The newly authorized products are four G2 pods made by the vape company Glas: Classic Menthol, Fresh Menthol, Gold and Sapphire. The latter two are mango and blueberry flavors, making them the first non-tobacco, non-menthol vaping products the FDA has authorized. 

Youth use has always been the FDA’s reason for denying authorization for flavored vapes—which are important for harm reduction because many adults find them the best way of switching from cigarettes. But the agency determined that Glas’s device-access restriction technology—pairing a vape with an age-verified smartphone via Bluetooth—would, combined with marketing restrictions, effectively deter youth use. 

This is not a simple story of a product moving cleanly through a scientific review process, but one that has continually involved politics, pressure and public perceptions.

The story behind this authorization began in July 2021, when Glas submitted Premarket Tobacco Product  Applications (PMTA) for these products. By then, the PMTA process was already becoming a maze for flavored-vape applicants. 

Internal FDA memos later showed how the agency handled many such applications through what became known as the “Fatal Flaw” review. Instead of fully evaluating each application on its merits, the review looked for the presence of certain types of studies in applications for non-tobacco-flavored products—a systematically different approach from that used with other applications. 

That helped fuel criticism that the PMTA process was chaotic, opaque, stacked against smaller companies and amounted to a de facto flavor ban.  

By then, starting in August 2021, the FDA had already begun issuing waves of marketing denial orders for flavored vaping products. Those decisions helped set the pattern: FDA would repeatedly say flavored products had not shown enough adult benefit to offset youth risk, while many adults who had switched insisted that flavors were helpful—if not critical—to making the switch.

For years, the public was told that the FDA’s tobacco decisions were based on science. They should be. But the science office’s recommendation has not always been the final word.

In 2022, internal FDA memos involving Logic’s menthol vaping products showed that the CTP’s Office of Science had recommended authorization, but CTP leadership pushed back. The documents revealed substantial disagreement inside CTP, with FDA scientists on one side and the agency’s bureaucratic and political leadership on the other. 

In December 2025, tobacco harm reduction advocate Gregory Conley noticed a Google Alert showed a PDF indicating the FDA had added the Glas G2 device and multiple Glas pods to its authorized list. In an unusual twist, the update to the authorized list later that day no longer included the Gas products. The FDA attributed the weekend changes to a glitch.

In March, the FDA authorized the Glas G2 device and one Blonde Tobacco pod. There was no press release, but that authorization represented the first of a vaping product with age-gating technology that must be activated before use. Glas also stood apart from most companies with authorizations because it has never been owned by or previously tied to a tobacco company. 

Combustible cigarettes, we should remember, do not require Bluetooth pairing. Age-gating vapes makes the safer option much harder to access than the more dangerous one.

But the flavors that had drawn attention in December were still missing. Had the FDA reviewed them and said no? Or had something else happened?

By April, internal FDA records suggested that the story was not so simple. Scientific staff had recommended marketing orders for flavored Glas products, but senior leadership halted them. Because those records became public through Glas, they should be read carefully. But they were not hard to believe, because the Logic case had already shown a similar pattern: FDA scientists saw a path to authorization, and higher-level officials intervened.

This difference was evidently resolved in favor of authorization. And this happened at a time when the pressure around the FDA has visibly shifted. 

For years, health and parents’ groups have pushed the agency not to authorize flavors, and that’s still the case. After the Glas announcement, the Campaign for Tobacco-Free Kids called the decision a “big step backward,” warning that fruit flavors appeal to youth. 

But pressure is now coming from the other direction, too. Earlier on May 5, news broke that President Donald Trump had rebuked FDA Commissioner Marty Makary for not moving quickly enough to approve flavored vapes and nicotine products. Advisers described Makary as blocking Trump’s pledge to “save” vaping. Hours later, the FDA announced the Glas authorizations.

So this is not a simple story of a product moving cleanly through a scientific review process, but one that has continually involved politics, pressure and public perceptions.

The age-gating technology may well be what finally made the authorization politically viable, which suggests the FDA is not opening the door to many other flavored vapes. The Glas G2 requires users to download an app, upload a selfie and driver’s license images, and use the device while near the paired phone. That may be a path through FDA’s maze, but it is a narrow one.

Combustible cigarettes, we should remember, do not require Bluetooth pairing or any of the other elements of this digital lock; anyone who obtains them, including youth, can use them. So age-gating vapes makes the safer option much harder to access than the more dangerous one.  

People who smoke deserve more than a regulatory system that offers them cigarettes quickly and harm reduction alternatives slowly.

That does not make the Glas authorization bad news. It is good and historic news. But it also shows how many hoops a company had to jump through before the FDA could say yes.

The evidence on flavors makes this story bigger than one company. Fruit and sweet flavors are positively related to moving away from cigarettes, and helping people select a flavor can improve the chance of switching. It took until 2024 for the FDA to authorize any non-tobacco flavored vape, in the form of menthol.

For adults who smoke, the practical question has never been whether a product fits neatly into a regulatory debate. The question is whether there is a regulated, accessible option that helps them move away from cigarettes. Glas may be an answer for some people. It will not be the answer for everyone.

The authorization does not solve the larger problem. It does not suddenly create a broad legal market of smoke-free products that reflect the mostly unregulated variety adults already use. It does not erase the damage done by years of uncertainty, denials and misinformation about safer options.

It does mark a change, but the next step should not be to declare victory. It should be to ask why it took this long, how many adults were left without acceptable legal options along the way, and whether the FDA will apply this lesson more broadly.

People who smoke deserve more than a regulatory system that offers them cigarettes quickly and harm reduction alternatives slowly.  

Photograph (cropped) by Global State of Tobacco Harm Reduction via Flickr/Public Domain

The post FDA Finally Authorizes Fruit-Flavored Vapes. Here’s What It Took. appeared first on Filter.

In an April 4 letter to CDC Acting Director Jay Bhattacharya, Dr. Pesko, professor of economics at the University of Missouri, urged the agency to reconsider the term “E-cigarette, or Vaping, Product Use-Associated Lung Injury,” or EVALI. 

The term was adopted during a highly publicized spate of cases in 2019, which the CDC and other health authorities rapidly implied were caused by nicotine vapes. This sparked alarm in the United States and around the world—causing many people to revert from vaping to smoking, and leading to global policy ramifications that reverberate to this day. 

Never mind that evidence soon indicated a different culprit; the damage to tobacco harm reduction was done.

“EVALI” still lumps together fundamentally different products in ways that mislead clinicians, the public and people who smoke.

Pesko wrote that the evidence points overwhelmingly to vitamin E acetate in unregulated, adulterated THC vaping products—not standard nicotine e-liquids—yet “EVALI” still lumps together fundamentally different products in ways that mislead clinicians, the public and people who smoke who might otherwise switch to less harmful alternatives.

It is vital that public health language should not spread confusion. Inaccurate terminology fosters public mistrust of our health organizations. Language shapes clinical assumptions, media framing, regulation and personal decisions. When the name of an outbreak points people toward the wrong product category, the misunderstanding can persist for years after the science has moved on.

