michael barbaro

From The New York Times, I’m Michael Barbaro. This is “The Daily.” Today: When John Steffen died, his family had little doubt that a lifetime of cigarette smoking was to blame. Then, the Nebraska Department of Health got an unusual tip. Part 1 of a two-part series on the promise and the peril of vaping. It’s Monday, October 28.

kathleen fimple You will see the animals on the wall. So, there’s a rainbow trout and an antelope and a deer above the fireplace. So, yeah.

michael barbaro

Julie, tell me about this trip you took to Nebraska.

julie bosman

So, a couple of weeks ago, I went to Omaha, Nebraska.

michael barbaro

Julie Bosman is a national reporter at The Times.

julie bosman

And I went to the home of Kathleen Fimple —

kathleen fimple You guys can sit —

julie bosman

— where she lives with her dog, Bo, a little terrier. And Kathleen showed me around her house.

kathleen fimple That room’s a mess, but we could pull some things off —

julie bosman

And I sat down with Kathleen and her daughter, Dulcia, and her granddaughter, and they showed me something that Dulcia had made after the death of her father, John Steffen.

kathleen fimple My daughter made this.

julie bosman

It was a glass box.

kathleen fimple That’s what we used for the funeral.

julie bosman

And inside were mementos that represented his life.

kathleen fimple He played guitar, so we’ve got guitar picks, and “Grandma’s Feather Bed” was a song we all liked to sing together.

julie bosman

So John was a very active outdoorsman. There was a turkey feather from one of his hunting expeditions.

kathleen fimple There’s a shotgun shell, there’s the antler — this knife has an antler.

julie bosman

There were badges and pins.

kathleen fimple He was a Scout leader.

julie bosman

And there were dried flowers from his funeral spray.

kathleen fimple Those were from the casket spray.

michael barbaro

And how exactly did he die?

julie bosman

So, John died after a long illness.

kathleen fimple He was a lifelong smoker. julie bosman What did he smoke? kathleen fimple Marlboros. julie bosman Not the lights, the — kathleen fimple Oh, no. No, no.

julie bosman

So he started smoking back in the ‘60s when he was a teenager, and it was a habit that he really stuck with for most of his life.

julie bosman How did he feel about his smoking? Was he like, “Ugh, I hate this,” or, “I love it, and I don’t want to quit.” Or how — kathleen fimple I love it, and I don’t want to quit. And also, a lot of denial, especially early on. My grandpa lived to be, whatever, 80-something, and he smoked.

julie bosman

So he was kind of clinging to the idea that smoking wasn’t bad.

kathleen fimple Eventually, I think he reconciled that, yes, smoking was bad, and it could cause cancer.

julie bosman

He tried very, very hard to quit.

kathleen fimple In his 30s, while we were first married, he quit several times briefly.

julie bosman

Sometimes he would be successful, and then he started up again.

kathleen fimple He’d stop for a month or two, and then, yeah.

julie bosman

And his daughter, when she had her own baby daughter, she would take little pictures of the baby and tuck them into his packs of cigarettes.

dulcia steffen So that he would see her face every time he pulled out a cigarette. I was like, O.K., I’ve tried all the little tactics.

julie bosman

So, she tried everything she could, but his addiction to nicotine was decades strong.

[music]

julie bosman

But then he developed C.O.P.D., chronic obstructive pulmonary disease, which is a very common disease that many smokers develop. And in his case, it gave him a very bad cough, and it made it difficult to breathe at times.

kathleen fimple We’d go to church, and he sing a line, and then he’d stop, and then he’d have to pick it up later because he’d have to catch his breath in between. And he used to whistle all the time — he couldn’t whistle anymore.

julie bosman

He had atrial fibrillation, and sometime later, he got non-Hodgkin’s lymphoma, and had to have chemotherapy for years.

kathleen fimple I think that was when he started vaping. julie bosman Do you know how he got the idea? kathleen fimple No. We both, I had kind of seen advertisements for it and things, but it was his idea, and he bought one and came home with it.

julie bosman

So, John started vaping about five years ago.

julie bosman Do you know which brand? kathleen fimple Mistics. dulcia steffen Then he had blu, and then he went to Juul. kathleen fimple And he only went to Juul less than a year ago.

julie bosman

And he had heard about vaping as the cleaner, healthier alternative to cigarettes. So he became just as enthusiastic of a vaper as he was a smoker. So, earlier this year —

kathleen fimple There was a cough, cold going around —

julie bosman

It was a cold winter, and everybody had a cold, and a cough. And John kind of got it the worst.

