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


                  LEGISLATION TO REVERSE THE YOUTH TOBACCO 
                                EPIDEMIC

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                            OCTOBER 16, 2019

                               __________

                           Serial No. 116-70

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

      Printed for the use of the Committee on Energy and Commerce
                  govinfo.gov/committee/house-energy
                        energycommerce.house.gov
                        
                               __________

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
43-572 PDF                 WASHINGTON : 2022                     
          
-----------------------------------------------------------------------------------                        
                       
                    COMMITTEE ON ENERGY AND COMMERCE

                     FRANK PALLONE, Jr., New Jersey
                                 Chairman
BOBBY L. RUSH, Illinois              GREG WALDEN, Oregon
ANNA G. ESHOO, California              Ranking Member
ELIOT L. ENGEL, New York             FRED UPTON, Michigan
DIANA DeGETTE, Colorado              JOHN SHIMKUS, Illinois
MIKE DOYLE, Pennsylvania             MICHAEL C. BURGESS, Texas
JAN SCHAKOWSKY, Illinois             STEVE SCALISE, Louisiana
G. K. BUTTERFIELD, North Carolina    ROBERT E. LATTA, Ohio
DORIS O. MATSUI, California          CATHY McMORRIS RODGERS, Washington
KATHY CASTOR, Florida                BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland           PETE OLSON, Texas
JERRY McNERNEY, California           DAVID B. McKINLEY, West Virginia
PETER WELCH, Vermont                 ADAM KINZINGER, Illinois
BEN RAY LUJAN, New Mexico            H. MORGAN GRIFFITH, Virginia
PAUL TONKO, New York                 GUS M. BILIRAKIS, Florida
YVETTE D. CLARKE, New York, Vice     BILL JOHNSON, Ohio
    Chair                            BILLY LONG, Missouri
DAVID LOEBSACK, Iowa                 LARRY BUCSHON, Indiana
KURT SCHRADER, Oregon                BILL FLORES, Texas
JOSEPH P. KENNEDY III,               SUSAN W. BROOKS, Indiana
    Massachusetts                    MARKWAYNE MULLIN, Oklahoma
TONY CARDENAS, California            RICHARD HUDSON, North Carolina
RAUL RUIZ, California                TIM WALBERG, Michigan
SCOTT H. PETERS, California          EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan             JEFF DUNCAN, South Carolina
MARC A. VEASEY, Texas                GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
A. DONALD McEACHIN, Virginia
LISA BLUNT ROCHESTER, Delaware
DARREN SOTO, Florida
TOM O'HALLERAN, Arizona
                                 ------                                

                           Professional Staff

                   JEFFREY C. CARROLL, Staff Director
                TIFFANY GUARASCIO, Deputy Staff Director
                MIKE BLOOMQUIST, Minority Staff Director
                         Subcommittee on Health

                       ANNA G. ESHOO, California
                                Chairwoman
ELIOT L. ENGEL, New York             MICHAEL C. BURGESS, Texas
G. K. BUTTERFIELD, North Carolina,     Ranking Member
    Vice Chair                       FRED UPTON, Michigan
DORIS O. MATSUI, California          JOHN SHIMKUS, Illinois
KATHY CASTOR, Florida                BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland           H. MORGAN GRIFFITH, Virginia
BEN RAY LUJAN, New Mexico            GUS M. BILIRAKIS, Florida
KURT SCHRADER, Oregon                BILLY LONG, Missouri
JOSEPH P. KENNEDY III,               LARRY BUCSHON, Indiana
    Massachusetts                    SUSAN W. BROOKS, Indiana
TONY CARDENAS, California            MARKWAYNE MULLIN, Oklahoma
PETER WELCH, Vermont                 RICHARD HUDSON, North Carolina
RAUL RUIZ, California                EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan             GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire         GREG WALDEN, Oregon (ex officio)
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
LISA BLUNT ROCHESTER, Delaware
BOBBY L. RUSH, Illinois
FRANK PALLONE, Jr., New Jersey (ex 
    officio)
                            
                            C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Anna G. Eshoo, a Representative in Congress from the State 
  of California, opening statement...............................     1
    Prepared statement...........................................     3
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................     3
    Prepared statement...........................................     5
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     6
    Prepared statement...........................................     8
Hon. Richard Hudson, a Representative in Congress from the State 
  of North Carolina, opening statement...........................     9
    Prepared statement...........................................     9
Hon. Greg Walden, a Representative in Congress from the State of 
  Oregon, prepared statement.....................................   108

