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Pulmonary Illness Associated with Black Market Vaping Products The New York State Department of Health (NYSDOH) has received numerous reports from New York State physicians of severe pulmonary (lung-related) illness among patients ranging from 14 to 69 years of age who were using at least one cannabis-containing vape product prior to becoming ill. Laboratory test results show very high levels of vitamin E acetate in nearly all cannabis-containing samples analyzed by New York State’s Wadsworth Laboratory as part of this investigation. At least one vitamin E acetate containing vape product has been linked to each patient that submitted a product for testing. Anyone using vape products and experiencing symptoms including shortness of breath, cough, chest pain, fever, nausea or vomiting should contact their health care provider immediately. Health care providers should report possible cases to their local poison control center (1-800-222-1222). People should never use products purchased “off the street” because they may contain unknown and harmful ingredients. Cannabis-containing products are not legally available in New York State for recreational use. New York State Press Releases: Governor Cuomo and Health Commissioner Zucker Issue Renewed Warning as Vaping-Associated Illnesses Continue to Climb Nationwide (9/20/2019) Governor Cuomo Announces New York State Implements First-in-the-Nation Ban on Flavored E-Cigarettes (9/17/2019) Governor Cuomo Takes Aggressive Action to Protect New Yorkers from Harmful and Addictive Vaping Products Following Rise in Vaping-Associated Illnesses Nationwide (9/9/19) New York State Health Commissioner Issues Guidance on Vaping-Associated Illnesses (9/7/19) New York State Department of Health Announces Update on Investigation Into Vaping Associated Pulmonary Illness (9/5/19) For the Public: What You Need to Know (CDC) Health Care Providers and State and Local Health Departments: New York State Health Advisory: Update Unexplained Vaping-associated Pulmonary Illness (9/20/19) New York State Health Advisory: Unexplained Vaping-associated Pulmonary Illness (8/15/19) Outbreak of Lung Disease Associated with E-Cigarette Use or Vaping (CDC) Clinician Outreach and Communication Activity (COCA) (CDC) Health Alert Network (CDC) Link to Black Market Vaping Product Pictures Vaping Can Expose You to Toxic Chemicals and Kill You! Poster (PDF) Total reported patients statewide: 93 (Updated: 9/24/2019) Breakdown of reported patients by region: Western New York: 24 Central New York: 9 Capital Region: 14 Northern New York: 1 Metropolitan Region (outside of NYC): 21 New York City: 21 Out of State: 3* *Patients treated at hospitals in NYS but are residents of another state. Electronic cigarettes and similar vapor products are tobacco products.1 Most contain a battery that heats a flavored liquid, usually containing nicotine, into an aerosol users inhale. The liquid is often called e-liquid or e-juice. E-liquids usually contain nicotine and flavorings in a base of propylene glycol (PG) and vegetable glycerin (VG). Nicotine is highly addictive and harms brain development. Some flavorings, such as diacetyl, can cause serious disease. PG and VG are generally recognized as safe to eat but inhaling them can irritate the eyes, nose and throat and make it hard to breathe. Some other names for electronic cigarettes are: e-cigarettes, e-smokes, e-cigs and cigalikes; vapes, personal vaporizers (PVs) and advanced personal vaporizers (APVs); mods, pod mods, pod vape devices, vape mods and box mods; wop machines; pens and vape pens; and electronic nicotine delivery systems (ENDS). Other electronic vaping products that that use e-liquids include e-cigars, e-pipes and hookah pens (e-hookah). The top-selling e-cigarette brand is a USB-shaped device called JUUL. News outlets and social media sites report widespread use of JUUL by students in schools, including in classrooms and bathrooms. All JUUL e-cigarettes have a high level of nicotine. Similar products are available. Use of an e-cigarette is often called "vaping" or "JUULing." Who Is Using E-cigarettes and Why? Youth and young adults are the primary users of e-cigarettes.1,2 High school students use e-cigarettes at rates five times higher than adults over age 25.3,4 Youth and young adults say their reasons for trying and using e-cigarettes are flavor and taste, curiosity and the belief that they are less harmful than other tobacco products.1 The U.S. Food and Drug Administration (FDA) regulates tobacco products, including e-cigarettes. Currently, e-cigarettes are not as strictly regulated as cigarettes. Except for menthol, the FDA does not allow cigarettes to contain flavored tobacco. This is not the case for e-cigarettes. E-cigarette companies know youth are attracted to many of the over 15,000 e-liquid flavors. Some of the sweet and fruity flavors that appeal to young people are cereal and milk, mango, cherry cola, bubblegum, crème, chocolate mint, blueberry cheesecake and fruit punch. Nicotine is Addictive and Dangerous for Youth and Young Adults Most e-liquids contain nicotine, the highly addictive chemical in all tobacco products. Nicotine is harmful for young people.1 Nicotine can harm the developing brain of adolescents and young adults, which can: lead to lower impulse control and mood disorders; disrupt attention and learning among youth and young adults; and prime the developing brain for addiction to alcohol and other drugs, such as cocaine.1 E-cigarette Aerosol is Harmful The e-cigarette aerosol users inhale and exhale is not harmless water vapor. Some e-liquids are advertised as nicotine free, but this may not be true. With or without nicotine, e-cigarette aerosol is unsafe. E-cigarette aerosol can contain: fine and ultrafine toxic particles that can interfere with the growth