kathleen fimple And it probably, in some ways, was less obvious to us because he had a smoker’s cough. So he coughed, but it was also obvious that this was worse.

julie bosman

And his daughter, Dulcia, started nagging at him, and saying, Dad, you really need to go to the doctor.

kathleen fimple That’s probably why he went, though, in April, just because you kept pushing him. dulcia steffen Yeah.

julie bosman

So he did, and he was diagnosed with pneumonia.

kathleen fimple Dr. Simon said, “You have pneumonia, and you’re going to the hospital.”

julie bosman

And he was in the hospital for a week. And seven, eight days into his hospital stay —

dulcia steffen His hands were like ice. kathleen fimple They were starting to turn blue. dulcia steffen He couldn’t blink, and his mouth was propped open, and he wasn’t breathing very often. And his last breath I could tell because there was just a slight twitch in his neck.

julie bosman

He died of acute respiratory failure, which the doctor said was a consequence of the C.O.P.D.

michael barbaro

So essentially, he died of smoking, or smoking-related lung disease, it sounds like.

julie bosman

Yes. His wife said that he always believed that he was going to die of lung cancer. So when the doctors said that he had died, essentially, as a consequence of C.O.P.D., they had no reason to question the doctor’s conclusion.

michael barbaro

And as tragic as that is, it all kind of lines up with our understanding of what a lifetime of smoking does to a person.

julie bosman

Right. But then four months after John died, Kathleen was sitting at work one day.

kathleen fimple I was in a meeting when the Department of Health called.

julie bosman

She got a phone call from an investigator at the Nebraska Department of Health, and he asked her all kinds of questions.

kathleen fimple He asked about any exposure in the past to moldy wood, or wood chips, to asbestos, to pesticides. Then they asked about symptoms.

julie bosman

He asked if he had had any kind of vomiting before his death.

kathleen fimple Did he lose weight, was he coughing?

julie bosman

And he also asked her about vaping.

kathleen fimple I said, I don’t know why vaping — I mean, yes, he vaped, but I don’t think it’s from vaping. They said he had pneumonia. Lifelong smoker, C.O.P.D. —

julie bosman

And the investigator got off the phone with her and said he would be in touch.

michael barbaro

So Julie, what was John’s relationship to vaping?

julie bosman

Kathleen told me that when he was smoking cigarettes, he would smoke a cigarette two or three times an hour. And very quickly, he was vaping two or three times an hour.

dulcia steffen It was a straight replacement for cigarettes. kathleen fimple Yeah. dulcia steffen Yeah, and part of it was habit. Years and years of habit, when you get in the vehicle, you light up a cigarette. So when he’d get in the vehicle and start to drive, he would vape.

julie bosman

It was a good way to help him get his nicotine fix.

kathleen fimple I knew it wasn’t the perfect solution, but again, figured it was better. julie bosman Right. kathleen fimple For him, and for us. julie bosman Did you ever think, could they be dangerous? kathleen fimple No. No, I — dulcia steffen You know, when they first marketed them, they said it was a safer alternative. We assumed it was healthier for those around him as well.

julie bosman

And then a few days later, Kathleen spoke to the medical investigator again, and he told her that it had been confirmed. John was Nebraska’s first official vaping-related death.

archived recording 1 This morning, Nebraska health officials have announced the state’s first vaping-related death. archived recording 2 That’s right, the person was over 65, and from the Douglas County, which is the Omaha area. The individual died in May, but the State Health Department just identified it as vaping-related.

michael barbaro

So Julie, what exactly is going on here? Why is an original conclusion about John’s cause of death now being re-evaluated, and, it seems, challenged? What is happening?

julie bosman

So, back in May, when John died, there really was no such thing as a vaping-related death or a vaping-related illness. But throughout the summer, all these illnesses and deaths began to be reported. And all over the country, people began to look back at cases of people who had died, people who had gotten sick, and started to think a little differently about them. And in Nebraska, the State Health Department wouldn’t have even looked at John’s death if they hadn’t received a tip.

michael barbaro

We’ll be right back. So Julie, tell me about this tip.

julie bosman

So, here’s what happened.

