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


                 DON'T VAPE: EXAMINING THE OUTBREAK OF.
                     LUNG DISEASE AND CDC'S URGENT
                    WARNING NOT TO USE E-CIGARETTES

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

                                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

                               __________

                           SEPTEMBER 24, 2019

                               __________

                           Serial No. 116-64

                               __________

      Printed for the use of the Committee on Oversight and Reform

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                  Available on: http://www.govinfo.gov
                    http://www.oversight.house.gov or
                        http://www.docs.house.gov                        
                        
                               __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
37-976 PDF                  WASHINGTON : 2019                     
          
--------------------------------------------------------------------------------------                        
                        
                        
                        
                   COMMITTEE ON OVERSIGHT AND REFORM

            CAROLYN B. MALONEY, New York, Acting Chairwoman

Eleanor Holmes Norton, District of   Jim Jordan, Ohio, Ranking Minority 
    Columbia                             Member
Wm. Lacy Clay, Missouri              Paul A. Gosar, Arizona
Stephen F. Lynch, Massachusetts      Virginia Foxx, North Carolina
Jim Cooper, Tennessee                Thomas Massie, Kentucky
Gerald E. Connolly, Virginia         Mark Meadows, North Carolina
Raja Krishnamoorthi, Illinois        Jody B. Hice, Georgia
Jamie Raskin, Maryland               Glenn Grothman, Wisconsin
Harley Rouda, California             James Comer, Kentucky
Katie Hill, California               Michael Cloud, Texas
Debbie Wasserman Schultz, Florida    Bob Gibbs, Ohio
John P. Sarbanes, Maryland           Ralph Norman, South Carolina
Peter Welch, Vermont                 Clay Higgins, Louisiana
Jackie Speier, California            Chip Roy, Texas
Robin L. Kelly, Illinois             Carol D. Miller, West Virginia
Mark DeSaulnier, California          Mark E. Green, Tennessee
Brenda L. Lawrence, Michigan         Kelly Armstrong, North Dakota
Stacey E. Plaskett, Virgin Islands   W. Gregory Steube, Florida
Ro Khanna, California                Frank Keller, Pennsylvania
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 September 24, 2019...............................     1

                               Witnesses

Panel One
Dr. Anne Schuchat, Principal Deputy Director, Centers for Disease 
  Control and Prevention
    Oral Statement...............................................     4
Panel Two
Dr. Ngozi O. Ezike, Director, Illinois Department of Public 
  Health
    Oral Statement...............................................    28
Dr. Albert Rizzo, Chief Medical Officer, American Lung 
  Association
    Oral Statement...............................................    30
Ruby Johnson, Parent
    Oral Statement...............................................    31
Vicki Porter, Minority Witness
    Oral Statement...............................................    34

* The prepared statements for the above witnesses are available 
  at:  https://docs.house.gov.

                           INDEX OF DOCUMENTS

                              ----------                              

The documents listed below are available at: https://
  docs.house.gov.

  * Questions for the Record: from Chairman Krishnamoorthi to 
  Vicki Porter, minority witness.

  * Unanimous Consent: Associated Press articles, ``How the 
  Associated Press collected information on CBD vapes'', Sept. 
  16, 2019, and ``Vapes spiked with illegal drugs show dark side 
  of CBD craze,'' Sept. 16, 2019; submitted by Rep. Comer.


 
                 DON'T VAPE: EXAMINING THE OUTBREAK OF
                     LUNG DISEASE AND CDC'S URGENT
                    WARNING NOT TO USE E-CIGARETTES

                              ----------                              


                      Tuesday, September 24, 2019

                  House of Representatives,
      Subcommittee on Economic and Consumer Policy,
                         Committee on Oversight and Reform,
                                                   Washington, D.C.
    The subcommittee met, pursuant to notice, at 10:25 a.m., in 
room 2154, Rayburn House Office Building, Hon. Raja 
Krishnamoorthi (chairman of the subcommittee) presiding.
    Present: Representatives Krishamoorthi, DeSaulnier, Hill, 
Khanna, Pressley, Tlaib, Cloud, Grothman, Comer, and Miller.
    Also present: Representatives Wasserman Schultz, Cox, 
Meadows, and Jordan.
    Mr. Krishnamoorthi. Good morning. Sorry for the delay. The 
subcommittee will come to order.
    Without objection, the chair is authorized to declare a 
recess of the committee at any time.
    Without objection, I'd like to have a few Members waived on 
to the committee, Congressman Jordan, Congressman Meadows, 
Congressman Cox, shall be permitted to join the subcommittee on 
the dais and be recognized for questioning the witness.
    Without objection, so ordered.
    I now recognize myself for five minutes to give an opening 
statement. We are here to amplify the recent health warnings 
issued by the Centers for Disease Control related to 530 e-
cigarette incidents of lung disease in 38 states and the U.S. 
Virgin Islands.
    First, I want to make clear that we did not plan to have 
this emergency hearing at the beginning of this Congress, let 
alone this time last month. But on August 23, officials from my 
home state of Illinois reported the first death due to a 
mysterious vaping-related lung illness. And since then, a total 
of eight individuals have tragically died in this outbreak.
    In response to this crisis, CDC is warning the American 
public to consider not using e-cigarettes of any kind. Because 
this subcommittee has investigated the youth vaping epidemic 
and the companies behind it, we feel that it is our duty to 
draw attention to recent government health warnings about the 
dangers of e-cigarette use. The long-term health effects of 
continued vaping is unknown, but what we do know should give us 
pause.
    State health departments continue to conduct retroactive 
analyses of patient records to better understand exactly when 
this outbreak began. As they do, the number of affected people 
will grow. Unfortunately, illness related to e-cigarettes is 
not new. The FDA has received 127 reports of seizures and other 
neurological conditions caused by e-cigarettes. When a product 
is released onto the market without safety testing or clinical 
trials, this is what we fear.
    This is a problem exacerbated by e-cigarette companies that 
make what appear to be unfounded and illegal claims that their 
products are safer and healthier than combustible cigarettes. 
People trust and rely on those claims even when there is no 
evidence to back them up. That is why this subcommittee wrote a 
detailed letter to the FDA outlining our findings about JUUL 
illegally marketing its product as safe, healthy, and a smoking 
cessation device. FDA agreed with us and days after our letter 
responded with its own letter to JUUL declaring that JUUL had 
broken the law. JUUL's response is due next week on September 
30. After that, the FDA will have the opportunity to act.
    I encourage all of you to follow that development closely. 
We certainly will. Just days after the FDA responded to our 
letter, the administration, in part citing our investigation, 
announced that it would move to ban all e-cigarette flavors, 
including mint and menthol. The fact that flavors hook kids is 
a point this subcommittee hammered home over our two days of 
hearings in July. The administration cited our hearings in 
rolling out its proposal.
    We should all be encouraged that Democrats and Republicans 
are coming together when the health of our Nation's youth comes 
under attack. Today, as we focus on the tragic outcomes of this 
lung disease outbreak, we must view it as another chance to 
come together to protect public health. At the heart of the 
recent vaping-related outbreak, our families are be being 
blindsided.
    With us today is Ruby Johnson, a mother of seven from near 
Chicago. This August, as she prepared to drop her oldest 
daughter off to start college, already a stressful time, the 
Johnson family faced a terrifying health scare. Instead of 
moving into a dorm room, her daughter moved into a hospital bed 
far from home, where she stayed for what would have been her 
first week of classes. Ruby's daughter could have died. 
Thankfully, she recovered enough from her bout of lung disease 
to be released, but she still has trouble breathing, and 
doctors cannot tell her how much longer that may last.
    Mrs. Johnson, thank you for coming to share your family's 
her harrowing experience.
    We are also joined by leaders from the public health 
community to provide a neutral assessment of the outbreak and 
provide their advice to the public they serve. We have Dr. Anne 
Schuchat from the CDC, Dr. Ngozi Ezike of the Illinois 
Department of Public Health, and Dr. Albert Rizzo of the 
American Lung Association. Thank you all for joining us today. 
We look forward to learning more about how we can avoid more 
preventable deaths.
    With that, I recognize the ranking member, Mr. Cloud of 
Texas, for five minutes for an opening statement.
    Mr. Cloud. Thank you, Mr. Chairman.
    Over the last several weeks, it's been clear that certain--
that users of certain vaping products have become very ill, 
some tragically and to the point of death.
    Mr. Chairman, I do greatly appreciate your desire to 
utilize this committee's authority to get to the bottom of 
what's causing these mysterious illnesses. In the Center for 
Disease Control's prevention September 19 update, the number of 
those sick reached 530, and eight deaths had been confirmed. 
This is very concerning, and it is clear that we need to 
examine the cause and what can be done to prevent it.
    To the best information available, many of these cases seem 
linked to the use of products that present themselves to be 
something they are not. Based on the limited data available 
about those impacted by this mysterious lung illness, 
approximately 16 percent are under 18 years of age. And while 
each life affected is important, these recent incidents also 
serve to further bring attention to what has become an epidemic 
increase in teen vaping with currently 20 percent of high 
school students vaping. Add to that the decades-long epidemic 
of addiction to traditional tobacco smoking that will leave 
five people dead by the end of these opening statements. As a 
father of three, this is very concerning.
    I wish we had a quick fix to ensure that each child is 
protected, that no American finds themselves bound by a 
substance, and that all of us are able to find complete 
personal fulfillment in experiencing the purpose for which we 
were created.
    Today we're here to discuss what should be the appropriate 
response to the lung illnesses associated with certain vaping 
products. Complicating this discussion is the lack of 
scientific data and studies available, counterfeit products, 
untraceable supply lines, a lack of enforcement that allows 
players to pass the buck of accountability.
    For example, data available leads us to believe that many 
of the recently reported 530 cases involved vaping cannabinoid 
products. I hope today we're able to do the good work for which 
this investigating committee exists. I believe there's a lot of 
bipartisan support for addressing this situation. I appreciate 
the chairman's heart in this. To the point of examining this to 
find the solution and our desire to end teen vaping, there is 
unity.
    Please know my heart goes out to those impacted and my 
condolences to those who lost loved ones. Again, I appreciate 
the chairman's work on this issue and look forward to a 
productive discussion today.
    Mr. Krishnamoorthi. Thank you, Mr. Cloud.
    I should say we recently just started a bipartisan, 
bicameral, anti-youth vaping caucus.
    And thank you, Mr. Cloud, for joining that caucus.
    Today happens to be National Recovery Day, a bipartisan 
endeavor to recognize the folks in our lives who may be 
affected by substance-use disorders and our attempts to try to 
wean them off their addictions. I just hope that vaping is not 
that next substance use disorder.
    Today, we are joined on panel one by Dr. Anne Schuchat, 
Principal Deputy Director of the CDC. If you would 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?
    Dr. Schuchat. I do.
    Mr. Krishnamoorthi. Let the record show that the witness 
answered in the affirmative.
    Thank you very much, and please be seated. The microphones 
are sensitive, so please speak directly into them. Without 
objection, your written statement will be made part of the 
record.
    With that, Dr. Schuchat, you are now recognized for five 
minutes. Thank you.

