[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]






 
      EXAMINING JUUL'S ROLE IN THE YOUTH NICOTINE EPIDEMIC: PART I

=======================================================================

                                HEARING

                               before the

              SUBCOMMITTEE ON ECONOMIC AND CONSUMER POLICY

                                 of the

                         COMMITTEE ON OVERSIGHT
                               AND REFORM

                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 24, 2019

                               __________

                           Serial No. 116-51

                               __________

      Printed for the use of the Committee on Oversight and Reform
      
      
      
      
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                  Available on: http://www.govinfo.gov
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                        http://www.docs.house.gov
                        
                        
                             ______

             U.S. GOVERNMENT PUBLISHING OFFICE 
 37-935 PDF          WASHINGTON : 2019                       
                        
                        
                        
                   COMMITTEE ON OVERSIGHT AND REFORM

                 ELIJAH E. CUMMINGS, Maryland, Chairman

Carolyn B. Maloney, New York         Jim Jordan, Ohio, Ranking Minority 
Eleanor Holmes Norton, District of       Member
    Columbia                         Paul A. Gosar, Arizona
Wm. Lacy Clay, Missouri              Virginia Foxx, North Carolina
Stephen F. Lynch, Massachusetts      Thomas Massie, Kentucky
Jim Cooper, Tennessee                Mark Meadows, North Carolina
Gerald E. Connolly, Virginia         Jody B. Hice, Georgia
Raja Krishnamoorthi, Illinois        Glenn Grothman, Wisconsin
Jamie Raskin, Maryland               James Comer, Kentucky
Harley Rouda, California             Michael Cloud, Texas
Katie Hill, California               Bob Gibbs, Ohio
Debbie Wasserman Schultz, Florida    Ralph Norman, South Carolina
John P. Sarbanes, Maryland           Clay Higgins, Louisiana
Peter Welch, Vermont                 Chip Roy, Texas
Jackie Speier, California            Carol D. Miller, West Virginia
Robin L. Kelly, Illinois             Mark E. Green, Tennessee
Mark DeSaulnier, California          Kelly Armstrong, North Dakota
Brenda L. Lawrence, Michigan         W. Gregory Steube, Florida
Stacey E. Plaskett, Virgin Islands   Frank Keller, Pennsylvania
Ro Khanna, California
Jimmy Gomez, California
Alexandria Ocasio-Cortez, New York
Ayanna Pressley, Massachusetts
Rashida Tlaib, Michigan

                     David Rapallo, Staff Director
              Richard Trumka, Subcommittee Staff Director
      William Cunningham, Chief Counsel and Senior Policy Advisor
                     Joshua Zucker, Assistant Clerk

               Christopher Hixon, Minority Staff Director

                      Contact Number: 202-225-5051
                                 ------                                

              Subcommittee on Economic and Consumer Policy

                Raja Krishnamoorthi, Illinois, Chairman
Mark DeSaulnier, California,         Michael Cloud, Texas, Ranking 
Katie Hill, California                   Minority Member
Ro Khanna, California                Glenn Grothman, Wisconsin
Ayanna Pressley, Massachusetts       James Comer, Kentucky
Rashida Tlaib, Michigan              Chip Roy, Texas
Gerald E. Connolly, Virginia         Carol D. Miller, West Virginia


                         C  O  N  T  E  N  T  S

                              ----------                              
                                                                   Page
Hearing held on July 24, 2019....................................     1

                               Witnesses

Panel I

Ms. Meredith Berkman, Co-founder, Parents Against Vaping E-
  cigarettes
    Oral Statement...............................................     4
Ms. Rae O'Leary, Public Health Analyst, Missouri Breaks 
  Industries Research
    Oral Statement...............................................     6
Dr. Jonathan Winickoff, Member, American Academy of Pediatrics
    Oral Statement...............................................     8

Dr. Robert Jackler, Professor, Stanford University
    Oral Statement...............................................     9
Dr. Raymond Niaura, College of Global Public Health, New York 
  University
    Oral Statement...............................................    11

Panel II

The Honorable Richard Durbin, United States Senator from Illinois
    Oral Statement...............................................    30

Written opening statements and the witnesses' written statements 
  are available on the U.S. House of Representatives Repository 
  at: https://docs.house.gov.

                           INDEX OF DOCUMENTS

                              ----------                              

The documents entered into the record are listed below, and are 
  available at: https://docs.house.gov.

  * Statement from Dr. Bonnie Halpern-Felsher; submitted by Rep. 
  Krishnamoorthi.

  * Statement from Dr. Brian Primack; submitted by Rep. 
  Krishnamoorthi.

  * Statement from Kamal Mazhar, President, Teens Against Vaping; 
  submitted by Rep. Krishnamoorthi.

  * Letter from Dr. Frances Leslie; submitted by Rep. 
  Krishnamoorthi.



      EXAMINING JUUL'S ROLE IN THE YOUTH NICOTINE EPIDEMIC: PART I

                              ----------                              


                        Wednesday, July 24, 2019

                  House of Representatives,
                 Committee on Oversight and Reform,
              Subcommittee on Economic and Consumer Policy,
                                                   Washington, D.C.
    The subcommittee met, pursuant to notice, at 9:06 a.m., in 
room 2154, Rayburn Office Building, Hon. Raja Krishnamoorthi 
(chairman of the subcommittee) presiding.
    Present: Representatives Krishnamoorthi, DeSaulnier, 
Pressley, Tlaib, Cloud, Grothman, Comer, and Miller.
    Mr. Krishnamoorthi.[Presiding.] Good morning. This 
subcommittee will come to order. Without objection, the chair 
is authorized to declare a recess of the subcommittee at any 
time. This hearing is entitled ``Examining JUUL's Role in the 
Youth and Nicotine Epidemic: Part I.'' I recognize myself for 
five minutes to give an opening statement.
    After years of steady decline, youth nicotine use has 
suddenly reversed course, seemingly overnight. Between 2017 and 
2018, youth e-cigarette use, also known as vaping, rose 78 
percent in one year to the point where over 20 percent of high 
school students now vape. The lingering question is why? What 
was the role of JUUL, the country's dominant maker of e-
cigarettes with almost 80 percent of e-cigarette market share, 
in the dramatic rise in vaping? The panel assembled today will 
help us address these questions and frame our discussion for 
Part II of this hearing here tomorrow at 2 p.m. when JUUL 
founder, James Monsees, will testify.
    Today we will examine what exactly about JUUL's advertising 
and marketing make it irresistible to kids. Dr. Robert Jackler, 
the preeminent tobacco advertising scholar in the country, will 
help us answer that question. After today we hope to understand 
how JUUL appealed to youth while simultaneously avoiding 
detection by adults. We will hear about JUUL's efforts to 
market directly to kids, including how JUUL entered schools 
under the guise of anti-vaping presentations. Then after all 
school personnel left the assembly room in a lot of these 
schools, unfortunately these JUUL presenters told kids that 
their vaping tools were safe.
    We will hear from the parents of kids who sat through one 
such presentation. Two devoted mothers were so angry that they 
founded a nationwide advocacy group. I suspect that of all the 
schools JUUL entered, it regrets going into that one the most 
because it incited the righteous anger that only comes from 
parents who feel that their kids were being exploited.
    We will also hear that JUUL's targeting of vulnerable 
populations was not limited to kids. Rae O'Leary will describe 
JUUL's attempts to test its market on Native Americans. JUUL 
tried to pay her tribe to give free JUUL starter kits to tribal 
members. JUUL told the tribe that its product is healthy and 
proposed pushing it through the tribe's medical professionals. 
JUUL appeared to think it could get away with this on tribal 
land, and it tried to ensure no one else found out about it.
    The JUUL product itself contains very high nicotine levels, 
three to six times the amount of the e-cigarettes that came 
before it. Its formulation eliminated the harsh taste that 
would have previously accompanied that much nicotine, and 
further masked it with flavors--flavors--which appeal to youth. 
Kids do not grasp this. Sixty-three percent of users aged 15 to 
24 do not know JUUL contains nicotine. They think that it is 
only has flavorings and mistakenly believe that the product is 
not harmful. Dr. Winickoff will help to explain the health 
impact of youth JUUL use.
    Perhaps we can better under what led to parents sending 
JUUL letters, like one from June of last year, stating, ``My 
daughter is highly addicted to the nicotine in JUULing. It is 
very sad and occurred very quickly over the past several 
months. She is 16 and now has addictive behaviors that she 
never had before JUULing, such as stealing money and other 
teens' JUUL's. She also lies and sneaks out at night to get a 
nicotine fix.'' Perhaps we can understand why a therapist wrote 
to JUUL in July of last year disheartened at how many of her 
teen clients came to her about JUUL addiction, talking about 
how ``desperately they need to vape.'' She expressed concern 
about kids using JUUL to ``self-medicate from mental health 
issues, like anxiety and depression.''
    We will also examine what about the JUUL device makes it so 
attractive to teens. It is discreet in a way that no cigarettes 
or prior e-cigarettes were. It puts off a limited cloud of 
aerosol and its smell doesn't linger. It is small. And before 
JUUL was a household name, parents could have looked right past 
it thinking it was a thumb drive. In fact, I have had one in my 
hand during this entire statement.
    JUUL hasn't provided satisfactory answers for these open 
questions. It is my sincere hope that our hearings today and 
tomorrow will help us better understand JUUL's role in this 
terrible epidemic and point us toward solutions to prevent teen 
vaping addiction.
    The chair now recognizes the distinguished ranking member 
from Texas, Mr. Cloud, for five minutes for an opening 
statement.
    Mr. Cloud. Thank you, Chairman, and thank you, witnesses, 
for appearing this morning. For decades now, we have known that 
smoking is dangerous and linked to cancer. Cigarettes result in 
approximately 480,000 preventable deaths in America each year. 
These deaths are only preventable, however, if individuals are 
able to stop smoking.
    For years now, smoking has been on the decline, but we are 
far from eradicating it. It is clear that the methods for 
cessation that existed just a few years ago--quitting cold 
turkey, using nicotine gum or patches--sometimes simply are not 
enough. Recent studies suggest that electronic cigarettes could 
be part of a broader tobacco control strategy and could be 
considered viable components to cessation.
    There is a growing consensus in the scientific community 
that electronic cigarettes are significantly less harmful than 
traditional tobacco products. In fact, a study commissioned by 
the Public Health Service of England found that e-cigarettes 
were 95 percent less harmful than tobacco cigarettes. And for 
this reason, some smokers wanting to quit have turned to e-
cigarettes as a cessation aide. Though the FDA has yet to 
determine that e-cigarettes are effective for this purpose, 
other studies have found the e-cigarette use was associated 
with nearly twice the rate of successful smoking cessation than 
other nicotine replacement therapies.
    We do need to be clear about one thing. No one wants kids 
to use tobacco. No one wants kids vaping, and no one wants 
vaping companies to target children with advertisements. It is 
illegal for anyone under 18 to purchase and to consume these 
products. The Tobacco Control Act of 2009 also applies to e-
cigarettes. Members of Congress draft and pass legislation that 
legislation. That process should always begin with strict 
fidelity to facts and research, and in order to obtain these 
facts and hear the research, the questions I hope to have 
answers to today are: what are, if any, the public health 
benefits to e-cigarettes, can electronic cigarettes be part of 
an overall tobacco control strategy, and, if so, how do so in a 
way that ensures that kids are protected, and many more 
questions that I hope we will hear answers to today.
    As Dr. Scott Gottlieb, I believe, said, ``Two-thirds of 
adult smokers have stated they want to quit. They know it is 
hard, and they probably have tried many times to quit. We must 
recognize the potential for innovation to lead to less harmful 
products.'' If two-thirds of smokers in this country want to 
quit, which is a great thing, Members of Congress could be 
cautious in moving forward with making transitions more 
difficult than it already is. Like anything else, whether it is 
use, access to marijuana, or alcohol, the first line of defense 
is engagement by parents, schools, and local communities to 
educate children about the risk and ensure healthy lifestyles.
    I hope we have a productive discussion today. Thank you 
very much for being here.
    Mr. Krishnamoorthi. Thank you, Mr. Cloud. Now, I would like 
to turn to our witnesses. First of all, thank you all for 
joining us today. We very much appreciate you taking time out 
of your very busy schedules. And thank you to all of you in the 
audience for coming here on an otherwise slow, fake news day.
    [Laughter.]
    Mr. Krishnamoorthi. Today we are joined by Ms. Meredith 
Berkman, who is the co-founder of Parents Against Vaping E-
cigarettes. Also, Ms. Rae O'Leary, a member of the Turtle 
Mountain Band of the Chippewa and a public health analyst and 
researcher with Missouri Breaks Industries Research in South 
Dakota. Dr. Jonathan Winickoff, a member of the American 
Academy of Pediatrics. Dr. Robert Jackler, who is the Sewall 
Professor and departmental chair at Stanford University Medical 
School and a practicing surgeon. And finally, Dr. Raymond 
Niaura of the Department of Social and Behavioral Sciences of 
the College of Global Public Health at New York University.
    Thank you all for coming. If you would all please rise and 
raise your right hand, I will begin by swearing you in.
    Do you swear or affirm that the testimony you are about to 
give is the truth, the whole truth, and nothing but the truth, 
so help you God?
    [A chorus ayes.]
    Mr. Krishnamoorthi. Thank you. Let the record show that the 
witnesses answered in the affirmative. Thank you and please be 
seated.
    Without objection, your written statements will be made 
part of the record. With that, Ms. Berkman, you are now 
recognized for five minutes. And let me just quickly explain 
the lighting system here. So you have five minutes, and there 
is a countdown on the clock. Green means you are in good shape. 
Unlike with stoplights, yellow means speed up and red mean 
stop. So with that, please begin, Ms. Berkman.