and work of the lungs and increase the risk of heart disease, lung cancer and asthma attacks; heavy metals such as lead, tin and nickel; chemicals used for flavoring such as diacetyl that can cause a serious lung disease called bronchiolitis obliterans; and volatile organic compounds (VOCs) that can cause long-term health effects including cancer.1 Many of the chemicals found in cigarette smoke are also found in e-cigarette aerosol. They include: formaldehyde, also found in embalming fluid;1,7 cadmium, used in batteries;1,8 benzene, found in gasoline;1,9 and toluene, an industrial solvent.1,10 E-cigarette Use Among Youth and Young Adults is a Major Public Health Concern Youth use e-cigarettes more than cigarettes, cigars, smokeless tobacco and hookah.3 Almost five times as many high school students in New York State use e-cigarettes than smoke cigarettes.3 The New York State smoking rate among youth is at a record low (4.3%), but their e-cigarette use doubled between 2014 and 2016 (from 10.5% to 20.6%).3 Few high school students say they plan to try smoking, but increasing numbers are open to trying e-cigarettes.5 More than half of teens believe nondaily e-cigarette use causes little or some harm.1 Of young people who use e-cigarettes, a third falsely believe nondaily e-cigarette use is harmless.1 E-cigarette use does not prevent from smoking. Adolescents and young adults who use e-cigarettes are at increased risk for starting smoking and continuing to smoke.1,6 More than half of high school students and young adults who smoke cigarettes also use e-cigarettes (called dual use).1 What New York State is Doing to Protect Youth from Nicotine Addiction Almost all adults addicted to nicotine started smoking or using other tobacco products in their teens. Nearly 9 out of 10 adult smokers started smoking by age 18, and 99 percent started by age 26.11 New York State's strong laws and programs protect youth from accessing tobacco products and denormalize tobacco use to prevent lifelong addiction, illness and early death. As of November 22, 2017, e-cigarettes and similar devices are included in the state's Clean Indoor Air Act, which prohibits their use and tobacco smoking in virtually all indoor public areas, including workplaces, bars and restaurants. State law also prohibits the use of tobacco products and e-cigarettes on the grounds of all public and private pre-schools, nursery schools, and elementary and secondary schools as well as in school vehicles used to transport children or school personnel. E-cigarettes are not Proven to Help People Quit Smoking Most youth and young adults do not report using e-cigarettes to quit smoking.1 Most adult smokers want to quit.12 Every year, more than half of smokers quit for at least one day as an attempt to stop smoking.12,13 But, highly addictive nicotine makes it hard to quit for good, and fewer than one in 10 smokers successfully quits for good.12 Some smokers have heard that e-cigarettes can help them quit. Researchers are investigating if substituting e-cigarettes for cigarettes may help adults quit smoking, but this is unproven.14,15 E-cigarettes are not an FDA-approved smoking cessation product. However, the FDA has approved seven products proven to help smokers quit: Five nicotine replacement therapies (NRTs): patch (available over-the-counter and by prescription for Medicaid enrollees) gum (available over-the-counter and by prescription for Medicaid enrollees) lozenge (available over-the-counter and by prescription for Medicaid enrollees) nasal spray (by prescription) inhaler (by prescription); and Two non-nicotine oral medicines: varenicline tartrate, brand name Chantix® (by prescription) bupropion hydrochloride, brand names Zyban® and Wellbutrin® (by prescription).14 People who smoke or use other tobacco products can improve their chances of quitting for good with treatment from their health care provider.13 Treatment that includes brief counseling and FDA-approved medication can double or triple the chances of permanently quitting.15 To learn more, talk to your health care provider. For additional assistance, call or visit the New York State Smokers' Quitline at 1-866-NYQUITS (1-866-697-8487). E-cigarette Infographics and Fact Sheets Vaping Can Expose You to toxic Chemicals and Kill You! Poster (PDF) Teachers and Parents: That USB Stick Might Be an E-cigarette (Centers for Disease Control and Prevention) E-cigarettes Shaped Like USB Flash Drives: Information for Parents, Educators and Health Care Providers (Centers for Disease Control and Prevention) Electronic Cigarettes: What's the bottom line? (Centers for Disease Control and Prevention) Cigarrillos electrónicos ¿Cuál es la conclusión? (Centers for Disease Control and Prevention) For More Information about E-cigarettes Know the Risks – E-cigarettes & Young People (U.S. Department of Health and Human Services) The Real Cost (U.S. Department of Health and Human Services) Smokefree Teen – E-Cigarettes (U.S. Department of Health and Human Services) E-Cigarettes and Young People: A Public Health Concern (Centers for Disease Control and Prevention) Smoking and Tobacco Use: Electronic Cigarettes (Centers for Disease Control and Prevention) The Flavor Trap: How Tobacco Companies are Luring Kids with Candy-Flavored E-cigarettes and Cigars. (American Academy of Pediatrics, American Cancer Society Cancer Action Network, American Heart Association/American Stroke Association, American Lung Association and Campaign for Tobacco-Free Kids) Youth Cigarette Use at All-Time Low, ENDS Use Doubles (New York State Department of Health) Openness to Smoking Conventional Cigarettes and Openness to Using Electronic Cigarettes and Similar Devices among NYS Youth (New York State Department of Health) Use of Electronic Cigarettes and Similar Devices among NYS Youth, 2014‐2016 (New York State Department of Health)

