This summer, the Kentucky Injury Prevention and Research Center published a report showing what appears to be a shocking trend: Emergency department (ED or ER) visits linked to vaping have risen sharply.
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