The CDC has been asked this question before. 

In August 2021, Pesko and a group of distinguished colleagues led a petition signed by 75 multidisciplinary experts, including seven former presidents of the Society for Research on Nicotine and Tobacco, asking the CDC to retire the term EVALI. The signers argued that the name was “ineffective and misleading” because, in ordinary language, “e-cigarette” refers to nicotine vaping. They warned that the term was driving misperceptions, stigmatizing nicotine vaping and confusing both the public and health professionals.

The CDC refused.

The 2019 outbreak was time-limited and geographically concentrated. That pattern is consistent with a poisoning event—not with an inherent property of nicotine vaping products.

In its September 22, 2021 response, the agency acknowledged that most cases were linked to THC-containing products from informal sources and that vitamin E acetate was strongly linked to the outbreak. But it still declined to rename EVALI, pointing to residual uncertainty and to reports that 14 percent of patients said they had exclusively used nicotine-containing products. But such self-reports warrant caution, especially in places where cannabis use remains banned, giving people a clear incentive not to disclose it. 

The CDC’s decision may have sounded cautious. In practice, it has been costly.

The central facts have been clear for years. The 2019 outbreak was time-limited, geographically concentrated and strongly associated with a contaminated THC supply chain. It peaked in September 2019 and faded rapidly by early 2020. That pattern is consistent with a poisoning event—not with an inherent property of nicotine vaping products that had already been used for years.

Tobacco harm reduction expert Clive Bates put the logic bluntly in 2021: The evidence indicates that nicotine vaping was not the cause of the outbreak. Vitamin E acetate was the identified contaminant. It served an economic purpose in unregulated THC oils. It is not soluble in the propylene glycol and vegetable glycerin base used in nicotine e-liquids. And no parallel change in nicotine products explains why the outbreak rose and fell when it did.

That conclusion also fits what careful reporting uncovered in real time.

Polling showed that after the outbreak and the flood of media coverage, two-thirds of respondents associated the deaths with “e-cigarettes such as JUUL.”

Early in the crisis, investigators and journalists followed a trail through illicit-market THC cartridges, thickening agents, counterfeit packaging and fly-by-night brands like Dank Vapes. Reporting from Leafly, Inverse, Columbia Journalism Review and Filter documented how unregulated THC carts are often filled using tainted additives to mimic purity and stretch profits. New thickening agents had entered this market in late 2018. Vitamin E acetate emerged as a prime suspect because it was widespread, newly popular, cheap and found in the products used by sick patients.

Meanwhile, the very term EVALI nudged the public toward the wrong conclusion.

The 2021 experts’ letter cited polling showing that, after the outbreak and the flood of media coverage, two-thirds of respondents associated the deaths with “e-cigarettes such as JUUL,” while only 28 percent associated them with “marijuana or THC e-cigarettes.” That is not a harmless misunderstanding. It is a failure of risk communication. When the CDC’s label points people toward nicotine vaping, many people will never make it to the fine print.

Worse, as Pesko and the other experts warned, the confusion appears to have had behavioral consequences.

A 2021 article summarizing new evidence reported that the EVALI scare was associated with a sharp drop in nicotine vape sales and an immediate rise in cigarette consumption in both Massachusetts and around the US.

The damage did not stop there.

Once a misleading name takes hold, it spreads through hospital coding, state data systems and clinical practices. The misnamed EVALI outbreak heightened health care provider wariness, and later coding changes made it easier to tag visits as a “vaping-related disorder” without distinguishing the substance involved. Old panic can then live on in new datasets, where nicotine, THC, smoking and unrelated illness blur together.

The CDC cannot undo the frightened headlines from 2019. It cannot persuade every person who went back to cigarettes. But it can stop repeating the mistake.

The 75 experts proposed one replacement, ATHCVALI: Adulterated THC Vaping Associated Lung Injury. Whether or not that is the perfect substitute is almost beside the point. The larger issue is that the current label remains anchored to the confusion of the outbreak’s earliest days, not to the evidence. 

Pesko’s new letter takes a restrained approach. It does not demand a specific acronym. It simply asks the CDC to revisit its terminology in light of the evidence and the real-world consequences of continued conflation.

The CDC should do exactly that. It should clearly state, without hedging, that the 2019–2020 outbreak was driven by adulterated THC vaping products, especially those contaminated with vitamin E acetate.

The CDC cannot undo the frightened headlines from 2019. It cannot reopen the vape shops that went under because of the panic. It cannot persuade every person who went back to cigarettes because they were falsely told, directly or by implication, that nicotine vaping had caused a wave of damaged lungs and death.

But it can stop repeating the mistake.

Photograph (cropped) by Reed Mansour via Flickr/Creative Commons 2.0

The Influence Foundation, which operates Filter, has received unrestricted grants from Juul Labs, Inc. Filter‘s Editorial Independence Policy applies.

The post Will the CDC Finally Abandon the Damaging Term “EVALI”? appeared first on Filter.

Most of those people in my life smoked—a significant risk factor for many cancers besides the most obvious ones. Only a couple of them survived cancer, which means I’ve become familiar with premature death and the long-term emotional and financial strains families are left with.

So when World Cancer Day takes place on February 4 each year, it isn’t a meaningless awareness campaign to me. It’s personal. 

As I watch entities like the World Health Organization (WHO) mark World Cancer Day, despite willfully spreading misinformation about things that can reduce cancer risk, I find myself lost in dark anger. I know that more people will die because they don’t know the truth.

Public health organizations’ messaging should make it easier, not harder, for people to reduce their risk of early death.

People need to know that it is the smoke from combustible tobacco, not the nicotine, that greatly increases cancer risk. People need to know that quitting smoking at any age, by any means, has health benefits. 

Public health organizations’ messaging and policy recommendations should make it easier, not harder, for people to reduce their risk of early death. The WHO’s constant blurring of a crucial distinction—between deadly combustible tobacco and the safer nicotine products that have helped millions quit smoking—does the opposite. 

A recent example comes from the WHO’s International Agency for Research on Cancer (IARC) and the fifth edition of its European Code Against Cancer. Released to the medical community in late 2025, it’s due to be presented to the public this World Cancer Day. It contains drastic changes in its messaging about smoking and nicotine. 

In the European Code’s 2014 fourth edition, the tobacco guidance included the basic recommendation of “Do not smoke. Do not use any form of tobacco.” But what made it extra helpful was that it anticipated questions people might have and answered them in plain language. It accurately explained that it’s not nicotine that causes cancer, but exposure to carcinogens in combustible tobacco.

The fourth edition also addressed nicotine vaping with a degree of nuance. While stating that “Long term safety is unknown at present” and raising concerns about potential youth use, it said that vaping “is expected to have a lower risk of disease and death than tobacco smoking,” due to the absence of combustion. If people switch to vapes, it added, that has “the potential to reduce the enormous burden of disease and death caused by tobacco smoking.”

This is not some minor editorial adjustment. It fundamentally changes what the public will understand.