  STATEMENT OF MEREDITH BERKMAN, CO-FOUNDER, PARENTS AGAINST 
                      VAPING E-CIGARETTES

    Ms. Berkman. Not stressful at all. Thank you very much. 
Good morning, Chairman Krishnamoorthi and Congressman Cloud--
thank you for your words--and distinguished members of the 
House Oversight Committee on Economics and Consumer Policy. I 
am Meredith Berkman, and I represent Parents Against Vaping E-
cigarettes--we call it PAVe--a grassroots group founded over a 
year ago by three concerned moms. We already have groups of 
activated parents across the country from California to New 
York and places in between. We have people with us here today 
from Texas, from Georgia, from Virginia, New York, New Jersey, 
et cetera.
    My co-founders, Dina Alessi and Dorian Fuhrman, are behind 
me with members of our families. Between us we have nine kids 
between the ages of seven to 19. Along with our friend, Mimi 
Boblich, also here, we created PAVe in response to the JUULing 
epidemic that, as you said, seemed to come out of nowhere, yet 
experts consider one of the most serious adolescent public 
health crises our country has faced for decades.
    Our goal today is to give voice to the 3.6 million teens 
who are vaping, most of them JUULing. This most recent figure 
from the CDC is already outdated. As you said, between 2017 and 
2018, there was a 78 percent rise in the use of these products 
by high school students and a 48 percent rise in use by middle 
school students. Experts believe that the new figures due this 
fall will likely be much higher because nothing has happened to 
have them go down.
    We hear from desperate parents every day who contact us 
seeking resources, information, and help for their JUUL-
dependent, nicotine-addicted kids, but there is not yet any 
FDA-approved treatment for this kind of teen nicotine 
addiction. I will share very briefly just one or two stories 
because they are heartbreaking, and they come from every state 
represented here on the panel and probably every state of 
people in this room.
    From Massachusetts, our PAVe advocate, Kristin Beauparlant, 
speaking about her son, Cade, a hockey player, described how he 
developed a cough and complained he was not able to breathe 
while skating. He became distant, moody, irritable, and had 
extreme bouts of anger, a very common thing that people report. 
``Our home environment was toxic, and it turns that Cade has 
restrictive lung disease. He needs inhalers and oral steroids. 
He had smoking a pod a day, the equivalent of more than a pack 
of cigarettes a day, for years, for three years.''
    Kelly Kinard from North Carolina is with her son, Luca, 
whose addiction was so severe, he spent 39 days as an inpatient 
at rehab in California. Kelly said, ``We began living with a 
stranger. Our straight A student's grades dropped to F. It was 
the extreme anger. It turned out our 14-year-old had a 
substance abuse problem, and that substance was JUUL.''
    Now I want to share a personal story, the story of how JUUL 
went after our kids and their friends by coming into their 
school. Without the knowledge of the school or of us concerned 
parents, JUUL sent a representative to talk to our kids about 
its product under the guide of education. On April 3, 2017, my 
then 15-year-old son, Caleb, who is here, told us there had 
been an anti-addiction talk at school for the 9th grade. The 
teachers left the room, and the man named Ali gave a confusing 
talk about JUUL, telling them it was not for kids, but for 
adults. It was much safer than cigarettes. The FDA would 
approve it any day.
    When Ali was done, Caleb and his friend, Phillip, Dorian's 
son, went up to talk to him. Ali repeated that JUUL was for 
adults, not kids, then he took out this sleek-looking JUUL, 
showed the boys how it worked, and called it the iPhone of 
vapes. That's when we moms decided to fight back. We had 
discovered a few months before that our kids were JUULing at 
home right under our noses, which is also very common. It 
doesn't mean you're a bad parent if your kids are JUULing. It 
is stealth by design.
    We knew that nicotine was harmful to our kids' brains, and 
as we researched and put pieces together, we learned that 
JUUL's deceptive behavior seemed to be part of its marketing 
strategy. In California, a retired school superintendent was 
offering schools in his state and in Massachusetts money if 
they would implement the anti-JUUL curriculum that a man named 
Bruce Harder was offering on JUUL's behalf. We came across the 
Stanford Medical School's Tobacco Prevention Tool Kit with an 
odd disclaimer, that we immediately realized was reference to 
JUUL taking information it shouldn't have.
    None of this is surprising. As I said, JUUL is stealth by 
design. JUUL says it no longer restocks retail orders of the 
flavors that research has proven are hooking the kids. Yet just 
the other day in a 1-block radius in two different stores, I 
was able to buy these mango pods that JUUL says are no longer 
on the market, but they are still online.
    And that is the problem. If JUUL really wants to slow the 
youth vaping epidemic and keep younger kids from starting, they 
will immediately remove all flavors from the market, including 
menthol and mint, one of the most popular kid flavors, and they 
will stop spending millions of dollars on lobbyists to oppose 
sensible legislation that PAVe's parents and our many coalition 
partners are fighting for all over this country to restrict 
youth access to JUUL and other products.
    We hope today's hearing motivates Members of Congress on 
both sides--we all care about kids--to hold JUUL accountable 
not only for the epidemic, but for its predatory practices and 
for causing harm to so many kids in this country. It is not a 
political issue, but a moral one. If we don't take action now, 
we face an entire generation of kids addicted to nicotine, who 
are human guinea pigs for the JUUL experiment overall. Thank 
you.
    Mr. Krishnamoorthi. Thank you. Thank you, Ms. Berkman. Now 
Ms. O'Leary, you are on the clock.

                    STATEMENT OF RAE O'LEARY

    Ms. O'Leary. Good morning, committee members, and thank you 
for the opportunity to explain JUUL's marketing to minority 
populations is relevant to this hearing. My name is Rae 
O'Leary, and I'm serving as a fact witness representing the 
Cheyenne River Sioux Tribe, which I will refer to CRST.
    I am the founder of the Canli Tobacco Coalition, which is a 
grassroots anti-tobacco coalition on the reservation. The Canli 
Coalition opposes the use of all commercial tobacco products 
because of the tobacco industry's historical targeting of 
American Indians which has contributed to the health 
disparities and death on the Cheyenne River Reservation.
    In January and February 2019, three representatives from 
JUUL used the historic tactic of the tobacco industry by 
handing out free product to tribal decisionmakers and offering 
a switching program to the CRST Health Committee. JUUL proposed 
that healthcare professionals from the CRST Health Department 
refer smokers that are 21 years or older to their switching 
program. Using their referral, American Indian patients would 
enroll in JUUL's online portal by entering personal data and 
health behaviors.
    JUUL proposed to sell starter kits valued at $50 to the 
tribe for $5 apiece. The tribe would then turn around and 
provide free JUUL starter kits to patients who enroll in the 
switching program. Throughout JUUL's presentation, they made 
multiple claims that their product is effective for smoking 
cessation and less harmful than tobacco products. These claims 
as well as JUUL's actions to hand out free product are all 
clear violations of the Family Smoking Prevention and Tobacco 
Control Act.
    JUUL indicated that their investment in the tribe switching 
program was worth over $600,000 to the tribe. Initially, some 
tribal council members were convinced that JUUL's switching 
program could help members of the Cheyenne River Sioux Tribe 
quit smoking, improving their quality of life for smokers, and 
eventually resulting in fewer healthcare costs to the tribe. 
Despite initial interest in JUUL's switching program, the CRST 
Health Committee members wisely requested written documentation 
of JUUL's switching program proposal.
    JUUL did not provide written documentation detailing the 
program as requested. Instead, they sent a mutual nondisclosure 
agreement to the tribe's attorney general with untrue 
information that the nondisclosure agreement had already been 
discuss by the CRST Health Committee. The nondisclosure 
agreement was not signed. As a result, JUUL has not returned to 
the Cheyenne River Sioux Tribe.
    Earlier this month, the CRST Health Committee unanimously 
approved a resolution that declares ``CRST shall neither 
solicit nor accept any tobacco, electronic smoking device, or 
nicotine-related funding or sponsorship.'' This resolution is 
currently being considered by the CRST Tribal Council as well 
as several other sovereign tribal nations and the National 
Indian Health Board.
    The Canli Coalition emphatically opposes the offer JUUL 
made to the CRST Health Committee for many reasons, including 
grave safety concerns regarding exploding e-cigarette batteries 
and nicotine poisoning of children, and unknown, but probable, 
long-term health risks, such as cardiovascular disease and 
cancer. Even though the switching program is intended for adult 
smokers, the Canli Coalition has great concern that our 
American Indian youth will begin using JUUL due to increased 
access and a highly concealed and flavorable product. This 
concern is supported by the data that American Indian middle 
school students in South Dakota are using e-cigarettes three 
times more than their white counterparts.
    Another concern is that JUUL has not been proven to be safe 
or effective for smoking cessation. In fact, there is a growing 
body of evidence that e-cigarette users smoke more and quit 
less. It is true that some smokers have successfully quit 
smoking using e-cigarettes like JUUL, but it has also been 
found that for every 1 adult smoker who quits using an e-
cigarette, 81 adolescents will initiate e-cigarette use. 
Clearly JUUL and other e-cigarettes are being used for more 
than an alternative to smokers.
    The CRST may have looked like an easy target for JUUL 
because of the FDA's inability to enforce tobacco regulations 
or publish reports of our 51 percent adult smoking prevalence, 
coupled with our genetic propensity to addiction, or maybe they 
were drawn to the CRST because of our young population base or 
a recent status as the poorest county in the Nation. JUUL did 
not provide an acceptable justification for their choice to 
offer the switching program to sovereign tribal nations. I 
would challenge the members of the subcommittee to uncover why 
JUUL is interested in partnering with tribes and exactly how 
this partnership will improve lives of CRST members as JUUL 
claims it will.
    As an American Indian woman educated in public health and 
knowledgeable about the tobacco disparities that exist among 
indigenous populations, I am putting my words on the record 
that the scenario of the tobacco industry targeting American 
Indians and exploiting tribal sovereignty has played out for 
far too long. I put a great deal of thought into my decision to 
testify at this hearing today. In the end, it was the Lakota 
Seventh Generation Belief that helped me reach my decision to 
testify. What happened on CRST and other tribes is simply too 
important not to be shared. It is time to take action to 
prevent JUUL and all tobacco companies from preying on at-risk 
populations.
    As you consider possible actions and policy following this 
hearing, I challenge you to learn from the Lakota people's 
Seventh Generation Belief that in every decision, leaders must 
consider how it will affect our descendants seven generations 
into the future. Thank you.
    Mr. Krishnamoorthi. Thank you, Ms. O'Leary. Dr. Winickoff, 
you have five minutes.