Total reported patients statewide: 93 (Updated: 9/24/2019) Breakdown of reported patients by region: Western New York: 24 Central New York: 9 Capital Region: 14 Northern New York: 1 Metropolitan Region (outside of NYC): 21 New York City: 21 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/

09/12/2019 Department of Health Warns Against Vaping Illegally Obtained Products as Life-Threatening Illnesses Rise Harrisburg, PA - As cases of e-cigarette-related lung injury have rapidly increased in Pennsylvania and nationwide, Secretary of Health Dr. Rachel Levine is warning all Pennsylvanians of the dangers of vaping, especially illicit drugs like recreational marijuana, especially using unregulated products purchased illegally. “It is essential that people who use e-cigarettes heed this warning, as their life could be at-risk,” Dr. Levine said. “One of the largest concerns with vaping is that we do not know many of the chemicals and additives contained in the products. While we applaud the Food and Drug Administration’s moves to remove products with flavor additives from the market, initial findings in Pennsylvania and across the country indicate patients were vaping illicit products, primarily recreational marijuana or other unregulated products with THC.” Pennsylvania has 17 suspected cases and nearly 30 additional cases that are being investigated. Each of these cases have suffered serious lung injuries and have been hospitalized. No cases have been associated with medical marijuana bought at a Pennsylvania dispensary. “Pennsylvania’s medical marijuana program is carefully regulated, with products going through extensive laboratory testing,” Dr. Levine said. “Pennsylvania has a safe, effective and high-quality program designed to help those suffering from any of the 23 serious medical conditions.” Most of the lung injury cases are male, and the average age is mid-20s. Vaping e-cigarettes containing nicotine of any kind is extremely dangerous for those with developing brains due to nicotine in the products. Lung injury cases have also been seen in older adults. It is imperative that everyone is aware of the potential harm vaping can do to their health, now and in the future. Signs and symptoms of a potential lung injury associated with vaping include: Cough; Shortness of breath; Chest pain; Nausea or vomiting; Diarrhea; Fatigue; Fever; or Weight loss. Please see your health care provider if you or a loved one are showing signs or symptoms. The department is continuing to work with the Poison Control Centers in Philadelphia and Pittsburgh, the Centers for Disease Control and Prevention, and the Food and Drug Administration as part of this widespread investigation. Generally, e-cigarettes are not safe for youth, young adults, pregnant women or adults who do not currently use tobacco products. It is also important to remember that e-cigarette aerosol is not harmless “water vapor.” It can contain harmful and potentially harmful substances, including: nicotine and ultrafine particles that can be inhaled deep into the lungs; flavoring such as diacetyl, a chemical linked to a serious lung disease; volatile organic compounds; cancer-causing chemicals and heavy metals such as nickel, tin and lead. Additional information on e-cigarettes, the dangers of vaping, and how to quit smoking can be found on the Department of Health’s website at health.pa.gov or follow us on FacebookOpens In A New Window and TwitterOpens In A New Window. MEDIA CONTACT: Nate Wardle, 717-787-1783 or [email protected]