Compare that with what the European Code’s fifth edition emphasizes. Its headline guidance on smoking is short and misleading: “Do not smoke. Do not use any form of tobacco or vaping products. If you smoke, you should quit.” 

Smoke and vapor are now treated as if they belong under the same warning label, without the explanatory details previously provided. 

This is not some minor editorial adjustment. It fundamentally changes what the public will understand. When you remove the nuance and the “why,” and keep only the “don’t,” people will be led to believe that vaping and smoking are equally harmful, which is unequivocally false.

It doesn’t stop at individual advice. The fifth edition policy brief calls for measures such as heavy taxation—”All tobacco products should be taxed in a comparable way as appropriate, in particular where the risk of substitution exists.”—and steps to “restrict the availability and accessibility of tobacco products.” And it explicitly says that policymakers should “Extend such regulations to apply to all tobacco products, electronic cigarettes and all novel tobacco and nicotine-containing products.” 

The document states that products like vapes and pouches are “relatively new,” and that “further research is needed to understand their potential links to cancer.” Yet it doesn’t mention that no cancer link has been proven to date, despite the best efforts of some researchers. It completely ignores these products’ role in smoking cessation. It just goes ahead and includes them in its blanket policy recommendations.   

When institutions conflate nicotine and smoking, they harden confusion into common knowledge; myths become facts. One of the most damaging misperceptions I’ve seen, widespread among the public and among clinicians, is the belief that nicotine causes cancer. The consequence is that some people will continue to smoke instead of trying a much safer alternative.

If the WHO were to include people who use nicotine in the conversation, it would find it harder to ignore our experiences and our needs.

The WHO’s framing of harm reduction communication adds another layer of confusion by arguing that nicotine companies “cloak” their marketing in “the public health language of harm reduction.”

Regardless of what companies do, harm reduction is not a tobacco-industry invention. It’s a longstanding public health framework that the WHO supports in other areas of drug use. This framework acknowledges that drug use will happen, but that public health efforts can still reduce death and disease by making it safer. The public deserves balance: skepticism about marketing claims, paired with truthful risk communication that keeps the focus on whatever helps save the lives of people who smoke.

Harm reduction is also a movement—led by and centered on the agency of directly impacted people. If the WHO were to include people who use nicotine in the conversation, it would find it harder to ignore our experiences and our needs. 

The WHO is already aware, but chooses to obscure, that modern vapor products were invented in 2003 by Hon Lik—a pharmacist who was seeking to quit smoking after his father, who also smoked, was diagnosed with lung cancer. Legacy tobacco companies did not enter the vapor market until years later, long after people who smoke had been taking matters into their own hands, building and improving vaping devices, and spreading the word in an inspired grassroots effort. To equate tobacco harm reduction with Big Tobacco is no more valid than equating opioid harm reduction with the Pharma companies that make opioids and medications for opioid use disorder.

The goal should not be a moralistic crusade to make people do what the WHO wants. The goal should be fewer funerals of the kind I’ve attended far too often.

Unfortunately, the perversion of harm reduction messaging and the truth is a pattern the WHO has repeated, growing more brazen over the years. 

World Cancer Day is not the time to hide the truth behind a mask of moral outrage. It’s time to communicate risk precisely. That means naming the core cancer hazard clearly: smoking. It means being clear that nicotine is associated with dependency, but not with cancer. And it means recognizing and learning from the lived experience of people whose health and lives have been transformed by switching to safer nicotine.

The goal should not be a moralistic crusade to make people do what the WHO wants. The goal should be fewer funerals of the kind I’ve attended far too often.

Photograph (adapted) by Klaus Nielsen via Pexels

The post Shameful Changes in the WHO’s European Code Against Cancer appeared first on Filter.

I chose stores that looked clean and professional. Inside, well-trained staff taught me what we could do to filter our air. They helped me decide which furnace filters, vacuum cleaner, air conditioner and air purifiers to purchase.

I also have plantar fasciitis, a painful foot condition. My doctor told me to stop buying cheap shoes at a big-box store and to find a shop with knowledgeable staff who could advise me on sturdy shoes to properly fit and support my feet. 

We have a couple of nice-looking shoe stores where I live. They have attractive wall displays and bright, inviting lighting. Inside, the staff were as helpful as they could be. Plantar fasciitis isn’t something they’re familiar with, so I’m still looking for the right pair of shoes.

I recently read a prominent LinkedIn post that stopped me in my tracks. The writer, an academic in the United Kingdom, described walking past a vape shop that “looks like a modern community pharmacy, with clean blue and white branding, bright lighting and ‘solutions’ language in the window.” 

She worried that, amid concerns about youth vaping, this appearance could “risk normalizing” vaping as “healthy” or “professionally endorsed,” rather than “a ‘less harmful but still addictive’ option for current smokers only.”

What would people with such concerns prefer a vape shop to look like? Blacked-out windows, with signs saying, “Danger”?

I’m trying to understand the concern behind that reaction. But I keep coming back to a basic question: What would people with such concerns prefer a vape shop to look like?

Would blacked-out windows, with signs saying, “Danger! Addictive products sold here!” increase their comfort level? And would they apply that standard to shops that sell coffee, sugar, alcohol, video games or lottery tickets? Perhaps they would find a dim storefront, with dingy curtains drawn—located in a back alley, with discreet signage and no products visible—more acceptable. 

But what messages would those presentations send to people who stand to gain the most by stepping inside? 

I’m not convinced that a bright, professional-looking shop is what draws kids. If anything, a forbidden-fruit vibe can be part of the appeal for some adolescents. Nor is a glass-fronted, brightly lit store an ideal set-up if you’re planning to conduct illegal transactions with underage customers. 

But of course, there’s much more to this debate than youth initiation. The part that too often gets ignored is that more than a billion people worldwide smoke, and millions die from smoking-related disease every year. When vaping is an alternative that doesn’t kill, it should be normalized.

I’m 67 years old. I quit smoking with the help of vapes, when nothing else had worked. When I go into a vape shop, I’m not looking for a clinic, but I am looking for a place that feels welcoming, safe and competent, because switching away from smoking is serious business. 

Let vape shops look like responsible and inviting adult establishments. Because people who smoke deserve a door they’re comfortable walking through. 

A clean, professional shop makes me feel like I’m less likely to be sold junk, less likely to be misled, and more likely to get practical help from someone who actually knows what they’re talking about.

I’m proud that I was finally able to quit smoking after decades. I’m grateful that the right products existed to help me do that, and grateful for the advice I received. I want this life-changing opportunity to be available to others—our neighbors, families and community members—in an open, welcoming way. Not in a stigmatizing way that treats safer options like contraband, sold in places that scream “keep out.” 

If I’m honest, that LinkedIn post stung. I don’t think the author meant harm, and in any case, the sentiments are far from unique to her. But the question of Should a vape shop be allowed to look like that? lands like a judgment on where I shop and what products I use, as if my efforts not to smoke are something wrong or shameful.