 STATEMENT OF JONATHAN WINICKOFF, M.D., M.P.H., M.D., M.P.H., 
             MEMBER, AMERICAN ACADEMY OF PEDIATRICS

    Dr. Winickoff. Good morning, Chairman Krishnamoorthi, 
Ranking Member Cloud, members of the subcommittee. My name is 
Dr. Jonathan Winickoff. I'm a practicing pediatrician at 
Massachusetts General Hospital, and I have over 20 years of 
experience caring for children and adolescents. I'm here today 
representing the American Academy of Pediatrics, a professional 
medical organization representing over 67,000 pediatricians 
across the United s.
    JUUL use among adolescents has reached epidemic 
proportions, and I see the impact of this every day in my own 
practice. Every one of my teenage patients, and even many of my 
pre-teen patients, either uses e-cigarettes or has friends who 
use them. Many of my patients have wildly incorrect beliefs 
about e-cigarettes. They know that cigarettes are dangerous, 
but believe that JUUL is harmless.
    I have to explain that e-cigarettes do not have the same 
positive health benefits as the fruit flavors that they copy. 
Rather e-cigarette liquid contains, in addition to nicotine, a 
number of toxins and carcinogens. E-cigarettes are also not 
good for growing lungs. They're particularly bad for children 
with asthma. They can cause serious lung conditions, including 
hypersensitivity pneumonitis.
    The FDA has publicly warned now about increasing reports of 
seizures in children who use e-cigarettes. My patients are 
often not aware of JUUL's massive nicotine content and that one 
JUUL pod contains as much nicotine as 20 cigarettes. They also 
don't understand that nicotine dependence impacts areas of the 
brain that control executive function, memory, and mood. 
Nicotine addiction can take hold in only a few days, especially 
in the developing adolescent brain that is particularly 
vulnerable to addiction.
    E-cigarette addiction concerns us because use of e-
cigarettes can lead to combustible tobacco use. Compared to 
adolescents who do not use e-cigarettes, those who use e-
cigarettes are 3.5 times more likely to begin smoking 
traditional cigarettes. Many of my patients use JUUL daily and 
find it impossible to stop. Nicotine withdrawal can cause 
headaches, insomnia, irritability, anxiety, and depression, yet 
doctors lack effective tools to help adolescents stop using 
JUUL. The only surefire way to eliminate e-cigarette use in 
adolescents is to stop it before it starts. Luckily, we already 
know what needs to be done. We need to make e-cigarettes less 
appealing to children, we need to make them harder for children 
to access, and we need to make them regulated appropriately by 
the FDA.
    First and foremost, we must discuss JUUL's flavors. JUUL 
pods come in a number of sweet flavors, including mint, mango, 
and creme. Youth surveys show that e-cigarette flavors are one 
of the primary reasons teens try e-cigarettes, yet flavors also 
help mask the harsh taste of nicotine, making repeated use more 
likely an increasing addiction. JUUL has chosen to keep mint 
and menthol flavored pods available for sale everywhere. It is 
completely false to suggest that mint is not attractive to 
children. From candy canes to toothpaste, children are 
introduced to mint from a young age. In tobacco products, 
menthol's anesthetic properties cool the throat and make it 
easier for children to inhale the poison.
    When JUUL removed some of its other flavors from stores, I 
saw the majority of my JUUL-using patients switch to mint. 
Nevertheless, children are still gaining access to other 
flavored JUUL pods, even though they are now sold online. If 
the products are available for sale somewhere, children will 
get their hands on them. We must eliminate child-friendly 
flavors from all tobacco products. We urge Congress to pass 
legislation immediately to prohibit flavors, including mint and 
menthol, from tobacco products.
    Mr. Chairman, members of the subcommittee, JUUL is a 
fatally flawed product. A recent study showed that 15-to 17-
year-olds are 16 times more likely to report JUUL use than 25-
to 34-year-olds, even though JUUL claims its product are only 
intended for adults. When so much of the product ends up in the 
hands of children, it is time we declare it a failed product.
    The American Academy of Pediatrics believe that JUUL is a 
public health threat that must be removed from the market as 
soon as possible. JUUL and products like it are eroding the 
progress we've made in reducing teen tobacco use. Teenagers 
today are using e-cigarettes when many of them would otherwise 
never have used a tobacco product. JUUL must be held to account 
for the epidemic it has created, and Congress and the 
Administration take action to end it. Thank you.
    Mr. Krishnamoorthi. Thank you, Dr. Winickoff. Dr. Jackler, 
you have five minutes.

    STATEMENT OF ROBERT JACKLER, M.D., PROFESSOR, STANFORD 
                           UNIVERSITY

    Dr. Jackler. Chairman Krishnamoorthi and Ranking Member 
Cloud, thank you for the opportunity to testify before your 
subcommittee today.
    Almost all smoking begins during adolescence. It is part of 
teen rebellion, typically commencing between the ages of 12 and 
19. It would indeed be a very rare 40-year-old who woke up and 
said, hey, I think I'll start smoking today. Once a teen 
becomes hooked on nicotine, it is exceedingly difficult to 
quit. Many are stuck with a lifelong addiction. From the 
beginning, JUUL professed a noble mission of improving the 
lives of a billion smokers. Instead they have spurred an 
epidemic of nicotine addiction amongst youth. So how did JUUL 
stray so far from its stated mission?
    As a majority of smokers in America are ages 30 to 60, JUUL 
should have designed their advertising to connect to a middle-
age audience. Over the first year--could we have the slides, 
please, Garrett? Okay. Over the first year after JUUL launched 
in June 2015, it held at least a series of 50 highly stylized 
parties with youth-oriented entertainment in cities across 
America. Thousands of young people were given free JUULs, often 
by attractive young girls. JUUL's initial campaign called, 
Vaporized, was designed by an advertising agency whose goal was 
to create a cult-like following, and they succeeded beyond 
their wildest dreams. Vaporized featured models in their 20's 
in trendy-appearing poses and exhibiting behaviors more typical 
of underage teens than mature adults. The tobacco advertisers 
have long known that these imageries are exactly how to target 
underage kids.
    Just last week in a televised documentary on CNBC, JUUL co-
founder, Adam Bowen, claimed that the 2015 Vaporized campaign 
only lasted less than six months, it was lifestyle oriented, 
and ``had no impact upon sales.'' Lifestyle oriented? It was 
obviously, if we could see the images, it is obviously youth 
oriented in that way.
    Now, contradicting Mr. Bowen, JUUL's co-founder, James 
Monsees, a mere seven months after JUUL launched, bragged, 
``Now we're actually the fastest-growing e-cigarette company in 
the world.'' So today they say their early advertising, which 
was patently youth oriented, made no difference. But, in fact, 
at the time, they were bragging they were the most rapid 
growing in the world. This is either revisionist history or 
intentional deception. I'll let you be the judge.
    From its inception, JUUL mostly advertised on social media, 
especially Instagram, which skews heavily toward youth. JUUL 
paid influencers, who are social media stars with a large 
number of online followers, to praise JUUL. JUUL multiplied its 
reach by the use of hashtags, which became online gathering 
places for teenagers. Under intense regulatory pressure, JUUL 
halted its own social media postings in November 2018. However, 
this was a hollow gesture. It didn't matter much, and the 
reason was that viral peer-to-peer promotion amongst teens 
assured a massive visibility of their products on an ongoing 
basis.
    For example, after JUUL quit its own postings last 
November, community posts and #JUUL by kids surged, tripled. 
Now there are 540,000 posts and millions of views of that 
youthful material. JUUL leadership claims, ``We were completely 
surprised by the youth usage of the product.'' Co-founder James 
Monsees brags, ``We are the most educated company, the most 
diligent, the most well-researched.'' They are indeed a data-
driven company. They know their market, to whom their products 
are distributed, and the identity of their customers. The New 
York Times interviewed a former JUUL manager who disclosed that 
JUUL knew that their products were becoming popular amongst 
underage users within the first months on the market.
    So JUUL professes to be a technology which disrupts big 
tobacco. Like many tech startups, as the money starts rolling 
in, JUUL made many compromises to their grand vision. What 
should have become an offramp for adult smokers instead has 
become a heavily traveled onramp to nicotine addiction amongst 
teens, many of whom graduate to traditional combustible 
cigarettes. From a policy point of view, the best way to 
eliminate adult smoking is to keep teens from starting in the 
first place. So JUUL's recent partnership with Altria combines 
the leading youth initiation cigarette, Marlboro, with a 
leading youth initiation e-cigarette, JUUL. Their agreement 
specifies joint JUUL/Marlboro marketing is of great concern. So 
JUUL has been unmasked for its hypocrisy.
    Rather than obsoleting big tobacco, JUUL is very much part 
of it. It is as though they lit the kindling, stood by making 
no effort to contain the resulting fire, even stoked it, and 
when the fire department came, expressed shock and dismay about 
the resulting major conflagration, while loudly protesting that 
their actions had absolutely nothing to do with it. Thank you.
    Mr. Krishnamoorthi. Thank you, Dr. Jackler. Dr. Niaura, you 
are on the clock.

