine. Such research is still in the early stages, despite e-cigarettes exploding in popularity in the past decade. Although Juul has claimed that e-cigarettes is an alternative to cigarettes, many adolescents are introduced to vaping before cigarettes. The CDC reported that in 2018, nearly one of every 20 middle school students said that they used e-cigarettes in the past 30 days, and nearly one of every five high school students said that they used e-cigarettes in the past 30 days. In the wake of the new vaping disease, the FDA released a warning letter to Juul on Sept. 9, claiming it had been illegally advertising the message that vaping is healthier than smoking. In the decade since its founding, Juul had not received federal approval to market its product as a safer alternative to smoking. Juul also has not received any federal punishment for marketing this product as such. Despite boasting fewer carcinogens, Juul pods have more than twice the nicotine found in most cigarettes, according to the Public Health Law Center. Marijuana pens also boast exponentially higher numbers of THC, and yet we still do not know how this historically disproportionate consumption of marijuana affects the human body, particularly when consumed as an oil. As the consumption of e-cigarettes skyrocketed, particularly among adolescents, the battle against Pax Labs’ claims have begun slowly. When states began to legalize marijuana, vape cartridges containing THC became available to the public, and sales of THC cartridges increased by 50% between 2017 and 2018, according to Forbes. Again, vendors claimed that vaping THC was healthier than traditional smoking methods; on Select Oil’s website, they state, “Actually, it started in Portland, Oregon with a puff, then a bad cough, that led to a thought — why not make a safer cartridge?” Regulations on cartridges were little to none. The question remains: will the FDA hold THC vendors to the same standard as Juul when claiming that vaping is healthier than smoking? The call for regulation is not new. A 2014 study claimed that an increase in internet and unregulated sales posed a threat to health. Even last year, marijuana smokers reported being tricked into buying synthetic-laced cannabis oil online. In illegal selling of THC cartridges, dealers often use “thickening agents” to dilute the amount of THC in a product. Such thickeners have been easily available for purchase online; one can find thickeners easily online. Vitamin E acetate, a thickener that can be bought “for pennies,” had not been approved as an additive for New York’s authorized vape products, according to reporting by UPI. However, that does not stop black market dealers. In the investigation of the vaping disease, the CDC has found that a large number of oil samples included the vitamin E acetate. On Sept 10, New York subpoenaed three companies involved in selling vitamin E acetate. Putting Together a National Solution When the Union County Narcotics Officer first came to my family, he informed us that possession of THC cartridges is a felony in the state of Georgia due to its high amount of THC; in the eyes of the law, it is akin to heroin possession. On Sept. 11, Trump called to ban flavored e-cigarette juices, after six official deaths to the vaping illness. But is keeping marijuana illegal and banning vape oil really the right solution? This disease and outbreak on the verge of national marijuana legalization is not a new phenomenon. During the prohibition period of the 1920s, the lack of federal regulation of alcohol allowed the black market to sell adulterated and even poisonous alcohol. Moonshine, a common alcoholic drink on the black market during that time, has been linked to lead poisoning. Due to its lack of regulation, moonshine has historically been manufactured using lead pipes, lead soldering and even car radiators. Cannabidiol, or CBD, also has a dangerous black market history prior to its partial 2018 legalization and regulation. In 2017, five Utah patients experienced seizures, confusion, loss of consciousness and hallucinations after consuming what was thought to be CBD oil, but turned out to be a synthetic alternative. Alternatively, in California, some who have been affected by the vaping disease had turned in favor of cheaper black market alternatives to steeply-priced legal marijuana and nicotine oil. USA Today reports that some websites advertise synthetic marijuana for as little as $25 per pound, whereas natural CBD can cost hundreds or even thousands of dollars. A survey of Ohio medical dispensaries showed that many users found legal marijuana to be just too pricey. The reason for such high prices may be overregulation, with many legal sellers noting the high taxes and compliance costs. Balanced regulation is ultimately what is needed to drive out black-market competition and keep marijuana and nicotine oil clean. We need more research and balanced regulation, and we need them to be swifter than this disease. For the inaction of the government, my family pays the consequences. For the past decade, where was the research to tell my mother that no, actually, we don’t know if vaping is healthy and that she should rethink that e-cigarette in favor of nicotine patches or medication? Where are the regulations that should have protected my mother’s life from something as careless as a potential vitamin e-oil contamination in her marijuana pen? This vape-borne disease spared us no time for goodbyes, I-love-yous or last words. All that my family is left with is anger for the inaction of local authorities and the government and a new understanding of the value of air. In a hotly debated issue of e-cigarette and marijuana regulation, do not forget the lives that may be at stake. Always remember that breath is precious. ________________ Email Mary Margaret Davis: [email protected] http://pepperdine-graphic.com/breath-is-precious-the-vaping-disease-killed-my-mother/