Pennsylvania has 17 suspected cases and nearly 30 additional cases that are being investigated. Each of these cases have suffered serious lung injuries and have been hospitalized. No cases have been associated with medical marijuana bought at a Pennsylvania dispensary. “Pennsylvania’s medical marijuana program is carefully regulated, with products going through extensive laboratory testing,” Dr. Levine said. “Pennsylvania has a safe, effective and high-quality program designed to help those suffering from any of the 23 serious medical conditions.” Most of the lung injury cases are male, and the average age is mid-20s. Vaping e-cigarettes containing nicotine of any kind is extremely dangerous for those with developing brains due to nicotine in the products. Lung injury cases have also been seen in older adults. It is imperative that everyone is aware of the potential harm vaping can do to their health, now and in the future. https://www.media.pa.gov/Pages/Health-Details.aspx?newsid=651

Vaping-Associated Lung Injuries Minnesota Investigation Number of confirmed or probable cases: 45 Number of people under review: 22 Updated Wednesday, 25-Sep-2019 08:45:43 CDT The Minnesota Department of Health (MDH) is working with local public health and health care providers to investigate reports of severe lung injury potentially related to vaping and e-cigarette use among teens and adults. With similar reports coming from other states in recent weeks, MDH is partnering with the U.S. Centers for Disease Control and Prevention (CDC) to determine a cause and what steps may be taken to prevent additional illness. To date more than 500 cases have been reported from multiple states. Many of the patients report having vaped illicit THC (a component of cannabis). We are asking health care providers to report similar cases. Symptoms In Minnesota, symptoms have resulted in hospitalizations lasting from days to weeks, with some patients admitted to intensive care units. Symptoms included shortness of breath, fever, cough, vomiting and diarrhea. Some patients also reported headache, dizziness and chest pain. People experiencing lung symptoms after vaping should seek clinical care and avoid e-cigarettes or other vaping products, as continued use may lead to worsening symptoms. People should avoid vaping non-medical cannabis-based products, as the ingredients in these products are unknown. Basics E-cigarettes, vapes, e-pipes and other vaping products are battery-powered devices that allow users to inhale aerosolized liquid. E-cigarettes typically contain nicotine, which is highly addictive and harmful to the adolescent brain. In addition, e-cigarette aerosol contains harmful substances, such as ultrafine particles, oil, and heavy metals like nickel, tin and lead. The U.S. Surgeon General has called teen e-cigarette use an epidemic. The 2017 Minnesota Youth Tobacco Survey found that nearly 20% of high-school students use e-cigarettes and 40% have tried them. In addition, 34.7% of high school students and 15.8% of middle school students who use e-cigarettes have used an e-cigarette for recreational marijuana, THC or hash oil, or THC wax at least once. Information for Parents and Schools E-cigarettes and Vapes School E-cigarette Toolkit: Addressing Student Use of E-cigarettes and Vapes Information for Health Care Professionals Vaping-Associated Lung Injuries: Information for Health Professionals Related Information 9/10/19 Frequently Asked Questions: Lung Injury Investigation 9/6/2019 Health officials report death in a patient hospitalized for vaping-related lung injury 8/17/2019 CDC, states investigating severe pulmonary disease among people who use e-cigarettes 8/13/2019 News Release: Minnesota identifies severe lung injury cases among teens who reported vaping 8/13/2019 Health Advisory: Severe Acute Lung Disease Among Youth Who Report Vaping (PDF)

Vaping-Associated Lung Injuries Minnesota Investigation Number of confirmed or probable cases: 45 Number of people under review: 22 Updated Wednesday, 25-Sep-2019 08:45:43 CDT https://www.health.state.mn.us/diseases/lunginjuries/index.html

Vaping Epidemic in Kansas KDHE Update 9/23/2019: As of today, September 23, Kansas has had two confirmed deaths related to vaping. The second death is a male over the age of 50 who had underlying health conditions. Kansas currently has nine probable/confirmed vaping related cases, including the two deaths. Of the cases, five are male and four are female and range in age from 17-67 years old. All were hospitalized, five have been released from the hospital 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. Statement from Dr. Lee Norman, KDHE Secretary and Kansas State Health Officer Statement from Dr. Farah Ahmed, State Epidemiologist Kansas Vaping Statistics Youth In Kansas, the last statistics available show that 34.8% of Kansas high school students have ever tried e-cigarettes and 10.6% of Kansas high school students use e-cigarettes. (2017 Youth Risk Behavior Survey). Adult In 2017, 4.6% of Kansas adults reported that they use e-cigarettes. (2017 Kansas Behavioral Risk Factor Surveillance System) Vaping Education Additional Resources CDC Outbreak of Lung Illness Associated with Using E-cigarette Products CDC Quick Facts on the Risks of E-cigarettes for Kids, Teens, and Young Adults Ready to Quit Smoking? Kansas Vape-Free Schools Toolkit?