   STATEMENT OF RAYMOND NIAURA, PH.D., PROFESSOR, COLLEGE OF 
           GLOBAL PUBLIC HEALTH, NEW YORK UNIVERSITY

    Mr. Niaura. Thank you. Mr. Chairman and members of the 
committee. Thank you for holding this important hearing on a 
topic of great concern to the Nation's public health. I'm 
privileged to appear before you this morning to testify about 
the challenges we face regarding youth use of e-cigarettes and 
other tobacco products.
    My name is Dr. Ray Niaura. I'm a clinical psychologist, 
professor of social and behavioral sciences and epidemiology at 
the College of Global Public Health at New York University, and 
I have spent my entire professional career engaged in research 
on understanding and treating tobacco dependence and finding 
and testing ways to help smokers quit smoking.
    As a public health and tobacco use scientist, I, too, share 
concerns about youth tobacco use, including vaping. For the 
record, I believe no youth should be using any tobacco or 
nicotine-containing product or any drug for that matter. We 
should do all we can to discourage youth use by providing 
appropriate education and counseling, and by making it 
difficult to purchase such products. I also believe that 
companies that manufacture and sell vaping products should do 
all they can to make sure that products are marketed only to 
adult smokers. I take some comfort in the fact that marketing 
strategies and health claims will eventually be subject to the 
U.S. Food and Drug Administration review and approval.
    During the fall of 2018, the FDA and the U.S. Centers for 
Disease Control and Prevention expressed acute concern about 
youth vaping when they looked at data from national surveys, 
and this prompted Dr. Scott Gottlieb, who was the FDA 
commissioner at the time, to declare that youth vaping is an 
epidemic. This concern was reinforced by data coming from the 
National Youth Tobacco Survey in 2018.
    When the data were eventually released to the public, we 
looked at it ourselves, and we indeed confirmed that past 30-
day vaping had increased from the prior year. And while an 
increase in uses are of concern, our analysis showed that most 
adolescent vaping was occasional, and that most regular use was 
concentrated in adolescents who had already been smokers. I 
think this is an important point. Yes, we need to be concerned 
about vaping, but we also need to be concerned about use of 
other tobacco products. We also looked at youth who had never 
used tobacco products, and thankfully vaping rates were quite 
low. Again, this is not to minimize the importance of concern 
about youth vaping.
    Cigarette smoking remains a major concern here in the 
United s of America, and I would like to also emphasize another 
point, which is that e-cigarettes have the potential to help 
adult smokers stop smoking, and we've seen evidence 
accumulating showing that adult smokers who use e-cigarettes 
can quit smoking. Regular cigarette studies have come out, for 
example, in the New England Journal of Medicine, indicating the 
same. Just last week, a survey reported that smokers who 
switched to e-cigarettes and used them every day were 
significantly more likely to quit smoking compared to those who 
did not use e-cigarettes.
    These results are important because we know that despite 
their effectiveness, smokers don't often use quitting methods, 
such as nicotine replacement therapy or other medications. So 
as they stand now, e-cigarettes are a consumer product that is 
proving to be very popular with smokers, and helping them to 
actually quit smoking cigarettes. Quitting smoking is the 
number one health priority for cigarette smokers, and we need 
to use all the tools available to help reduce this burden, 
which prematurely claims the lives of over half a million 
Americans every year. So currently about 38 million adults in 
the U.S. smoke cigarettes, and clearly this is and ought to be 
a huge public health priority.
    I would like to close by saying I think that this set of 
issues, both youth tobacco and nicotine use and adult smoking 
have been portrayed as at odds with one another, and they 
really should not be. We in the public health community and 
Congress ought to find ways where we can do both. I think we're 
smart enough to figure out how, but I don't think we have all 
the answers yet. Thank you very much.
    Mr. Krishnamoorthi. Thank you, Dr. Niaura. I now recognize 
myself for five minutes of questioning.
    First of all, Mrs. Berkman and Mrs. Fuhrman, after you 
discovered that a presenter representing JUUL gave a closed 
assembly at your children's school, you researched the issue 
and formed an advocacy group to inform parents around the 
country about the dangers of adolescent e-cigarette use. Thank 
you for your continued advocacy. As a parent of three young 
children myself, including a teenager, I was shocked to hear 
JUUL had access to children without the presence of teachers or 
administrators, and without parental permission. JUUL continues 
to partner with youth organizations across the country, so it 
is important to understand what outreach looks like on their 
part.
    Mrs. Berkman and Mrs. Fuhrman, I would like to ask a couple 
questions of your sons, if that is okay.
    Ms. Berkman. Yes.
    Mr. Krishnamoorthi. Phillip and Caleb, can you please come 
to the table for a couple minutes? I would like to first 
address Caleb. Caleb, what grades were you and Phillip in the 
year of the JUUL presentation?
    Mr. Berkman. Ninth grade.
    Mr. Krishnamoorthi. Can you just speak directly into the 
microphone?
    Mr. Berkman. Ninth grade.
    Mr. Krishnamoorthi. Thank you. What were students told 
about the presentation before it began?
    Mr. Berkman. We were told that we were having a mental 
health/addiction seminar that we have three times a year, and 
the teachers are told the room so it is a safe space for kids 
to talk.
    Mr. Krishnamoorthi. Did most of your classmates believe 
JUUL was safe prior to the presentation?
    Mr. Berkman. I think many kids were already JUULing and had 
their doubts to if it was safe, but I think a lot of kids still 
thought it was possibly dangerous.
    Mr. Krishnamoorthi. Did the presenter ever mention his 
connection to JUUL, and were your teachers in the room when he 
spoke?
    Mr. Berkman. He did mention his connection to JUUL, and my 
teachers were not in the room when he spoke.
    Mr. Krishnamoorthi. Did the presenter ever say that JUUL 
was safe?
    Mr. Berkman. Yes.
    Mr. Krishnamoorthi. Did the presenter call JUUL ``totally 
safe'' more than once?
    Mr. Berkman. Yes.
    Mr. Krishnamoorthi. What impact did those ``totally safe'' 
comments have on your classmates, some of whom may have already 
started vaping?
    Mr. Berkman. For my classmates who were already vaping, it 
was a sigh of relief because now they were able to vape without 
any concern.
    Mr. Krishnamoorthi. Were there kids who had never been 
JUULing that were more likely to try after hearing it was 
``totally safe?''
    Mr. Berkman. I can't say for sure, but I believe that after 
this meeting, kids were more inclined to vape because now they 
thought it was just a flavor device that didn't have any 
harmful substances in it.
    Mr. Krishnamoorthi. You and Phillip approached the 
presenter when the assembly concluded. What motivated you to 
even approach him in the first place?
    Mr. Berkman. I believed the presenter was sending mixed 
messages by saying JUUL is totally safe and following up every 
``totally safe'' statement with ``but we don't want you as 
customers.'' I saw a mixed message being sent, and I believed 
that the presenter was playing on the rebellious side of teens 
where when teens are told not to do something, they are more 
likely to do it.
    Mr. Krishnamoorthi. Phillip, let me ask you a couple of 
questions. What was your experience speaking to the presenter?
    Mr. Fuhrman. So we went up and talked to him, and Caleb 
asked a question about what can you do if your friend is 
addicted to nicotine.
    Mr. Krishnamoorthi. Phillip, were you addicted to JUUL at 
the time of this presentation.
    Mr. Fuhrman. I was.
    Mr. Krishnamoorthi. And when Caleb asked the presenter what 
he should do if he had a friend that was addicted to nicotine, 
was Caleb referring to you?
    Mr. Fuhrman. He was.
    Mr. Krishnamoorthi. How did the presenter answer Caleb's 
question of how he could help his nicotine-addicted friend, 
namely you?
    Mr. Fuhrman. Since Caleb was not specific on what kind of 
nicotine he was addicted to, whether it was an e-cigarette or 
cigarettes, the speaker thought that he was talking about 
cigarettes. And he said that he should mention JUUL to his 
friend because that is a safer alternative than smoking 
cigarettes, and it would be better for the kid to use.
    Mr. Krishnamoorthi. So let me get this straight. He wanted 
you to switch from a combustible cigarette to JUUL.
    Mr. Fuhrman. Yes.
    Mr. Krishnamoorthi. Did the presenter demonstrate the 
product to you?
    Mr. Fuhrman. He didn't use it, but he did take it out and 
show it to us.
    Mr. Krishnamoorthi. Okay. This is very disturbing behavior 
to say the least. A person connected to JUUL pulled out a JUUL 
device to demonstrate its safety to teenagers, and then lied 
about the product being ``totally safe.'' Did he say anything 
else about whether the government had approved JUUL?
    Mr. Fuhrman. He mentioned that the FDA was about to come 
out and say that JUUL was 99 percent safer than cigarettes, and 
he said that that would happen very soon, and that it was in 
FDA approval while the talk was going on.
    Mr. Krishnamoorthi. Thank you, Caleb and Phillip. Let me 
ask Dorian, Phillip's mother, to say a couple words here. 
Dorian, thank you for coming today.
    Ms. Fuhrman. Hi. Thank you.
    Mr. Krishnamoorthi. Your son, Phillip, just stated he was 
addicted to JUUL.
    Ms. Fuhrman. Yes.
    Mr. Krishnamoorthi. How did his addiction impact your 
family?
    Ms. Fuhrman. It was difficult, and at first we didn't 
understand what was going on. As a young 14-year-old, he was 
interested in so many different things from surfing to cooking 
to his little sister. And I started to find these flash drives 
and these green plastic caps in his pockets, and I didn't 
really know what it was at first. So he kept saying, you know, 
they belonged to a friend, and we would have fights about it.
    I figured out what it was because I Googled the name on the 
side, and it was difficult. He changed kind of overnight. He 
started spending a lot of time in his room in the dark. He 
became moody. We had a very contentious relationship. I became 
very suspicious obviously. I think he didn't really understand 
what was going on himself, and neither did we.
    Mr. Krishnamoorthi. Thank you, Dorian.
    Ms. Fuhrman. Thank you.
    Mr. Krishnamoorthi. Let me now recognize Ranking Member 
Cloud for five minutes of questioning.
    Mr. Cloud. Thank you, Chairman. Ms. Berkman, I am curious 
at the reaction. I assume you approached the school board, the 
principal? Was the reaction?
    Ms. Berkman. The school had no idea that the outside group 
had brought a JUUL representative into the school. The school 
had no idea.
    Mr. Cloud. So the school had hired a group that had----
    Ms. Berkman. Yes, and we believe that the outside group was 
naive definitely, but in good faith, because when I called to 
ask about this presentation, the staffer who answered the phone 
said, oh, you found the right person. I was researching anti-
JUUL education online, and I came across the name of a woman 
named Julie Henderson, who was listed then, no longer, on the 
JUUL website as its youth prevention coordinator. Then she 
called, and this woman, Ms. Henderson, said I have the perfect 
person and sent Ali.
    Mr. Cloud. Okay. Thank you. Dr. Niaura. Did I pronounce 
that right?
    Mr. Niaura. Yes.
    Mr. Cloud. Okay. Could you explain the difference from a 
health perspective, I guess, between a traditional cigarette 
and an e-cigarette? Is there one?
    Mr. Niaura. Yes, there are many differences. You know, 
traditional cigarettes consist of a preparation of tobacco 
leaves, which when burned create, you know, smoke and contains 
roughly 7,000 different chemicals, most of which are not good 
for the human body. E-cigarettes contain far fewer ingredients 
in addition to nicotine, usually something like propylene 
glycol glycerol which are, you know, commonly found 
ingredients, for example, in food stuffs, and some flavorings.
    This, in general, just the difference in terms of the 
number of compounds in e-cigarettes make the e-cigarettes in 
general safer, although they probably can vary from product to 
product. A lot of the safety of e-cigarettes depends on 
temperature controls, so, for examples, if products have 
adequate temperature control, they tend to be, you know, less 
toxic.
    Mr. Cloud. Okay. I guess we have known cigarettes for a 
while cause cancer, and talking about prevention, I remember in 
3d grade seeing lungs sitting in a jar of somebody who had 
passed away from cigarette use. But I guess what I am trying to 
do get down to is what are the health effects of the 
combustible side of it and what is the health effects of the 
nicotine side?
    Mr. Niaura. Well, yes, and that is actually an important, 
you know, point to raise. So if we look at nicotine in and of 
itself, it is not risk free, but it is probably a lot less 
toxic compared to the other chemicals that come out of 
cigarette smoke. So, for example, nicotine probably does not 
cause cancer. It may have some small effects on existing 
cardiovascular disease and so forth. You know, the brain might 
have to adapt to, you know, having a drug on board. These are 
neural adaptations which are true for any drug. But the 
nicotine itself is not the culprit when it comes to things 
like, you know, cancers, at least as far as we know.
    Mr. Cloud. We seem to have a kind of a competing set of 
facts here. We have data that shows that teen e-cigarette use 
has gone up a lot, and then Dr. Niaura, you mentioned that a 
lot of that is, I guess, transitional or is it not? Is it new 
use? I guess, Dr. Jackler and Dr. Niaura, if you can kind of 
clarify that a little bit for us to have a better understanding 
of what is new use, what is transitional use.
    Mr. Niaura. Yes, that is an important question that I don't 
think we have a good handle on yet because a lot of the surveys 
that we look at are what are called cross-sectional, meaning it 
is a dipstick or a slice in time. You know, we see kids that 
report to us, oh, they are using one or two days or, you know, 
every day and so forth. What we need are studies that track 
kids over time to actually see whether the ones who are 
starting out, you know, one or two days go on to use more.
    But, you know, once again, we don't know what the real 
implications are of these different patterns of use, and, you 