 STATEMENT OF ANNE SCHUCHAT, M.D., PRINCIPAL DEPUTY SECRETARY, 
           CENTERS FOR DISEASE CONTROL AND PREVENTION

    Dr. Schuchat. Good morning, Chairman Krishnamoorthi, 
Ranking Member Cloud, and members of the subcommittee. Thank 
you for the opportunity to testify today about CDC's 
investigation into lung injury associated with using e-
cigarettes or vaping products.
    Today, I'll discuss with you what we know and don't know 
and what we're doing to address this outbreak of lung injury. 
I'll also discuss our efforts to address the epidemic of youth 
e-cigarette use or vaping. I want to make four key points.
    First, as soon as we learned about the initial cases of 
lung injury, CDC has been working 24/7, hand-in-hand with the 
FDA, and our state and local public health partners to find the 
cause. Second, our ability to do this type of investigation 
relies on a critical underlying public health infrastructure, 
including data systems that need modernization and a trained 
public health work force. Third, the CDC has made important 
recommendations to the public, including the following: While 
this investigation is ongoing, people who are concerned about 
lung disease associated with e-cigarette use or vaping should 
consider refraining from using e-cigarette products or vaping. 
People should not buy these products off the street and should 
not modify them further. Adults who use e-cigarettes or vaping 
products because they have quit cigarette smoking should not 
return to smoking cigarettes.
    We have a need to address the epidemic of youth use of e-
cigarettes, and this current outbreak reinforces the need to 
address the broader youth e-cigarette epidemic. So what do we 
know so far? As you've heard, several hundred cases have been 
reported from nearly all states. We've had a number of deaths. 
The cases are occurring in young people. One-half of all cases 
are less than 25 years old.
    People present with cough, shortness of breath, chest pain, 
and sometimes with symptoms like nausea and vomiting, fatigue 
or fever. Most of the cases, with information so far, have 
reported use of either THC or THC and nicotine-containing 
products. Some have reported nicotine only. There may be some 
challenges with the histories of exposure in some subset of the 
patients.
    Well, what do we not know so far? Probably, the most 
important thing: We don't know the cause. No single product, 
brand, substance or additive has been linked to all cases. This 
investigation is ongoing, and it's very dynamic.
    What are we doing to respond? CDC is working closely with 
state and local public health, with the FDA and clinical 
community to get to the bottom of this. We've deployed staff 
through what we call Epi-Aid assistance to help states with 
their investigations. We provided technical assistance, 
developed a case definition, standardized clinical guidance and 
a reporting system, and working every day on coordinating the 
parts of the investigation and response. We set up an incident 
management system and activated our emergency operations 
center, as we do in other public health urgent situations. We 
have convened the public health, clinical, and media numerous 
times to share what we know and don't know and how they can be 
part of the solution.
    One such example is a clinical outreach and communication 
activity call that we held in the past few days that had 2,500 
lines active and clinicians around the country listening to the 
latest information. We're working very closely the FDA on the 
laboratory aspects of trying to trace back and study the 
products from affected patients. There are challenges with this 
response, including the nature of the outbreak itself.
    Many states--some of the cases report using illicit 
products and may not be fully forthcoming. The marketplace for 
e-cigarettes is wide and diverse, with a multitude of products, 
and it may be very complicated to tease out the problematic 
exposures. Our public health data collection systems are in 
need of an upgrade.
    In terms of the youth e-cigarette use, we are seeing an 
epidemic, and in the questions, I'd be happy to go into many 
more details about that, but our most recent data for 2019 is 
continuing to be concerning.
    I'll just leave you with this. CDC is dedicated to working 
around the clock together with FDA and the state and local 
health officials to identify the cause or causes of the 
outbreak and will continue to update you during the course of 
the investigation.
    Mr. Krishnamoorthi. Thank you very much, Dr. Schuchat.
    I now recognize myself for five minutes of questioning. Dr. 
Schuchat, thank you for the work that you are doing. The CDC 
has been very clear that it is not yet possible to determine 
the cause of the vaping-related lung disease outbreak. CDC has 
recommended that people consider not using any e-cigarettes. 
From that, we gather that nothing is off the table as a 
possible cause.
    Let's first describe the general types of e-cigarettes out 
there. From what I understand, there are two major categories. 
First, there are nicotine e-cigarettes, which have been the 
focus of this subcommittee's hearings up to this point. Then, 
second, there are THC e-cigarettes that replicate the effects 
of marijuana.
    Dr. Schuchat, you are examining both of those types of 
products as factors in the current outbreak of lung illness, 
and is it correct to say that you cannot rule out either as 
contributing to the outbreak?
    Dr. Schuchat. Yes, that is correct at this point. We are 
getting new information in every day, but we think it's very 
important until we know more that our recommendations be broad. 
Separate from this outbreak, we are quite concerned about the 
rise in nicotine-containing e-cigarette use among youth, which 
is really epidemic. But for this particular outbreak, we don't 
know yet what the product or products are, or whether they are 
components of the products that might be contained in both 
nicotine-and THC-containing devices.
    Mr. Krishnamoorthi. I want to focus on the nicotine e-
cigarettes for a second. In the Illinois and Wisconsin 
published analysis, almost 20 percent of the victims there were 
using only nicotine e-cigarettes, and overall, 61 percent of 
the victims were using, among other e-cigarettes, nicotine e-
cigarettes as well.
    So, Dr. Schuchat, there may be people out there who would 
like for this to be a THC-only problem so that they can go back 
to vaping nicotine e-cigarettes. If almost 20 percent of 
victims are using only nicotine e-cigarettes, do we still need 
to be concerned about all e-cigarettes at this point?
    Dr. Schuchat. At this point, I think caution regarding all 
containing--all products is recommended. It may not even be the 
THC or nicotine part; it may be additives or substances that 
may be common. It may material that is not labeled 
appropriately, and so we really do think consumers need to be 
quite cautious right now.
    Mr. Krishnamoorthi. Got it. And you can't rule out any 
brand of e-cigarettes at this point, Right?
    Dr. Schuchat. No single brand, product, substance, or 
additive has been ruled out as of today.
    Mr. Krishnamoorthi. I'd also like to better understand some 
of the possible contributing factors to the outbreak that you 
are considering. First of all, on August 22, CDC said, quote: 
Even though the cases seem similar, it is not clear if these 
cases have a common cause or if they are different diseases 
with similar presentations.
    Does that mean that it could be multiple separate problems 
with e-cigarettes that are causing similar results?
    Dr. Schuchat. Yes, that's right. The respiratory symptoms 
are very nonspecific and the X-ray findings are diverse. So we 
also have cases in nearly all states at this point. Whether the 
products in one state are the same as the problematic products 
in another or the manipulation of the products is what's going 
on, we don't know. So I think we have to have a very open mind.
    Mr. Krishnamoorthi. We don't know the full impacts of 
vaping. If so many different vaping products are causing the 
same result, could the common link possibly be the process of 
vaping itself, inhaling aerosolized liquid particles into our 
lungs?
    Dr. Schuchat. We don't know enough about the aerosol that 
vaping produces or that e-cigarette produces in terms of the 
shorter term or longer term health impacts and products--it may 
be that the process itself is risky.
    Mr. Krishnamoorthi. All e-cigarettes include solvents like 
propylene glycol and vegetable glycerin, while they are 
considered safe in food, a recent Baylor study found those 
solvents, when inhaled, reduced the lung's ability to fight 
infection, increased the chances of getting the flu and of 
dying from it.
    Dr. Schuchat, these solvents are in all e-cigarettes. Can 
the CDC rule them out as a factor in the current outbreak?
    Dr. Schuchat. We have not ruled out any substance within 
the e-cigarettes or vaping products yet.
    Mr. Krishnamoorthi. Many of the victims were using flavored 
products. To add flavor to an e-cigarette requires additional 
chemicals on top of the various solvents that we just talked 
about. Can CDC rule out the chemicals in flavors as a factor in 
the current outbreak?
    Dr. Schuchat. No, we can't.
    Mr. Krishnamoorthi. Dr. Schuchat, I just want to remind 
everybody that you took a far-reaching warning or admonition to 
the public; that is, the CDC advises the public to consider not 
using any e-cigarettes at this point. The CDC also advised that 
those who do not vape, not to start; that children and pregnant 
women never use e-cigarettes; and, for those trying to quit 
smoking, to use an FDA-approved cessation device. E-cigarettes 
are not approved by FDA for smoking cessation.
    With that, thank you. And now I recognize Mr. Cloud for 
five minutes of questioning.
    Mr. Cloud. Thank you.
    Dr. Schuchat, previously, the CDC has said that the 
illnesses that we're seeing aren't necessarily a result of 
infections but rather chemical exposure. Do you maintain that 
distinction, or is it possible that the chemical exposure is 
leading to reduced immune system, therefore, leading to 
infection?
    Dr. Schuchat. Part of the case definition is to rule out 
infections as a cause. Certainly people presenting with cough, 
shortness of breath, and abnormal X-rays often have an 
infection, but in these episodes, we don't believe infection is 
what's causing the problem, and we do think it's one or more 
chemical exposure.
    Mr. Cloud. Okay. Do the patients generally have symptoms 
immediately after vaping, or is it after--do they appear later?
    Dr. Schuchat. We understand from the early reports that 
there's a progression between days and weeks of worsening 
symptoms until the difficulties are severe enough to present 
for hospitalization. Nearly all the cases have required 
hospitalization. Many of them have required intensive care unit 
and mechanical ventilation, and, as you know, sadly, several 
cases of have passed away.
    Mr. Cloud. Have you been able to investigate supply lines? 
What I've read it seems like it's been very difficult to 
backtrack where a number of these products are coming from?
    Dr. Schuchat. This is a very active investigation. The FDA 
is leading the product tracebacks, and they are also working 
with the DEA in that effort. We're certainly trying to gather 
information on the products that individuals have used. Many 
people have used more than one product, and they have acquired 
them from a variety of retail, online, social sources, or sort 
of on the street.
    Mr. Cloud. Right. When it comes to teen vaping, do you have 
a sense of where teens are acquiring products.
    Dr. Schuchat. I don't have that data right now, but we do 
see a significant rise in the use of e-cigarettes among 
teenagers, both middle school and high school students. One of 
the things that we see in common there is the role of flavors, 
that flavors are a big attractor for teenagers, and usually the 
first product people are using is flavored.
    But in terms of where they're getting them, I don't have 
the data. Sometimes it's really just a friend or a peer who's 
providing something to them.
    Mr. Cloud. To followup on that, I guess my question is, in 
most states, it's already illegal for teens to acquire the 
vaping products, right?
    Dr. Schuchat. That's right. In terms of e-cigarette use is 
not supposed to be for anyone under 18, and that is since the 
2016 legislation.
    Mr. Cloud. Is there any effort underway really in the realm 
of enforcement and prosecution for those who are getting 
products to teens?
    Dr. Schuchat. That would be the realm of the FDA in terms 
of the Federal legislation for the e-cigarettes, and so the 
issue of access to products is a key barrier to use of e-
cigarettes among youth, and the stricter it is, the better. So 
we are very much in support of making it extremely difficult 
for young people to get products that they're not supposed to 
have.
    Mr. Cloud. What are some of the recommendations you would 
have when it comes to that?
    Dr. Schuchat. There are a variety of population-based 
strategies that are shown to be effective to limit access for 
youth to cigarettes or e-cigarettes at this point. One of the 
issues is the advertising that is particularly appealing to 
youth. That is a problem that we saw with cigarettes decades 
ago, and we have been seeing again with e-cigarettes more 
recently. Another is the retail sites requiring proof of age.
    There are a number of other efforts we're doing in terms of 
raising--that we don't do, but the states select strategies 
like raising the price, as well as using efforts to educate in 
the schools, you know, toolkits for schools and so forth.
    Mr. Cloud. Right. Do you have--we talk about product lines 
and supply chain. Do you have any sense of how much is coming 
from counterfeiting places or China, or, I mean, there's a lot 
of loopholes when it comes to freight and air freight, products 
that aren't shipped coming in? Do we have any sense of where 
the illicit product is coming from?
    Dr. Schuchat. What I would say is that this is an extremely 
dynamic market. The legal market and perhaps the illicit market 
are very dynamic. We've seen huge changes in market share for 
e-cigarettes in the past couple years, and I believe there's 
likely to be an illicit market that is mirroring the rise that 
we're seeing in the legal market.
    Mr. Krishnamoorthi. Thank you, Mr. Cloud.
    I now recognize Congressman DeSaulnier for five minutes of 
questioning.
    Mr. DeSaulnier. Thank you, Mr. Chairman. Thank you and the 
ranking member for having this hearing.
    And, Doctor, thank you for the work you do and being here.
    On September 6, the CDC issued the following statement 
during a press conference announcing this investigation, and I 
quote: While the investigation is ongoing, CDC advises that 
individuals consider not using e-cigarettes because, as of now, 
this is the primary means of preventing this type of severe 
lung disease, and that e-cigarette use is never safe for youth, 
young adults, or pregnant women.
    During the same press conference, you announced that you 
were setting up your emergency operation center. Doctor, could 
you describe to the committee what factors led CDC to that 
decision and what kind of expertise will result from that. And 
given the life-threatening emergency that we're faced in, how 
do we make sure that we don't lose anyone else?
    Dr. Schuchat. You know, this is a fast-moving and very 
serious outbreak of a new condition in primarily young people. 
CDC established an incident management system to respond to the 
outbreak and then took the additional step of activating our 
emergency operations center. We have more than a hundred people 
responding to the outbreak right now in Atlanta as well as 
deployed to assist its states. We took the step of activation 
to better support the state and local public health who are on 
the front line of this.
    We have hundreds of cases getting reported to us from all 
across the Nation in order to work efficiently and effectively 
with the states as well as the FDA and others. The EOC 
activation facilitates that.
    Mr. DeSaulnier. Doctor, I'm from the San Francisco Bay 
area. When I go home, JUUL is now spending up to $40 million, 
probably more, in overturning a local ordinance by the San 
Francisco municipal government that merely says that e-
cigarettes are banned until the FDA comes up with the end of 
their investigation of whether they're safe or not.
    Recently, we had an executive and a founder of JUUL sit 
here and, from my perspective, try to say that e-cigarettes, 
their product, actually is helpful to keeping people away from 
tobacco, particularly young people. In Richmond, California, in 
my district, they just passed a similar ordinance.
    So those ordinances--and we'll talk about this more in the 
second panel--seems to me to be a preventative cautious 
approach to this. You've got something--a product out there--
that's leading to deaths.
    What could we do further as a Congress to make sure this 
doesn't happen? We have a company, in my view, that has no 
ethical boundaries, is in the business of addicting people, 
particularly young people, and is willing to spend $40 million. 
And the FDA has announced that their criminal division is 
investigating them, and I hope they investigate their political 
consultants as well. They are shameless when it comes to the 
information they give.
    So, given you're getting the public health officials 
involved, given that this committee is actively involved, this 
is a daunting task to try to make sure that the public actually 
understands, particularly young people, who are vulnerable, as 
you alluded to in your opening statement, to advertising like 
this.
    Dr. Schuchat. You know, I appreciate the committee's 
interest in the topic and the attention that you have given to 
this. We know that youth should not use e-cigarettes, that 
nicotine is one of the most addictive substances that there is, 
and that nicotine is dangerous for the developing brain that 
adolescents and young adults have.
    We also know that flavors are a major attraction for young 
people and that they often are the first e-cigarette type that 
children use and that the latest generation of e-cigarettes has 
a higher available nicotine level that is particularly 
additive.
    So the last few years of data raise our concerns 
substantially in terms of the epidemic of youth e-cigarette 
use, and I appreciate all that the committee is doing to 
address that.
    Mr. DeSaulnier. Do you need more statutory authority? In 
this instance, when young people, in particular, and life and 
death are on the line, would it be helpful for the CDC to, if 
they had the statutory authority to not just encourage people 
not to use it, but prohibit it people from using this until 
your investigation is done?
    Dr. Schuchat. Well, the CDC doesn't typically have 
regulatory authority over this type of matter; the FDA does. 
And, as you know, the FDA is taking many measures now to 
intensify their work in light of this epidemic, both the 
epidemic of youth vaping and the outbreak of lung injury.
    I think one of the key things that could help in this 
investigation, though, in terms of the outbreak, is 
modernization of our data systems that are really outdated, 
slow, that the epidemic is moving faster than our data 
gathering, and we're really losing people in the meantime.
    Mr. DeSaulnier. I appreciate that. The reason I asked the 
question is to suggest that the FDA is moving too slowly, and 
it might be, in my perspective, more efficient if the CDC 
actually had the authority to say that this product should be 
removed from being legally sold.
    Thank you, Mr. Chairman.
    Mr. Krishnamoorthi. Thank you, Mr. DeSaulnier.
    I now recognize Congressman Grothman for five minutes of 
questioning.
    Mr. Grothman. Okay. How long have these e-cigarettes been 
on the market?
    Dr. Schuchat. There are a number of different products, and 
there's really--we're on the fourth generation now, so----
    Mr. Grothman. Yes, but how many years?
    Dr. Schuchat. Well, in 2011, we are were seeing the first 
of the products, and, by 2012, there was a doubling in their 
use.
    Mr. Grothman. The first e-cigarettes were on the market in 
just 2011?
    Dr. Schuchat. We started measuring. Oh, excuse me, excuse 
me, this just in: 2007.
    Mr. Grothman. Yes, I thought it was before that. Okay. You 
said maybe 80 percent of the people who got sick, got sick on--
they admitted to putting THC in their e-cigarettes. How do you 
determine whether or not they had an illegal substance in their 
e-cigarettes or not?
    Dr. Schuchat. The information that you're citing is based 
on history. Individuals said what they thought they were using. 
There has been some testing of products that are still 
available.
    Mr. Grothman. Okay. I'll tell you what I'm trying to get at 
here. You're the one who testified that 80 percent of the 
people that got sick may have had THC in the product. Because 
THC is, I believe, illegal in most states in the countries, and 
I assume that some people don't like to volunteer that they've 
been doing something illegally. I wondered whether that is a 
hard number or maybe it's closer to 100 percent because some 
people, when asked, don't admit that they are breaking the law.
    Dr. Schuchat. The number that you're citing comes from an 
Illinois-Wisconsin report in the New England Journal of 
Medicine about what a small number of patients described using. 
We acknowledge that individuals may be reluctant to describe 
use.
    Mr. Grothman. Self-reporting. Yes. Self-reporting. Okay.
    Next question. You guys report that about 72 percent of the 
people who got sick were male. Could you tell me, e-cigarettes 
overall, what percentage of people who buy legal e-cigarettes 
are female and what percent are male?
    Dr. Schuchat. More males buy e-cigarettes than females.
    Mr. Grothman. Okay. Seventy-two percent, though, hits me 
has a high number.
    Dr. Schuchat. The statistics on the proportion of these 
lung injury cases that are male has been decreasing as we get 
more cases reported to us. So we'll be updating those numbers. 
But you're right that, so far, nearly three in four of the 
reported cases are in boys or men.
    Mr. Grothman. Well, how about people who buy e-cigarettes 
to prevent smoking, which is what, you know--10 years ago, I 
thought that was the whole deal. We had this new way to prevent 
people from smoking. We have over 400,000 people a year dying 
of smoking-related illnesses. I mean, 10 years ago, this was 
perceived to be a good thing.
    Of people who buy e-cigarettes to stop smoking, do you have 
a breakdown male by female--male versus female?
    Dr. Schuchat. We know that e-cigarette use is much more 
frequent in young people than adults.
    Mr. Grothman. Yes, I know, but you haven't answered my 
question.
    Dr. Schuchat. I don't have the breakdown of those who are 
using e-cigarettes for cessation.
    Mr. Grothman. Okay. I think, in most states, THC is 
illegal. But, over time, more and more states are legalizing 
marijuana. I don't know who to blame for that, but--including 
my neighbor to the south in Illinois. Are these cartridges or 
these new things legal in states which legalized marijuana or 
not?
    Dr. Schuchat. The legal provinces in states are quite 
different right now. It's a very diverse landscape, and I don't 
have the specifics on individual states.
    Mr. Grothman. I wish you'd look into that. I'm concerned 
because, right now, right to the south of Wisconsin, Illinois 
has decided to go all in on making marijuana legal. You do not 
know, though, whether the Illinois statute will make these 
things legal or not?
    Dr. Schuchat. You know, the key thing about the 
investigation is that there is no----
    Mr. Grothman. But just say yes or no.