As of today, September 23, Kansas has had two confirmed deaths related to vaping. The second death is a male over the age of 50 who had underlying health conditions. Kansas currently has nine probable/confirmed vaping related cases, including the two deaths. Of the cases, five are male and four are female and range in age from 17-67 years old. All were hospitalized, five have been released from the hospital 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. http://www.kdheks.gov/vaping/index.htm

https://health.mo.gov/news/newsitem/uuid/6aa00c1e-504f-43a0-ad83-7b01390cfe8b/dhss-announces-first-vaping-associated-death-in-missouri-eighth-nationally September 19, 2019 DHSS Announces First Vaping-Associated Death in Missouri - Eighth Nationally For Immediate Release: Sept. 19, 2019 Media Contact: Lisa Cox Chief, Office of Public Information Missouri DHSS of Health and Senior Services [email protected] ST. LOUIS (Sept. 19, 2019) - A Missouri man in his mid-40s died this week at Mercy Hospital St. Louis due to an illness associated with the use of e-cigarettes. This is the first vaping-related death in Missouri and the eighth nationwide. Missouri Department of Health and Senior Services (DHSS) concluded it was a vaping-related lung injury after lung samples were taken of a Mercy patient who had a history of vaping but normal lung function prior to starting vaping in May 2019. He developed mild respiratory symptoms that worsened, leading to hospitalization on Aug. 22 before being transferred to Mercy St. Louis on Sept. 4. “This is an unfortunate case of a young man with no prior lung illness who started vaping because of chronic pain issues,” said Dr. Michael Plisco, Mercy critical care pulmonologist and medical director of Mercy’s extracorporeal membrane oxygenation (ECMO) program. “He started out with shortness of breath and it rapidly progressed and deteriorated, developing into what is called acute respiratory distress syndrome (ARDS). Once the lungs are injured by vaping, we don’t know how quickly it worsens and if it depends on other risk factors.” In the case of the Mercy patient, the man’s lungs were unable to provide enough gas exchange, leading to heart failure and near cardiac arrest. He was emergently placed on venoarterial ECMO in an effort to support his heart and rest his lungs. “Unfortunately, because ECMO doesn’t fix the problem and only buys time for healing, it didn’t work in this case,” Dr. Plisco said. “Due to the nature of this critical illness, acute respiratory distress syndrome ultimately led to his death.” Since the Missouri DHSS began advising, and now requiring, physicians to report possible vaping-associated pulmonary illnesses in late August, DHSS has received 22 reports from throughout the state of Missouri. Seven of these cases, including this first death, have been confirmed using the case definition developed by the Centers for Disease Control and Prevention (CDC). Nine are still under investigation, and six reports were investigated and did not meet CDC’s case definition. “We are sad to report that this illness associated with vaping has now resulted in a death in Missouri and extend our condolences to his family,” said Dr. Randall Williams, DHSS director. “As previously stated, we encourage Missourians to follow the CDC guidance to refrain from using e-cigarette products if you are concerned about these specific health risks, especially while the investigation is ongoing.” No infectious diseases have been identified with the illness, meaning it doesn’t spread from person to person. These lung illnesses are likely associated with a chemical exposure from vaping. Patients report e-cigarette use and similar symptoms including: Cough, shortness of breath or chest pain. Nausea, vomiting, or diarrhea. Fatigue, fever, or weight loss. Elevated heart rate. DHSS and the CDC advise anyone using vaping products who experience the symptoms listed above to seek medical care promptly. In addition, if someone uses e-cigarettes, they shouldn’t buy products off the street (for example, e-cigarettes with THC or other cannabinoids). They also shouldn’t modify e-cigarette products or add any substances to them that are not intended by the manufacturer. If someone is concerned about their health after using e-cigarettes, call the local poison control center at 1-800-222-1222. Regardless of the ongoing investigation by the health department and CDC, youth, young adults and women who are pregnant should not use e-cigarettes. Adults who do not currently use tobacco products should not start using e-cigarettes. Adult smokers who are attempting to quit should use evidence-based treatments, including counseling and Food and Drug Administration-approved medications. If someone needs help quitting tobacco products, including e-cigarettes, contact your doctor or other medical provider or call the Missouri Tobacco Quitline at 1-800-QUIT-NOW (1-800-784-8669). For information on the text-based e-cigarette quit program from Truth Initiative, visit truthinitiative.org/quitecigarettes or text “DITCHJUUL” to 88709. For more information, please visit the DHSS website.