know, I would want to emphasize and share the concern that, you 
know, kids shouldn't be trying these products, and they 
shouldn't be using them. Certainly shouldn't be using them on a 
frequent basis.
    Dr. Jackler. The CDC data show a huge use, over 2 million 
American high school students and many hundreds of thousands of 
middle school students. A fraction of them, of course, 
experiment and others become regular users. I just want to 
touch as a physician on the healthfulness of vaping. You know, 
if you start smoking today, it is 20, 30, 40 years before you 
get emphysema or lung cancer. Nobody knows what it does to the 
human lung to breathe in and out aerosolized propylene glycol 
and glycerin over and over. It is an experiment frankly. We 
will find out years from now the results.
    The flavoring industry knows that the compounds that we put 
into our food that are safe in your intestinal tract, when you 
breathe them in, so, for example, the classic example is 
buttered popcorn, microwave butter popcorn. The diacetyl 
compounds in the industrial setting cause severe restrictive 
lung disease on the part of the industrial workers. The e-
cigarette industry has taken flavored chemicals, thousands of 
different ones--cotton candy and cookie flavors--mixed them 
with propylene glycol, and then they are exposed over and over 
into the lungs. We just don't know yet the long-term results.
    There is no doubt in my mind that vaping is safer than 
conventional smoking, but that doesn't mean that it is safe.
    Mr. Cloud. Thank you.
    Mr. Krishnamoorthi. Thank you, Mr. Cloud. I now recognize 
Congresswoman Tlaib for five minutes of questioning. 
Congresswoman?
    Ms. Tlaib. Thank you so much, Mr. Chairman. I want to thank 
all of the witnesses for being here. And, Ms. Berkman, as a 
mother, I can sense your frustration. I just want you to know 
being here just a short seven months and kind of hearing, you 
know, some people call it rhetoric to kind of discredit a lot 
of the things that we are pushing forward. I just want you to 
know you have the truth on your side. And just be stronger for 
that because we don't need more studies. We already know the 
truth here.
    In the few years after JUUL was founded in 2015, it 
dominated the market through a targeted advertising campaign 
that seems to be a winning strategy as JUUL now accounts for 76 
percent of the U.S. e-cigarette market, which is simply 
staggering. What I find troubling is that in the same 
timeframe, the rate of teen nicotine addictions skyrocketed. 
The CDC found a 75 percent increase in e-cigarette use among 
high school students from 2017 to 2018. So it is no coincidence 
to me that teens who use e-cigarettes almost exclusively refer 
to the activity as JUULing.
    So, Professor Jackler, you have studied JUUL's marketing 
practices since the company started in 2015. Based on your 
expertise, should JUUL have been aware its marketing campaign 
would appeal to youth and teens?
    Dr. Jackler. Absolutely. You know, huge teenage fads don't 
happen by accident, you know. The Beatles and beanie babies 
were products of very clever promotional activities, and so is 
JUUL. Now, JUUL engaged ad agencies, which are professionals, 
and ad agencies understand very well the difference between 
marketing to baby boomers, like newspapers, radio, broadcast 
TV, and Gen Z-ers, who will sit all day long on their phones 
looking at social media.
    Now ad agencies follow the instructions of their clients. 
They don't work independently. Certainly the company knew very 
well when it chose to use Instagram who the heaviest users of 
Instagram were. It is the underage youth by and large, and the 
``Insider Report'' from the New York Times validates it. So I 
think there is any question that JUUL knew that its actions 
were perpetuating the youth epidemic that happened within JUUL.
    Ms. Tlaib. You are a professor at Stanford, the same 
university that the founders of JUUL attended as students. Have 
you ever met James Monsees or Adam Bowen?
    Dr. Jackler. Yes, James Monsees. And my research team, we 
went up JUUL last summer in August. You know, he was quite 
interesting. He thanked us for the data base that we have of 
50,000 traditional tobacco ads online. He said they were 
helpful as they designed JUUL's advertising, and this struck us 
so much that as the seven of us left the two-hour meeting was 
the very first thing we talked about, how surprising it was 
that he indicated the JUUL was grounded in traditional 
advertising.
    In fact, we know very well, having studied tobacco 
advertising, that JUUL's marketing faithfully recapitulates the 
methods used by the tobacco industry to target young people. 
That includes brands such as Marlboro, which they closely 
emulated, American Spirit, Newport. There are direct 
derivatives' advertising in those.
    Ms. Tlaib. Thank you. So JUUL's mission statement asserts 
that it aims to ``improve the lives of the world's 1 billion 
adult smokers.'' Do JUUL's marketing practices, which you have 
studied for years, align with that stated mission?
    Dr. Jackler. Well, not for its first three-and-a-half 
years. On the fourth year, at that point when already the youth 
fad was raging, their ads became more calibrated to an adult 
audience, and the channels that they used it as well. They have 
now switched campaigns depicting middle-age and older adults. 
It is in printed newspaper and on television, and no longer 
they are promoting on social media.
    Now, this only happened long after there was a youth 
epidemic, and it was because of the unwanted and intense 
attention by regulators. Also interestingly, as Mr. Monsees 
pointed out when we visited with him, they were concerned about 
their investors, particularly national companies, like 
Fidelity, who was an investor, who certainly didn't want to be 
associated with products that were widely seen----
    Ms. Tlaib. No, it always leads to profits. So last 
November, JUUL deleted its Instagram and Facebook, as you 
accounted to, but the explosion of their marketing had already 
had an impact on youth. How do we continue to see initial 
marketing campaigns' influence on kids on social media today?
    Dr. Jackler. Yes. So JUUL taking off its own marketing 
didn't stop all of the JUUL-branded hashtags, and there are 
dozens of them. #JUUL alone in the first three years and five 
months, June 2015 to November 2018, there are about a quarter 
of a million posts, mostly by young people on #JUUL. Since last 
November to now, it doubled to over half a million.
    Ms. Tlaib. And, Professor, yes, I really do appreciate 
that. But, Chairman, it is important to note what astounded me 
the most is they deleted Facebook and Instagram, but JUUL's 
Twitter followers, half of them are under the age of 18.
    Dr. Jackler. Yes, and if I might say, just because you 
delete them, doesn't mean it never happened.
    Ms. Tlaib. No. Thank you so much.
    Mr. Krishnamoorthi. Thank you, Congresswoman. Next, Mr. 
Comer, you are recognized for five minutes.
    Mr. Comer. Thank you, Mr. Chairman. The topic of the 
committee hearing today is youth's use of electronic 
cigarettes, and it has been mentioned today the potential 
possible correlation with tobacco and cigarettes. Dr. Niaura, 
you conducted a lot of research and published several studies 
on this very topic. How reliable of a predictor of future use 
of tobacco products is current use of vaping for youth?
    Mr. Niaura. Well, there is a statistical association 
between, you know, use of e-cigarettes and subsequent cigarette 
smoking. But what we looked at, and we looked at this in the 
Population Assessment of Tobacco and Health Study, which is 
funded and sponsored by the FDA and the NIH. So we did find 
that, but then we also found that if kids had, in fact, started 
with a cigarette, they were 20 times more likely to continue 
smoking a cigarette.
    So the message that we take from this is that, you know, 
use of all or any nicotine or tobacco containing products for 
kids probably will increase the risk for subsequent cigarette 
smoking. The worst thing to start with would be with a 
combustible product like a cigarette.
    Mr. Comer. Has the rate of decline in smoking among adults 
and youth decreased or increased since 2010 when e-cigarettes 
started to rise in popularity?
    Mr. Niaura. Well, we have seen steady declines in, you 
know, cigarette smoking, both in youth and adult populations, 
which we should, you know, take as good news.
    Mr. Comer. Absolutely.
    Mr. Niaura. We certainly have more work to do.
    Mr. Comer. Right.
    Mr. Niaura. Yes, there is, you know, sort of a diverging of 
the trends with e-cigarettes picking up and use of cigarettes 
going down. That is the area of active research - to see 
whether those two things are actually connected with one 
another.
    Mr. Comer. Mm-hmm. If e-cigarettes were a gateway to 
smoking, wouldn't evidence show a substantial increase in 
smoking among youth and young adults by now?
    Mr. Niaura. Well, again, we have seen, you know, a decrease 
in use of other tobacco products, cigarettes, in particular, in 
youth. So right now at least it doesn't appear that e-
cigarettes are translating into subsequent use of cigarettes, 
at least as far as we can tell right now.
    Mr. Comer. Does evidence show that teens are diverting to 
e-cigarettes instead of taking up smoking?
    Mr. Niaura. Well, that is an important question that I 
think we need more research to address. Kids are trying a lot 
of different products, you know, including vaping. We need to 
understand more about who are the high-risk kids who, you know, 
might try a lot of products, who may inadvertently become, you 
know, more addicted to nicotine. We really need more and better 
understanding of those factors so that I think we can do a 
better job at, you know, doing some kind of intervention.
    Mr. Comer. Mm-hmm. Well, I just want to make a point here 
that I am certainly opposed to youth vaping. I am opposed to 
youth smoking. I am not a smoker, never have been, but I am a 
farmer, and I do represent probably the biggest tobacco-growing 
district in America. Without a doubt this is something that has 
been a big economic boom to Kentucky. Having said that, we 
recognize the risks and the danger and the bad effects of 
cigarette use and tobacco use.
    The industry, I think, has tried to do things to curb 
underage smoking. I know that Senator McConnell has a bill that 
I support to raise the minimum age to purchase cigarettes, and 
I think that that is something that needed to be mentioned 
today, that, you know, tobacco is still legal. I know this is 
about e-cigarettes, but I have to conclude with this because it 
is a big industry in my district. You know, in Kentucky, you 
are not able to grow fruits and vegetables because of the 
climate, so you are limited as to what types of crops you can 
grow.
    It is still a legal industry, and as long as it is still a 
legal industry, I would rather the tobacco be grown in Kentucky 
by middle class farmers, small farmers, which is who grow 
tobacco, than importing tobacco from other countries. But 
having said that, I certainly want to work with my colleagues 
on both sides of the aisle to make sure that youth use of e-
cigarettes goes down, and certainly as I have always been a 
proponent of doing everything we can to prevent underage 
smoking. With that, Mr. Chairman, I yield back.
    Mr. Krishnamoorthi. Thank you, Mr. Comer. Congresswoman 
Pressley, you have five minutes.
    Ms. Pressley. Thank you, Thank you, Mr. Chairman, and 
thanks to all of our witnesses for sharing your expertise and 
sounding the alarm on this. In addition to the experts and 
those that are at the dais here, I did want to just acknowledge 
and recognize representatives of the African-American Tobacco 
Control Leadership Council who are also in the room with us 
today, and we thank you for your good work.
    The growing youth vaping epidemic has taken the 
Commonwealth, which I represent, by storm. Across the state, it 
is estimated that nearly one in five high schoolers and one in 
20 middle school age kids are using these products. Student 
advocates report school bathrooms have turned into JUUL lounges 
that smell fruity and minty. I have spent the last 10 years of 
my life as an elected official advocating for a school nurse in 
every school, and we have learned from our school nurses that 
80 percent of high school students are vaping. That is from 
their youth risk behavior surveys.
    Leaders at the local and state level in Massachusetts, from 
our city council to our attorney general, who was the one to 
initiate at the first investigation into JUUL's problematic 
marketing and sales practices, and our Boston City Council is 
looking to push for a hearing on banning flavored vaping 
products. But we have to act on the Federal level.
    So I would be remiss not to highlight how similar many of 
JUUL's tactics seem to be right out of the big tobacco 
playbook. For decades, big tobacco targeted black communities 
to the point where almost 90 percent of all black smokers use 
menthols. Nearly 45 percent of black menthol smokers state they 
would quit smoking if menthols were all together banned. So it 
is extremely disturbing. We have been here before. We don't 
need a bunch of studies. The only studies we need are the 
millions of casualties that are behind us and that we run the 
risk of seeing ahead of us. So this is very disturbing.
    The flavor crisis is even worse for children, 66 percent of 
whom the National Institute on Drug Abuse found believed e-
cigarettes only contained flavors, as we learned from the youth 
who spoke today, and we thank you for telling your story. It 
seems obvious that the elimination of flavors would help 
eliminate this confusion.
    So, Dr. Winickoff, why are menthol-flavored tobacco 
products particularly exploitive in the context of e-
cigarettes?
    Dr. Winickoff. Well, thanks for the question. The tobacco 
industry has a long history of targeting mint-and menthol-
flavored tobacco products to African-Americans, and 
specifically African-American children. A recent study in the 
American Journal of Preventive Medicine, however, showed that 
the majority of Americans believe that mint and menthol should 
be banned as a flavor in tobacco products.
    Now interestingly, and contrary to what the tobacco 
industry and the tobacco product industry claims, if you just 
look at the opinions of blacks and African-Americans, an even 
greater majority believed it should be banned. So I think no 
one is fooling anybody here.
    Ms. Pressley. Agreed. And aside from potentially preying 
upon the black community, JUUL's marketing playbook, as we 
learned from Ms. O'Leary, has targeted children in native 
populations. Ms. Berkman, you were so disturbed by JUUL's 
practices that you created an organization to spread awareness 