    Dr. Schuchat [continuing]. is that there's no single 
product, cartridge, substance, or additive----
    Mr. Grothman. If you don't know, just say you don't know.
    Dr. Schuchat [continuing]. that's been linked to the cases 
in this outbreak.
    Mr. Grothman. Okay. But you don't know; it's possible that 
Illinois just made this stuff legal?
    Dr. Schuchat. Which stuff?
    Mr. Grothman. THC in cartridges.
    Dr. Schuchat. I don't know.
    Mr. Grothman. Okay. I'd like you to look into it because 
it's something we should know. It sounds like it's big trouble 
if Illinois just made these things legal. Could you explain 
why--we dealt with these a little bit when I was in the state 
legislature, maybe eight years ago, and at the time, you never 
heard about this.
    Why is this a new thing happening now, and you never heard 
about it eight years ago?
    Dr. Schuchat. Do you mean the youth vaping or do you mean 
the outbreak of lung injury?
    Mr. Grothman. People dying.
    Dr. Schuchat. Thank you. We don't know, but we know that 
the products out there have changed a lot, and the use has 
probably increased. But we don't yet know if there's a new 
particularly risky product out there or a substance that's in 
the products or a manipulation that's dangerous.
    There's a fourth generation of e-cigarette products that 
are out there that may perhaps be related in some way to this, 
but we don't know yet why this condition is occurring in this 
particular epidemic.
    Mr. Grothman. Thank you.
    Mr. Krishnamoorthi. Thank you, Mr. Grothman.
    I now recognize Congresswoman Hill for five minutes of 
questioning.
    Ms. Hill. Thank you so much, Mr. Chairman.
    Dr. Schuchat, on September 6th, LA County had its first 
reported vaping death. The week before, an LA County teenager 
began an anti-vaping campaign from her hospital bed where her 
lungs had failed from using e-cigarettes and where she had to 
be put on a ventilator.
    LA County public health officer, Dr. Muntu Davis, has 
compared the revelations about e-cigarettes to the slow 
discovery of the danger of cigarettes several decades ago. 
Across California, there have been 57 cases of acute lung 
disease among people with a recent history of vaping since late 
June, according to state health officials. Parents, kids, and 
adult vaporers are understandably scared by the outbreak of 
lung disease sweeping the country and claiming lives.
    The CDC and state health departments, with Illinois at the 
forefront, have been working together to investigate the 
outbreak.
    Dr. Schuchat, as of a couple days ago, CDC has reported 530 
confirmed and probable cases of lung disease in 38 states. Are 
those numbers expected to grow as states examine older cases 
against the current case definition?
    Dr. Schuchat. We are seeing more and more cases each day, 
and I expect the next weekly numbers will be much higher.
    Ms. Hill. Thank you. How does the disease typically present 
itself in patients' symptoms?
    Dr. Schuchat. People have days or even weeks of worsening 
breathing problems, cough, shortness of breath, sometimes with 
fever or nausea and vomiting.
    Ms. Hill. And what do we know about the time range for 
symptoms to set in after the last use of e-cigarettes?
    Dr. Schuchat. We don't have lots of details. It may be days 
or weeks.
    Ms. Hill. For those affected by the lung disease, how long 
are they being hospitalized, and are they typically in 
intensive care?
    Dr. Schuchat. The average hospitalization length so far is 
about six days. Many are in intensive care. Many require 
mechanical ventilation.
    Ms. Hill. That's what I was going to say. How many of the 
patients require medical intervention to breathe?
    Dr. Schuchat. A large proportion.
    Ms. Hill. And what has been successful in treating them?
    Dr. Schuchat. As of now, we know that antibiotics don't 
have an effect, and that's consistent with the idea it's not an 
infection. But some are seeing improvement after use of 
corticosteroids or steroids. We don't have evidence yet about 
the benefits and risks, but we do think that individuals 
should--clinicians should consider use of corticosteroids in 
treating patients on an individual basis.
    Ms. Hill. So potentially some kind of inflammation, like an 
acute inflammation?
    Dr. Schuchat. That's right.
    Ms. Hill. So the joint study by Illinois and Wisconsin 
found a median age of 19 years old in those two states and that 
32 percent of those affected are under 18. Why is this 
affecting young, otherwise healthy, kids?
    Dr. Schuchat. We don't have all of the answers, and as we 
gather more data, we're finding more individuals who are older 
also at risk. But we do see in our national data half of the 
cases are under 25.
    Ms. Hill. We're deeply alarmed by the nine deaths, 
including one reported last night, that are linked to this 
disease and the short span of its outbreak. Is there anything 
that we've learned about how this lung disease results in death 
and what we can do to avoid it?
    Dr. Schuchat. We're really looking into that closely right 
now. Sadly, we are hearing about more deaths, as you just 
mentioned, and we do expect more. That's one of the reasons 
we've been trying to get our health recommendations out there, 
so that, until we know more, people who are concerned about 
their health risks refrain from using e-cigarettes or vaping 
products, or at least consider that.
    Ms. Hill. Is it possible that this disease has been going 
on longer than we thought, and it's just now being linked to e-
cigarette use?
    Dr. Schuchat. I think it's less likely that large scale 
we've been seeing this and missed it. We're using something 
called syndromic surveillance now to look back in time at 
emergency department visits, and we have evidence that things 
really started to pick up in the spring or summer for this 
condition. Of course, there probably have been individual 
instances that we missed.
    Ms. Hill. So, when I think about families in my district 
whose kids are vaping and who are deeply concerned, to me, this 
is one of the most important questions: When specifically 
should someone go to the doctor, and what information should 
they convey?
    Dr. Schuchat. You know, if you you've been using e-
cigarettes or vaping and you're having difficulty breathing or 
cough and the kinds of symptoms that we've described, you 
should talk to your doctor about that. We don't know exactly 
how rapidly people progress, but we are concerned about the 
very severe cases we've been seeing in young people.
    Ms. Hill. We've heard from some patients that doctors have 
not uniformly asked about vaping or JUULing. Vaporers say no if 
doctors ask if they smoke. Do you think doctors need to change 
the questions they ask their patients, and how can we make that 
happen?
    Dr. Schuchat. Yes. We recommend that doctors not only ask, 
do you smoke cigarettes, but ask if you use e-cigarettes or 
vaping products. We think it's really important at this time 
for clinicians and parents to educate themselves about the 
types of products that are out there and to ask the right 
questions.
    Ms. Hill. Patients are being--who have recovered and 
released--are being told they'll need periodic lung scans. Do 
we know whether this outbreak will result in long-term or 
permanent lung damage?
    Dr. Schuchat. I fear that it may, but we do not know that 
yet, and we do recommend clinicians do regular followup of 
individuals. The clinical community, the pulmonologists and so 
forth are studying patients, and of course, it's so new that we 
don't have long-term followup yet.
    Ms. Hill. Thank you so much. I'm out of time, and I yield 
back.
    Mr. Krishnamoorthi. Thank you, Congresswoman Hill.
    I now recognize Congressman Comer for five minutes of 
questioning.
    Mr. Comer. Thank you.
    Mr. Chairman, I want to spend my five minutes talking about 
CBD because I believe there's a lot of misinformation and 
confusion about exactly what CBD is and what THC is.
    So CBD is cannabidiol. And it is something that a lot of 
people take, a lot of people in Congress take CBD. Millions of 
Americans take CBD. I take CBD. These are two of the CBD 
products that I take, and I'll talk about that in just a 
minute. There are two sources of CBD. There's hemp and 
marijuana. And hemp and marijuana are two different plants in 
the same plant family, kind of like broccoli and cauliflower. 
If you could image what broccoli and cauliflower look like, 
they have some similarities, but they're also very different. 
That's the way it is with hemp and marijuana.
    Then there's THC. And THC is an acronym that measures the 
level of psychoactive material in CBD. So, if you look at CBD, 
a lot of--the majority of the CBD that most Americans are 
taking- and they're having really positive effects from CBD- is 
coming from hemp, not marijuana. The hemp CBD has little to no 
THC, and that's something that there's a lot of confusion about 
when I hear people talk about CBD and THC.
    Prior to coming to Congress, I was Commissioner of 
Agriculture in Kentucky, and we were the first state--this was 
something that was a platform of mine when I was elected to 
Commissioner of Agriculture, to make industrial hemp a reality 
in America. We weren't growing hemp in America. America was the 
only industrialized Nation that didn't grow industrial hemp.
    So, in Kentucky, we became the first state to grow hemp. 
Today, Kentucky is the leading hemp-producing state in the 
Nation. There are at least 15 hemp processors in Kentucky that 
are making CBD oil. I have been in the--these two products here 
that I take, I've been in those companies. I've seen their 
labs. Those companies are, in my opinion, producing a good 
legitimate product. But those companies want the industry to be 
regulated.
    Currently, there are no FDA regulations on CBD oil. And the 
legitimate credible companies want regulation. I have worked 
with Congresswoman Pingree in Maine. We have submitted a 
bipartisan letter with 24 other Members of Congress, both 
parties, asking the FDA to hurry up and issue FDA regulations 
with respect to CBD.
    Let me note, JUUL does not sell any CBD pods. All their 
pods are nicotine pods. So the sickness that happened and the 
deaths that came from CBD, from people JUULing or using e-
cigarettes with CBD, these were counterfeit pods. And the 
people that were producing these pods, not only were they 
counterfeit, they don't know what levels of THC they were 
putting in the pods because there's really no regulations on 
it.
    This CBD industry is like the Wild West. It's a good 
industry. It's a good product, but there needs to be 
regulations. I'm very conservative, very pro-business. 
Normally, I'm against regulations, but sometimes we need 
regulations.
    A young man in my district was recently hospitalized from 
vaping CBD with excessive amounts of THC. He bought the pods 
from a friend. They released him from the hospital, and he got 
sick again and was hospitalized again with a collapsed lung, 
and he had to be put on life support--in my district.
    Mr. Chairman, I ask unanimous consent that this article 
detailing my constituent's story be inserted into the record.
    Mr. Krishnamoorthi. Without objection, so ordered.
    Mr. Comer. I also want to note: The Associated Press has 
tested 30 vapor products that were marketed containing CBD and 
found that 10 of the 30 contained synthetic marijuana; 22 of 
the 30 contained very little or no CBD. The CBD--this CBD 
produced in my congressional district, processed in my 
congressional district, has no THC, zero THC. So there's a lot 
of misinformation and confusion about CBD that I wanted to make 
sure that everyone understood.
    The Associated Press also reported on testing that the DEA 
had done and found that 128 of the 350 CBD products they had 
tested contained synthetic marijuana. Three of these tested 
products contain fentanyl.
    So, Mr. Chairman, I ask unanimous consent that the two 
articles from the Associated Press be inserted into the record.
    Mr. Krishnamoorthi. Without objection, so ordered.
    Mr. Comer. And, Mr. Chairman, if I may, I'll conclude by 
saying that I think that there's a lot of positive benefits 
from cannabidiol oil, but this industry needs to be regulated. 
This industry is very prevalent in my congressional district, 
and they want regulations to make sure there are no bad actors, 
to make sure there are no fly by-night companies that are 
coming in producing cannabidiol oil with excessive amounts of 
THC. So that's something that I'm working on.
    I had Chairman Collin Peterson in my congressional district 
Sunday visiting with some of these hemp processors. Our office 
is working with USDA and FDA to try to see that we have good 
regulations that protect the consumers while helping the 
industry grow.
    Thank you, Mr. Chairman, I yield back.
    Mr. Krishnamoorthi. Thank you, Mr. Comer.
    I now recognize Congressman Khanna for five minutes of 
questions.
    Mr. Khanna. Thank you, Mr. Chairman, and thank you for your 
leadership on this issue.
    Dr. Schuchat, is it true that 28 percent of the Nation's 
12th graders reported vaping nicotine at least once in the past 
30 days?
    Dr. Schuchat. Those data are from the preliminary results 
of the 2019 National Youth Tobacco Survey. The final results 
aren't quite available, but that's right.
    Mr. Khanna. And is there a statistical analysis that found 
that for one smoker that successfully quits, thanks to e-
cigarettes, 81 young e-cigarette users will become traditional 
cigarette smokers. Are you familiar with that?
    Dr. Schuchat. I don't have that statistic, but what I can 
say is that e-cigarette use is much more frequent among young 
people, youth, than it is among adults.
    Mr. Khanna. And are you familiar that people who use e-
cigarettes then end up going and using regular cigarettes?
    Dr. Schuchat. That's right. The National Academy of 
Medicine looked at that, and whether e-cigarette use may lead 
to tobacco--lead to smoking cigarettes, and there's moderate 
evidence about that. The newest generation of e-cigarettes 
isn't really covered under that study, and the newest 
generation seems to have a number of factors that make it even 
more addictive or even more popular among youth. So we don't 
really have the long-term followup on that.
    Mr. Khanna. On September 11, 2019, President Trump 
announced a ban on flavored e-cigarettes. He finally did 
something I agree with. And it hasn't been implemented yet at 
the FDA. My understanding is the CDC came out in strong support 
of the flavor ban, with the Director stating that it's needed 
to reduce the epidemic. But Washington is a very political 
place, and so now you have the President's advisers telling him 
that this is going to hurt his reelection in battleground 
states because there are hundreds of thousands of people in 
battleground states who vape.
    What would you tell the President about that argument that 
his advisors are making and whether he should stick to his 
original ban?
    Dr. Schuchat. Let me just say that the regulation of 
tobacco products is under the FDA, not the CDC. As a public 
health expert and as a leader at the CDC, I can say that we're 
extremely concerned about flavors and the role that they play 
in hooking young people to a life of nicotine and that we 
really want to avoid another generation being addicted to 
nicotine.
    So addressing flavors directly is a good idea in terms of 
the role that they play in young people, particularly middle 
school and high school students beginning to use e-cigarettes.
    Mr. Khanna. At a substantive level, how would you answer 
the tradeoff where people say, we agree with you on children 
not having these flavors, and that's why I support a ban; 
that's why people support a ban. But what do you say adults 
should do who want to transition off cigarettes? Are there ways 
that they can still use e-cigarettes without the flavor, with 
only the tobacco flavor? Is there evidence to suggest that it 
would diminish their ability to reduce their addiction to 
cigarettes.
    Dr. Schuchat. We don't think that flavors are the critical 
factor in e-cigarettes for adults who are trying to get off of 
smoking cigarettes. We think the nicotine level is the 
principal issue there. We certainly encourage adults to quit 
smoking and use FDA-approved devices or approaches to do that. 
Behavioral counseling is also recommended, and there's emerging 
data that is being looked at about the role of e-cigarettes. 
None of the e-cigarette companies have applied to FDA to be 
approved as a cessation device as of yet.
    Mr. Khanna. So would it be fair to say then that you do not 
think banning flavors in e-cigarettes would in any way harm 
adults who seek to quit regular cigarettes by using e-cigarette 
products?
    Dr. Schuchat. I think the way you characterized that, I 
would agree with.
    Mr. Khanna. I have no further questions.
    Mr. Krishnamoorthi. Would the gentleman yield your 30 
seconds?
    Mr. Khanna. I do.
    Mr. Krishnamoorthi. Dr. Schuchat, fourth generation 
devices, you keep referring to this. What are those?
    Dr. Schuchat. What I'm trying to imply is that JUUL and 
related products use nicotine salts, which can lead to much 
more available nicotine. We believe they can cross--the product 
can cross the blood-brain barrier and lead to potentially more 
effect on the developing brain in adolescents.
    Mr. Krishnamoorthi. When was this fourth generation 
introduced to them?
    Dr. Schuchat. Well, the JUUL itself was 2015, but the 
market share really ratcheted up more recently. So the 2018 
data was 78 percent higher than 2017 for high school students, 
and the preliminary data is even higher for 2019.
    Mr. Krishnamoorthi. That's based on the fourth generation 
device really taking off?
    Dr. Schuchat. Right. We know that JUUL went up to over 70 
percent market share more recently than 2015. In 2015, it had a 
tiny market share.
    Mr. Krishnamoorthi. Okay. Thank you so much.
    I now recognize Congresswoman Miller for five minutes of 
questioning.
    Mrs. Miller. Thank you, Chairman Krishnamoorthi and Ranking 
Member Cloud.
    Thank you for being here today. There are two key issues 
that we must keep in mind surrounding e-cigarette usage. First, 
we must do everything we can to keep e-cigarettes out of the 
hands of those who are underage. Second, we must also recognize 
e-cigarettes' critical role in harm reduction. For that reason, 
we must not throw the baby out with the bath water.
    We can both prevent children from using e-cigarettes while 
also ensuring that they remain available for those adults who 
are choosing to quit smoking and trying to do it through such a 
mechanism. We have to work together with our Federal agencies 
to curb the online procurement of e-cigarettes, pods, and vape 
fluid by underaged individuals.
    This unregulated black market does not have any of the 
protections for those to use their products and to pose a 
safety risk for the public. I understand that there are 
companies who sell in the United States that have taken 
proactive and positive steps to prevent underaged individuals 
from procuring their products both online and in stores.
    Dr. Schuchat, can you first discuss the dangers of buying 
illegal or counterfeit vape products online?
    Dr. Schuchat. We think it's really critical to know what 
you are using, and it's very difficult right now, in terms of 
online purchases or off-the-street purchases or getting 
products from a friend, to know what you have. We also know 
that labels may be misleading and counterfeited. So, right now, 
the products are very diverse and vastly changing, and it's 
really one of those eras where consumers have to beware.
    We do think that retail stores really need to be enforcing 
the rules about not selling to underaged individuals and that 
we need to ensure that companies are not marketing to youth 
directly or indirectly through influencers or social media. 
There's just a lot of evidence that--ads that are attractive to 
youth, help them begin, and that the type of products we have 
on the market right now are extremely addictive.
    Mrs. Miller. Testing performed by a lab in California found 
that some black-marketed THC cartridges contained more than 35 
percent vitamin E acetate, and some tested positive for 
pesticides. What would substances like this do to the lung of 
an unsuspecting user?
    Dr. Schuchat. You point out a couple different substances 
that no one would really want to have in the middle of their 
lungs. And I think right now what we're working very vigorously 
on is trying to understand what are the products that 
individuals who have come down with this lung injury use and 
what was in them--and what was in them in a lot of other 
products. So FDA laboratories are working very hard on that 
issue right now.
    Mrs. Miller. So is that present in the cases that the CDC 
is monitoring right now?
    Dr. Schuchat. There's a variety of different substances 
that we're hearing about. We don't have full data yet. It's 
important to know that there may not be much remaining product 
from an individual. They might have used up the pod, for 
instance. And there may be differences in what you measure in a 
pod and what is--what the lungs are exposed to when that 
substance is heated to a very high temperature.
    So there are kind of sophisticated studies going on to try 
to analyze both the product and then potentially the vapor or 
aerosol as well. So we can't say any particular substance has 
been linked to all cases or the majority of cases as of yet.
    Mrs. Miller. Is there a name of this disease that people 
are getting?
    Dr. Schuchat. We're calling it ``lung injury associated 
with e-cigarettes or vaping.'' It's not particularly catchy. So 
we don't have a name that's shorter yet.
    Mrs. Miller. Just lung disease.
    Dr. Schuchat. We're saying ``lung injury,'' because it 
really looks like an injury, not like a long-term disease like 
emphysema. Of course, long-term, there may be consequences of 
the injury that we're seeing.
    Mrs. Miller. Isn't it true that counterfeit products 
sometimes design their packaging to look like legitimate 
manufacturers? And is the CDC seeing cases of pulmonary illness 
coming from these counterfeit products?
    Dr. Schuchat. I don't have information about counterfeit 
products, but that's exactly why counterfeit products make 
labels to deceive the consumer.
    Mrs. Miller. Okay. I yield back my time. Thank you.
    Mr. Krishnamoorthi. Thank you.
    I now recognize Congresswoman Pressley for five minutes of 
questioning.
    Ms. Pressley. I thank you, Mr. Chairman, for your 
leadership on this committee to hold JUUL and other e-cigarette 
manufacturers accountable for what is an urgent public health 
crisis.
    I am heartened to see the bipartisan interest and 
commitment to address what is a fast-moving outbreak and am 
hopeful that we will show similar and equitable outrage when it 
comes to gun violence, which is also a public health crisis.
    Dr. Schuchat, thank you for being here and thank you for 
your efforts in addressing this outbreak.
    I wanted to just revisit the line of questioning from 
Representative Khanna in talking about the Trump 
administration's intent to ban all flavored e-cigarettes from 
the market. The administration's ban clearly states that mint 
and menthol will be included. And I just wanted to get this 
answer on the record: Mint and menthol are, of course, flavors, 
correct?
    Dr. Schuchat. Correct.
    Ms. Pressley. Yes or no, to be effective, do you agree that 
the flavor ban needs to include mint and menthol?
    Dr. Schuchat. Yes.
    Ms. Pressley. Thank you.
    I'm encouraged by Federal and state efforts to ban flavors 
in e-cigarettes, especially as flavors continue to be a main 
driver of why youth are using these products.
    I want to do a special bit of acknowledgement in my home 
state, the Commonwealth of Massachusetts, our attorney general, 
Maura Healey, and the leadership of cities like Somerville and 
Cambridge.
    Even worse, 63 percent of JUUL users ages 15 to 25 have no 
idea that the product contains nicotine; they think it just has 
flavors--a dangerous misconception, considering that all JUUL 
products deliver nicotine and, according to the company's 
website, a single JUUL pod is equivalent to smoking one pack of 
cigarettes.
    Dr. Schuchat, are you familiar with the term ``nic sick''?
    Dr. Schuchat. No, actually.
    Ms. Pressley. What about ``nicotine poisoning''?
    Dr. Schuchat. Yes.
    Ms. Pressley. Can you describe how these syndromes might 
present themselves in children with high intake of nicotine?
    Dr. Schuchat. You know, the variety of symptoms that can 
occur from extremely high levels of nicotine is scary. The 