The UK has been a leader in meeting people where they are, and I hope that never stops. There are hospitals with vape shops in them, and yes, they look “pharmacy-like” if you choose to interpret it that way. Some hospitals and stop smoking services supportively provide vapes to people who smoke.

Let vape shops look like responsible and inviting adult establishments. Because people who smoke deserve a door they’re comfortable walking through. 

Photograph (adapted) by E-Liquids UK on Unsplash

The post What Should a Vape Shop Look Like? appeared first on Filter.

Somewhere in statistics like those are people like my Grandma.

One of my favorite places in the world was the log cabin my great-grandpa built in 1924, along the shores of Lake Sylvan outside Pillager, Minnesota. I spent a lot of time there with my grandparents. 

In summer, we’d throw the windows open and let in the sounds of loons calling and fish leaping. I loved lying in the bottom bunk with a book. It was one of the few places I felt safe.

Grandma and Grandpa were always the kindest people in the room. She’d spend hours playing with us kids. Poverty shaped her life, but it didn’t break her. It taught her how to make do. She cooked as if she were feeding an army, kept a massive garden and canned enough food to get everyone through into the next growing season.

Grandma was never afraid to speak her mind, and she always said my favorite comic books—Archie, Scooby Doo and all the superheroes—were “brain pollution.” If she found them, she’d throw them away. I got really good at hiding them.

After Grandpa died, my mom moved up there. In 1990, I got a panicked call from my mom, as she told me something wasn’t right with Grandma.

When I arrived, Grandma was sitting in the living room, smiling and looking perfectly fine. But when she tried to speak, her words came out as gibberish, and she didn’t seem to realize we couldn’t understand her.

It took both of us to convince Grandma to go to the emergency room. The doctors confirmed it was a stroke, then told us her kidneys weren’t functioning.

Once she was stable, they transferred her by ambulance to the nearest hospital with dialysis, about an hour away. With dialysis, Grandma quickly felt better. Her speech returned. She was herself again.

But the question hung in the air: Why were her kidneys failing? That’s when the doctors said the word no one wants to hear: cancer.

I can’t help asking hard questions about prevention, because prevention is where we still have a chance to spare other families the moment I lived through.

Cervical cancer had spread throughout Grandma’s body. There was nothing they could do to stop it, only keep doing dialysis and keep her comfortable. We didn’t know that, because Grandma forbade the medical team from telling us her cancer was terminal.

A couple of weeks later, my mom called again. Grandma was unresponsive. She’d had another stroke. The nurses said she didn’t have much time. That hour drive felt endless. When I got to the hospital, I ran across the parking lot and down the halls to her room.

My mom told me what she knew and then stepped out to give me a few minutes alone with Grandma.

I sat on the edge of the bed and held her hand. I talked to her like she could hear me, though I didn’t know if she could. I reminisced about the cabin and the garden. And I told her where I used to hide my comic books—I don’t know why; it just came out.

I told her we loved her as tears stung my eyes. I said we’d hold on to what she taught us for the rest of our lives. I told her it was okay to go. 

Her eyes opened briefly. I felt a slight pressure as she squeezed my hand.

And then she was gone.

The wedding of Dorothea Katzung and Merrill Carrier, in 1935

That’s why I can’t help asking hard questions about prevention, because prevention is where we still have a chance to spare other families the moment I lived through.

The World Health Organization recently launched a global push to eliminate cervical cancer, laid out in a 56-page report. Its approach focuses on vaccination, screening and treatment: three pillars that can save lives. 

I’m grateful that these powerful and important tools exist, and it’s absolutely right that they’re being promoted. At the same time, medical access is limited for many people, and the tools themselves have some limitations. The HPV vaccine, for instance, targets the most common cancer-causing HPV types, but does not provide protection against all types.

HPV is the leading known cause of cervical cancer, but it isn’t the only factor linked to risk. One of the clearest cofactors is smoking, which according to some research is associated with women having double the risk of cervical cancer. Tobacco-related compounds have been detected in cervical mucus, and smoking-related damage to cervical cells has been documented. Smoking also affects immune function, which matters when the body is trying to clear an HPV infection.

It concerns me, then, that tobacco shows up only twice in the WHO report: first in a figure on page 25 recommending health information and warnings about tobacco use, and then on page 26 with a brief reference to tobacco cessation. Smoking—when use of combustible tobacco is the primary concern—is not specifically named at all.

We can prevent more cervical cancer by addressing tobacco smoke exposure as a significant part of the prevention story, not as a footnote. 

My Grandma didn’t smoke. But she spent her life surrounded by people who did, and evidence also links secondhand smoke to cervical cancer. I can’t help wondering how much smoke she breathed in year after year, decade after decade, back when “smoke-free” wasn’t even a concept. I keep asking myself if the smoking by those of us around her contributed to her death.

January is Cervical Health Awareness Month. It’s the perfect time to say the whole truth out loud: We can prevent more cervical cancer by vaccinating, screening and treating. And we can prevent more still by addressing tobacco smoke exposure as a significant part of the prevention story, not as a footnote. 

For those who can’t or don’t want to stop using nicotine, we need to educate them on options to reduce their risk, such as the array of smokeless products that are available to them.

But I needn’t have read the whole WHO report to know that these options would not be mentioned there.

Cancer prevention communication should routinely include a clear, plain-language reminder that avoiding smoke exposure and quitting smoking can reduce risk, not just for lung cancer, but for cervical cancer too. Prevention should include helping people who smoke quit, preventing smoking initiation and avoiding secondhand smoke. This should be communicated in every country, at every income level, and to adults who are long past the teenage vaccination window.

My Grandma was a strong woman with a lifetime of survival skills. But none of her life’s lessons provided a way to survive cancer.

We owe it to women and their families to do everything in our power to prevent cancers we already know how to prevent, while we keep pushing research forward for better treatments and cures.

Because “every two minutes” is not just a statistic. 

It’s a family. It’s a hand held in a hospital room. It’s someone’s Grandma.

Top photograph via Rawpixel/Public Domain

The post Smoking Should Not Be a Footnote in Cervical Cancer Prevention appeared first on Filter.

I love living here, as my family has done since the 1800s. My memories are full of lakes and forests, and the stick-to-your-ribs, warm-your-soul hotdishes that appear at every community potluck.

I have darker memories, too. I’ve watched generations of my loved ones smoke, get sick and die years too soon. Robbed of my elders, I’m left as the family elder long before I ever expected to be.

You’ve probably heard of “Minnesota Nice,” and I think we earned that tag. So how is it that here, tobacco control and harm reduction don’t go hand in hand?

Minnesota was one of the first states to establish a nonprofit dedicated to tobacco control in the early 1970s. We were the first state to pass a Clean Indoor Air Act in 1975, restricting indoor smoking in public places to designated smoking areas; a 2007 law later banned indoor smoking in public places, with a few exceptions, such as tribal lands.  