of JUUL's dangers to families across the country. You know that 
expression, ``Hell hath no fury like a woman?''
    Ms. Berkman. Yes.
    Ms. Pressley. They need to make up one about moms, okay, 
because that is next level. And so, you know, we thank you for 
your fierceness and your advocacy.
    Ms. Berkman. Thank you.
    Ms. Pressley. What have parents told you about how JUUL's 
marketing influenced their children's use of the product?
    Ms. Berkman. Well, I wish we had those slides because I 
hope everyone will get to see them. When you see the sexy young 
influencers that were giving this product away, when you see 
how similar the old tobacco ads, they are almost identical, so 
JUUL knew what it was doing. What we tell parents is, you know, 
you are not a bad parent because unfortunately, as you said, 
the old ``everyone is doing it.''
    The scary thing is in this case, it is true. It is stealth 
by design. As you said, we are very upset. These are kids who 
would otherwise not have been initiated into tobacco use. We 
are talking about kids, known harm to kids versus potential 
benefit for adults. I hope there is a potential benefit for 
adults in general, but known harm to kids who can't make those 
decisions for themselves because they are being deceived 
through the use of social media. That is a problem.
    Ms. Pressley. Thank you. I want to pick up on the deception 
and how that affects adults. Ms. O'Leary, did JUUL make any 
claims to Cheyenne River Sioux Tribe about its product helping 
people quit smoking? Did they claim that these products were 
healthy?
    Ms. O'Leary. Yes, you can see in slide 21 from my 
attachment that it states, ``Have smokers that can't quit? JUUL 
has created a program where you can help them switch with 
minimal cost to you.'' So using words like ``quit,'' 
``switch,'' cessation is implied, and that was the impression 
of the tribal council members who were on the other end of this 
presentation. I think that the other claim that was made was 
the harm reduction. In slide 6 of their presentation, they 
state ``Elimination of combustible cigarettes is crucial to 
reduce the risk of harm,'' and on slide 12, ``Vaping is a 
fraction of the risk of smoking, at least 95 percent less 
harmful.'' But I want to point out that in that study that 
found that that this was done with not JUUL, but other e-
cigarettes, that had much less nicotine content.
    Ms. Pressley. I can't tell the clock. Do I still have time 
here? Am I at time or do I still have time?
    Mr. Krishnamoorthi. You are out of time.
    Ms. Pressley. Okay. All right. Thank you, Mr. Chairman. 
Hopefully I will a second----
    Mr. Krishnamoorthi. Thank you, Congresswoman. Congresswoman 
Miller, you have five minutes.
    Mrs. Miller. Okay. Thank you, Mr. Chairman, and thank you 
all for being here today. My home state of West Virginia ranks 
among the top states in the Nation for the highest percentage 
of adult smokers, about 26 percent of our population. Thirty-
eight million people in the United States smoke. I agree that 
we need to ensure that we keep nicotine products like e-
cigarettes out of the hands of youth, but we must also ensure 
that we do not overregulate this industry to the point that 
they are no longer available for those people of legal age who 
would like to use them either recreationally or as a means to 
quit smoking.
    When I was a child, one of my chores was to empty the trash 
every day. Both of my parents were smokers. That was really 
icky. I will tell you, if anything would keep you from smoking, 
it would be emptying ashtrays every single day. And I believe 
it was in 1963 when the surgeon general came out and said that 
cigarette smoking caused cancer, and both my parents quit. My 
father just plain old quit cold turkey. My mother smoked three 
quarters of a cigarette, then half of a cigarette, then a 
quarter of a cigarette. She did it very slowly. But that 
ashtray thing is what really kept me from ever wanting to 
smoke, and coming into a house that smelled like smoke. It was 
really nasty.
    Dr. Niaura, in you research, do you find that most used to 
vapor also utilize other nicotine or tobacco products as well?
    Mr. Niaura. Yes. As I indicated in my testimony, close to 
three-quarters of kids, at least based on the most recent 
survey data that we have, have also, you know, tried or are 
using, you know, other tobacco products.
    Mrs. Miller. Is the use of e-cigarettes by youth correlated 
to them smoking cigarettes later in life?
    Mr. Niaura. Well, that is that is the million-dollar 
question that we are all concerned about and trying to figure 
out. At least, as I mentioned, you know, there is some 
statistical correlation. I don't know if we can say that one 
causes the other. That is a pretty high bar to prove 
scientifically. But, you know, nonetheless, you know, I 
maintain my position, and I am in amendment with everyone, you 
know, kids should just not be using any tobacco or nicotine-
containing products.
    Mrs. Miller. I know when I went to college, the girls all 
had little cigarette cases and little things that they always 
carried, and oftentimes I felt like is it more of a crutch 
because you wanted to do something with your hands, or was it 
because it really was addicting. Often younger people, you 
know, they want to carry keys or they just want to have 
something to do with their hands, and that is more of an 
observation than a question.
    In your testimony, you talk about protecting youth from 
accessing nicotine products and giving smokers a useful tool to 
quit smoking, and it shouldn't be a tradeoff, and that we can 
do both of these things at the same time. Could you elaborate 
on suggestions on how you think we could accomplish both of 
these goals?
    Mr. Niaura. Well, I wish I had all the answers, but I am I 
am hoping, you know, that the FDA with, you know, the power of 
the Tobacco Control Act, can work hard, and I know they are 
working hard, to figure out how to achieve, you know, both 
goals, which is to minimize, if not eliminate, youth use and 
maximize the ability of adult smokers to access, you know, safe 
and effective products. I think we are still in the early 
stages of figuring out, you know, which e-cigarette type 
products are going to prove to be the most useful. But, you 
know, that is what the FDA is there for, you know, to review 
applications and use their scientific powers to determine which 
products are, in fact, fit for approval.
    Mrs. Miller. In regard to adult smokers, how can the health 
risks associated with cigarettes be mitigated by the use of e-
cigarettes?
    Mr. Niaura. Well, the major thing is if cigarette smokers 
can switch completely to an e-cigarette product, we know that 
that, in fact, will result in pretty quick changes in 
biological markers of harm that are normally associated with 
smoking cigarettes. So in other words, we have signals that 
their bodies are actually kind of getting better and improving. 
But Dr. Jackler is right in saying that we need more 
information about long-term effects of use of these products, 
and so that is an area of active research. But at least in the 
short term, it looks like, you know, if people switch to these 
products, they actually are in some ways improving their 
health.
    Mrs. Miller. You mean like coughing?
    Mr. Niaura. More like, you know, biological markers that 
are associated with higher risk of cancer, so blood levels of 
certain chemicals, things like that.
    Mrs. Miller. Okay. Thank you, Mr. Chairman.
    Mr. Krishnamoorthi. Thank you, Congresswoman. Now Mr. 
DeSaulnier for five minutes.
    Mr. DeSaulnier. Thank you, Mr. Chairman. Thank you for 
having this hearing. I must admit the longer you have these 
political jobs, the more depressing you get sometimes when you 
see human beings doing things to other human beings. I am old 
enough to remember introducing a second-hand smoke ordinance as 
a restaurant owner in Concord, California 30 years ago. I am 
also old enough to remember doing an ordinance at the county. 
It was a public health ordinance. And our hearings then showed 
very clearly the tobacco industry was marketing directly 
through retailers all across the country, where they put their 
placement of advertising. So how close it was to other products 
that kids would be drawn to. Literally research that they had 
done showing the height when kids came in.
    I also remember being a restaurant owner - having owned 
multiple liquor licenses - that when we went through Mothers 
Against Drunk Driving where colleagues of mine in the 
restaurant business said, "well, if we try to assume more 
liability, then we will go out of business, we should protect 
small business," and thinking and talking to colleagues at the 
California Restaurant Association saying, "well, why would we 
want to be in business if that is what..." and, of course, we 
passed laws that have helped with that.
    So here we are again, and, Ms. Berkman, I have had some 
fairly regular group of young people that is growing in my 
district in the San Francisco Bay Area come into my office, and 
they are trying to do similar things that we did with tobacco 
settlement money, getting young people to help advocate. But 
they are also telling me stories pretty compelling that on 
their campuses, this is pervasive, and there is a reinforcement 
from the marketing, from peer to peer that it is not dangerous, 
that people have taken care of all that. You have had the same 
experience I take it.
    Ms. Berkman. Yes, and actually we have a PAVe group, 
Parents Against Vaping group, in San Francisco where we are 
working all the time. But, yes, peer-to-peer, even now when 
there has been so much talk about the harmful content of these 
sweet JUUL pods, the known toxins, the nicotine, kids still 
don't get it, right? They think it is water vapor. I mean we 
heard those numbers earlier. And you said, we have been here 
before and we should not be here again.
    We don't want our kids to be guinea pigs for this 
experiment, especially when we saw what happened the first time 
around when big tobacco 1.0 targeted our kids. JUUL is big 
tobacco 2.0, and we can't wait. This is a race against time. If 
we don't act soon and take the flavors off the market, because 
the flavors continue to hook the kids, then the generation of 
nicotine addicts and worse.
    In West Virginia, for example, I know that the member just 
left the room, but there is research that has given conclusive 
evidence of cardiovascular damage caused by e-cigarettes. So 
there is known damage, not only to developing brains, but 
cardiovascularly. And I keep hearing over and over we don't 
know yet, we are waiting. These are kids. There is known harm 
now. Why wait and, God forbid, see what happened the time 
around. We don't have that time, so thank you.
    Mr. DeSaulnier. Dr. Winickoff and Dr. Jackler, so 
secondhand smoke. It t strikes me, and this is where we were 
effective with tobacco, and particularly, say, in Northern 
California where it started in California, as a public health 
issue to employees. Having been in the restaurant business in 
the 70's--I am dating myself--you couldn't wear your clothing a 
second day because of the stench of tobacco, someone who has 
never been a smoker. Why should it take long for us to look at 
the measurement and the content of what is in these products 
and measure it against what we already know about secondhand 
smoke?
    Dr. Winickoff. Pediatricians worry a lot about this, and in 
the family context, we have some smokers which have gotten the 
message and smoke outside, but for parents, they will be vaping 
right next to their child. Those ultra-fine particles are 
getting into their children's lungs. And, in fact, when they 
vape indoors, the entire surface of that home becomes coated in 
an ultra-fine particulate of nicotine and other chemicals. Now, 
kids interact with their environment in a very intense way. 
They exhibit mouthing behavior. They breathe from close down to 
the floor, and they may only way a 10th as much as adults, so 
they end up eating house dust and getting in a level of toxic 
aerosol that is probably 20 times higher than what a nonsmoking 
adult in that household would get. And that is concerning for 
us.
    Mr. DeSaulnier. Doctor, do you have anything to add just 
quickly?
    Dr. Jackler. Well, just the place of use regulations around 
smoking and vaping need to parallel. Otherwise, what happens is 
that smokers will use them in the workplace, in recreational 
places, in automobiles with their kids and things, and that is 
not a good thing. So those local policies are very important to 
parallel.
    Mr. DeSaulnier. Ms. O'Leary, can you talk a little bit 
about how the industry has targeted Native Americans and the 
tribal community?
    Ms. O'Leary. I think there has been historical tactics by 
the tobacco industry to target many groups that are at risk, 
including American Indians, as well as others that have been 
stated already. But I think the main thing is, you know, 
getting product to the reservation. I think that tobacco 
industry feels a little bit invisible on the reservation. We 
have, you know, no compliance checks that happen on the 
reservation by FDA because it is a sovereign nation. So there 
is great concern about what JUUL coming to the reservation and 
trying to hide behind nondisclosure agreements could result in.
    I have heard that there are multiple other tribes that have 
been approached by JUUL, but I have really struggled to find 
anybody that is willing to speak with me about it, and it is 
likely because that there has been NDAs signed by these tribes. 
So I think that it is ruthless the attempts that are going on 
to embed these at-risk populations. Thank you for your 
question.
    Mr. DeSaulnier. Thank you so much, and thank you to all the 
panelists. I yield back, Mr. Chairman.
    Mr. Krishnamoorthi. Thank you, Congressman. Congressman 
Grothman, you have five minutes.
    Mr. Grothman. Okay. I don't know a lot of people use e-
cigarettes. You sure don't seem around like you used to see 
cigarettes around when I was a child. Good grief, when I was in 
high school, they had a smokers lounge in the high school. But 
at least one person I know well who vape credits this with, you 
know, stopping smoking cigarettes. And I wonder do you feel in 
this an effective way? If that is true, we are saving lots of 
lives aren't we? Could you respond to the idea that this is an 
effective way to stop smoking?
    Dr. Jackler. There is certainly potential that electronic 
cigarettes, particularly those that are high nicotine, that 
when the user breathes them in has a similar spike in nicotine 
that the----
    Mr. Grothman. Well, people know about by now. Does it work 
or not work? Is this an effective way to stop smoking?
    Dr. Jackler. We actually don't know scientifically very 
well. There are certainly anecdotes, as in your friend. Some 
