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[3] This European iteration of Joe Camel was first seen in the United States in 1988 when Greensboro, North Carolina company Trone Advertising used the character in promotional materials created for the Camel brand's 75th anniversary

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However, the reliance on lipid-laden macrophages alone to diagnose EVALI has been challenged (21,22) because lipid-laden macrophages are relatively nonspecific and may be found in lung biopsies in patients with infections, medication reactions, and autoimmune disorders (22)