specifics I'll probably need to get to you. But I think that we 
are aware of a number of Poison Control calls related to e-
cigarette use and, sort of, overdosing, if you will, and then 
in terms of seizures having been reported----
    Ms. Pressley. Okay.
    Dr. Schuchat [continuing]. as adverse events. But the 
specifics of that I'd have to get back to you.
    Ms. Pressley. And do you know what impacts are the harms of 
high-dose nicotine when it comes to adolescent development? 
We've talked about how it might more acutely present, but 
what's the impact on adolescent development?
    Dr. Schuchat. Yes, the concerns about the developing brain 
in adolescents are that nicotine can lead to difficulty with 
memory, learning, and attention. It can also prime the brain 
and prime the body for addiction to other substances, and 
that's of particular concern.
    Ms. Pressley. All right.
    Then I'm just curious, have any states that the CDC 
coordinates with observed improvements in any of the 530 
confirmed cases since they fell ill? In other words, are you 
noting any improvements for those that have been diagnosed with 
a lung injury? And what best practices would you recommend to 
states and hospitals as they begin to track long-term impacts?
    Dr. Schuchat. Yes, we know that in small numbers the use of 
steroids during treatment may improve outcome, but we don't 
have scientific data or large-scale numbers yet on that.
    We're recommending right now that clinicians individualize 
care but they consider the use of steroids in terms of its 
benefit and its potential harm, since sometimes steroids can be 
risky if you do think there's infection going on.
    We also recommend that clinicians follow patients after 
discharge, including with pulmonary function tests, to see 
whether the lungs really come back fully to what you'd expect 
in an otherwise healthy young person.
    And then clinical communities are gathering the data to 
come out with more official recommendations.
    Ms. Pressley. Thank you.
    You know, no matter what you call it--JUULing, vaping, 
smoking--it's all the same. A new generation of young people 
are becoming addicted to nicotine through these kid-friendly 
flavors, and we have no idea, truly, the long-term impacts this 
will have. As a mother and lawmaker, I find this frightening.
    I yield back.
    Mr. Krishnamoorthi. Thank you. Will the gentlewoman yield 
her time for questioning?
    Fourth-generation e-cigarettes and the nicotine salts, what 
is the importance of that? You said it penetrates the blood-
brain barrier. What's the import of that?
    Dr. Schuchat. You know, the issue is, easier access of 
nicotine to the brain may have a higher risk of leading to 
those issues that I mentioned--the learning difficulty, the 
attention problems, the memory issues--as well as priming for 
addiction. So I think that the brain is pretty central in the 
issue of addiction as well as in cognitive functioning, and 
we're concerned that higher doses of nicotine getting into the 
brain may lead to larger problems.
    That fourth generation is not just JUUL but it's the other 
pod-mod combos. And the other factor I haven't mentioned yet is 
just, the devices are ones that are very easy to conceal. You 
can have them in the classroom; the teacher doesn't even know 
that you're using the e-cigarette. So, between the very high 
levels of accessible nicotine and the discreet use of the 
product, we think that the rise in teen use is particularly 
dangerous.
    Mr. Krishnamoorthi. Thank you.
    I now recognize Ranking Member Jordan for five minutes of 
questioning.
    Mr. Jordan. Thank you, Mr. Chairman.
    Doctor, 530 cases. And then is it accurate, eight deaths as 
well, that there have been eight deaths associated with the 
lung illness and vaping?
    Dr. Schuchat. Yes. It's even more than that now, but we'll 
be updating the official numbers on Thursday. So we believe 
that probably hundreds more have come in since the numbers we 
released last week.
    Mr. Jordan. What about--but no additional people passed 
away, right?
    Dr. Schuchat. There may--when a death occurs, the state 
investigates to identify whether they do believe it's related 
to this condition, and then they report to us. And so we let 
the states report publicly before we report on the mass number. 
I think we're above eight at this point.
    Mr. Jordan. Okay.
    Let's stick with the numbers 530 and eight. You said this 
about the 530 cases: Most patients have reported a history of 
using e-cigarette products containing THC; many patients have 
reported using THC and nicotine; some have reported the use of 
e-cigarette products containing only nicotine.
    So ``most,'' ``many,'' and ``some,'' if I get the 
distinctions right. Can you give me percentages on each of 
those? So most of the 530 have used e-cigarette products with 
THC. What percentage is that?
    Dr. Schuchat. Actually, those terms are related to the very 
small number that had been described in the Illinois-Wisconsin 
series. The most was--this is really about less than 50 cases. 
And ``most'' was about 80 percent; ``many'' was about 60 
percent; and ``some'' was less than 20 percent.
    But we'll be updating the numbers----
    Mr. Jordan. You don't have the percentages on the 530 
number, just on----
    Dr. Schuchat. No, not yet.
    Mr. Jordan [continuing]. the smaller population sample of 
Illinois-Wisconsin.
    Dr. Schuchat. That's right.
    Mr. Jordan. Okay. Any guess at the 530? Do you think it 
would be similar, 80 percent have used--do you think it would 
be similar and it'd be 80 percent of the 530 cases were using 
the THC?
    Dr. Schuchat. The trend continues in the preliminary look 
at larger numbers, but I don't have the precise final numbers 
yet. So I do believe that the majority report use of THC or THC 
and nicotine products.
    Mr. Jordan. Then, of course, there is the issue that the 
gentleman from Wisconsin raised, that the people who say they 
only used e-cigarette products containing only nicotine may not 
be totally forthcoming, they may be fudging a little bit on 
that.
    Dr. Schuchat. Absolutely.
    Mr. Jordan. Okay. So it could be, potentially, that THC is 
linked to all the cases of a health concern.
    Now, do you have the data on the eight people who have 
passed away? Do you know if it was--do you have any data on 
those? Were they using THC or not?
    Dr. Schuchat. I don't have that data. But a really 
important point is, it may not be the THC or the nicotine but 
it may be something associated with those products that people 
are using.
    Mr. Jordan. You just don't know yet.
    Dr. Schuchat. Right.
    Mr. Jordan. Okay.
    Now, you also said--you talked about the epidemic at the 
youth level, particularly high school level. What were the 
numbers--and I agree, you know, this is--I don't want any kids 
using this product, a bunch of other things either. But what 
was the number for high school students who were using the 
product?
    Dr. Schuchat. Yes, the preliminary data that was reported 
from the FDA--preliminary look at 2019 data was about 28 
percent of high school students reported using e-cigarettes, 
which was a big jump from about 20 percent the year before.
    Mr. Jordan. Yes, that is.
    Do you know the numbers for high school students who have 
used marijuana?
    Dr. Schuchat. It's less common, but I don't have the 
numbers right in front of me.
    Mr. Jordan. My understanding is it's over 20 percent as 
well. Is that right?
    Dr. Schuchat. I think you need to differentiate numbers 
that are used in the past year versus used in the past month. 
And the numbers I was giving you for e-cigarettes was used in 
the past month.
    Mr. Jordan. Okay.
    Dr. Schuchat. But I don't have those numbers for marijuana.
    Mr. Jordan. Is it over 20 percent as well?
    Dr. Schuchat. I don't know. I'm sorry.
    Mr. Jordan. Okay. Okay. I mean, I figured it was.
    Okay. I just was curious on some of these numbers. It seems 
to me we've got an epidemic with marijuana use, with vaping, 
with all kinds of things, and we should be talking about all of 
those issues that are of concern for young people.
    With that, I yield back, Mr. Chairman. Thank you.
    Mr. Krishnamoorthi. Thank you.
    Dr. Schuchat. Actually, I'm sorry, I----
    Mr. Krishnamoorthi. Go ahead, Dr. Schuchat.
    Dr. Schuchat [continuing]. did find the number for you. 
Sorry. I knew I'd seen it. But the number that I have for 
adolescents' use of marijuana is 12-1/2 percent in the past 
year.
    Mr. Jordan. Okay.
    Dr. Schuchat. So not the past month, but the past year. So 
a bit less than the 28 percent in the past month for e-
cigarettes.
    Mr. Jordan. Okay. Thank you.
    Mr. Krishnamoorthi. Mr. Jordan, would you yield your 
remaining 14 seconds for a question?
    Mr. Jordan. Yes.
    Mr. Krishnamoorthi. Dr. Schuchat, of the 530 cases, how 
many of them were related to fourth-generation devices?
    Dr. Schuchat. I don't have that data yet.
    Mr. Krishnamoorthi. Okay. Thank you.
    I now recognize Congresswoman Tlaib for five minutes of 
questioning.
    Ms. Tlaib. Thank you, Mr. Chairman.
    Earlier this month, my home state of Michigan became the 
first to ban flavored e-cigarettes. This came after news of e-
cigarette smokers showing up in emergency rooms with shortness 
of breath, chest pain, coughing, vomiting.
    Nationally, we have seen, as we've repeated in this 
committee, at least 530 cases of lung disease in e-cigarette 
users in 38 states. It exposes just how little we know about 
these products.
    Nicotine e-cigarettes were allowed onto the market with 
little regulation and advertised as safer alternatives to 
cigarettes. In practice, I truly believe that we've become 
testing ground, the American public, most disturbingly our 
American youth. And right now there is so much that we do not 
know about the long-term impact of e-cigarettes, but what we do 
know now, currently, is pretty alarming.
    So, Dr. Schuchat, why do you believe e-cigarettes have not 
been approved as cessation methods? Because they're advertised 
that way.
    Dr. Schuchat. Right. To my knowledge, the companies haven't 
submitted the data in support of getting them approved as 
cessation methods.
    Ms. Tlaib. But why?
    Dr. Schuchat. The companies would need to answer that, but 
it can be a costly process, and it may be that they would also 
need to describe the public health standard being met, and that 
may be difficult at this time.
    Ms. Tlaib. That's right.
    And, Ms. Schuchat, yes or no, is it ever safe for kids or 
young adults to use e-cigarettes?
    Dr. Schuchat. No.
    Ms. Tlaib. What about traditional cigarettes?
    Dr. Schuchat. No.
    Ms. Tlaib. CDC has stated that e-cigarettes harm the parts 
of the brain that control attention, learning, mood, impulses. 
Could that account for why we've heard so many teen JUULers 
complain about mood swings, you know, bouts like anger, 
depression, and trouble concentrating?
    Dr. Schuchat. Well, there's a lot going on in adolescents, 
but it may be part of that.
    Ms. Tlaib. We have also heard from many people who believed 
e-cigarettes were safe, and it's easy to see why, as we 
continue to see the misleading and the lies to the American 
public.
    But earlier this month, we wrote a letter to the FDA 
outlining our findings of instances of JUUL telling the public 
that its products were safe. Those included testimony at our 
July hearing that JUUL went into schools and told ninth-graders 
that its products were, quote, ``totally safe.'' They used the 
words ``totally safe.''
    We were pleased to see the FDA answered our call by 
declaring that JUUL broke the law and issuing a warning letter. 
FDA gave JUUL until September 30th to respond.
    To those listening, please pay attention to that response 
and what we hope will be prompt action by FDA to hold JUUL 
accountable.
    So, Dr. Schuchat, the CDC has asked the public to consider 
not using any e-cigarettes. Has the industry's false safety 
narrative made it more difficult to get your message out?
    Dr. Schuchat. We know that there's a lot of noise out 
there, and we've been repeating our messages. We do hope that 
the seriousness of disease, and including death, is getting 
attention, but there's a lot of competing messages.
    Ms. Tlaib. As much as e-cigarette companies imply that they 
are smoking-cessation products, none are approved by the FDA 
for that purpose, as we talked about. CDC has recommended that 
adult smokers who are using e-cigarettes to quit smoking 
traditional cigarettes should instead use, quote, ``evidence-
based treatments, including counseling and FDA-approved 
medications.''
    So, Dr. Schuchat, to your knowledge, has there ever been 
any outbreak of lung disease associated with FDA-approved 
cigarette-smoking-cessation devices, like patches and gum?
    Dr. Schuchat. Not to my knowledge.
    Ms. Tlaib. Thank you so much.
    I yield the rest of my time, Chairman.
    Mr. Krishnamoorthi. Thank you, Congresswoman Tlaib.
    Without objection, Ms. Wasserman Schultz, the gentlewoman 
from Florida, shall be permitted to join the subcommittee on 
the dais and be recognized for questioning the witness.
    Ms. Wasserman Schultz, you have five minutes.
    Ms. Wasserman Schultz. Thank you, Mr. Chairman. I thank the 
committee's indulgence for including me.
    Dr. Schuchat, welcome, and thank you so much. I've had the 
honor of working with CDC on a number of different important 
initiatives, and the work of you and your colleagues is really 
remarkable.
    I want to ask you a couple of basic questions and then a 
few illustrative ones.
    Is there any evidence at all that nicotine addiction is 
harmful to an individual's health?
    Dr. Schuchat. Yes.
    Ms. Wasserman Schultz. Could you elaborate?
    Dr. Schuchat. You know, we're particularly concerned about 
nicotine use in youth, in pregnant women--or women who are 
pregnant, and in adults who are not already using cigarettes. 
The issue is the developing brain, the developing fetus, and 
the risk of going on to cigarette smoking.
    In the developing brain, I think it's key, most people 
don't realize the brain continues to develop until age 25 in 
most people. And nicotine can cause many problems, including 
difficulties with attention, memory, learning problems. It can 
also prime the individual for addiction to other substances.
    Ms. Wasserman Schultz. I asked you that because sometimes 
you ask a question that you already basically know the answer 
to, but as a parent of twin 20-year-olds and a 16-year-old, 
having children and young adults in the target audience for 
these vaping products, that's important information to note, 
particularly in light of the fact that we had JUUL executives 
testify here in what I found to be a very deceptive way, 
including a direct answer to a question of mine in which the 
JUUL executive that sat where you are sitting actually had the 
audacity to say that they didn't market their product as a 
smoking-cessation product, splitting hairs between the idea 
that they are an alternative, a safer alternative, to smoking 
versus marketing it specifically as a smoking-cessation 
product.
    That, to me, is a distinction without a difference. And so, 
having an expert, a public health expert, actually say, ``No 
health benefits to nicotine; in fact, nicotine addiction is 
harmful, particularly to the developing brain,'' is critical, 
particularly because we do have a very real human impact of 
this outbreak, and I think it's important that it not be lost.
    There is a story that I want to share of a mother of three 
in Abilene, Texas, Sherie, who nearly died from vaping. She had 
never smoked cigarettes before. She tried e-cigarettes because 
she liked the taste of the flavors, and she became addicted.
    Sherie initially thought she had the flu, but within days 
she had to be rushed to the emergency room and put in a 
medically induced coma. There are now countless people who have 
had to be put into medically accused comas due to the impacts 
of vaping. She spent nearly a month in the hospital.
    Dr. Schuchat, Sherie was a nonsmoker drawn to e-cigarettes 
by their flavors. Is there evidence that you've found that 
other nonsmokers are being drawn in by the attraction to 
flavors?
    Dr. Schuchat. Yes, that's right. Among youth right now, 
we're seeing that e-cigarettes are more common than cigarettes 
and that flavors are pretty much always what brings the youth 
into starting use of e-cigarettes.
    Ms. Wasserman Schultz. And do you think a ban on flavors of 
any type would bring a dramatic reduction to people who either 
might be attracted to the flavors to begin vaping or if they 
were no longer available have people cease to vape?
    Dr. Schuchat. We know that flavors are a big attractant, 
and so I hope that if flavors were not there, fewer people 
would take the product up in their teen years.
    Ms. Wasserman Schultz. Okay.
    And e-cigarette use is still relatively new. I support harm 
reduction, public health activities. Advocates often describe 
e-cigarettes as a harm reduction for smokers, but I'm concerned 
that we don't actually know enough to say with confidence that 
e-cigarettes reduce harm. In fact, there have--I mean, JUUL is 
actually being federally prosecuted in a criminal proceeding 
because of their deceptive practices, much less that these e-
cigarettes don't produce harm.
    Can you talk to us about the challenges of being able to 
accurately assess the safety of e-cigarettes?
    Dr. Schuchat. The products have been changing quite a bit 
over the past several years, so short-term effects might have 
been looked at but the long-term effects we don't know yet. And 
the aerosol that e-cigarettes can produce has a lot of 
substances in it. Their long-term effect we just don't know. 
Ultrafine particles, heavy metals----
    Ms. Wasserman Schultz. So it's not just nicotine----
    Dr. Schuchat. Exactly.
    Ms. Wasserman Schultz.--that is the public health problem 
and the threat. So, I mean, hyper-focusing on nicotine or any 
other substance that is found to have been mixed in with all of 
the other chemicals that could be harmful and likely are 
harmful is misleading at best.
    Dr. Schuchat. Uh-huh.
    Ms. Wasserman Schultz. Thank you.
    Thank you for your indulgence, Mr. Chairman. I yield back.
    Mr. Krishnamoorthi. Thank you.
    Now I recognize Congressman Cox for five minutes of 
questioning.
    Mr. Cox. I want to thank Chairman Krishnamoorthi and 
Ranking Member Cloud for allowing me to waive on to this very 
important hearing.
    As you've pointed out, the recent CDC outbreak figures show 
that at least 500 people have experienced e-cigarette vaping-
related lung injuries and at least eight people have died. I 
represent the Central Valley of California, and one of those 
most recent deaths was from one of my communities. I'm troubled 
to hear that we have yet another major health crisis on our 
hands, and this one is a special threat to our children and 
certainly our families.
    We need to know why this has happened. We need to 
understand what your agency is doing to combat this epidemic. 
And, certainly, we need solutions to prevent this from 
happening again so not one more American dies needlessly.
    I understand coordination efforts are underway, but last 
week we called over to the Public Health Department in Tulare 
County to find out more about what happened to this individual. 
Unfortunately, they didn't have much information to share with 
us, but they did say they sent the vaping device to the state's 
Public Health Department for further analysis.
    Naturally, I'm concerned about the data collection 
processes, the coordination efforts that we're employing to 
stop this outbreak from worsening.
    Earlier, you pointed out one of the actions that your 
office or the CDC is doing is to consider refraining--quote, I 
think you said ``consider refraining''--from using the product. 
No disrespect, but to me that sounds like pretty weak tea.
    Would it be more accurate to state simply that use of the 
product could cause death?
    Dr. Schuchat. We are trying to be careful when we don't 
know what the substance that's at risk is, and we're trying to 
sustain credibility against those who may think we're 
exaggerating. We know that people are dying right now in this 
outbreak of lung injury and we really want people to protect 
themselves and not take risks unnecessarily.
    Mr. Cox. I'm sorry, Dr. Schuchat, but I'm really looking 
for a ``yes'' or ``no'' answer. Would it be accurate to state 
that use of this product could cause death?
    Dr. Schuchat. The ``this product'' part is hard to say.
    Mr. Cox. One of these vaping products.
    Dr. Schuchat. Right. So our recommendations are very broad 
because something that is in either e-cigarettes or other 
vaping products is leading to death, and so use of whatever 
that substance or brand or product or additive is can cause 
death. So, yes, I think your comment is right.
    It's just that when we don't have a specific product, 
consumers may not take action. So we're trying to make them 
take this seriously in a way that they'll believe us.
    Mr. Cox. Yes. I think the admonition that it could cause 
death would be a warning they should take seriously.
    Really, more in the broader sense that regulations, in my 
mind, are really protections. So when this administration 
boasts of deregulating things, what's really happening is that 
protections are being eliminated. And these deaths could be 
prevented if we enforce preventative public health measures of 
evaluating new products before they hit the market, especially 
products with known harm, like nicotine.
    So the question is really, why is the default procedure 
letting products onto the market first and then evaluating 
whether or not they present a public safety or health risk?
    Dr. Schuchat. I don't know.
    Mr. Cox. That's true, right?
    I can tell you is that--do you think that any product 
delivered through inhalation should be rigorously evaluated 
before marketing?
    Dr. Schuchat. Yes.
    Mr. Cox. Thanks. I can tell you that the CDC in this 
regard, in my opinion, needs to find its voice again, and we in 
Congress are committed to helping you do just that.
    Further, you know, some of the specifics about what the CDC 
is currently doing. I'd like to know a little bit more about 
the individuals that have got the confirmed lung illnesses from 
e-cigarettes. And although very little is known about the long-
term health consequences of using these products, what is the 
CDC going to do about tracking the consequences and so on?
    Dr. Schuchat. You know, we--the individuals who have the 
condition right now, a majority are male, half are under 25, 
many were previously healthy. We're just gathering data now in 
more detail, but we're working with the clinical communities, 
including lung specialists, to try to understand what long-term 
followup should look like and how that information should be 
collected.
    We're also working with the NIH, in terms of some of the 
research questions. But the pulmonary community may help us 
come up with guidance for systematic evaluation and followup.
    Mr. Cox. Thanks so much, Dr. Schuchat. We really appreciate 
what you and the CDC are doing for our benefit.
    Mr. Krishnamoorthi. Thank you, Dr. Schuchat.
    I think that concludes panel one, and we will now commence 
panel two.
    Thank you again for your testimony.
    I'd also like to remind everybody, the witnesses are 
reminded that there may be additional questions for the record, 
and the committee requests that you answer them properly.
    Mr. Krishnamoorthi. If the second panel could please come 
forward.
    We are pleased to have you here. Thank you so much.
    We begin our second panel here. We have Dr. Ngozi Ezike, 
director of the Illinois Department of Public Health--thank 
you--Dr. Albert Rizzo, chief medical officer of the American 
Lung Association; Ruby Johnson, the parent of a teenager 
affected by the e-cigarette-related lung disease outbreak.
    I will yield to my colleague Mr. Grothman to introduce his 
constituent.
    Mr. Grothman. I'd like to thank the chair.
    I'd like to take this opportunity to introduce a good 
friend from Wisconsin, a passionate advocate for tobacco harm 
reduction. She's helped countless people quit smoking by 
sharing her story. Vicki Porter.
    Mr. Krishnamoorthi. Thank you so much.
    If you would all please rise and raise your right hands, 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?
    Let the record show that the witnesses answered in the 
affirmative.
    Thank you, and please be seated.
    The microphones are sensitive, so please speak directly 
into them. Without objection, your written statements will be 
made part of the record.
    With that, Dr. Ezike, you are now recognized for five 
minutes.