adults will dual use smoke and vaping and keep their nicotine 
levels high even in places they can't smoke. So it can be a 
deterrent to adults. Certainly it is probably better than 
patches and gums, but still marginal.
    Dr. Winickoff. And I would just add that we have not seen 
strong evidence that flavored e-cigarettes are necessary for 
adults to stop smoking. I think if a manufacturer develops a 
flavored e-cigarette that generates data and proves that it 
would help adults quit smoking and not attract children, then 
the manufacturer is able under the law to ask FDA to approve it 
as a cessation device or authorize it as a new tobacco product. 
But for now, the evidence is strongly in favor of taking 
flavored products off the market.
    Dr. Winickoff. Doctor, you wanted to speak.
    Mr. Niaura. Yes, so I just take issue with the notion that 
there is not strong evidence. We do have, you know, the results 
of a randomized controlled trial, which is the gold standard 
for scientific evidence, published in probably the most 
prestigious medical journal in the world, the New England 
Journal of Medicine, earlier this year, demonstrating that, you 
know, smokers who managed to switch to e-cigarettes quit at 
twice the rate compared to those who use nicotine replacement 
therapy. So the evidence base is building so, you know, I don't 
think we can any longer say that we don't have evidence that 
these products that can help smokers quit.
    Mr. Grothman. Well, you know, America, at least we are told 
is supposed to be a free country. Why do you think, what is the 
reason for these other people then to not want to allow people 
to use e-cigarettes if there is some strong evidence out there 
that it is a way to stop smoking? What is their motivation? Do 
you know?
    Mr. Niaura. Well, I don't know. I think a lot of this has 
to do with, you know, these are these are relatively new 
products. There are a lot of unknowns, and I understand the 
tendency to want to rely on, you know, proven methods such as, 
you know, medications and nicotine replacement therapy. But 
this is now a consumer product that has kind of taken things by 
storm, and again we are seeing signals that are positive.
    So from my point of view, if this is a type of product that 
actually is consumer friendly and is more apt to be used by 
smokers compared to some of these other products, then we ought 
to look for ways to leverage that opportunity to help smokers 
switch.
    Mr. Grothman. Okay. I have one general thing. You know, 
they give us all this data, and I am not sure whether this is 
right or not. I guess in 2018, the FDA claimed that 20 percent 
of high school students vaped in the last 30 days, but I know 
how, you know, the world works. If your buddy has got a vape, 
maybe you vape. It also says here that only six percent use it 
more than 20 days per month, and only four percent described 
themselves as daily users. So, you know, it seems like one of 
those things that kids have when they pass it around, but 
really we are under four percent. Does anybody think those 
numbers are wrong?
    Dr. Winickoff. That is exactly how tobacco use starts. 
Tobacco products begin as an intermittent use, and they 
graduate to daily use. So there is nothing surprising about 
that data. In fact, the standard, the gold standard for 
assessing adolescent current tobacco use is past 30-day use. So 
there is nothing unusual about that data.
    Ms. Berkman. Congressman, if I may?
    Mr. Grothman. Yes.
    Ms. Berkman. I am a mother of four children, of four teens, 
and I can tell you that this is rampant. You can ask. I mean, 
we are trolled and harassed and threatened all the time by the 
pro-vaping community. We are not prohibitionists. We want the 
flavors that are hooking the kids off the market.
    Mr. Grothman. I am going to run out of time, so I am just 
going to ask you. So you are saying that when I have this FDA 
data that less than four percent of the kids vape every day, 
you think that FDA data is wrong.
    Ms. Berkman. I am telling you that kids under report. They 
don't admit it. Then some of those early studies, unless you 
ask someone if they are JUULing. If you ask them if they are 
vaping, they will say no because kids do not associate vaping 
and JUULing. It is, like, Kleenex or band aids. And there have 
been articles written about this and studies written about 
this. I know because my son and I have commented on those 
stories. Kids think they are JUULing. They don't think they are 
vaping. They don't think they are using e-cigarettes. They just 
know that they are JUULing. That is the truth.
    Mr. Grothman. Thank you.
    Mr. Berkman. I also ask you, would you say that nicotine 
addiction is something that goes away after a couple of days or 
it just a fad?
    Mr. Grothman. Well, I don't know, so I don't have an 
opinion.
    Mr. Krishnamoorthi. Well, thank you. We have two final 
lines of questioning, three minutes each. This is going to be a 
little bit of a lightning round here. Congresswoman Tlaib, you 
have three minutes.
    Ms. Tlaib. But it was getting so good, Mr. Chairman.
    [Laughter.]
    Ms. Tlaib. Mr. O'Leary, thank you so much for being here, 
and I want to give you majority of the time because I read on 
February 1, JUUL came before your health committee of your 
tribe, and they were proposing the product and so forth. But, 
you know, one of things I would love for you to talk about is, 
you know, the statement that they said is that the letter said 
from JUUL, the tribe said it was to promote JUUL as a healthy 
way for patients for patients to quit smoking. JUUL wanted the 
tribe's health department to provide the JUUL starter kits for 
free of charge to tribal members trying to quit smoking as part 
of our smoking cessation program. And so if you can talk a 
little bit about that, and, you know, who was in the room. I 
know some people had to sign some sort of right to be able to 
come forward and disclose.
    And, Mr. Chairman, as Ms. O'Leary starts, I think for the 
record, you know, JUUL, from a number of folks up here, has 
misled the American people, has lied, has used our broken 
system to honestly target and then manipulate and say that it 
is not going to cause certain things. We can continue to say we 
are going to study, study. But I can tell you when I go into 
kids because I say well, you know, they always ask me what I do 
for a living. I tell them, you know, I make laws and things, 
and they are still looking at me. I say, you know, when I was a 
kid when I went to a restaurant, they would say, "okay, how 
many people in your party?" The second question they would ask 
is, "do you want a smoking or a nonsmoking section?", and all 
the kids look at me. These second and third graders, they are 
like, "what are you talking about?" I said, yes, they used to 
smoke in restaurants. "No way!" Oh, they used to smoke on 
airplanes. Uh-uh. In hospitals. "Eww."
    You know, and it is like [to] these kids that is crazy, but 
they used to gaslight us to believe that secondhand smoking 
wasn't killing us. And I am not going to get here and allow the 
committee to be used by anybody, even from the other side, to 
say that e-cigarettes, vaping, JUUL is not killing our people. 
They are. It is leading to health harms, leading to addictions 
that are going to hurt people.
    So with that, I am so sorry, Ms. O'Leary, you can have the 
rest of my time. I really do want to put it in the record what 
they did in your tribe.
    Ms. O'Leary. I share your passion. Thank you for your 
comments. So what happened is when they came, it was in front 
of initially the tribal council, and that is when they handed 
out free product to our decision-makers. Free product. And we 
have council members now who are regular users of JUUL when it 
was initiated at that meeting. They were then re-routed back to 
the correct process, which is through the committee level of 
the tribal governments system. So they went to the health 
committee, and at that meeting, that is when they made those 
claims of less harm and smoking cessation. I will reiterate 
that that is not allowed. They cannot claim smoking cessation 
or at less harm at this point.
    I also want to say that, you know, there has been a lot of 
questions about that it might be effective for smokers, but 
there is also data that suggests that for every one person who 
is able to quit using JUUL, 81 kids will start. So the rate at 
which the smokers are finding this product helpful, it is 
incredible the amount of uptake that we are seeing in our 
youth. And I think that the tobacco industry in general, as 
well as JUUL specifically, targeting at-risk populations, like 
American Indians and African-American, and youth, it is, again, 
I say ruthless. There is no end in sight for these companies 
unless there is some regulations that take place by Congress.
    Ms. Tlaib. Mr. Chairman, I hate calling it regulations 
because they have hijacked that word. It is called 
accountability. Thank you.
    Mr. Krishnamoorthi. Thank you, Congresswoman. And our final 
three-minute line of questioning, Mr. Cloud.
    Mr. Cloud. Well, with that buildup, I just had three 
questions. We will try to get through in three minutes. I 
wanted to clear up the data. I guess teen vaping use is up. We 
talked about that. Overall, teen cigarette use is down.
    Dr. Winickoff. No.
    Mr. Cloud. No?
    Dr. Winickoff. In the latest year, actually for the first 
year----
    Mr. Cloud. My question was overall tobacco use.
    Dr. Winickoff. Yes, teen use is increasing actually in the 
last year according to national data from the CDC.
    Mr. Cloud. There are different sets of data. Does everybody 
agree with that?
    Mr. Niaura. There may be a flat line, but it is not 
increasing.
    Dr. Winickoff. The data show that it is increasing, but we 
can show you the data. We will submit it.
    [The information referred to follows:]
    Mr. Cloud. Overall tobacco use. Overall tobacco use? I 
would be interested to see the study, Mr. Niaura.
    Mr. Niaura. It is in my written testimony.
    Mr. Cloud. Right, okay. Yes, I looked at that. Why the 
increase? Why the decline, I guess, if you can----
    Dr. Winickoff. Well, I think that what we would have seen 
had JUUL not been around, had e-cigarettes not been around, I 
think we would have seen a very steep decrease in adolescent 
tobacco use. Unfortunately, what we have seen is a flat line, 
as Dr. Niaura mentions, a slight uptick in the past year. This 
is a problem because when I ask kids do you like----
    Mr. Cloud. I only have a little bit of time. I have to move 
on.
    Dr. Winickoff. Yes, go ahead.
    Mr. Cloud. I think we covered most of what you are saying.
    Mr. Niaura. Well, if you look at the----
    Mr. Cloud. I understand there is a decline. Why is there a 
decline?
    Mr. Niaura. Yes, if you look at the patterns over the past, 
you know, four or five years, again, we are record lows for 
youth smoking, which, you know, is hard to reconcile with the 
fact that, you know, teen vaping is up. Those are just the 
facts.
    Mr. Cloud. And when you say ``youth smoking,'' that 
includes vaping?
    Mr. Niaura. Cigarette smoking. No, no, just cigarettes.
    Mr. Cloud. Yes, that was my question.
    Mr. Niaura. Cigarette smoking.
    Mr. Cloud. Okay.
    Dr. Winickoff. Total product use is up dramatically in the 
last few years.
    Mr. Cloud. Okay. That is----
    Mr. Niaura. But that includes vaping.
    Mr. Cloud. Okay. That was the question I was trying to get 
to. Thank you. Both Jackler and Niaura, you touched for a 
second on patches and others. Could you touch about 20 seconds 
on e-cigarettes compared to those other alternatives, patches, 
what have you?
    Mr. Niaura. Right. So, you know, nicotine patches are a 
form of nicotine replacement therapy, proven to be effective to 
help smokers quit. Again, this one study appears to show that 
e-cigarettes are even better than nicotine patches. But my 
interpretation of that is that e-cigarettes are actually a form 
of nicotine replacement therapy. They are just more efficient. 
They are better at doing it compared to products like patches.
    Mr. Cloud. Okay. And of course we are all talking outside 
the context of teens when we are talking----
    Mr. Niaura. Yes. No, this is for adults.
    Mr. Cloud. Right. How can policymakers ensure that non-
combustible nicotine products, like electronic cigarettes, are 
available for smokers wanting to make a transition while 
limiting the access of unintended users like youth? What are 
your recommendations?
    Mr. Niaura. I don't have any concrete recommendations 
because I think this is a very tough issue. We are seeing a lot 
of suggestions coming out from folks in terms of different 
types of, you know, restrictions in terms of where products can 
be sold, maybe restricting flavors and so forth. I think these 
are important conversations that we ought to continue to have 
to figure out the best road forward.
    Mr. Krishnamoorthi. Thank you. I will let Dr. Jackler 
finish.
    Dr. Jackler. So high nicotine products like JUUL, and it 
has exceptionally potent nicotine, from my point of view, 
should be available by doctor's prescription for adult smokers. 
I care very much about adult smokers and would have like to 
have products that help them quit, and I think it is a superior 
product compared with patches and gums. But they should not be 
on the market to be bought over the counter in sweet and fruity 
flavors by kids.
    Mr. Krishnamoorthi. Thank you very much, Doctor, and you to 
the first panel for their testimony. With regard to the 
panelists, if you could please come back to the anteroom. We 
are going to switch out, and we are going to have our final 
panelist, Senator Dick Durbin, and we will hear from him. So we 
will take a two-minute break just to switch out the panelists. 
And please, audience, please stay seated for Senator Durbin.
    Well, welcome, Senator Dick Durbin, to the Committee on 
Oversight and Reform, Subcommittee on Economic and Consumer 
Policy. My favorite senior senator from my home state of 
Illinois.
    [Laughter.]
    Mr. Krishnamoorthi. Senator Dick Durbin needs no 
introduction on the issue of his valiant advocacy efforts to 
combat smoking among youth, and also to combat smoking in 
general. He is the author of the Ban on Smoking on Flights in 
America, which came into being in 1990, 29 years ago, when he 
was a member of this House. At that time, powerful interests in 
the tobacco industry fought his efforts to put this law into 
place, but now we know the tremendous positive impact of that 
law. And we have Senator Durbin to thank.
    But he has also been an outstanding advocate on the issue 
of fighting e-cigarettes for youth, and so we welcome him to 
our committee. Without objection, sir, your written statement 
will be made part of the record. And with that, Senator Durbin, 
you are now recognized for your statement.

