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He Tried E-Cigarettes to Quit Smoking. Doctors Say Vaping Led to His Death.

Months after John Steffen died in Nebraska, officials said his death was part of a mysterious outbreak of vaping-related deaths and illnesses.

In the spring, Kathleen Fimple buried her husband, John, and by the fall, she had reluctantly settled into her new life as a widow.

She accepted what the doctors told her: that he had died at 68 from respiratory failure and pulmonary disease after years of smoking cigarettes, coupled with a bout of pneumonia. She went back to work. She canceled a trip around Europe that the couple had planned to take this month.

Then she got an unexpected call from a doctor at Nebraska’s health department. The department was investigating her husband’s death and would come to conclude that he had actually died of a vaping-related illness.

The news made headlines across the state: John Steffen, a tall, bearded father of three who loved to fish, watch the Cornhuskers play football and sing in a baritone so beautiful it could make heads swivel at Mass on Sundays, was the first such case in Nebraska. He was one of at least 29 people across the country whose lives have been claimed in the outbreak.

Mr. Steffen’s death deepens the medical mystery surrounding vaping-related illnesses, since most people who have been sickened by vaping have used products containing THC, but Mr. Steffen is believed to have exclusively vaped nicotine.

Since the announcement, his family has been beset by fresh anguish and questions. What was it about vaping that killed Mr. Steffen, who had used e-cigarettes and nicotine cartridges that he bought from Walgreens or Walmart? And perhaps most painfully: Would he still be alive if he hadn’t taken up vaping?

“It frightens me, because we don’t know what effect vaping has,” said Dr. Fimple, an education administrator in state government, as she sat with her daughter, Dulcia Steffen, in her living room this month. Dr. Fimple nodded in the direction of an e-cigarette package on the coffee table, a crumpled item found while sorting through her husband’s belongings. “It’s like looking at a gun with a bullet,” Ms. Steffen said.

As a teenager growing up on a dairy farm in northeast Nebraska in the 1960s, Mr. Steffen picked up smoking casually, and kept the habit into adulthood.

During winters, he would sometimes light up next to the kitchen stove, blowing smoke into the exhaust fan.

“He would say, ‘I love it and I don’t want to quit,’” Dr. Fimple recalled. “Eventually, he reconciled that smoking was bad.”

Mr. Steffen had two sons from his first marriage, and the daughter he had with Dr. Fimple, Dulcia, would beg him to stop smoking. When Dulcia had her own daughter 15 years ago, she took pictures of the baby and tucked them into her father’s packs of cigarettes.

“He would see her face every time he pulled out a cigarette,” Ms. Steffen said. “I was like, O.K., I’ve tried all the little tactics.”

As he approached middle age, Mr. Steffen, who worked as a land surveyor, was beginning to face complicated medical problems. Doctors told him he had atrial fibrillation, a heart ailment. He learned he had non-Hodgkins lymphoma and endured chemotherapy. After decades of smoking, he was diagnosed with chronic obstructive pulmonary disease.

“He figured he was going to die from lung cancer,” Dr. Fimple said.

Only one thing helped Mr. Steffen ditch smoking for good: an e-cigarette.

After he began five years ago vaping nicotine — e-cigarette brands like Mistic, blu and Juul that were sold over the counter at big-box retailers and drugstores — he never picked up another cigarette. But just as he had smoked a cigarette several times an hour, now he began to vape several times an hour.

Earlier this year, Mr. Steffen was unable to shake a cold. He could not go to Sunday Mass because his cough was so ferocious that it would practically rattle the walls of the church.

He went to the doctor in April and got antibiotics, which did little to help his cough.

At a second visit in May, a chest X-ray revealed pneumonia. Mr. Steffen was taken to the hospital and given more medication. Nothing seemed to help. His appetite, weak before he had entered the hospital, dwindled even further.

One Friday morning, a week into his hospital stay, he woke up unable to move his right arm.

His family said that when a hospital chaplain visited his room, Mr. Steffen was blunt. “I think I’m dying slowly,” he told her. She asked if he was afraid to die. “No,” he answered. “I just wish it would happen a little quicker.”

