The first thing I noticed wasn't on the monitor. It was the smell.

I was walking into the room of a teenager in status asthmaticus in our pediatric ICU, and the air carried artificial blue raspberry and cotton candy, the unmistakable residue of a flavored vape. Her chest had gone silent. Every clinician who cares for children knows what that silence means: the wheeze you can hear is air still moving; the wheeze that disappears is the sound of airways closing entirely. We escalated through continuous albuterol, magnesium, and the familiar calculus of whether we were minutes from an ICU save or an intubation. She did well, eventually. The smell stayed with me longer than the case did.

I trained in Ireland and Canada before coming to the U.S., and I thought that breadth had shown me most versions of a public health failure: the opioid crisis in Vancouver, the burden of alcohol-related liver disease in Dublin. But I was not prepared for how completely flavored e-cigarettes have saturated the adolescents I care for in the American Midwest. The overwhelming majority of young people who vape use flavored products, and when I ask my patients about it in a confidential interview, the brand names and flavors come out with the fluency of a menu order. Blue Razz. Watermelon Ice. They do not think of it as smoking. Many do not think of it as anything at all.

That is the first place we fail them clinically: our screening language is a generation out of date. Adolescents who would truthfully answer “no” to “Do you smoke?” will describe daily nicotine use if asked specifically about vaping, pods, or disposables, ideally in a confidential portion of the visit, without a parent in the room. If the question isn't asked in their vocabulary, the answer doesn't make it into the chart, the nicotine dependence goes unaddressed, and the next contact with the healthcare system may be an ED at 2 a.m.

The second failure is upstream of the exam room, and this is where I have come to believe clinicians belong in the fight. In my state of Iowa, legislature recently passed its first excise tax on vape products: 5 cents per milliliter of nicotine, with revenue directed to pediatric cancer research. The research funding is welcome. But legislators on both sides of the aisle acknowledged on the floor that a nickel will deter no one, and several called the bill an industry-friendly substitute for a real deterrent. Meanwhile, the state's more ambitious attempt, a registry law that would have removed most unauthorized flavored products from shelves, is enjoined in federal court on preemption grounds. In the fine print of that ruling, the court affirmed that states retain full authority to regulate tobacco sales directly, including restricting flavored products.

I have started spending some of my nonclinical time on this: tracking the bills, writing for local papers, preparing a one-page legislative summary for my co-residents, and working with the American Lung Association's advocacy program. None of it is complicated, and none of it required training I didn't already have. What it required was noticing that the story I could tell — the smell of cotton candy in a room where a child could not breathe — is precisely the story that legislators do not hear from lobbyists on either side. When a physician describes a specific, preventable ICU admission to a lawmaker, the room changes. We underestimate how much weight the white coat carries in a committee hearing, mostly because so few of us ever bring it there.

I am a resident planning a career in pediatric cardiology, and I sometimes get a raised eyebrow for spending my energy on a “lung” issue. I don't accept the distinction. The lungs and the heart share one circulation and one fate, and the teenager addicted to nicotine today is the cardiovascular patient of tomorrow. Prevention is the only intervention in medicine that works better the earlier you are in training, because you will spend the rest of your career watching it pay off, or watching it fail.

Ask your adolescent patients about vaping in their own vocabulary. Document what you find. And when your state legislature takes up flavored nicotine (most of them will), consider telling them what you've seen. The industry has a business model. Our patients have us.