:28 PBy Erika Edwards Maggie Davis cannot remember a time when her mother, Mary Kerrie, didn't smoke. Davis, of Blairsville, Georgia, said her mother gravitated toward e-cigarettes about a decade ago, as a way to quit traditional tobacco. She assumed they were healthier. On Sept. 6, Mary Kerrie Davis, 52, died suddenly. Davis' father called her with the crushing news. "The first thing I said was, 'You have to get this investigated,'" Davis told NBC News. "I'm never smoking again" Davis, 21, said her mother usually smoked e-cigarettes with nicotine, but started using THC cartridges about a year ago. Because THC is illegal in Georgia, Davis said her mother turned to the black market. This past July, Mary Kerrie traveled from her Georgia home to California and vaped legal marijuana, according to Davis. When Mary Kerrie returned home, she developed a ragged cough, and was initially diagnosed with pneumonia. Davis wrote about her mother's illness, death and the ensuing investigation in a poignant essay published by her college's newspaper, the Pepperdine University Graphic. "My mother groaned between coughs, 'I'm never smoking again; I'm throwing out all of my e-cigarettes and weed pens,'" she wrote. "My father, a doctor who is all too familiar with the dangers of vaping, responded to her declaration of quitting by saying, 'Good, Mary. There are some things that are precious, like your vision and your breath, and you just can’t hurt those things.'" "'Breath is precious,' my mom repeated." Davis said she texted her mom, telling her she hoped it wasn't the "vaping disease" that was going around. At that time, news of the mysterious illnesses had started to circulate nationwide. Two days later, Mary Kerrie was dead. "It was devastating," Davis said. "Over and over again, all I could say was, 'why MY mom?'" It's torn my family apart. It took my mom away from me. Despite an ongoing national investigation of vaping-related illnesses and deaths, Davis told NBC News that it was difficult at first to convince health officials to look for a link between Mary Kerrie's vaping history and her death. An autopsy and other tests have since been completed, with results pending. The Georgia Department of Health has reported one death from vaping-related lung illness, but it's believed to be of a different person. Davis is convinced vaping is to blame for her mother's death. "It's torn my family apart," she said. "It took my mom away from me." Maggie Davis, seen here as a baby, says vaping is to blame for her mother's death at age 52.Courtesy Maggie Davis She said writing the essay for her college paper has been therapeutic in the weeks since her mother's death. "My mother had declared she was done with vaping, yet her decision came too late," Davis wrote. "She will never see her youngest daughter graduate high school, nor her oldest graduate college. She will never see her daughters married or meet her grandchildren." "Her absence, a sudden and jarring hole in my family, will be felt for decades to come." oman who died from vaping speaks out Her mother turned to e-cigarettes because she thought they were safer than regular tobacco. They ended up killing her.

Despite an ongoing national investigation of vaping-related illnesses and deaths, Davis told NBC News that it was difficult at first to convince health officials to look for a link between Mary Kerrie's vaping history and her death. An autopsy and other tests have since been completed, with results pending. The Georgia Department of Health has reported one death from vaping-related lung illness, but it's believed to be of a different person. Davis is convinced vaping is to blame for her mother's death. https://www.nbcnews.com/health/vaping/breath-precious-daughter-woman-who-died-vaping-speaks-out-n1059101

THURSDAY Dr. Henry Niman PhD Vaping Crisis Exploding Almost 1,000 Cases And At Least 12 Dead

Monday's interview http://mediaarchives.gsradio.net/rense/special/rense_092319_hr1.mp3