Since the Missouri DHSS began advising, and now requiring, physicians to report possible vaping-associated pulmonary illnesses in late August, DHSS has received 22 reports from throughout the state of Missouri. Seven of these cases, including this first death, have been confirmed using the case definition developed by the Centers for Disease Control and Prevention (CDC). Nine are still under investigation, and six reports were investigated and did not meet CDC’s case definition. https://health.mo.gov/news/newsitem/uuid/6aa00c1e-504f-43a0-ad83-7b01390cfe8b/dhss-announces-first-vaping-associated-death-in-missouri-eighth-nationally

Oregon Health Authority is monitoring a nationwide cluster of respiratory illnesses associated with use of vaping devices, and is working with local public health and health care partners to track any illnesses in Oregon. Oregon Cases Updated September 24, 2019 In Oregon, five cases have been reported, one of which resulted in death. Frequently Asked Questions English FAQ Español / Spanish FAQ Русский / Russian FAQ 简体中文 / Simplified Chinese FAQ Tiếng Việt / Vietnamese FAQ For Clinicians The OHA Public Health Division and local public health departments are urging clinicians to be on alert for signs of severe respiratory illness among individuals who report vaping or e-cigarette use. Clinicians should report immediately (971-673-1111) any cases of hospitalized patients with radiologic finding of pulmonary infiltrates and history of vaping any substance in the preceding 90 days. News and Updates State investigating death from severe lung illness linked to vaping - 09/03/2019 State health officials alert clinicians to watch for severe respiratory illness among people who vape - 08/22/2019 Statement from CDC and FDA - 08/30/2019 Latest information from CDC

Oregon Cases Updated September 24, 2019 In Oregon, five cases have been reported, one of which resulted in death. https://www.oregon.gov/oha/PH/DISEASESCONDITIONS/COMMUNICABLEDISEASE/Pages/vaping-illness.aspx

The Mississippi State Department of Health is investigating an outbreak of severe lung illness related to e-cigarette use (vaping). This investigation is part of a national outbreak of vaping-related pulmonary illness whose cause has yet to be determined. About This Outbreak Nationally, all reported cases have a history of e-cigarette product use or vaping. Most of the cases have reported vaping cannabis products, such as tetrahydrocannabinol (THC). Many patients have reported using THC and nicotine. Some have reported the use of e-cigarette products containing only nicotine. The specific cause of these lung injuries remains unknown. No single e-cigarette product, device or ingredient has been consistently identified in all cases. More outbreak information from the CDC Mississippi Cases Last updated September 23, 2019. Outbreak Cases 3 Since September 17, 2019 Deaths 0 Age Range 28–33 Healthcare providers: Report suspected cases to MSDH at 601-576-7725 or 601-576-7400 after hours, weekends and holidays. Symptoms Symptoms of severe pulmonary disease include: cough shortness of breath chest pain nausea or vomiting diarrhea fever fatigue Symptoms develop anywhere from over a few days of use to weeks of using e-cigarettes. If you have recently used an e-cigarette or vaping product and you have symptoms like these, see your healthcare provider. Recommendations Until an exact cause of the illness has been determined, the national Centers for Disease Control and Prevention (CDC) recommends the following actions: If you are concerned about the health risks, consider refraining from using e-cigarettes or vaping products. If you are an adult who used e-cigarettes containing nicotine to quit cigarette smoking, do not return to smoking cigarettes. If you have recently used an e-cigarette or vaping product and you have symptoms like those reported above, see your healthcare provider. If you are an adult who wants to quit smoking, use approaches that are approved and effective. The Mississippi Tobacco Quitline offers free, expert help in quitting. E-cigarette use Youth and young adults should not use e-cigarette products. Find out more » Women who are pregnant should not use e-cigarette products. Find out more » Adults who do not currently use tobacco products should not start using e-cigarette products. The Mississippi State Department of Health cautions Mississippians to not buy products off the street containing THC or other cannabinoids. Do not modify or add substances to e-cigarette products that are not intended by the manufacturer. About E-Cigarettes E-cigarettes produce an aerosol by heating a liquid that usually contains nicotine, flavorings, and other chemicals that help to make the aerosol. Users inhale this aerosol into their lungs. Bystanders can also breathe in this aerosol when the user exhales into the air. E-cigarettes can be used to deliver marijuana and other drugs. E-cigarettes are known by many different names. They are sometimes called “e-cigs,” “e-hookahs,” “mods,” “vape pens,” “vapes,” “tank systems,” and “electronic nicotine delivery systems (ENDS).” Some e-cigarettes are made to look like regular cigarettes, cigars, or pipes. Some resemble pens, USB sticks, and other everyday items. Larger devices such as tank systems, or “mods,” do not resemble other tobacco products. Using an e-cigarette is sometimes called “vaping.” Healthcare Providers Mississippi Healthcare Providers are asked to report any cases of severe pulmonary disease with no clear cause and a history of e-cigarette product use within the past 90 days to MSDH at 601-576-7725. Reporting of cases helps MSDH and the CDC determine more about the cause of these pulmonary illnesses. Ask all patients who report e-cigarette product use within the last 90 days about signs and symptoms of pulmonary illness. Update: Health Professional Advisory: Severe Pulmonary Disease Associated with E-Cigarette (Vaping) Product More Information Outbreak information from the CDC: What You Need to Know