STATEMENT OF HON. RICHARD DURBIN, A UNITED STATES SENATOR FROM 
                     THE STATE OF ILLINOIS

    Thank you, Chairman Krishnamoorthi and Ranking Member 
Cloud, for holding this important hearing. It is good to be 
back in the people's House of Representatives and also to be at 
a hearing flanked by the Campaign for Tobacco Free Kids. It 
seems like old times. But I know today you are taking a close 
look at the role of JUUL and the FDA and how we have reached 
this point where we are facing literally, in the words of the 
FDA, a vaping epidemic.
    You know the numbers. In the last year alone, 80 percent 
increase of high school students vaping, 50 percent increase in 
middle school students using e-cigarettes. Today because of 
devices like JUUL and the accompanying kid-friendly flavors, 4 
million children nationwide are vaping. JUUL and other e-
cigarette companies like to claim that their products are only 
meant for adults looking to quit cigarettes, but a look at the 
facts quickly dispels that notion.
    Here's the starting point. There is no clinical trial 
proving that JUUL devices help adults quit smoking cigarettes. 
None. Despite all the marketing claims and all the paid 
testimonials, there is no credible medical evidence of JUUL's 
most fundamental marketing claim. None. Further, more than 20 
percent of children under the age of 18 are using e-cigarettes 
compared with less than three percent of adults. JUUL knows 
exactly where the money can be found, and it's not from adults 
looking to quit smoking. It's kids.
    Today's youth vaping epidemic is a new version of an old 
battle that I'm personally familiar with. I won't go into the 
details, but on Friday, November 13, 1959, one week before my 
15th birthday, I stood at my father's hospital bedside as he 
died from lung cancer - two packs of Camels a day. He was 53 
years old. When I came to Congress, I decided to make tobacco 
my issue. We had some success, as you noted.
    In 1987, in my third term in the House, second term on the 
Appropriations Committee, I successfully passed an 
appropriations amendment banning smoking on 80 percent of 
airline flights in the United States. It was a major miracle. 
No one expected this young Congressman from Illinois, with the 
opposition of both Republican and Democratic leadership, to 
pass this measure on the floor. What they failed to understand 
is the House of Representatives is the largest frequent flyer 
club in America, and they sick and tired of secondhand smoke on 
airplanes and voted with me. The bill was signed into law by 
President Ronald Reagan despite big tobacco fighting all the 
way. They called my ban ``an intrusion on individual rights.'' 
You may hear echoes of that in this room today.
    It was just the first step. I didn't realize that 
eliminating this inconvenience was a tipping point, but it was. 
It turned out that a lot of people thought, well, if secondhand 
smoke is dangerous on a plane, why isn't it dangerous in a 
movie theater, in a restaurant, in a bowling alley? We also 
went directly after big tobacco's efforts to addict children, 
which is why we made cigarettes more expensive with taxes. That 
is the single greatest deterrent to children turning to 
cigarettes.
    We dumped Joe Camel and the Marlboro Man as part of a 
national lawsuit. We prohibited kid-friendly flavors in 
cigarettes like strawberry and grape. And since these historic 
changes, the percentage of youth smokers declined from 28 
percent--28 percent--in the year 2000 to less than eight 
percent today. However, anyone who believes that the 
multibillion dollar tobacco industry would go quietly ignored 
the power of their greed, and that is why we are here today.
    Losing their precious market share, big tobacco put their 
researchers and marketers to work. First, they needed a new 
product that didn't carry the moral taint of cancer-causing 
tobacco. Even better, if it looked like a USB flash drive, it 
could easily slip into a kid's laptop. They needed a campaign 
that included an unproven, positive health claim such as JUUL's 
current Make the Switch slogan. They relied on a multibillion 
dollar, $12.8 billion, investment from an old standby, Altria, 
formerly known as Phillip Morris. They needed a special 
strategy focused on kids because they knew that children, for a 
variety of reasons, are the most susceptible new users of 
products. It worked with cigarettes. It was going to work again 
with JUUL and vaping.
    How did they lure the kids? I have got a bag full here, of 
all of the different flavors. I won't go through them all, but 
they include Fruit Medley, Gummy Bear, Whip Cream, Unicorn 
Poop, Razzle Berry, and Cotton Candy. Now, go tell me that is 
all about adults switching from cigarettes to vaping.
    Finally, and this is critical, they needed the Food and 
Drug Administration to look the other way as their massive 
empire mushroomed and metastasized. Unfortunately, the FDA has 
been happy to serve as that accomplice, delaying commonsense 
regulation of the e-cigarettes industry by years, refusing to 
remove illegal products from the market, and standing silent in 
the face of these false health claims by JUUL. I have made it 
clear to the acting FDA commissioner, Dr. Sharpless, and 
Commissioner Gottlieb before him, that FDA's hapless 
spectatorship has to come to an end, whether by law, 
regulation, court order, or discovering the political will to 
get off the sidelines.
    So what's been the result of big tobacco and big vape's 
efforts combined with the FDA's as abject failure to regulate 
the industry despite their authority? Between 2017 and 2018, 
the number of American teenagers using any tobacco product 
increased by nearly 40 percent. This was the largest single-
year increase in youth tobacco use ever. That's right, all of 
our significant, hard-earned gains to reduce youth use of 
tobacco products are being reversed because of e-cigarettes 
like JUUL and the accompanying kid-friendly flavors. And all of 
the full-page JUUL ads decrying children, you know where you 
see them? You see them in The Hill, Roll Call, Politico, 
Washington Post, New York Times, Wall Street Journal. This 
isn't a new tactic. That's exactly what big tobacco did when we 
said lay off the kids. They bought full-page ads in the Wall 
Street Journal saying we don't want kids to smoke cigarettes. 
How many kids do you think get up in the morning to read the 
Wall Street Journal? Exactly none. This is just a PR campaign 
now by JUUL, once by big tobacco, to try to say that they have 
a business model that really isn't directed at kids. The facts 
tell us otherwise.
    To combat today's vaping epidemic, I've introduced 
bipartisan and bicameral legislation to crack down on kid-
friendly e-cigarette flavors. I'm joined by Senator Lisa 
Murkowski, Republican of Alaska, and Representatives DeGette 
and Raskin. Our Safe Kids Act would give each e-cigarette 
companies one year to prove their products meet three criteria. 
First, companies would have to prove that their products 
actually help adult cigarette smokers to quit. Second, they'd 
have to prove their products don't harm the people using them. 
Third, e-cigarette companies would have to prove their products 
do not cost children to start using nicotine.
    If a Federal Tobacco to 21 bill this year, year and I think 
it might in the Senate, it's imperative that the legislation 
include strong provisions to crack down on kid-friendly e-
cigarette flavors that are addicting our kids.
    As someone who lost his father as a kid to smoke-related 
lung cancer, I had hoped that e-cigarettes would prove to be a 
smoking cessation device for adults. To date, there is no 
proof. Instead these devices and the candy dessert fruit 
flavors are causing children to develop this addiction at far 
greater rates than they're helping adults quit smoking 
cigarettes. A recent Dartmouth study found that e-cigarette use 
leads to 81 new smokers for every one smoker who quits. 
According to the Truth Initiative, 15-to 17-year-olds are 16 
times more likely to use JUUL compared to people over the age 
of 25. A recent study published in the Journal for the American 
Medical Association found the teenagers who start vaping are 
three times more likely to go on to smoke cigarettes than 
teenagers who don't. And consider this: JUUL is widely popular 
with kids and accounts for 70 percent of e-cigarette sales in 
the United States.
    Make no mistake. JUUL, now partnered with tobacco giant, 
Altria, is driving this epidemic even as they come before this 
committee and pose for holy pictures. Congress waited for too 
long to start protecting children from cigarettes. History is 
now repeating itself with e-cigarettes. Our inaction, combined 
with FDA's complacency, is dooming an entire new generation of 
children to nicotine addiction. Most parents care when their 
teenager is lost in a cloud of vape smoke. Does Congress? I 
look forward to working with you on a bicameral basis to 
address public health epidemic head on.
    I will close by saying this. I never dreamed when I went 
after taking cigarette smoking off of airplanes in my third 
term in the House, for God's sake, that I had a chance to win, 
but I did. The net result of it, because of unforeseen 
developments, was a change, a dramatic change, in America in 
their view toward smoking. We stepped in at that moment finally 
and took on big tobacco. The question is can we work the 
bipartisan political will to take on big vaping now for the 
benefit of the young people sitting behind me and those across 
America? Thank you, Mr. Chairman.
    Mr. Krishnamoorthi. Thank you very much, Senator Durbin, 
for that eloquent statement, and thank you for your efforts, 
your lifelong efforts, to combat nicotine use.
    I want to thank all the panelists, I want to thank the 
entire audience for taking time out of your busy schedules to 
be here. Part 2 of this very, very important hearing is 
tomorrow when we have the founder of JUUL before us at 2 p.m. 
in this very same room.
    I ask unanimous consent to insert the following items into 
the official record of the hearing: the statements from Dr. 
Bonnie Halpern-Felsher of Stanford University, a statement from 
Dr. Brian Primack, a letter from Kamal Mazhar, president of 
Teens Against Vaping, and a letter from Dr. Frances Leslie of 
the University of California, Irvine.
    Hearing no objection, so ordered.
    Mr. Krishnamoorthi. We are adjourned.
    [Whereupon, at 10:55 a.m., the subcommittee was adjourned.]