STATEMENT OF DR. NGOZI O. EZIKE, DIRECTOR, IIILINOIS DEPARTMENT 
                        OF PUBLIC HEALTH

    Dr. Ezike. Chairman Krishnamoorthi, Ranking Member Cloud, 
and distinguished members of the subcommittee, thank you for 
inviting me to discuss this very concerning situation where 
hundreds of people across the country, including 69 in 
Illinois, have experienced severe respiratory illness after 
vaping or using e-cigarettes. And, tragically, there has been 
one death in Illinois, and additional suspected cases are being 
reported to the department every day.
    Our patients in Illinois have ranged in age from 15 to 42, 
with a median age of 22. The majority of the patients have been 
male, representing many counties throughout the state, both 
rural and urban areas. Over 95 percent of our cases have 
required hospitalization, three-fourths have needed placement 
in the intensive care unit, and over a third have required 
mechanical ventilation.
    While we have yet to clearly define the causative agent, 
what is clear is that there is nothing healthy about vaping, 
and there are heightened consequences for youth.
    Dr. Schuchat has amply covered the details of the current 
outbreak, and it's imperative that the investigation continue 
so as to definitively identify the etiology of acute illnesses.
    But there is another matter that needs to be addressed. We 
need to address that in parallel to the illness investigation. 
That matter is the youth vaping epidemic.
    Perhaps public health should have rung the alarm even 
louder as the epidemiology showed the rising rates of vaping. 
Even so, the current investigation has highlighted the creation 
of the next generation of nicotine-addicted Americans.
    E-cigarette use increased 900 percent amongst middle and 
high school students from 2011 to 2015, according to Dr. Wang's 
June 2018 MMWR report. The 2019 National Youth Tobacco Survey 
showed 68 percent of youth vapers used flavored e-cigarette 
products. In December 2018, the U.S. Surgeon General did 
discuss these alarming trends, noting research that found that 
more than 3.6 million youth were using e-cigarettes.
    Action is required now to protect our youth.
    I have led youth focus groups in the state and have heard 
recurring reports of symptoms that depict nicotine withdrawal 
in middle and high school students, many that have been vaping 
for as little as three to six months.
    We must permanently change the narrative around vaping and 
e-cigarettes. E-cigarettes are harmful. They are highly 
addictive. They are highly addictive because they are so 
efficient at delivering nicotine directly to the brain. And 
nicotine has no redeeming qualities for youth and young, 
developing brains.
    In 2018, traditional cigarette smoking among Illinois high 
school seniors was down to five percent, but also in 2018 e-
cigarette use was already at 27 percent among high school 
students. Our top priority has to be keeping these harmful 
products out of the grasp of our Nation's youth. Most youth 
that are currently vaping never smoked traditional cigarettes 
before they took their first hit on the e-cigarette.
    Contemporary product designs, attractive technology--these 
devices actually sync up with their iPhones--the vapewear 
merchandise, all of this is targeted to youth. There are ads on 
Snapchat. There are hoodies that allow the wearer to take a hit 
from their e-cigarette using the drawstring of the hood--
clearly a tool to conceal the vaping.
    We cannot stand idly by and watch the high-tech e-cigarette 
erase the progress against youth smoking with enticements to 
vape through the marketing of trendy devices, cool accessories, 
and e-juice flavors like strawberry, watermelon, and mango.
    In the state of Illinois, Governor J.B. Pritzker supports 
moving forward with strong and effective legislation to ban 
flavored vaping products, which are exceedingly popular amongst 
young people. We need revised health curriculums in elementary 
and middle school to discuss the dangers of vaping.
    I urge Congress to take up similar initiatives to protect 
our youth and to support our message urging all people not to 
vape, especially while this national investigation is ongoing.
    Thank you.
    Mr. Krishnamoorthi. Thank you, Dr. Ezike.
    Next is Dr. Rizzo.
    You are now recognized for five minutes.

    STATEMENT OF ALBERT RIZZO, M.D., CHIEF MEDICAL OFFICER, 
                   AMERICAN LUNG ASSOCIATION

    Dr. Rizzo. Mr. Chairman, Ranking Member Cloud, and members 
of the committee, thank you for the opportunity to testify 
today.
    I am Dr. Albert Rizzo. I'm the chief medical officer of the 
American Lung Association. I still see patients in my pulmonary 
practice in Delaware. I am privileged to be here to speak about 
the dangers of e-cigarette use.
    For more than a decade, the American Lung Association has 
been raising the alarm about e-cigarettes. We will continue to 
reiterate our recommendation that the public not use any 
tobacco product, including e-cigarettes. We believe that all 
tobacco products can harm health and believe that there is no 
proven public health benefit to e-cigarettes.
    Our Nation is currently in the midst of two different e-
cigarette crises. First, according to the 2019 National Tobacco 
Youth Survey, 27.5 percent of youth are now using e-cigarettes, 
which is a 135-percent increase from just two years ago. 
According to a CDC study, one of the primary reasons teenagers 
use these products are because the candy and fruit flavors are 
so appealing.
    This high use of flavored e-cigarettes among youth is 
alarming and requires urgent and immediate action. The American 
Lung Association commends President Trump and his 
administration for the announcement that the FDA will remove 
all non-tobacco-flavored e-cigarettes from the marketplace. We 
believe this is a vital and positive step to address the youth 
e-cigarette epidemic, and we urge FDA and Congress to act.
    The second health crisis is the current cluster of 
pulmonary illnesses related to vaping. As we've heard today, 
CDC and state and local health departments are conducting an 
ongoing investigation of these pulmonary-related illnesses due 
to vaping.
    Both crises are caused by the failure of two different 
administrations to fully implement the Tobacco Control Act of 
2009 and protect the public health. The delay in FDA 
implementing the Tobacco Control Act has left unregulated 
products with unknown chemicals on the market.
    Some of the chemicals found in e-cigarettes are 
carcinogenic. Will the use of e-cigarettes cause cancer? Will 
the inhalation of chemicals in e-cigarettes cause lung diseases 
such as COPD? How do e-cigarettes impact people with asthma? 
And the latest question is, what will be the long-term health 
consequences of those who've been hospitalized as a result of 
the pulmonary vaping illness outbreak?
    In 1964, the Surgeon General released the first report on 
health hazards of smoking, concluding that smoking cigarettes 
caused lung cancer. Fifty years later, the Surgeon General's 
report in 2014 added even more smoking-related diseases. It's 
hard to predict the possible health consequences we will see in 
another 50 years as a result of e-cigarettes.
    We are very troubled by what we see so far. E-cigarettes 
contain nicotine. In addition to being extremely addictive, it 
can increase blood pressure, heart rate. And, according to CDC, 
nicotine use among youth and adults can alter brain development 
and cause memory and learning problems.
    Two of the other primary ingredients found in e-cigarettes, 
propylene glycol and vegetable glycerin, can expose users to 
high levels of toxins, and these harmful chemicals can cause 
irreversible lung and heart disease.
    Flavors attract kids, which is why the American Lung 
Association has long advocated for the removal of flavored 
tobacco products from the market. According to a study from the 
Journal of the American Medical Association, 81 percent of 
youth who have ever used tobacco products initiated with a 
flavored product.
    The American Lung Association believes everyone who uses 
tobacco products can quit if they use proven, safe, and 
effective drugs by the FDA. The FDA has not found any e-
cigarette to be safe and effective in helping smokers quit.
    We are often asked about a study from earlier this year in 
the New England Journal of Medicine comparing e-cigarettes to 
nicotine replacement therapy. In this study, over 90 percent of 
the smokers using nicotine replacement therapy quit smoking, 
ending their nicotine addiction entirely. In contrast, 80 
percent of the smokers given e-cigarettes did not quit but 
switched and, instead, remained addicted to e-cigarettes and, 
therefore, nicotine.
    Switching is not quitting. Quitting means ending your 
addiction to nicotine, which can be very difficult. I have 
patients who have switched to e-cigarettes, believing they had 
quit. Some remain addicted to nicotine, some have been dual 
users, and some have returned to regular cigarettes.
    In conclusion, the American Lung Association supports 
President Trump's call to clear the markets of flavored e-
cigarettes. E-cigarettes, as they now exist, have not been 
shown to be safe. They're responsible for the possible loss of 
another generation of American youth to tobacco use, death, and 
disease.
    Thank you for the opportunity to testify, and I'll be happy 
to take questions later.
    Mr. Krishnamoorthi. Thank you, Dr. Rizzo.
    Next we have Mrs. Johnson.
    You are recognized for five minutes.