We hold the distinction of being the first state to develop a comprehensive tobacco control plan. In 1994, Minnesota was the second state to sue the tobacco industry; the landmark case was settled in 1998. Blue Cross and Blue Shield of Minnesota was a party to that suit, in a first for the health insurance industry. 

Minnesota’s resistance to tobacco harm reduction began quietly in 2010 … Years later, economists would look back at this and call it a natural experiment.

Minnesota was also the first state to fund a media campaign encouraging its citizens not to smoke, and here we see the root of the problem. In 1989, the health department printed posters of animals smoking, with the line “It looks just as stupid when you do it.” The department handed out over 20,000 copies at the State Fair that year—sending the message it’s ok to stigmatize people who smoke.

Minnesota’s resistance to tobacco harm reduction began quietly in 2010, when the state became the first in the country to tax nicotine vapes. At the time, vaping products were still new; they didn’t have a proper legal category. Because their nicotine came from tobacco, Minnesota classified them as “other tobacco products,” and taxed them accordingly. That mattered less when the tax rate was 35 percent. But in 2013, it was raised to 95 percent of the wholesale price, without significant debate about relative risk. 

Years later, economists would look back at this and call it a natural experiment. Their findings were not subtle. The Minnesota tax made vaping much more expensive, and as prices rose, fewer adults quit smoking. 

One research team estimated that during the study period (2013-2015), roughly 32,400 Minnesotans who would otherwise have quit smoking did not—a predictable result when the safer substitute becomes dramatically more expensive, and when smuggled cigarettes from lower-tax jurisdictions are widely available.

In 2014, vaping was banned in schools and government buildings. That ban was extended in 2019 to all indoor public spaces, including bars and restaurants.

If the state laid the groundwork, our cities built on it. Local governments adopted their own layers of restrictions: flavor bans, zoning limits, Tobacco 21 ordinances, coupon bans and minimum prices. 

Minnesota’s policies have created a state where it is easier to keep smoking than to switch away from it.

In early 2020, St. Louis Park went so far as to ban the sale of vaping products altogether, while leaving combustible cigarettes on the shelf. Council members acknowledged that the “EVALI” lung injuries dominating the news at the time were tied to illicit THC cartridges rather than legal nicotine vapes, but moved ahead anyway. Overnight, adults who had switched from smoking to vaping lost access to the very products that had helped them stay away from cigarettes.

St. Paul followed with one of the strictest commercial tobacco ordinances in the country, including restrictions on vapes. Then came Saint Anthony Village and Minneapolis, which in 2024 raised the minimum floor price for cigarettes to $15—an idea that might sound good, until you consider that the cost is overwhelmingly borne by people on low incomes, and that the state has an unusually large illicit cigarette market. 

Worse still, the following year, Minneapolis voted unanimously to set a $25 minimum floor price for vapor devices, while St. Anthony Village set the price at $20.

The result is a landscape in which a Minnesotan trying to save their life by quitting smoking encounters a simple, consistent message everywhere they go: Smoking remains affordable and accessible, while lower-risk alternatives are increasingly expensive and, in some places, entirely unavailable. 

Our state’s primary health authority speaks as though all forms of nicotine use carry comparable risks.  

Given the messaging we hear, this outcome should not surprise us. The Minnesota Department of Health states: “Commercial tobacco use like smoking, using chew, or vaping kills over 6,530 Minnesotans every year.” The implication is unmistakable: that vaping contributes to this toll. The deaths are caused by diseases linked to combustible products. Yet our state’s primary health authority speaks as though all forms of nicotine use carry comparable risks.  

When public agencies talk this way, it becomes easier for policymakers to believe that vaping must be taxed, restricted or banned with greater intensity than combustible cigarettes. 

Vaping eliminates combustion, and it is combustion, not nicotine, that causes the overwhelming share of smoking-related harm. Studies consistently show that people who switch completely from cigarettes to vaping dramatically reduce their exposure to carcinogens and toxicants. For many people, vaping is the only smoking-cessation method that ever worked for them. Yet Minnesota’s policies have created a state where it is easier to keep smoking than to switch away from it.

Research also shows that when vape prices rise or products are banned, smoking, including by youth, increases. Some estimates suggest that a hefty federal vape tax, similar to the effective tax burden already in place in Minnesota, would lead to millions of additional adults smoking daily. 

For people on low incomes, older adults, people living with mental health conditions, and others who are disproportionately affected by smoking-related illness, this is not an abstract policy discussion. It is a question of survival. Every time a person chooses a cigarette because the safer product was priced or regulated out of reach, a policymaker and the tobacco control groups supporting those policies made that choice more likely.

We’ve learned the value of harm reduction and how it saves lives. But harm reduction is still not the norm when we’re talking about nicotine use.

Tobacco control is not the only time Minnesota has been thought of as a leader in the addiction field. We are also known for the “Minnesota Model.” First developed in the 1950s, it pertains to treatment programs that involve professionals and people with lived experience, and insists that anyone living with a substance use disorder practice abstinence. That model quickly spread across the United States. 

Since then, we’ve learned the value of harm reduction and how it saves lives. Long before statewide harm reduction policies existed, Minnesotans were already practicing it—distributing naloxone, offering syringe access and building community care in places where formal systems had failed.

Today, that early grassroots work has grown into something extraordinary. Minnesota recently became the first state in the nation to repeal its drug “paraphernalia” laws fully, and the second state, after Rhode Island, to authorize overdose prevention centers, dedicating millions to support supervised consumption and safer-use services. In 2025, Minnesota became the first state to earn Recovery Friendly Workplace certification, following a 2024 executive order directing agencies to recognize recovery from substance use disorder as a strength and reduce workplace stigma.

These are landmark, evidence-based reforms that treat people with dignity. But harm reduction and the inclusion of people with lived experience are still not the norm when we’re talking about nicotine use. As we look toward 2026, we should ask ourselves whether the course we have charted for people who use nicotine is the kind we genuinely want to lead. 

Photograph of Minnesota State Capitol by Tony Webster via Wikimedia Commons/Creative Commons 2.0

The post In Minnesota, We Refuse to Apply Harm Reduction to Tobacco Use appeared first on Filter.

Every December, the world marks Universal Human Rights Month and Human Rights Day on December 10. The 2025 theme, Everyday Essentials, reminds us that human rights are basic conditions of life, like health, housing, safety and the freedom to make our own choices.

Many tobacco control authorities focus on youth’s “right to health” by preventing nicotine “addiction”—which, even if we accept the premise of addiction existing in the absence of severe harms, does not kill. Why can’t the same people wrap their heads around an adult’s right to health by helping them quit deadly cigarettes?

In tobacco and nicotine policy, one word has come to dominate global conversations about health and morality, often in ways that lose sight of those human-rights essentials: endgame. An endgame that feels more like the ill-fated drug war than a movement to improve public health.

Unfortunately, a consensus on what the “endgame” actually is has never been reached. For some, addressing smoking is not enough.