That afternoon, a doctor pulled Dr. Fimple aside. “I don’t think he’s going to make it through the afternoon,” she recalled the doctor saying.

Dr. Fimple began calling immediate family members. Their daughter and one of Mr. Steffen’s sons sped to the hospital; Dulcia found her father barely conscious, struggling to breathe, his skin turning blue. “His hands were like ice,” she said, wiping away tears.

He died about 15 minutes later.

By late September, Dr. Matthew Donahue, an internal medicine specialist at the state’s health department, was in the thick of an investigation.

He had received a tip from Kathy Dietsch, a high school classmate of Mr. Steffen’s, who called Nebraska’s health department in late summer — around the time that the outbreak of vaping-related illnesses was first drawing national attention. She had seen Mr. Steffen vaping at a high school reunion in 2014 and had heard about his death.

Ms. Dietsch, who lives in Omaha, worried that her phone call to the state would “open a can of worms” for Mr. Steffen’s family. But she said she had a nagging hunch. “I felt that somebody needed to check it out,” she said.

Dr. Donahue called Dr. Fimple and broke the news: The state was looking into the possibility that Mr. Steffen had died from illness tied to vaping.

“I don’t think so,” she said, recalling what she had been told while he was ill. “He had pneumonia.”

Dr. Donahue, trying to piece together Mr. Steffen’s medical history, began pressing her with questions. Was Mr. Steffen around asbestos in the weeks before he died? Did he have a cough? Could he have vaped THC?

As part of the investigation, the state health department contacted the doctors who had treated Mr. Steffen, and studied his medical records. There was no autopsy after Mr. Steffen’s death, typical under the circumstances. The official cause of death was acute respiratory failure as a consequence of chronic obstructive pulmonary disease.

Days later, Dr. Fimple was stunned to see a news bulletin on her computer screen at work announcing that Nebraska had for the first time identified a resident’s death related to vaping: a man in his 60s who had died in Douglas County in May.

She picked up the phone and dialed Dr. Donahue.

“Is that my husband?” she asked.

He said that it was.

Since then, Dr. Fimple has been searching for answers.

In their home in Omaha, Mr. Steffen smiles down from family portraits on the walls. The family room is full of his things: a beloved brown leather armchair, a safe where he kept his hunting rifles, a coyote pelt.

Public health officials believe there are more cases like Mr. Steffen’s, people who were sickened by vaping before the outbreak emerged in August, but whose doctors had probably not considered vaping as a cause. Dr. Thomas Safranek, the state epidemiologist, said that if the health department hadn’t received a tip, it “wouldn’t have had a clue” that his death was tied to vaping.

They used the criteria from the Centers for Disease Control and Prevention to determine the connection, including chest X-rays in Mr. Steffen’s medical record that showed the “ground glass” appearance of his lungs that doctors have tied to vaping.

Investigators say they have not pinpointed what is making people sick, whether it is the liquid being vaped, a material in vaping devices themselves, or something else. The C.D.C. says that nearly 1,300 people have become ill after vaping.

“The majority of people who have had a vaping-associated pulmonary illness do appear to have used THC- or CBD-related products, but there are a substantial portion — up to 30 percent — where the patient only used a nicotine-containing vape device,” said Dr. Hilary Faust, a pulmonologist who has treated patients with vaping-related illness. “We don’t know what exactly is causing the injury.”

Asked to comment on Mr. Steffen’s case, Juul Labs, the e-cigarette company, said in a statement: “We appreciate the work of the C.D.C., F.D.A., and state public health authorities, and are confident that they will get to the bottom of this issue.”

Representatives for Mistic and blu did not respond to requests for comment.

Dr. Safranek said that given Mr. Steffen’s history of smoking, he probably would have suffered a premature death from that habit alone.

“It’s a question of, what would have gotten him first, the vaping or tobacco?” Dr. Safranek said. “In his case, it looks to me like he would have been better off sticking with tobacco.”

Julie Bosman/NYT