 STATEMENT OF RUBY JOHNSON, ADVOCATE AGAINST E-CIGARETTES; AND 
            VICKI PORTER, ADVOCATE FOR E-CIGARETTES

    Ms. Johnson. Thank you so much for having me.
    My name is Ruby Johnson, and I am a mother of seven 
children, ranging from an 18-year-old college freshman all the 
way down to a 5-year-old kindergartner, from New Lenox, 
Illinois.
    I'm here to tell you about the biggest blessing in my life, 
which is the fact that my oldest child is still alive. As 
you'll hear, that could've easily not been the case.
    On August 16th, I loaded up our daughter and all the 
makings of a dorm room to drive her from Illinois to Colorado 
to begin her freshman year of college. As we set out, she began 
to cough, to complain of pain in her chest when she took a deep 
breath, and to shiver like she was running a fever. She also 
admitted to me that she had been vaping.
    What started as an exciting rite of passage turned into a 
terrifying near-death experience that involved a week-long 
hospital stay where my daughter went from a healthy, vibrant 
18-year-old to a patient who needed rapidly increasing amounts 
of oxygen and medications to treat her declining health.
    When we arrived in her college town, we went directly to 
the hospital. She was nauseous, tachycardic, coughing, running 
a high fever, couldn't take a deep breath without intense pain, 
and struggled to keep her oxygen saturation up to even the mid-
80's.
    A CT scan showed what the doctors called a diffuse 
pneumonia all over her lungs. Though antibiotics appropriate 
for pneumonia were started immediately, her condition continued 
to worsen as her oxygen needs increased steadily, and she was 
transferred to the ICU in case more extreme measures to help 
her became necessary.
    With every doctor came the same question: Have you traveled 
out of the country recently? Have you had a cold? And the 
million-dollar question, are you a smoker? The answer to all 
those questions was no.
    Finally, they asked, how about e-cigarettes? Her answer to 
that question was yes, though it wasn't until we got to the 
third doctor to see her that it actually seemed to be taken 
seriously.
    It was that doctor who paid attention to the fact that she 
said she had been vaping and that she was now experiencing 
symptoms that matched with the newly reported cases of a 
mysterious lung illness popping up. He did his research by 
contacting doctors and hospitals that had already seen similar 
cases in order to determine the best course of treatment.
    I'll never forget watching her cry that she literally 
couldn't breathe without excruciating pain, as she was pumped 
full of IV fluids, antibiotics, steroids, pain meds, anti-
nausea meds, and a diuretic to clear fluid from her badly 
inflamed lungs.
    She couldn't even get up to walk to the bathroom without 
her alarm screaming because her oxygen saturation was dipping 
so low. Her belly was dark purple from the nightly injections 
they gave her to prevent blood clots as she lay in a hospital 
bed.
    Our daughter ended up being one of the lucky ones in this 
case, because she got to leave the hospital and can breathe 
without supplemental oxygen, but it could've so easily been a 
totally different tragic outcome. Her pulmonologist said that 
he feared had we waited another 24 hours to seek medical 
attention she'd most likely have been unresponsive on a 
ventilator.
    We're so grateful that she received the care she did, 
though we don't know what the future holds in terms of 
permanent damage.
    It's hard enough to be a parent in today's world. We all 
know that teenagers will inevitably make bad choices, and we 
hope they learn from them. But it's scary to think that there's 
an industry full of largely unregulated products with zero 
long-term health studies that are so attractive and easily 
accessible to youth.
    The e-cigarette industry has actively targeted our kids 
through social media campaigns; advertising on Quizlet, a 
popular homework site for younger kids; and through flavors 
that were clearly created to appeal to young people.
    This committee knows better than anyone how youth have been 
fooled into believing these products are safe by companies that 
act as if they could care less about the health and well-being 
of these kids. Consequently, we have the most serious 
adolescent public health crisis our country has faced in 
decades.
    These products are designed to be hidden from parents and 
teachers, and they accomplish that well. With smells and vapors 
that disappear as quickly as they appear and devices that look 
like flash drives and Apple watches, it would seem we're 
fighting a losing battle.
    You may have read JUUL CEO Kevin Burns address this 
epidemic in the recent Time magazine article by saying, 
``[blank] happens.'' Well, ``blank'' happened to my family. And 
I'm joining the movement of moms that is Parents Against Vaping 
E-Cigarettes in saying, ``Enough is enough.'' Our kids should 
not be the guinea pigs.
    These products flooded the market without anyone knowing 
how they would cause damage, and now we're trying to clean up a 
mess that involves a cocktail of mystery toxins and proprietary 
flavors, devices that are easily tampered with, and a 
generation of teens who are addicted to nicotine.
    If this was romaine lettuce, the shelves would be empty. We 
desperately need our legislators to help us by banning the 
flavors that have drawn in youth like my daughter, including 
mint and menthol.
    What happened to my daughter is indicative of this 
outbreak, but it points to the bigger crisis: Our kids are 
being hooked by flavors. Kids who would've never picked up a 
cigarette instead started using flavored e-cigarettes, and 
nicotine becomes a gateway to other substances. The FDA has 
allowed these markets to proliferate, flourish, and remain for 
purchase and consumption without pre-market review.
    This was a terrifying experience and something that 
probably would've been easier to keep private, but I'm here 
today to share our story with the hope that no other family 
will have to live the same nightmare.
    I'm a mom who's in her teenager's business constantly, and 
I did all of the right things, and this still happened, because 
our youth are being actively targeted by manufacturers with 
appealing flavors, and they're able to satisfy their nicotine 
addiction using devices that are designed to be secretive. It's 
time we do something about it. This goes beyond party lines, 
because these are all of our children.
    Mr. Krishnamoorthi. Thank you, Mrs. Johnson.
    Ms. Porter, you have five minutes for your opening 
statement.