In chess, the endgame is characterized by just a few pieces remaining and every move being crucial. It’s a tense final stage. The word entered the tobacco control lexicon over a decade ago, describing the “final phase” of the campaign against smoking: It hinted at a future with little or no combustible tobacco use and far fewer deaths. It sounded bold, even heroic. Who wouldn’t want to end the suffering caused by smoking? 

Unfortunately, a consensus on what the “endgame” actually is has never been reached. For some, addressing smoking is not enough. For them, the endgame stopped meaning the end of death and disease from smoking, and started meaning the elimination of nicotine itself.

That shift matters. Words steer policy, and policy shapes lives. When we refer to a public health goal as an endgame, we turn it into a contest. Games have sides, opponents, winners and losers. In that framing, people who use nicotine start to look like the problem to be defeated. It may not be anyone’s intent, but that’s how it lands.

I’ve watched this play out: flavor bans that wipe out safer alternatives while cigarettes stay on every corner; punitive taxes that hit hardest those with the least; campaigns that trade empathy for shame. Even news coverage sounds like battlefield casualty updates.

Somewhere in all this competition, the humanity of the people most affected gets lost, and that’s when public health becomes inhumane.

When the goal becomes eradication instead of transformation, people become collateral damage.

Many in tobacco control defend the word, saying the endgame targets the tobacco industry, not individuals. I appreciate that distinction, but it’s not as clean as it sounds. Industries don’t vanish in a vacuum. Every supply-side policy echoes through the lives of real people—those who use nicotine, those who’ve switched to avoid smoke, and those who make a living in small shops selling these products.

When the goal becomes eradication instead of transformation, people become collateral damage. If regulation eliminates safer products faster than deadly ones, or if stigma drives people away from care, or if prohibitions boost unregulated versions of the same industries, then the line between targeting industry and targeting individuals becomes indistinct. The endgame rhetoric blurs that line even further, treating the entire ecosystem, from production to use, as something to be conquered and controlled.

A rights-based approach can challenge industry misconduct without devaluing the people whose needs those products meet. The real challenge isn’t to wipe out nicotine, but to reduce the number of people who die from using it. Pursuing the first of those goals is liable to impede the realization of the second.

The 1948 Universal Declaration of Human Rights ties health to life, security, and dignity. Human rights and public health should pull in the same direction. Yet an endgame against nicotine can easily collide with those rights.

Health is a fundamental aspect of the right to life and autonomy. That includes the right to make informed decisions about one’s own body, such as choosing safer nicotine products. But the endgame mindset often assumes elimination equals liberation, as if freedom only begins once every product is gone.

When you’re playing to win, harsh measures seem justified. For people with lived experience, the message is clear: You are what stands between us and victory.

And equality? Nicotine use isn’t random. It’s concentrated in communities facing the steepest hardship. The very same people who already bear the weight of health inequities. Erasing them from the conversation denies their humanity and deepens those inequities, rather than addressing them.

Stigma thrives on simplicity, and endgame makes everything sound simple. It divides the world into good and evil. It can even make cruelty sound noble. When you’re playing to win, harsh measures seem justified. For people with lived experience, the message is clear: You are what stands between us and victory. That’s not just alienating—it’s dangerous.

Stigma pushes people away from health care, discourages honesty, and can drive us back to the very products we’re trying to replace. It narrows policy down to punishment and prohibition, ignoring evidence that harm reduction saves lives.

In a world where words can decide whether safer options stay legal or vanish, metaphors matter. Endgame may have started as a visionary call to action, but now it’s a trap, one that confuses helping people with defeating them.

A genuine public health approach treats people as partners in progress, not pieces on a board. It fosters cooperation rather than conquest. It focuses on well-being, equity and respect, not erasure. 

On Human Rights Day, I reflect on how those 1948 words should continue to guide us. Progress isn’t measured by how efficiently we control the behavior of others, but by how deeply we respect one another.

Photograph (cropped) by Brateevsky via Wikimedia Commons/Creative Commons 4.0

The post The Lives of People Who Use Nicotine Are Not an “Endgame” appeared first on Filter.

“You need to come home. I can’t breathe.”

I abandoned my cart, apologized to the cashier and ran to my car. On the way home, I called our son and told him to meet us there so we could take his dad to the emergency room. My husband had never experienced anything like this. I knew it wasn’t something for a walk-in clinic. 

He had started smoking as a teenager. He tried many times to quit. Sometimes he stopped for days or months, but he always returned to it. Additionally, he spent over three decades working in a factory, inhaling dust, fumes and chemicals. The combined damage had been building quietly inside his lungs for years.

At the ER, they took him in right away and started a nebulizer treatment. It took two rounds before he could finally breathe normally. During intake, the nurse asked whether he smoked. As soon as he said yes, the tone shifted. No one asked about his decades of chemical exposure. No imaging, no blood work, no spirometry. Just a stethoscope to his back and a contemptuous look. 

“You shouldn’t have smoked,” a nurse told him sharply. “This is what happens when people smoke.” 

The doctor diagnosed him with chronic obstructive pulmonary disease—COPD—and gave him a prescription for a daily inhaler and a rescue inhaler. We were sent home after the doctor told him to quit smoking.

On the way home, he broke down and began to cry. The ER had made him feel like he deserved what was happening to him.

I wish I could tell you this kind of judgment is rare. It isn’t. People who smoke—and those who used to smoke—often describe being dismissed or chided when they receive diagnoses like COPD or lung cancer. 

Research has documented this pattern: People living with COPD report that stigma often comes directly from health care providers. Many say they are treated as if they are to blame for their suffering and therefore have less of a right to compassionate care.

For my husband, the stigma hit immediately. On the way home, he broke down and began to cry. He apologized repeatedly for “ruining our lives.” The ER had made him feel like he deserved what was happening to him.

The ER staff didn’t offer counseling, medication to help him quit smoking, a quit-smoking referral, or even basic information about COPD. So I Googled COPD myself. I found out how it is actually diagnosed: through spirometry, chest imaging and sometimes further testing to rule out heart disease or lung cancer. The COPD Foundation explains that these tests are necessary to confirm the diagnosis and guide treatment. None of that was offered to him.

My husband quit smoking cold turkey after that ER visit. It was difficult; emotionally, physically and psychologically. He was scared, grieving, ashamed, and dealing with withdrawal. All I could do was support him, because the health care system hadn’t even tried.

Years passed before a doctor finally revisited his diagnosis and ordered the tests he should have received on day one. He had pulmonary function tests, a CT scan to rule out lung cancer, and a stress test for his heart. We were relieved that the results showed COPD and not lung cancer. But COPD has devastated his health, his independence, and our family’s plans. It is not a minor diagnosis, just the one that wouldn’t kill him immediately.

The “what if” will always haunt me. Lung cancer often causes no symptoms early on. The Mayo Clinic notes that lung cancer and COPD can have some of the same symptoms as they progress, and early detection of lung cancer is crucial. If my husband’s shortness of breath had been something else, the ER’s assumptions could have been deadly.

November 19 is World COPD Day. But this year, something cruelly ironic is unfolding at the same time.