Mississippi Cases Last updated September 23, 2019. Outbreak Cases 3 Since September 17, 2019 Deaths 0 Age Range 28–33 Healthcare providers: Report suspected cases to MSDH at 601-576-7725 or 601-576-7400 after hours, weekends and holidays. https://msdh.ms.gov/msdhsite/_static/14,0,418.html

News/Highlights Note: We plan to update case counts by 4:00 pm on Thursdays. Updated 09/19/19 CDC Health Advisory: Severe Pulmonary Disease Associated with Using E-Cigarette Products Severe Lung Disease among People Who Reported Vaping: The North Carolina Department of Health and Human Services (NC DHHS) is investigating cases of severe lung disease among people who all reported recent vaping or dabbing (vaping products include nicotine, marijuana oils, extracts, or concentrates). NC DHHS is collaborating with the Centers for Disease Control and Prevention (CDC) and other state health departments as part of a national investigation. As of 9/18/2019, 33 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. NC DHHS Press Release Clinician Advisory Centers for Disease Control Prevention Media Release Outbreak of Severe Pulmonary Disease Associated with Using E-cigarette Products (CDC) Nicotine found in e-liquids is highly addictive. For help quitting, please call 1-800-QuitNow (1-800-784-8669) or visit QuitlineNC. Growing Number of North Carolina Teens at Risk of Addiction to Nicotine, Study Finds

As of 9/18/2019, 33 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. https://www.tobaccopreventionandcontrol.ncdhhs.gov/ecigs/

Severe Lung Disease Among People who Reported Vaping Updated 9/19/2019 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 19, 2019, we are aware of 48 cases. We have an additional 13 patients whose records need further investigation. Counties with cases include Adams, Dane, Dodge, Door, Grant, Green, Jefferson, Kenosha, La Crosse, Marathon, Milwaukee, Monroe, Portage, Racine, Sauk, Sheboygan, St. Croix, Walworth, Washington, Waukesha, 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(link is external). New England Journal of Medicine (9/6/2019) Severe Pulmonary Disease Associated with Electronic Cigarette Product Use - Interim Guidance(link is external). 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 19, 2019, we are aware of 48 cases. We have an additional 13 patients whose records need further investigation. Counties with cases include Adams, Dane, Dodge, Door, Grant, Green, Jefferson, Kenosha, La Crosse, Marathon, Milwaukee, Monroe, Portage, Racine, Sauk, Sheboygan, St. Croix, Walworth, Washington, Waukesha, 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 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 19, 2019, we are aware of 48 cases. We have an additional 13 patients whose records need further investigation. Counties with cases include Adams, Dane, Dodge, Door, Grant, Green, Jefferson, Kenosha, La Crosse, Marathon, Milwaukee, Monroe, Portage, Racine, Sauk, Sheboygan, St. Croix, Walworth, Washington, Waukesha, 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.

E-cigarettes, vapes, vape or hookah pens, e-pipes, and other vaping products are battery-powered devices that allow users to inhale, or vape, aerosolized liquid (e-juice). Beginning July 1, 2019, Illinois law prohibits the sale of tobacco products, including these products, to people younger than age 21. E-cigarettes recently surpassed conventional cigarettes as the most commonly used tobacco product among youth.1It is critical that public health officials and the general public understand the potential risks of using them. 2019 Respiratory Illnesses in Illinois Cases* Individuals needing more investigation Deaths ** 69 13 1 Updated September 19, 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 and Champaign, Cook, DeKalb, DuPage, Henry, Kane, Kendall, Lake, Macoupin, Madison, McHenry, Peoria, Rock Island, St. Clair, Tazewell, Vermilion, Wabash, Will, and Winnebago counties. Ages - 15-42 years. Median age - 22 years. Updates will be posted by end of day on Thursdays.