          STATEMENT OF VICKI PORTER, MINORITY WITNESS

    Ms. Porter. Thank you very much.
    My name is Vicki Porter. I'm from Lake Mills, Wisconsin. 
I'm 51 years old.
    I started smoking cigarettes in college. You know what? I 
even remember the evening I started smoking. I'd just gotten 
dressed to go out, and I was listening to jazz records, 
drinking Irish coffee. I spotted a pack of Benson and Hedges 
Ultra Lights that a friend had left behind in my dorm room.
    So, feeling invincible, I took out one of those cigarettes 
and I lit it. Because what goes better with whiskey and jazz, 
right, than a cigarette? In just a few weeks, I was addicted to 
cigarettes and began a lifestyle of smoking that lasted for 23 
years.
    After a few years of this smoking lifestyle, I realized 
it's not cool. It was revolting and embarrassing and deadly. 
But quitting smoking is very, very, very hard. Nobody tells you 
that.
    Over the years, I tried to quit many times, using many 
techniques. I tried cold-turkey, nicotine gum, nicotine 
patches, all approved by the FDA. I tried two FDA-approved 
drugs, even tried one of those drugs twice. I tried hypnosis 
twice. I tried some hocus-pocus called laser acupuncture. All 
failures.
    By now, I was around 40 years old, and I figured I'd just 
learn to live to be content to die a smoker, probably gasping 
for air like my grandmother and mother did when they died of 
lung cancer.
    Years ago now, a coworker of mine showed me an online ad 
for e-cigarettes. The promise was: smoking without the harm or 
smell. So I ordered one, because I thought, what if it's real? 
What if it's real? And as it turns out, it's actually real. 
Around 2010, I stopped smoking, only because of e-cigarettes. 
It literally changed and probably saved my life.
    Nine years later, my doctor says my lungs are healthy. I 
can climb stairs without being winded. I exercise four times a 
week. I can walk for miles and miles. I can do things now I 
haven't done since before my lungs became overwhelmed with the 
filth and deadly toxicity of cigarettes.
    Vaping is a health miracle to me, because without it I'd 
probably be on my way to a lung cancer diagnosis.
    Two main reasons why e-cigarettes work: first, the 
inhalation of a far less harmful--not safe, but less harmful 
nicotine dose, similar to smoking, without the deadly toxins 
caused by burning tobacco; and, second--and this is critically 
important--flavors. Flavors matter to me, an adult ex-smoker.
    Flavors are not an industry-driven innovation; they are a 
user-driven innovation. Big Tobacco didn't come up with the 
idea of flavors. Consumers, adult smokers like me, came up with 
the idea of flavors. We demanded it.
    The tobacco flavors that everybody seems to think are so 
wonderful of the early e-cigarettes were awful. Those flavors 
mimic the taste of a cigarette and were poor imitations of the 
cigarettes we actually liked to smoke. We don't want our vapor 
to taste like cigarettes. We're trying to quit them. We want 
something that tastes good, that makes us want to keep vaping. 
Flavors keep us vaping. Flavors keep us not smoking.
    I took a survey on my Facebook page of ex-smokers-turned-
vapers. About 150 people left comments, and I admit this is not 
scientific. But, at last count, approximately 90 percent use 
flavors other than tobacco. These are middle-aged and older ex-
smokers.
    These flavors are demanded by adults, sold by adults, 
consumed by adults. And we're not alone. According to a recent 
survey of more than 69,000 vapers, 92 percent preferred non-
tobacco flavors.
    Now, much has been made of the lung illnesses tied to 
vaping, but it's manifestly dishonest to blame e-cigarettes and 
nicotine liquid for these illnesses. All available information 
overwhelmingly suggests the lung diseases being diagnosed have 
exactly nothing to do with nicotine vapor products and 
everything to do with adulterated street drugs or products, 
notably oil-based THC. I have now been vaping for nine years, 
and I've never been healthier. And none of the nicotine vapor 
products that I use contain oil.
    E-cigarettes are a public health miracle that America is 
about to squander based on misinformation and disinformation. 
So let me remind the committee members of a few points.
    The FDA and local agencies, communities, and parents 
absolutely need to do a better job of enforcing existing laws 
and obligations to see to it that kids don't use e-cigarettes. 
But you don't need to ban the product to make progress on that 
mission.
    In 2018, the U.K.'s Royal College of Physicians published a 
comprehensive scientific report which concluded that vaping 
nicotine can eliminate almost all the harm from smoking 
cigarettes and recommended promoting the use of e-cigarettes to 
smokers as widely as possible. The report also indicated that 
vaping nicotine is at least 95 percent less harmful than 
smoking. Public Health England concurs.
    Even the American Cancer Society is beginning to understand 
the promise of tobacco harm reduction, stating that e-
cigarettes are, quote, ``likely to be significantly less 
harmful for adults than smoking regular cigarettes,'' and they 
encourage adults who have failed other FDA-approved methods to 
switch to e-cigarettes.
    E-cigarettes were the only thing--the only thing--that 
worked for me to quit smoking. This product probably saved my 
life. Vaping has helped more than 8 million adult smokers quit 
completely when all other options failed for them. I think 
that's incredible. Eight million people quit smoking.
    On behalf of former smokers, I hope you'll reject the 
general war on vaping, and I encourage you to proceed with 
these comments in mind.
    Thank you very much for your consideration.
    Mr. Krishnamoorthi. Thank you, Ms. Porter.
    I need to correct the record on a couple things that were 
just said.
    There is no evidence to suggest that e-cigarettes are safe 
or even safer than cigarettes. That's why the FDA just released 
their regulations directed at JUUL.
    Second, the CDC just came in and presented evidence that 
they don't know the cause of the current outbreak and did not 
rule out nicotine e-cigarettes.
    Ms. Porter. May I respond?
    Mr. Krishnamoorthi. No. We are about to start questioning, 
and you can respond then.
    Ms. Porter. Okay.
    Mr. Krishnamoorthi. I will recognize myself for five 
minutes--I'm sorry--Ms. Wasserman Schultz for five minutes 
first.
    Ms. Wasserman Schultz. I thank the chairman for his 
indulgence.
    Dr. Ezike and Dr. Rizzo and to all the panelists, thank you 
for joining us. Specifically, my initial question is directed 
at the two experts in public health.
    Is there any evidence--and I'm asking you the same question 
that I asked Dr. Schuchat. Is there any evidence that nicotine 
addiction is harmful to an individual's health?
    And are there any health benefits at all, including the 
reduction of the likelihood of smoking cigarettes, of inhaling 
nicotine on a short-term or long-term basis?
    Dr. Ezike. There is no evidence that nicotine is healthful 
at all to young kids or their developing brains.
    Ms. Wasserman Schultz. Dr. Rizzo?
    Dr. Rizzo. I agree with that.
    What was the second part of your question?
    Ms. Wasserman Schultz. Is there any evidence that nicotine 
addiction is harmful to an individual's health?
    Dr. Rizzo. It is harmful, yes.
    Ms. Wasserman Schultz. Individuals of any age?
    Dr. Rizzo. Yes. Nicotine, by itself, affects the vascular 
system--blood pressure, heart rate--and can cause heart and 
lung disease by itself, especially in the elderly.
    Ms. Wasserman Schultz. And do we have evidence that that is 
further complicated by the other chemicals combined with 
nicotine that are utilized in a vaping product?
    Dr. Rizzo. I was referring mainly to nicotine by itself, 
but certainly when it's combined with other ingredients in a 
vaping product----
    Ms. Wasserman Schultz. The accelerants----
    Dr. Rizzo. Yes.
    Ms. Wasserman Schultz.--the chemicals. I mean, it's not 
just nicotine that is----
    Dr. Rizzo. Correct.
    Ms. Wasserman Schultz.--inhaled when using a vaping 
product. And are there negative health impacts, including the 
potential for death, from the combination of chemicals in 
vaping?
    Dr. Rizzo. Yes.
    Ms. Wasserman Schultz. Thank you.
    The CDC has identified 530 cases of lung illness associated 
with the use of e-cigarette products in 38 states and 1 U.S. 
territory. It is important that we hear from partners like you 
at the state level, collaborating with the Federal Government, 
to stop what is a national outbreak of lung illness.
    Dr. Ezike--am I pronouncing your name correctly? Thank you. 
Illinois and Wisconsin were the first states to identify the 
outbreak and to spearhead investigations in July, when e-
cigarette-related lung disease sprung up in your states. Can 
you describe the severity of those initial cases and why your 
state felt compelled to act so swiftly?
    And as your office continues to collaborate with CDC, what 
steps has Illinois taken to identify all possible e-cigarette-
related lung disease incidents even prior to this summer's 
outbreak?
    Dr. Ezike. Thank you for that question.
    So, unfortunately, we did find ourselves at the epicenter 
of this outbreak. And because of the alert that the Wisconsin 
Department of Health had released, people were attuned to the 
possibility of these illnesses that were not well-described but 
had a connection between young healthy people without a reason 
otherwise to fall so sick who had presented with severe 
respiratory illnesses and had a connection with vaping.
    So when our first case came and was reported to the 
Department of Public Health, we didn't waste any time. And we 
were able to send out alerts to the medical professionals, 
sending alerts out to pulmonologists, hospitals, ER doctors, 
pediatricians, to alert everyone and encourage them to report 
any suspicious cases directly through their local departments, 
which would then come to the state department.
    So putting out press releases, putting out information on 
our social media, connecting with the state Board of Education, 
working with our advocates in the community who put messaging 
out to doctors----
    Ms. Wasserman Schultz. I just want to piggyback on my 
question, because I'm running a little bit short on time.
    You conducted detailed interviews of those struck by the 
disease. Sixty-one percent of the people you interviewed 
reported using nicotine e-cigarettes, and nearly 20 percent of 
them were using only nicotine e-cigarettes. Many did also 
report THC use.
    Is it safe to say that you cannot rule out any nicotine e-
cigarettes or any THC products as contributing factors to the 
outbreak?
    Dr. Ezike. That is correct.
    Ms. Wasserman Schultz. Your advice, like the CDC, has been 
for people to not use any e-cigarette products. I assume a 
decision like that is not made lightly. Can you tell us how you 
decided that recommendation was necessary for the public 
health?
    Dr. Ezike. As our role to protect the public, not knowing 
what the actual etiology is but knowing that the only 
commonality among all of our 69 cases was vaping, we know that 
something with the vaping activity, whether the product, the 
product device, the brand--something therein is the culprit. 
And without knowing specifically, it seemed safer to give a 
broader warning until we could get more information out.
    Ms. Wasserman Schultz. And, last, before my time expires, 
reports show that e-cigarette aerosol, which is present in all 
types of vaping, is not harmless. Why is e-cigarette aerosol 
dangerous to individuals that vape?
    Dr. Ezike. The chemicals within the aerosol are usually 
irritants to the lung. The lung then responds with different 
kinds of reactions that we're seeing in some of the patients, 
which obviously affects the oxygenation, which is the primary 
function of the lung, which sometimes results in needing a 
breathing machine to now perform that process of oxygenation.
    Ms. Wasserman Schultz. Thank you.
    And, Mr. Chairman, I know my time has expired, but I do 
just want to confirm, my understanding is that the testimony of 
Ms. Porter is anecdotal, related specifically to her opinion, 
and that she is not a public health expert.
    Mr. Krishnamoorthi. Thank you. I think that's correct.
    Ms. Wasserman Schultz. Okay. Thank you. I yield back.
    Mr. Krishnamoorthi. I now recognize Congressman Grothman 
for five minutes of questioning.
    Mr. Grothman. First of all, Dr.--I forgot--Ezike?
    Dr. Ezike. ``Ezike.''
    Mr. Grothman. Okay. I know you've recently legalized 
marijuana in the state of Illinois. Are these cartridges--are 
THC cartridges now legal in Illinois under the new law or not?
    Dr. Ezike. So THC cartridges are legal through the Medical 
Cannabis Act. So for patients who are on the Medical Cannabis 
Program, THC cartridges are available.
    Mr. Grothman. Do you think that was a mistake?
    Dr. Ezike. I beg your pardon?
    Mr. Grothman. Do you think that was a mistake?
    Dr. Ezike. We have no cases, of our 69 cases in Illinois, 
that are from the registry of medical cannabis patients.
    Mr. Grothman. Well, I'm sure they're not registered, but 
once you make these things legal, there's certainly more of 
them out there. That sort of thing. It implies they're Okay.
    Dr. Ezike. And, again, we're still waiting to identify the 
exact etiology, so----
    Mr. Grothman. Okay.
    Again, you mentioned that, in your study, 80 percent of the 
people who have a health problem self-reported that they had 
some THC in there. But, as I asked the last panel, I assume 
people don't usually admit that they're doing something 
illegally.
    If 80 percent admitted that they were using a product with 
THC in it, is it possible that the actual number is higher? 
Significantly higher?
    Dr. Ezike. The numbers could be higher, but we have 
interviewed and re-interviewed the patients. There wasn't a 
single go-round. So there have been persistent conversations 
with these----
    Mr. Grothman. Okay.
    Dr. Ezike [continuing]. people, and so people have reported 
more use.
    Mr. Grothman. Now, Ms. Porter, you wanted to respond to 
some of the other Congressmen. I'd like to give you an 
opportunity to say what you wanted to say.
    Ms. Porter. Well, what I wanted to say was, with regard to 
the chairman's comments that there is no evidence that e-
cigarettes are less harmful, that's just simply not true.
    It was a comprehensive scientific report that was generated 
by the United Kingdom's Royal College of Physicians. It wasn't 
just an opinion. It wasn't anecdotal, as it were. It was 
actually a scientific report.
    Also--and I'm not sure how many people had a chance to see 
this--on ``CBS This Morning'' last week, Dr. David Abrams from 
the NYU College of Global Public Health indicated that abundant 
evidence exists that the cancer biomarkers associated with e-
cigarettes are vastly lower than the ones that are associated 
with smoking.
    I would also like to ask, if somebody could please answer 
me this particular question, what is the particular mechanism 
by which PG and VG could possibly cause disease? I recall Dr. 
Rizzo said something about PG and VG causing disease. What is 
the particular mechanism that vegetable glycerin or propylene 
glycol actually could cause disease?
    Mr. Grothman. I don't think you're supposed to ask 
questions, but I'll ask that question. Doctor, could you 
respond?
    Dr. Rizzo. Well, the short answer, but I'll expand is that 
we really don't know anything about these devices because they 
haven't been studied in any rigorous manner. When you heat a 
substance up to the temperatures that e-cigarettes do, you no 
longer have the same properties of the compound that we knew 
before. A compound that could have been ingested safely is now 
being vaporized and inhaled into the lungs, which is a much 
different part of the body than the stomach.
    So, in short, we don't know the toxins--what the toxins are 
doing. We know toxins are created. And even if we say toxins 
are less than cigarettes, that is a very low bar to beat. And 
7,000 chemicals in tobacco means there are still 350 in 5 
percent of e-cigarettes.
    Mr. Grothman. Ms. Porter, if we banned e-cigarettes or 
you're no longer able to get them, it's obviously important for 
you not to smoke, what would you do? What will be fallback 
position?
    Ms. Porter. If I may, the 7,000 chemicals that the doctor 
was talking about are the chemicals that are generated when 
tobacco is burnt. The nicotine extracted from tobacco does not 
generate 7,000 chemicals in a 5 percent solution in e-liquid. 
That's when you actually light something on fire and inhale the 
particulate matter, the carbon monoxide, the various 
carcinogens into your lungs.
    I know this because I smoked, and I decided to learn about 
it. What would I do? I would probably just find a way to get my 
e-cigarettes, that's what I would do. That's me, though. I'm a 
very knowledgeable user, and I'm a very knowledgeable navigator 
of this marketplace. I would probably order from China.
    Most people, and, in fact, anecdotally again, but most 
people that I have spoken to who vape would simply go back to 
smoking because the reason we're vaping instead of smoking is 
because all of the FDA-approved quit methods have failed for us 
multiple times. That's the short answer. I would probably order 
from China, but other people would probably start smoking.
    Mr. Grothman. Thank you.
    Mr. Krishnamoorthi. Thank you, Mr. Grothman.
    I am going to recognize myself for five minutes of 
questioning.
    Dr. Rizzo, could you care to respond to the claim that e-
cigarettes are safer than combustible cigarettes?
    Dr. Rizzo. The quote about the United Kingdom's decision 
that it's 95 percent safer than tobacco, if you read the 
articles about how that decision was made, a group of experts 
got together for two days in Europe. Several of those experts 
admitted to working for the vaping industry. And the European 
Respiratory Society, The Lancet editorial, and 14 professional 
societies in this country wrote letters to the United Kingdom 
saying they don't agree with that public health decision.
    And, also, in the United Kingdom, there's a much different 
aspect of e-cigarettes. They are controlled and regulated much 
more strictly than this country. The tobacco flavors are not 
there. So you really can't compare what happens in England to 
this country, and it really is faulty science it was based on.
    Mr. Krishnamoorthi. Right. So that was a bogus study. 
What's the nicotine levels that are allowed for nicotine e-
cigarettes in the U.K. versus in America?
    Dr. Rizzo. I can get the exact number. I think 18 to 20 
milligrams is the most that is recommended in e-cigarettes in 
England, but----
    Mr. Krishnamoorthi. And here it's 59?
    Dr. Rizzo. I believe you're correct. Yes.
    Mr. Krishnamoorthi. So roughly almost three times the 
amount of nicotine here in the U.S. in any e-cigarette pod 
compared to in Britain.
    Now, Mrs. Johnson, I want to ask you a couple questions. 
How old is your daughter now?
    Ms. Johnson. She's 18.
    Mr. Krishnamoorthi. And when did she first start vaping?
    Ms. Johnson. After all this happened, she told us she tried 
it the first time when she was a sophomore in high school, and 
that she had tried it on and off for about 18 months before she 
became ill.
    Mr. Krishnamoorthi. And what devices had she been vaping?
    Ms. Johnson. She started using a JUUL, and the vast 
majority of what she used was a nicotine e-cigarette. She did 
try vaping THC as well and used mostly nicotine in the weeks 
leading up to her illness.
    Mr. Krishnamoorthi. Now, Mrs. Johnson, I presume--well, how 
is she doing now?
    Ms. Johnson. She's doing better. She's, you know, adjusting 
to life as a college freshman. She's still out of breath when 
she has to walk quickly or far, and we'll just kind of see what 
the future holds for her.
    Mr. Krishnamoorthi. So are you saying there's some kind of 
permanent injury associated with what happened due to the 
vaping?
    Ms. Johnson. Unfortunately, with this being such a new 
thing, the doctors can't really make any promises that there 
won't be permanent damage. So we'll just continue to followup 
with repeat CT scans of her lungs and see what that reveals as 
time goes on.
    Mr. Krishnamoorthi. And how did she first begin vaping in 
high school?
    Ms. Johnson. She said that a friend offered her--offered it 
to her to try. You know, they are passed around, the bathrooms 
in the high schools, even the junior highs. I mean, I've got 
two sons in high school as well, and it's kind of common for 
the high schoolers to refer to the bathroom as the JUUL room, 
because that's what goes on in there most.
    Mr. Krishnamoorthi. Now, 28 percent of high-schoolers today 
are vaping, and five percent of the middle-schoolers are 
vaping. What do you say to parents who are concerned about 
their children getting hooked on e-cigarettes?
    Ms. Johnson. Well, I think that it's super important to 
keep the conversation open. And, as parents, we have to ask 
questions. But the problem is that so many of us don't know 
what to look for, so I feel like it's also important that we 
work together with our schools to educate parents with what 
these devices actually look like, what the signs could be that 
your child is vaping, and to just educate ourselves and our 
kids.
    Mr. Krishnamoorthi. And you said mint flavor was one of the 
ones that got her hooked, correct?
    Ms. Johnson. Yes. And she's been super honest as this has 
all happened because she's terrified. You know, and she said: 
I'll never ever touch a vape again.
    But she said that mint was her favorite.
    Mr. Krishnamoorthi. You were very close to losing your 
daughter, correct?
    Ms. Johnson. That's correct.
    Mr. Krishnamoorthi. And before they correctly diagnosed 
what was happening, did you come up with the idea that it was 
the e-cigarettes, or how did they arrive at the question of 
about e-cigarettes?
    Ms. Johnson. Well, I think the timing really worked in our 
favor because there was just enough talk of what was going on 
and enough cases out there, that it was on my radar. I had seen 
the news articles, like I said, she was 100 percent honest, so 
she mentioned it to every doctor, but it wasn't until we got to 
the third doctor that it was really paid attention to. I mean, 
I remember this night where she just cried to her nurse saying: 
It hurt so bad; I can't take a deep breath.
    And the nurse reached out to the doctor, and he said that, 
since he had admitted her, he was trying to reach out to other 
hospitals and doctors, and that was when--you know, they had us 
wearing a mask at first thinking it was pneumonia, and that's 
when the masks came off, and they said: I think this is what 
we're dealing with.
    Mr. Krishnamoorthi. Thank you, Mrs. Johnson.
    Ms. Johnson. Thank you.
    Mr. Krishnamoorthi. I'd like to now recognize Ranking 
Member Cloud for five minutes of questions.
    Mr. Cloud. Thank you, Chairman.
    Dr. Rizzo, could you give--enlighten us a little bit on the 
distinction between infectious disease and chemical exposure as 
it relates to lung injury?
    Dr. Rizzo. Sure. When someone presents with the symptoms 
that were mentioned, it could be a bacterial or a viral 
pneumonia, meaning that organisms got into the lung, the immune 
system is led to the cells of the body going to the lung to try 
to fight off that infection. Basically that's inflammation. And 
when that occurs in the lung, and depending on the intensity 
that it occurs in the lung, it will fill the normal air spaces 
with fluid, pus, inflammatory cells, and, therefore, the 
ability to get oxygen in the bloodstream is diminished.
    So, when it's an infection, you can usually culture that 
media, whether it's sputum, or whether a tube is put down in 
the lung and aspirated fluid out. You culture that. You look 
for organisms under the microscope. Once that's ruled out, the 
inflammation must be being caused by something else. And in 
situations like this is where the history is very important. 
You have to find out, what could they have been exposed to? And 
in this case, the right questioning and putting two and two 
together, doctors started to realize there was a commonality in 
the process of vaping something.
    Mr. Cloud. This has been touched on already, but could you 
explain specifically why it's much more of an issue for young 
people to start vaping?
    Dr. Rizzo. The young people seem to start vaping more than 
the adults because of the flavors. Most smokers----
    Mr. Cloud. From a health perspective, what does it do to 
their body?
    Dr. Rizzo. Flavors--the inhalation into the lung occurs--
there's a couple different things. First of all, the lung 
doesn't reach its full development until about mid-20's. So 
you're dealing with a population where the lungs are still 