It’s been 10 years now. COPD has reshaped every part of our lives. We used to dream of buying a motorhome and traveling to sprint car races around the country. We don’t go to races anymore because he can’t climb the grandstands, and the dust from the track can trigger an exacerbation. Heat and humidity make breathing significantly harder. Since the COVID-19 pandemic, we live with even more heightened caution. I quarantine away from home if I’ve been exposed to someone sick. He rarely leaves the house.

His world has shrunk to what his lungs will allow. He tinkers around the house, but only for short stretches before he must rest. We run air filters in every room. He loves being outdoors, but pollen, wildfire smoke, humidity and even mowing the lawn can leave him struggling to breathe. The disease progresses slowly, slower because he quit smoking, but progressing nonetheless.

This is the reality for millions of families. COPD is a significant cause of long-term disability, affecting an estimated 392 million people. It is also the fourth leading cause of death worldwide, costing 3.5 million lives each year.

November is COPD Awareness Month and November 19 is World COPD Day—a time when the global public-health community is supposed to focus on improving diagnosis, treatment and compassion.

But this year, something cruelly ironic is unfolding at the same time. Global health leaders are currently in Geneva for the World Health Organization’s Framework Convention on Tobacco Control COP11—a meeting widely known for opposing tobacco harm reduction tools that help millions of people who smoke to move away from combustion. 

Experts from around the world have urged the WHO to correct course, pointing out that almost all of the harm from smoking comes from smoke, not nicotine, and that wider substitution of safer nicotine products would dramatically reduce smoking-related disease.

My husband’s life, like the lives of all people who smoke, is worth more than a lecture. 

But misinformation persists, especially in medicine.

Rutgers University found that a staggering 80 percent of doctors believe nicotine causes cancer, and 81 percent believe it causes COPD. A global survey of 15,000 physicians in 11 countries found the same pattern: 74 percent believe nicotine causes lung cancer and 76 percent believe nicotine causes COPD.

These beliefs are not supported by scientific evidence. They are rooted in decades-old messaging that conflates nicotine with smoking, and they have real consequences. If clinicians think nicotine itself causes COPD, they may avoid recommending effective ways to help people move away from combustion.

For people living with COPD, these misperceptions are dangerous. Switching completely from smoking to vaping has been shown to reduce exacerbations and improve symptoms. Studies have found persistent improvements in quality of life and lung function among patients with COPD who switched.

People with COPD do not deserve lectures. They deserve care. Many have lived with poverty, workplace hazards, air pollution, limited health care access, or genetic vulnerabilities. When smoking is involved, it is part of a complex story, not a moral failure. Stigma drives people away from health care, delays diagnosis, undermines quit attempts, and deepens suffering.

As I look at my husband—alive, still here, still fighting for breath—I think about all the people who never got the chance he had, because stigma stood between them and proper medical attention.

As we mark World COPD Day, we must confront stigma, misinformation and the harms they cause. And the people making global policy decisions must be reminded that people who use nicotine are human beings with the right to respect, accurate information and options that reduce harm.

My husband’s life, like the lives of all people who smoke, is worth more than a lecture. 

The post People With COPD, Like My Husband, Are Being Failed appeared first on Filter.

For some harm reduction advocates, it’s about personal freedom—the simple belief that what people choose to do with their own bodies is no one else’s business. But for most of us, the story runs deeper. 

Millions of people who once smoked have already achieved the public health goal of quitting combustible cigarettes. They’ve done it not by quitting nicotine, but by substituting vapes, pouches or other smoke-free nicotine alternatives. They shouldn’t be required to give up the very thing that helped them first to quit smoking, and then to stay quit.

Tobacco control, however, has moved the goalposts. The mission that once centered on ending the death and disease caused by smoking tobacco has shifted toward eradicating nicotine itself. Nearly every product containing nicotine—even those that contain no tobacco, indeed even those in which the nicotine is synthetic, not tobacco-derived—is now classified by regulators like the United States Food and Drug Administration as a “tobacco product.” 

The message is clear: Quitting smoking isn’t enough, unless you also quit nicotine.

Tobacco control has moved the goalposts. To those who’ve switched, this shift feels like betrayal.

Public discourse primarily focuses on youth initiation of vapes and pouches. The word “epidemic” is tossed around like New Year’s Eve confetti. Little or no concern is shown for the young people who smoke (though their numbers have plummeted since the advent of vaping), nor for the older people in their lives who still smoke in large numbers. The broader picture of a continuum of risk, from lethal cigarettes to much safer smoke-free options, is barely acknowledged.

To those who’ve switched, this shift feels like betrayal. They watch the spread of regulations that make it easier to buy cigarettes than to access safer alternatives, and they can’t make sense of it. If the goal is saving lives, why target what reduces harm? For them, resisting these policies isn’t defiance, it’s survival.

And when the goal keeps moving, compromise becomes impossible. There’s no agreed-upon endgame, no shared destination. Every concession to the tobacco control lobby, such as raising the purchase age, banning specific devices and restricting flavors, has been met with new demands. Those who hoped that one more regulation would calm the panic around vaping now see that each new restriction only strengthens the drive for prohibition.

This loss of trust goes beyond policy; it’s personal. People who use nicotine are outnumbered and outspent by the well-funded campaigns to eliminate the products they rely on. But they don’t give up. They know what switching has meant for their health and their families. They want others who still smoke to have that same chance.

What they face instead is stigma. They’re accused of being “shills for Big Tobacco,” of trying to “hook kids,” of spreading misinformation. The irony, of course, is that much of what they hear said about themselves and about harm reduction products, whether through ignorance or malice, is factually wrong. But stigma is powerful. Once it takes hold, facts rarely matter.

The social cost of that stigma is steep. Many describe losing job opportunities, facing higher insurance premiums, or receiving inferior medical care once providers learn they use nicotine. Online, they are moralized at, and mocked. In 2014, advocate Michael McFadden created The Wall of Hate, a poster composed entirely of real online comments about people who smoke, lines dripping with contempt and ridicule. That hostility has since expanded to anyone who uses nicotine at all.

For those in harm reduction, the most discouraging part is exclusion. People with lived experience rarely have a seat at the table. They’re absent from World Health Organization discussions, from FDA hearings, and even from academic conferences about nicotine policy. Decisions about their health are made without them in the room.

Some of us know that if the products we rely on are banned, we will go back to smoking, and we refuse to accept that risk quietly.

That’s beginning to change. Several conferences that are neutral or supportive of harm reduction have started inviting people with lived experience to speak. On October 28, I’ll join the Food and Drug Law Institute’s Tobacco and Nicotine Products Regulation and Policy Conference in Washington, DC, and participate on a panel dedicated to people who use nicotine. I’ll be honored to represent the millions whose voices are seldom heard.

I plan to talk about why we resist—why flavor bans, tax hikes and access restrictions are punitive, not protective. I’ll show what stigma looks like in real life and why seeing people, not just numbers, matters. My hope is that attendees leave with empathy and perhaps a renewed commitment to the original mission: ending death and disease caused by smoking.