2019 Respiratory Illnesses in Illinois Cases* Individuals needing more investigation Deaths ** 69 13 1 Updated September 19, 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

http://www.dph.illinois.gov/topics-services/prevention-wellness/tobacco/e-cigarettes-and-vapes

Don’t Vape: Examining the Outbreak of Lung Disease and CDC’s Urgent Warning Not to Use E-Cigarettes Date: Tuesday, September 24, 2019 - 10:00am Location: 2154 Rayburn House Office Building, Washington, DC 20515 “Don’t Vape: Examining the Outbreak of Lung Disease and CDC’s Urgent Warning Not to Use E-Cigarettes” Subcommittees: Economic and Consumer Policy (116) CHAIRMAN KRISHNAMOORTHI'S OPENING STATEMENT PURPOSE The hearing will examine the outbreak of lung illness associated with using e-cigarette products; the causes of the outbreak; the CDC and state health officials warning against the use of e-cigarettes; and CDC reports that youth use of e-cigarettes has risen again. As of September 11, 2019, CDC has identified 380 cases of lung illness associated with the use of e-cigarette products in 36 states and 1 U.S. territory. The outbreak has resulted in at least six deaths in California, Illinois, Indiana, Kansas, Minnesota, and Oregon. CDC, state health departments, and the Food and Drug Administration are investigating the multistate outbreak. The investigation has not identified a cause and has not identified any specific substance or e-cigarette product that is linked to all cases. Although various e-cigarette manufacturers such as JUUL have marketed their products as safe, the CDC warned the public to “consider not using e-cigarette products.” The statement applies to all e-cigarette products, as CDC is unable to rule any out as a cause of lung illness. Aside from the recent lung illness outbreak, the long-term health effects of continued e-cigarette use remain unknown as the scientific community continues to study the health hazard posed by e-cigarettes. WITNESS Panel One Dr. Anne Schuchat Principal Deputy Director Centers for Disease Control and Prevention Panel Two Ruby Johnson Parent Dr. Ngozi O. Ezike Director Illinois Department of Public Health Dr. Albert Rizzo Chief Medical Officer American Lung Association Vicki Porter Minority Witness Documents Notice Memo Issues: Health Care 116th Congress https://oversight.house.gov/legislation/hearings/don-t-vape-examining-the-outbreak-of-lung-disease-and-cdc-s-urgent-warning-not

As of September 17, 2019 at 5pm, 530* cases of lung injury associated with the use of e-cigarette or vaping products have been reported to CDC from the following states and 1 U.S. territory: AR, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MD, MI, MN, NC, ND, NE, NJ, NM, NV, NY, OH, OR, PA, SC, SD, TN, TX, UT, VA, WA, WI, WV, WY, and USVI. These numbers may change frequently. CDC has received complete sex and age data on 373 of 530 cases. Nearly three fourths (72%) of cases are male Two thirds (67%) of cases are 18 to 34 years old 16% of cases are under 18 years and 17% are 35 years or older Seven deaths have been confirmed in California (2), Illinois, Indiana, Kansas, Minnesota, and Oregon. CDC worked with states to create a case definition to classify confirmed and probable cases in a consistent way. State investigators determine if cases are confirmed or probable after examining the medical records of suspected cases and consulting with the clinical care team to exclude other possible causes of illness. Unlike nationally reportable conditions, these cases are requiring clinicians and public health professionals to interview patients to determine product use and individual behaviors. CDC will report numbers of confirmed and probable cases once states have finalized their classification of cases. States are in the process of classifying cases. We expect that states and clinicians may look back for older cases based on CDC’s case definition. All patients have a reported history of e-cigarette product use, and no consistent evidence of an infectious cause has been discovered. Therefore, the suspected cause is a chemical exposure. Based on initial data from certain states we know: Most patients have reported a history of using e-cigarette products containing THC. Many patients have reported using THC and nicotine. Some have reported the use of e-cigarette products containing only nicotine. No consistent e-cigarette or vaping product, substance, or additive has been identified in all cases, nor has any one product or substance been conclusively linked to lung disease in patients. Initial published reports from the investigation point to clinical similarities among cases. Patients reported a history of e-cigarette use and had similar symptoms and clinical findings. These align with the CDC health advisory released August 30, 2019. These investigations are ongoing. CDC will provide updates when more information is available. *The increase in cases from last week represents both new cases and recent reporting of previously-identified cases to CDC. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html Top of Page Map of Reported Cases

The California Department of Public Health (CDPH) urges everyone to refrain from vaping, no matter the substance or source, until current investigations are complete. Since June 2019, CDPH has received reports that 90 people in California who have a history of vaping were hospitalized for severe breathing problems and lung damage, and two people have died. Across the U.S., there are over 500 reports of lung damage associated with vaping across 38 states and 1 U.S. territory, and more reports are coming in nearly every day. https://www.cdph.ca.gov/Programs/CCDPHP/CDPH Document Library/California Department of Public Health - Health Advisory September 24, 2019.pdf

Audio of interview https://www.youtube.com/watch?v=Yy2lGSBZ5F8&feature=youtu.be