growing and developing. All of a sudden now, you're having an 
insult of inflammation, you're changing the immune system. And 
now the body has to try to compensate for that and recover from 
that but has lost ground with regard to what ultimately that 
lung development's going to be.
    So, in cases like you've heard about, this population will 
need to be monitored and followed for any permanent damage that 
may occur.
    Mr. Cloud. And, Dr. Ezike, could you explain kind of the 
legal framework in Illinois right now as it relates to teen 
vaping? Is it illegal for people under----
    Dr. Ezike. Right. We actually have Tobacco 21. So it is 
illegal to use products under the age of 21.
    Mr. Cloud. Okay.
    And, Ms. Johnson, first of all, as a mom of seven children, 
kudos. I have a number of parenting questions that are not 
appropriate for this setting.
    I'm happy to hear your daughter is doing well. Do you know 
where she was obtaining the product from?
    Ms. Johnson. I do know that--so she turned 18 in December, 
and so there was a small period of time where it was legal for 
her to buy vaping products. And I do know that she obtained 
some from a local store. I am also fairly certain that that 
store continued to sell to her after the Tobacco 21 law was 
passed in July, and she was no longer legally buying them.
    Mr. Cloud. Okay.
    Ms. Johnson. Like I said, there's a way for the kids to buy 
them, you know, but also they are being passed around in 
schools, which is a huge problem. I mean, we're scared enough 
as parents, but our poor educators are drowning because these 
products are not only accessible to the kids, but they are very 
discreet.
    Mr. Cloud. You mentioned a list of legitimate and 
illegitimate products.
    Ms. Johnson. That's correct.
    Mr. Cloud. Dr. Ezike, what's being done--because it was 
just mentioned that we have a store that was a bad actor, and 
we have people who are giving product to minors in the 
schools--what's being done on the enforcement end to prosecute 
bad actors in Illinois?
    Dr. Ezike. So not exactly within our realm, but we are 
working with the Illinois State Police, and they are very much 
on top of this issue, and they're going to step up enforcement 
in terms----
    Mr. Cloud. Has anyone been charged?
    Dr. Ezike. No one has been charged as far as I know, but 
they are going to step up sending people in to as decoys to 
come in and try to purchase the products who don't look of age, 
and seeing if they're getting carded. So those investigations 
and that enforcement is going to be stepped up.
    Mr. Cloud. Okay. Thank you.
    And, Ms. Porter, you've used e-cigarettes for a long time. 
What kind of regulation do you think is appropriate?
    Ms. Porter. I've used e-cigarettes for nine years, and just 
to kind of bring a point: There are 11 million regular e-
cigarette users who are adults and obtaining these products 
legally. And I also want to say that the products that I have 
been vaping for nine years are not 59 milligrams. They're 12 
milligrams.
    I think that regarding the product, the manufacturing of 
the product, insisting on good manufacturing practices, GMP, is 
something that is important, and that is something that I look 
for in the products that I purchase, as someone who has--you 
know, making sure that nothing gets adulterated, that there 
isn't cross contamination in the production of the product.
    With regard to kids, I think we don't even talk much about 
enforcement. You know, in the state of Wisconsin, the police 
would send decoys in to see if young people could potentially 
buy a pack of cigarettes. Stores were fined substantially if 
they violated that. The same with underaged drinking, we did 
the same thing. And that kind of regular enforcement, I think, 
is something that is quite important that doesn't seem to 
really be a priority is folks are fully, you know, neck deep in 
the panic about vaping.
    But, again, I point out, if you get rid of flavors from 
vaping or vapor products, then you are stranding 11--well, 8 
million people at least who are can ex-smokers and 11 million 
people from access to products that work so that they don't 
pick up a pack of cigarettes.
    With regard to advertising, I think I made a note here--
hoodies, who makes this garbage? This kind of stuff, obviously, 
if it is marketed directly to children, it's appalling. There 
isn't a single person who uses a vapor product who is an adult 
who thinks it's appropriate for young people, freshmen, ninth 
graders or eighth graders or sixth graders, to be able to pass 
around vapor products.
    And I also think that we need to really understand here 
that it appears, from all indications--and no, we don't have 
evidence, but from all indications, these diseases, which are--
and I don't want one of these diseases, by the way. I don't 
want to suddenly wake up one day and not be able to breathe. 
That's why I quit smoking.
    Mr. Krishnamoorthi. Your time is up. Thank you so much.
    Ms. Porter. But I do think we can do something about the 
adulterated products.
    Mr. Krishnamoorthi. Thank you.
    Congresswoman Pressley, you have five minutes of 
questioning.
    Ms. Pressley. Thank you, Mr. Chair.
    An NIH-funded study found that that over 8,000 e-liquid 
flavors are currently on the market. Some of these flavors 
include Banana Pudding, Rainbow Candy, and Hawaiian Punch. Dr. 
Rizzo, do we know how many of these 8,000 flavors have been 
tested for toxicity?
    Dr. Rizzo. The one study I know was done at the Harvard 
School of Public Health, the Chan School of Public Health. They 
looked at 51 different flavors, and 47 of those flavors did 
have chemicals in them they thought were toxic to the lung. I 
don't know about any other larger studies at this point.
    Ms. Pressley. Forty-seven out of 51?
    Dr. Rizzo. Out of 51, I believe, was the number, yes.
    Ms. Pressley. Dr. Ezike, you have collected samples of the 
products that were used by victims of the outbreak, and those 
are in the process of being tested, correct?
    Dr. Ezike. That's correct. They're with the FDA, and we're 
waiting for those results.
    Ms. Pressley. And as you search for the cause of the 
outbreak, you have not ruled out components of flavors as 
possible contributing factors to the outbreak, have you?
    Dr. Ezike. That is correct. We have not ruled that out.
    Ms. Pressley. Dr. Ezike, are any e-cigarettes approved by 
the FDA as smoking-cessation devices?
    Dr. Ezike. No, they are not.
    Ms. Pressley. Dr. Ezike, e-cigarettes companies have been 
allowed to apply for FDA approval as smoking cessation devices 
for years, but they have not done so, have they?
    Dr. Ezike. They have not.
    Ms. Pressley. Getting approval would require proving e-
cigarettes work for smoking cessation, and manufacturers 
haven't even conducted the clinical trials to back up that 
central claim?
    Dr. Ezike. That's correct.
    Ms. Pressley. So, Ms. Porter, you know, I'm grateful for 
every one adult smoker that e-cigarettes are actually helping 
to quit nicotine, but for every one adult smoker that is being 
helped, 81 kids will be introduced to nicotine through e-
cigarettes and graduate to cigarette addiction as an adult. 
None of us want that.
    Ms. Porter. And that's an impossible statistic. There are 
11 million vaporers. There are 11 million vaporers.
    Ms. Pressley. Reclaiming my time. I was just making a 
statement. I actually wasn't posing a question to you.
    Mr. Krishnamoorthi. Please let Ms. Pressley finish her 
question to you.
    Ms. Pressley. I just didn't want to take away from your 
personal experience.
    Now, I'll get to Dr. Rizzo. So we have seen no evidence 
that e-cigarettes are useful for smoking cessation. In fact, 
dual use is significantly more prevalent. Is dual use safe?
    Dr. Rizzo. No.
    Ms. Pressley. If someone cuts back on cigarettes and adds 
vaping, is that safe?
    Dr. Rizzo. No.
    Ms. Pressley. Dr. Rizzo, even if e-cigarettes were useful 
for cessation, have you seen any evidence that adults who want 
to use them for that purpose would refuse to use tobacco-
flavored e-cigarettes?
    Dr. Rizzo. No.
    Ms. Pressley. I yield back.
    Mr. Krishnamoorthi. Thank you, Congresswoman Pressley.
    Congresswoman Miller for five minutes of questioning.
    Mrs. Miller. Thank you, Chairman Krishnamoorthi.
    I want to thank all of you for being here today. This is 
very important.
    And, Ms. Johnson, thank you for sharing your story, and I 
hope your daughter is continuing to recover, particularly after 
listening to Dr. Rizzo say that our lungs continue to form into 
our 20's. I think that's a positive, and I hope and pray that 
she gets better.
    Ms. Johnson. Thank you.
    Mrs. Miller. Dr. Rizzo, is nicotine additive?
    Dr. Rizzo. Yes, definitely.
    Mrs. Miller. Is it also a depressant?
    Dr. Rizzo. It actually has two phases. It can initially be 
a stimulant, and then it can be depressive. It's a chemical 
that acts as a neurotransmitter in our body. The acetylcholine 
receptors, which are called nicotinic, and muscarinic 
receptors, they're all affected by nicotine.
    Mrs. Miller. People have been smoking for centuries, 
haven't they?
    Dr. Rizzo. Yes.
    Mrs. Miller. And it wasn't until the 1960's when they 
finally came out and established that it caused cancer?
    Dr. Rizzo. Yes.
    Mrs. Miller. I also remember in the early 1960's, trucks 
putting out vapor with DDT driving around my neighborhood and 
children riding bicycles behind the truck because they thought 
that was really neat. Were there ever any studies done to see 
if DDT caused cancer?
    Dr. Rizzo. I would have to look, but I suspect it was 
looked at as an inhaled toxin, but I don't know the details on 
that right now, but I can get back to you on that.
    Mrs. Miller. And that was another vapor that they put out. 
I just vividly remembering that happening.
    Ms. Porter, you said you smoked for 20-some years?
    Ms. Porter. Twenty-three.
    Mrs. Miller. When you started, did you just think that that 
was really cool?
    Ms. Porter. Sure did. I thought it was the coolest thing. I 
thought I'm listening to jazz and drinking whiskey and smoking 
a cigarette.
    Mrs. Miller. Yes. I remember, you know, movies about World 
War II, and everybody had a cigarette hanging out of their 
mouth, and the message was just that that was a cool thing to 
happen, you know, in 1950's and 1960's.
    Ms. Porter. My movie was ``House of Games,'' that was my 
movie.
    Mrs. Miller. I don't know that one.
    Ms. Porter. It's a good one.
    Mrs. Miller. And you are concerned about youths using e-
cigarettes?
    Ms. Porter. Absolutely. I'm concerned about youth using e-
cigarettes. I'm concerned about youth smoking, which is--it's 
an amazing statistic that now youth smoking is so low. And 
then, after today's testimony from multiple witnesses, I'm very 
concerned that the 12.5 percent of youth who are saying that 
they're using pot--but, yes, the youth--kids are going to do 
things that are risky, but we should try to make sure that they 
don't make dumb choices like I did when I was 18 or 19 years 
old.
    Mrs. Miller. Well, I remember our next-door neighbor had a 
catalpa tree and the kids thought it would be really cool to 
light those long cigar-looking things that really smelled 
terrible. Once you went to e-cigarettes, did you ever notice 
how bad your clothing smelled or how bad your hair smelled or 
your house?
    Ms. Porter. Yes. Oh, sure. Within about two weeks of 
switching to e-cigarettes, I couldn't tolerate the smell of 
smoking. I couldn't tolerate the, you know, smell of somebody 
who had been smoking an hour earlier. I became one of those 
people who just became an annoying ex-smoker. Everyone knows 
what I'm talking about. But, yes, I mean, it's very obvious.
    The more obvious change, though, came about three months 
after I had begun vaping. And just to see, I went to go with my 
physician and asked for a chest X-ray to see if I had done 
permanent damage. I wanted to know if I was going to be sick 
and die, potentially of lung cancer, if I had the beginnings of 
COPD.
    Mrs. Miller. Did you, I mean, in three months, did you 
think your lungs were going to change?
    Ms. Porter. Yes, because I felt so much better. And my doc 
said: Your lungs are pretty clear.
    And I said: Well, good, because I quit smoking.
    She said: I can tell.
    Mrs. Miller. Well, you mentioned a much lesser amount of 
nicotine in the e-cigarette. Is there like a step down if you 
were a----
    Ms. Porter. There's a lot of--there's a lot of 
misunderstanding of what the marketplace is for the vapor 
products, the liquid itself. It can go from zero milligrams of 
nicotine to, you know, with some of what they call salts, to as 
high as 60 milligrams of nicotine. People like me, I don't use 
salts; I use just regular old fashioned e-liquid. I use 12 
milligrams. Depending on the device, there are multiple 
different devices you can use. I can use as little as 3 
milligrams of nicotine in e-liquid. And, yes, you can 
absolutely--there are multiple different variations in 
concentration of the liquid itself.
    Mrs. Miller. So it would be possible that you could step 
down and totally get off of----
    Ms. Porter. People do it all the time. In fact, on my 
Facebook page, when I asked for some stories, multiple people 
said: I began at 18. I stepped down to 12. I went down to nine, 
and then I was at zero.
    Some people are still vaping zero. Some people just decided 
to use that zero point to quit vaping as well.
    Mrs. Miller. I didn't realize my time was up. Thank you.
    Mr. Krishnamoorthi. Thank you, Congresswoman Miller.
    Now, I'd recognize Congresswoman Tlaib for five minutes of 
questions.
    Ms. Tlaib. Thank you, Mr. Chairman.
    Thank you all so much for being here and for contributing 
to this important conversation.
    As a mother, thank you, Ms. Johnson, for coming here. I 
know it's not easy. Even for me, speaking publicly, to this 
day, my stomach turns. So I know how hard it is, especially 
something so personal. So I really do appreciate you being 
here.
    E-cigarettes were allowed onto the market without fully 
understanding the long-term effects and without regulation, as 
you all know. Their safety wasn't tested yet. Big tobacco 
companies, like JUUL, touted their products as safe and 
certainly safer than cigarettes. They even sent representatives 
into schools to tell students that it's, quote, this is--and I 
continue to repeat it because it's obvious they're tailoring it 
toward our kids--quote, totally safe.
    The result is that e-cigarette use took off. Now 27.5 
percent of the high school kids use e-cigarettes, and those 
kids are used a guinea pigs. We are just now beginning to find 
out the health risks they pose, risks like those who we--those 
that are suffering right now from it and the outbreak of lung 
disease and so forth. In fact, most e-cigarettes hold and 
discharge numerous other potentially toxic substances, such as, 
I'm going to try to pronounce this, formaldehyde and a compound 
named Benzene, which is found in car exhaust systems.
    Dr. Rizzo, yes or no, is it safe to inhale these liquids 
contained inside e-cigarettes directly into your lungs?
    Dr. Rizzo. No.
    Ms. Tlaib. Dr. Rizzo, what are the outcomes of inhaling 
such toxic substances, and are there any links to lung damage 
or heart disease? Are there any studies regarding the health 
risks associated with vaping?
    Dr. Rizzo. There are no long-term studies since it has only 
been in the marketplace here for about nine to 10 years.
    Ms. Tlaib. Likewise, the cigarette smoking process requires 
the user to inhale ultrafine particles that could possibly 
irritate their throat, eyes, and airways. Dr. Rizzo, could 
these particles exacerbate respiratory alignments that affect 
our breathing?
    Dr. Rizzo. Particularly, the ultrafine particles are very 
similar to the small particles that are talked about in air 
pollution. So they definitely get into the lung, the 
bloodstream, and can affect the cardiovascular system in the 
lungs.
    Ms. Tlaib. Thank you. Very little is definitely known about 
the long-term health effects of e-cigarettes use in vaping, but 
there is a consciousness as to nicotine's dangerous effects on 
development of adolescent brain and increased risk of future 
addiction.
    Dr. Ezike, can you explain how nicotine impacts brain 
development in adolescents?
    Dr. Ezike. Of course, the brain is still developing almost 
until age 26. And with nicotine, the receptors in pediatrics 
are more susceptible to being addicted. So they get addicted 
quicker, and the addictions predispose to future addictions 
down the road. So we have seen that people who have worse 
addictions usually started at earlier ages.
    Ms. Tlaib. This is very scary, and as a mom, you know, I 
hope e-cigarette users are aware of this fact and are not 
waiting for government to declare this kind of a national 
crisis right now--right?--that we already know from just the 
mere hospitalization cases like in your daughter's case and so 
forth that it's unsafe. We've heard today vaporing exposes 
users to harmful chemicals and so forth.
    You know, I go in to speak to kids all the time. You know, 
I do the second grade and third grade reading class. They 
always ask, what do you do? And I tell them I work at the 
Capitol, and I show them the picture and tell them where it is 
geographywise. And then I tell them: You know, when I was your 
age, I used to go to restaurants with my parents, and they say, 
you know, right now, you go, and they say, ``How many people in 
your group?'' When I was little, they said, ``Nonsmoking or 
smoking section?''
    And the kids are like: What?
    And I was like: Yes, they would say nonsmoking or smoking, 
because they smoked cigarettes in public places like 
restaurants, hospital, schools, planes.
    And the kids' eyes are wide, and they are like: What? 
That's unbelievable.
    And I said: Yes, even though scientists, people were saying 
secondhand smoking was worse--was worse--than directly smoking 
cigarettes. And even though health experts and others were 
coming forward, you had Big Industry, corporate greed, 
misleading information out there to the public, what the real 
impact was on health.
    And so it's so important that you all continue to speak 
truth about this because the long-term effects are very 
dangerous, especially because they have been targeted toward 
youth.
    And, you know, Ms. Porter, I was reading, because I want to 
know more about you and your beliefs. And I respect that. Well, 
we all have different beliefs. But you call yourself a 
converted Conservative and reformed Marxist. Are you conspiracy 
theorist?
    Ms. Porter. I think my politics are entirely irrelevant to 
this hearing.
    Ms. Tlaib. Oh, okay. Why were you winking at one of my 
colleagues on the other side of the aisle? You winked.
    Ms. Porter. Because I know Glenn Grothman.
    Ms. Tlaib. Oh, that's what it--so the winking----
    Ms. Porter. He introduced me. He's a friend of mine.
    Ms. Tlaib. Okay. I Understand. I didn't know what the 
winking was because I thought maybe there was something like a 
conspiracy thing going on there. I didn't know.
    Ms. Porter. You think there's a conspiracy in this hearing, 
ma'am?
    Ms. Tlaib. No. No. I actually think people are speaking 
truth here, and you can provide information----
    Ms. Porter. May I address the truth?
    Mr. Krishnamoorthi. No, no, no.
    Ms. Tlaib. Well, the truth to you is very different for the 
majority of people in this room who do believe that children 
are being targeted by----
    Ms. Porter. The truth for me is I quit smoking with e-
cigarettes, and so did 8 million other people.
    Ms. Tlaib. You're still smoking, ma'am. You're still 
smoking.
    Ms. Porter. I'm not smoking.
    Mr. Krishnamoorthi. Thank you. Order, please.
    Ms. Porter. And I'm not lying under oath.
    Mr. Krishnamoorthi. I'd like to recognize Congressman 
Connolly for five minutes of questions.
    Mr. Connolly. Thank you.
    And welcome to our panel. It seems to me that this is a new 
crisis that kind of came upon us real fast and unawares. And 
part of the problem is, frankly, the lack of any Federal 
structure in which to look at this issue and leaving states 
like Illinois kind of on their own. And is that a fair 
summation of where you think the state of Illinois finds 
itself, Dr. Ezike?
    Dr. Ezike. I believe that there's always ways for 
improvements. The support for research around data 
modernization tools so that we can quickly upload our 
information and share it across states or with our Federal 
partners is very key to being able to disseminate information 
faster around these kinds of epidemics as they emerge.
    Mr. Connolly. But if the Federal Government is not 
regulating the product and hasn't done the research and 
analysis of pros and cons, dangers, benefits, it kind of leaves 
you either to do nothing and wait, or to try to take some 
action to protect the citizens of your state, isn't that fair?
    Dr. Ezike. That's correct.
    Mr. Connolly. Yes. So we have a vacuum at the Federal 
level. Fair enough, Dr. Rizzo.
    Dr. Rizzo. Yes, I agree.
    Mr. Connolly. And what steps should the Federal--I mean, 
this reminds me a little bit of marijuana where we have haven't 
done our job at the Federal level in justifying how we 
categorize or classify marijuana. We have essentially limited 
the kinds of studies we sponsor at the Federal level and who 
gets to do them, with a clear bias toward ``it's dangerous,'' 
and as a result, we've lost control. So we have 27, 28 states 
that are moving to legalization in some form, some full 
legalization for recreational purposes and some for medical 
purposes. But, meanwhile, the Federal control is gone.
    In this case, the Federal Government hasn't really even 
acted yet. And I just wonder, what would be helpful, from your 
point of view, for the Federal Government to undertake so we 
deal with this, obviously, in an expeditious way because--you 
look at smoking. It can take 30, 40, 50 years for someone to 
have the negative health impacts of smoking, chronic smoking. 
What has shocked us about this crisis is that that timeline has 
collapsed, and we're looking at young people who have engaged 
in vaping and, according to some medical reports, at least 
anecdotally, their lungs look like that of a chronic smoker of 
40 years. How did that happen? What in the world is at work 
here that could do that? And what must we do to protect the 
public in an efficacious way and not and not take 10 years to 
do it. Dr. Rizzo?
    Dr. Rizzo. Well, I think the first step with regard to this 
recent crisis of the vaping illness, everything is being done 
and will continue to be done by the CDC and the FDA, and we're 
hoping they will come up with some answers. I think the bigger 
picture is, should there have been--and we think, at the Lung 
Association, there should have been a premarket review of any 
products that come out into the marketplace to deem whether or 
not they're appropriate for public protection. And I think the 
lack of that authority by the FDA, for multiple reasons, has 
been very slow in developing.
    Mr. Connolly. Dr. Ezike, anything?
    Dr. Ezike. I do concur with that.
    Mr. Connolly. Ms. Johnson, would that have made a 
difference, from your perspective?
    Ms. Johnson. I think so. The fact that nobody really knows 
how these products are going to affect people, especially young 
people, who I understand shouldn't be using them but have super 
easy access to them, it's just kind of Russian roulette. You 
know, you just don't know what's going to happen. And, with 
developing lungs, it seems to be worse.
    Mr. Connolly. You know, I'll just end on this note. 
Sometimes we have mindless debate about regulation, and all of 
it's bad. And I bring attention to the fact that my colleague, 
Mr. Comer, Republican, conservative Republican, stated earlier, 
but sometimes we need it. It ain't all bad, and sometimes we 
need to protect the public. And as you all said, frankly, 
absent the vacuum that we created, which wasn't deliberate--
nobody did it with malice--has cost lives and will cost more. 
And so we need to be seized of this issue, and we need to 
understand that meaningful regulation protects people and can 
save lives. And here is a great example where that's needed.
    Thank you for being here today. I appreciate it. And my 
time is up.
    Mr. Krishnamoorthi. Thank you so much. I'd like to thank 
our witnesses for their testimony today.
    Without objection, all members will have five legislative 
days within which to submit additional written questions for 
the witnesses to the chair, which will be forwarded to the 
witnesses for responses.
    I ask our witnesses to please respond as promptly as you 
are able.
    This hearing is adjourned.
    [Whereupon, at 12:58 p.m., the subcommittee was adjourned.]

                                 [all]