Map of Reported Cases

Below is a list of selected outbreaks and investigations with wide impact in Wisconsin. Severe Lung Disease Among People who Reported Vaping Updated 9/26/2019 We plan to update case counts by 10 a.m. on Thursdays. The Wisconsin Department of Health Services (DHS) and local health departments are investigating a cluster of people with severe lung disease who all reported recent vaping. As of September 26, 2019, we are aware of 60 cases. We have an additional 14 patients whose records need further investigation. Counties with cases include: Adams, Brown, Dane, Dodge, Door, Fond du Lac, Grant, Green, Jefferson, Kenosha, La Crosse, Marathon, Milwaukee, Monroe, Outagamie, Portage, Racine, Sauk, Sheboygan, St. Croix, Vernon, Walworth, Washington, Waukesha, Waupaca, and Winnebago. Most of the affected individuals have been adolescents and young adults, but some adults in older age groups have also been affected. Patients often have a range of initial symptoms, including shortness of breath, chest pain, cough, nausea, vomiting, fever, and weight loss. The majority of patients went on to develop severe respiratory illnesses requiring hospitalization, and in some cases, had to be put on ventilators in order to breathe. No deaths have been reported in Wisconsin. The majority of cases reported using e-cigarettes or other vaping devices to inhale THC-containing products, such as waxes and oils. THC is the active ingredient in marijuana. Vaping cartridges containing THC may contain chemicals or additives that are unknown, unregulated, and unsafe. Among patients who reported vaping THC, a wide variety of brand names and flavorings were reported. We urge the public to avoid vaping any THC products. This is a complex and ongoing investigation, and we are working to gather information about the products used, collect products for testing, and investigate new cases. We will continue to provide updates when new information becomes available. To learn more about this cluster, review these resources: News releases August 29: Majority of Wisconsin Lung Disease Patients Who reported Vaping Cite THC Products August 8: Older Age Groups Now Included in Investigation of Lung Disease Among People Who Reported Vaping August 2: New Cases Identified in Investigation of Lung Disease Among Teens and Young Adults Who Reported Vaping Memos September 10 memo outlining updated case information July 25 memo outlining initial case information Journal articles Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin - Preliminary Report. New England Journal of Medicine (9/6/2019) Severe Pulmonary Disease Associated with Electronic Cigarette Product Use - Interim Guidance. Morbidity and Mortality Weekly Report (9/6/2019) To learn more about vaping and e-cigarettes: Visit Tobacco is Changing to learn more about vaping and e-cigarettes, including how to identify products. Read our public health advisory on vaping and e-cigarettes for additional details on policy solutions and actions for parents, teachers, and health professionals.

The Wisconsin Department of Health Services (DHS) and local health departments are investigating a cluster of people with severe lung disease who all reported recent vaping. As of September 26, 2019, we are aware of 60 cases. We have an additional 14 patients whose records need further investigation. Counties with cases include: Adams, Brown, Dane, Dodge, Door, Fond du Lac, Grant, Green, Jefferson, Kenosha, La Crosse, Marathon, Milwaukee, Monroe, Outagamie, Portage, Racine, Sauk, Sheboygan, St. Croix, Vernon, Walworth, Washington, Waukesha, Waupaca, and Winnebago. Most of the affected individuals have been adolescents and young adults, but some adults in older age groups have also been affected. Patients often have a range of initial symptoms, including shortness of breath, chest pain, cough, nausea, vomiting, fever, and weight loss. The majority of patients went on to develop severe respiratory illnesses requiring hospitalization, and in some cases, had to be put on ventilators in order to breathe. No deaths have been reported in Wisconsin. The majority of cases reported using e-cigarettes or other vaping devices to inhale THC-containing products, such as waxes and oils. THC is the active ingredient in marijuana. Vaping cartridges containing THC may contain chemicals or additives that are unknown, unregulated, and unsafe. Among patients who reported vaping THC, a wide variety of brand names and flavorings were reported. We urge the public to avoid vaping any THC products. This is a complex and ongoing investigation, and we are working to gather information about the products used, collect products for testing, and investigate new cases. We will continue to provide updates when new information becomes available. https://www.dhs.wisconsin.gov/outbreaks/index.htm

Ohio Vaping Investigation Update (Information will be updated each Tuesday and Thursday at 2:00 p.m.) Information updated as of 2:00 pm September 26, 2019 Number of cases: 21 Age range: 16-59 years (median age: 21 years) Gender: 7 Female, 14 Male (67% Male) Number of hospitalizations: 21 Number of deaths: 0 Counties: Butler, Cuyahoga, Franklin (4), Hamilton (2), Jefferson, Lucas, Montgomery, Portage, Richland (2), Summit (3), Tuscarawas, Union (2), Wayne Additional illness reports under investigation: 19

As of 9/26/2019, 40 cases have been reported in individuals in North Carolina ranging in age from 16 to 72 years. Patients experienced severe respiratory symptoms including cough and shortness of breath. Patients also reported experiencing fever, fatigue, chest pain, nausea, vomiting, and diarrhea. Most cases have been hospitalized and have required respiratory support. No deaths have been reported.