What appears as resistance is, for many, self-preservation. Some of us know that if the products we rely on are banned, we will go back to smoking, and we refuse to accept that risk quietly. When policies make it easier to keep smoking than to stay smoke-free, we have no choice but to fight them.

We’re not fighting against public health; we’re fighting for it. We want sensible regulation, not prohibition. We want truth, not fear. And we want to return to that once-shared goal that everyone in tobacco control, public health and harm reduction can and should agree on: saving lives.

Image via the Change.org petition “Stop the Vape Ban in Mississippi”

The post Resistance to the Anti-Nicotine Movement Sparked by a Betrayal appeared first on Filter.

Moral panic duly set in. The headlines practically wrote themselves: “Vaping-Related ER Visits on the Rise in Kentucky Youth,” and, “Vape crisis grows: Teen ER visits surge.” Several states have reported similar increases. “Vaping ED visits have gone up 109% in Virginia since 2020,” read another headline. 

Is there really a new health crisis facing people who vape?

The numbers are real. However, the story behind them is more complicated, and it deserves a thorough examination before parents, policymakers and public health officials draw conclusions. 

The Kentucky data, for instance, show that the small total number of people admitted annually for “acute nicotine toxicity”—which would primarily be due to accidental ingestion in far greater quantities than normal use of nicotine products entails—actually fell from 2018-2024. The even smaller number for youth did rise, to a total of 16 cases in 2024.

What surged on a far larger scale was “e-cigarette dependence-related emergency department visits.” That’s a much more subjective reason, which could in part reflect parental concerns, or adults’ concerns about their own vaping, based on media outcry.

“The data encompasses … patients who have other illnesses like the flu who disclose that they use tobacco.” 

Meanwhile, a spokesperson for the Virginia Hospital & Healthcare Association acknowledged that the health risks of various products aren’t necessarily represented in his state’s data: “The data encompasses both people visiting the ER with a persistent cough that’s tobacco-related or patients who have other illnesses like the flu who disclose that they use tobacco.” 

In other words, “tobacco” use might have nothing to do with the reason for the person’s hospital visit, but they’re still being recorded in the data. And by “tobacco,” does Walker mean smoking, vaping, or both? The habitual public-health classification of vapes as “tobacco products” muddies the issue.  

Moreover, none of the articles about the increase in ER visits by people who self-reported vaping mention whether or not they currently or formerly smoked. Smoking is a contributing factor in many symptoms and illnesses. 

And then, there’s the question of coding.

Every ED visit results in a health record being generated for the patient. At the center of that record is the International Classification of Diseases, Tenth Revision code (ICD-10), a shorthand that tells insurers, researchers and public health agencies why the patient was there. For decades, tobacco-related codes were straightforward for nicotine or tobacco use and dependence. 

Nicotine vapes created a challenge. Before 2019, there was no specific code for a “vaping-related disorder.” Instead, clinicians used broader codes such as F17.29 (“Nicotine dependence, other tobacco product”) or T65.29 (“Toxic effect of other nicotine and tobacco, accidental”). 

Then came the misnamed E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI) outbreak in 2019. It was eventually traced to illicit tetrahydrocannabinol (THC) cartridges cut with vitamin E acetate—not nicotine vapes. But the scare heightened wariness of vaping among providers. 

In 2022, the Kentucky coding system caught up. The new code gave clinicians a direct way to flag “vaping-related disorder.” Unsurprisingly, case counts increased.

Due to EVALI, the World Health Organization (WHO) added U07.0, “vaping-related disorder,” to the list of ICD codes. The code became valid for immediate use in September 2019. 

The Centers for Disease Control and Prevention (CDC) implemented the new code in April 2020. It should be noted that this code is not specific to the substance vaped—meaning it could encompass nicotine, THC, CBD and more.

In October 2022, the Kentucky coding system caught up. The new U07.0 code (“vaping-related disorder”) gave clinicians a direct way to flag vaping. Unsurprisingly, case counts in Kentucky and other states increased after the CDC implemented the code.

Clinical attitudes have shifted, too. Many health care providers have misperceptions about nicotine, wrongly believing it causes cancer and other illnesses. That could make them hypervigilant in logging nicotine use and mistakenly attributing unrelated illnesses to it.

After the EVALI outbreak—and amid constant media coverage of youth vaping, with alarming headlines filled with misrepresentations about vaping being “designed to kill,” causing “popcorn lung,” cancer and seizures, containing toxic chemicals, and being a “gateway” to smoking tobacco—many providers now specifically ask patients whether they vape. 

Bias plays a role. If a teenager comes to the ER feeling unwell, and the record shows they vape, the clinician may quickly connect the two.

This is good practice; a thorough medical history matters. But it also means vaping is more likely than ever to be noted in the chart, even if it is incidental to the presenting problem. 

Bias plays a role. If a teenager comes to the ER feeling unwell, and the record shows they vape, the clinician may quickly connect the two—a judgment call that will then be embedded in the data. 

Later, when researchers scan for record codes, the case is counted as “vaping-related,” even if the underlying cause was something else. Kentucky’s epidemiologists explicitly state they used an “any mention” approach to capture cases in their report. 

The extent of the use and tracking of the U07.0 code is unclear in media reporting. But if a teen has an athletic injury or a cut needing stitches and also discloses vaping, an “any mention” criterion might capture that case.

For parents, the headlines are terrifying. Who wouldn’t be alarmed by a 10-fold increase in vaping-related ER visits among teens? But if much of that increase is due to coding changes and heightened documentation, then the trend tells us less about youth behavior than it does about our evolving surveillance system. Parents deserve clarity, not conflation. 

For policymakers, the stakes are also high. Emergency department data often drive funding and regulation. Lawmakers who believe vaping-related illnesses are skyrocketing (or that EVALI is still an issue) might well push for harsher restrictions on nicotine products, including those that help people quit combustible cigarettes. That will harm public health by discouraging people who smoke from switching to safer alternatives. 

Policymakers should ask: How much of this increase is due to coding and culture, and how much is an accurate measure of disease burden?

For public health officials, accuracy is paramount. Surveillance systems should exist to guide interventions, not to exaggerate or manufacture crises. If coding artifacts inflate vaping-related visits, resources are likely to be misallocated toward combating this perceived “epidemic” rather than addressing the real and pressing harms of smoking, which still kills nearly half a million people in the United States each year.

Our obligation here is not to dismiss youth use or potential harms, which should be identified and tracked. It’s to interpret the numbers wisely. Policymakers should ask: How much of this increase is due to coding and culture, and how much is an accurate measure of disease burden? They should demand transparent data that distinguishes between “primary diagnosis” and “any mention” cases. They need to know which substance was vaped.

They should also balance concern about youth vaping with the urgent need to reduce adult smoking, the far deadlier problem. Parents, too, should know that while vigilance is warranted, panic is not. Public health is best served by nuance, not alarmism. Otherwise, we risk letting a coding change write the next chapter of our nation’s nicotine policy.

Photograph via Picryl

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