[music]

julie bosman

John had an old friend who he went to high school with, and they saw each other at an alumni reunion a few years ago. They sat together with their spouses at this dinner, and throughout the dinner, as she described it, John was vaping constantly. And she had never seen anyone vape before. This was in 2014, it was kind of a new thing. And she told me that she was very alarmed by what she saw.

michael barbaro

What exactly alarmed her?

julie bosman

She was concerned because he was vaping so frequently. Of course, when you smoke, you generally have to go outside and do it. But John was vaping indoors, sitting at dinner. And she also just had this kind of gut sense that there was something kind of wrong about it. And she couldn’t quite shake the feeling, even after the reunion was over and years had gone by. And she and John really didn’t keep in touch, but earlier this year, when John was sick, she had heard that he was in the hospital. And then she heard that he died in May. So she waited all summer, and she started seeing things in the news about people getting sick and dying from vaping.

archived recording 1 There is breaking news tonight in the nationwide vaping crisis. Another death, and new reports of possible lung disease. The C.D.C. is looking into dozens of cases. archived recording 2 The C.D.C. can confirm 31 cases — archived recording 3 200 potential cases — archived recording 4 380 cases — archived recording 5 The 450 cases span — archived recording 6 530 cases — archived recording 7 It’s unclear just what’s causing the problem. The C.D.C. says it will continue to investigate.

julie bosman

And she told me that she kept looking in the paper, she kept looking on the news to see if John was one of those people, and that never happened. So at the end of the summer, she decided that she just couldn’t get rid of this feeling that vaping was related to his death, so she called the State Health Department.

michael barbaro

So she was the tip.

julie bosman

Yeah, so her tip gets passed along to a medical investigator, and he was the investigator who called John’s wife and spoke to her, and interviewed her about his medical history. He did a bunch of other things, too. So he spoke to the physicians who attended to John, who treated him when he was sick in the hospital in Omaha. He examined his medical records, he looked at his chest X-rays.

kathleen fimple And it showed pneumonia in the lower lobe of one lung. But the rest of his lungs, both sides and upper and lower were filled with what they call ground glass opacity.

julie bosman

A ground glass appearance on the lungs is an injury to the lung that is typically consistent with vaping. And in some cases, it can look like there are kind of opaque white spots on the X-ray.

kathleen fimple And I said, well, how does that — is that different from just a long-term smoker? And he said, yes. This is not what you would see in just, routine, if you will, long-term smoking.

julie bosman

And in this case, it was a very key piece of evidence for the investigator who was looking into John’s death.

michael barbaro

And what’s the understanding of how vaping might create this kind of ground glass-looking damage in the lung?

julie bosman

So when you vape, of course, you use a device that heats liquid to a very high temperature, and turns it into a vapor that you inhale. Now, that liquid can contain THC, which is the ingredient in marijuana that gets you high, or it could contain nicotine. And doctors who are investigating all these illnesses and deaths don’t know exactly what it is about vaping that is making people sick. But they have noticed that some of the people who have gotten sick, or died, have had the ground glass appearance on their lungs. Or in some cases, they’ve had damage on their lungs that resembles a chemical burn.

michael barbaro

Julie, my sense is that most of these vaping-related illnesses and the deaths that we have been reading about have been not from the well-known e-cigarette brands, but from basically counterfeit and bootleg products, right?

julie bosman

Yes. So here’s what we know about that. Of the people who have gotten sick or died from vaping in the last year, about three-quarters of them have vaped THC products. A little over half have vaped nicotine, and a lot of people do both, kind of toggle back and forth between vaping weed and vaping nicotine. But as best we can tell, John did not vape THC. When I asked his family, they kind of laughed at the idea that their 68-year-old husband and father would be procuring bootleg THC.

julie bosman Is that unthinkable? Do you have any — I mean, is that something that he might have possibly done? kathleen fimple I don’t think he would have even known where to go to get it. dulcia steffen We’ve been to Colorado since it was legalized, and he wouldn’t touch it. kathleen fimple He was never interested. dulcia steffen No. So I don’t think he would have ever considered getting it black-market, either.

julie bosman

They described his vaping habits as very aboveboard.

julie bosman Do you know where he bought it? kathleen fimple Walmart. Walgreens or Walmart. julie bosman Walgreens or Walmart. kathleen fimple I don’t think he bought them anyplace else. dulcia steffen He never went to any of the vape shops or anything. kathleen fimple Oh, never. Never.

michael barbaro

I mean, is it possible that John was vaping something like THC, but just didn’t tell his family? That no one knew?

julie bosman

His family very strongly discounts that possibility. He would have had to be doing it in secret, and they thought that that notion was rather ridiculous.

michael barbaro

So if he got sick from vaping, it was from regular old — I guess if the industry is old enough to call it this, but — traditional vaping?

julie bosman

Yes. And this really only deepens the medical mystery surrounding vaping, because so many people who have gotten sick or died from vaping have been using THC vapes, and especially vaping devices or cartridges that were bought off the street, and no one really knows where they came from.

michael barbaro

But that’s not the case with John.

julie bosman

Right.

michael barbaro

So Julie, how does John’s death, as defined and diagnosed by these medical professionals, locally and nationally, how does it change our understanding of vaping and its consequences?

julie bosman

I think that his death raises an alarming possibility. And that is that someone who apparently did not vape THC, did not buy any kind of products on the black market, could also become very sick and die from a vaping-related illness.

michael barbaro

Right. And his family told you that he took up vaping, as many people do, because he thought it was actually going to make him healthier. It was going to help him quit smoking.

julie bosman

Yeah. He thought that this would be the thing that would help him quit smoking for good, and it did. And you know, people like John Steffen are exactly the kind of person that e-cigarettes were ostensibly created for. When e-cigarettes were invented, and when companies started selling them on the mass market, they said that it was for people who wanted to quit smoking and wanted a healthier alternative. And John was exactly that person.

michael barbaro

So what’s the understanding of why so many people, not just John, but hundreds of people are getting sick from this, and maybe even dying from it?

julie bosman

Well, I would just point to cigarette smoking and when it was first introduced. Cigarette smoking really took off during World War I among American men. And it wasn’t until the 1930s when doctors began to link an increase in lung cancer rates to an increase in cigarette smoking. And it took decades after that — it wasn’t until 1964 when the surgeon general released a landmark report saying, yes, smoking does cause lung cancer. So I think what a lot of doctors out there are saying is that it is far too early to know what the long-term effects of vaping might be.

michael barbaro

In other words, the gestation period for any kind of public health problem is long, is maybe even decades.

julie bosman

Yes. And it’s very early in e-cigarettes’ life. I mean, they really didn’t enter the mainstream until the last 10 years.

michael barbaro

In which case, we would be at the beginning of whatever this is, not even the middle, and definitely nowhere near the end.

julie bosman

I think we can say for sure that the C.D.C. believes that there are many, many more cases coming, and that this is only the tip of the iceberg.

[music]

michael barbaro

Julie, does John’s family think that he would still be alive today if he hadn’t taken up vaping?

julie bosman

That’s a difficult question. It’s something that they do think about. And when they look back on his life, they know that taking up smoking as a teenager was certainly a bad decision, and continuing to smoke all those decades was something that they wish he had not done. But they thought that he made a really good decision when he switched to vaping. They didn’t worry about the health consequences of vaping. And when his daughter looked at the vaping container that was left over, sitting on the coffee table, she doesn’t see something that is harmless or something that might have helped prolong his life. She sees something very dangerous.

dulcia steffen To think that that box right there could be the sole reason he’s dead, in some ways, is like looking at a gun with a bullet. It’s just a method of death.

michael barbaro

Julie, thank you very much.

julie bosman

Thanks, Michael.

michael barbaro

We’ll be right back. Here’s what else you need to know today.

archived recording (donald trump) Last night, the United States brought the world’s number one terrorist leader to justice. Abu Bakr al-Baghdadi is dead.

michael barbaro

On Sunday, President Trump announced that the founder and leader of the Islamic State died during a U.S. military operation in Syria.

archived recording (donald trump) Capturing or killing Baghdadi has been the top national security priority of my administration.

michael barbaro

Abu Bakr al-Baghdadi inspired thousands of men and women from across the world to join ISIS, and in 2014 created a caliphate for the terrorist group that at its height was the size of Britain and imposed a brutal form of Islam on its inhabitants.

archived recording (donald trump) The thug who tried so hard to intimidate others spent his last moments in utter fear, in total panic and dread, terrified of the American forces bearing down on him.

michael barbaro

After years of eluding American forces, al-Baghdadi was recently discovered in northwest Syria, where U.S. commandos chased him into a tunnel. There, he detonated a suicide vest that killed himself and three of his young children.

archived recording (donald trump) He was a sick and depraved man, and now he’s gone.

michael barbaro