                               Witnesses

Matthew L. Myers, President, Campaign for Tobacco-Free Kids......    11
    Prepared statement...........................................    13
    Answers to submitted questions...............................   149
Dorian Fuhrman, Cofounder, Parents Against Vaping e-Cigarettes 
  (PAVe).........................................................    26
    Prepared statement...........................................    29
Susanne E. Tanski, M.D., on behalf of the American Academy of 
  Pediatrics.....................................................    33
    Prepared statement...........................................    36
    Answers to submitted questions...............................   154
Phillip Gardiner, D.P.H., Senior Program Officer, Tobacco-Related 
  Disease Research Program, University of California.............    45
    Prepared statement...........................................    47
Michael Siegel, M.D., Professor, Department of Community Health 
  Sciences, Boston University School of Public Health............    51
    Prepared statement...........................................    53
    Additional material submitted for the record.................    83

                           Submitted Material

H.R. 2339, the Reversing the Youth Tobacco Epidemic Act of 2019, 
  submitted by Ms. Eshoo.........................................   110
Letter of October 15, 2019, from Chad P. Gehani, President, and 
  Kathleen T. O'Loughlin, Executive Director, American Dental 
  Association, to Ms. Eshoo and Mr. Burgess, submitted by Ms. 
  Eshoo..........................................................   129
Letter of October 16, 2019, from Action on Smoking & Health, et 
  al., to Mr. Pallone and Mr. Walden, submitted by Ms. Eshoo.....   131
Statement of the National Medical Association by Niva Lubin-
  Johnson, President, April 16, 2019, submitted by Ms. Eshoo.....   133
Letter of October 15, 2019, from Lori Tremmel Freeman, Chief 
  Executive Officer, National Association of County and City 
  Health Officials, to Ms. Eshoo and Mr. Burgess, submitted by 
  Ms. Eshoo......................................................   134
Statement of the Cancer Action Network, American Cancer Society, 
  October 16, 2019, submitted by Ms. Eshoo.......................   136
Statement of CVS Health, October 16, 2019, submitted by Ms. Eshoo   139
Statement of the American Osteopathic Association, October 16, 
  2019, submitted by Ms. Eshoo...................................   141
Letter of June 11, 2019, from Vera Bumpers, National President, 
  National Association of Black Law Enforcement Executives, to 
  Mr. Pallone, submitted by Mr. Hudson...........................   142
Letter of October 11, 2019, from Major Neil Franklin (Ret.), 
  Executive Director, Law Enforcement Action Partnership, to Mr. 
  Pallone, submitted by Mr. Hudson...............................   144
Letter of October 11, 2019, from Paul Harden, President and Chief 
  Executive Officer, Texas Food and Fuel Association, to Mr. 
  Burgess, submitted by Mr. Burgess..............................   146
Fact sheet, Tobacco User Fee Assessment Formulation by Product 
  Class, 2019, submitted by Mr. Burgess..........................   148

 
           LEGISLATION TO REVERSE THE YOUTH TOBACCO EPIDEMIC

                              ----------                              


                      WEDNESDAY, OCTOBER 16, 2019

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:31 a.m., in 
room 2322, Rayburn House Office Building, Hon. Anna G. Eshoo 
(chairwoman of the subcommittee) presiding.
    Members present: Representatives Eshoo, Engel, Butterfield, 
Matsui, Castor, Sarbanes, Schrader, Kennedy, Cardenas, Welch, 
Ruiz, Dingell, Kuster, Kelly, Barragan, Blunt Rochester, Rush, 
Pallone (ex officio), Burgess (subcommittee ranking member), 
Upton, Shimkus, Guthrie, Griffith, Bilirakis, Long, Bucshon, 
Brooks, Mullin, Hudson, Carter, and Gianforte.
    Also present: Representatives Clarke and Schakowsky.
    Staff present: Joe Banez, Professional Staff Member; 
Jeffrey C. Carroll, Staff Director; Waverly Gordon, Deputy 
Chief Counsel; Tiffany Guarascio, Deputy Staff Director; 
Stephen Holland, Health Counsel; Zach Kahan, Outreach and 
Member Service Coordinator; Josh Krantz, Policy Analyst; 
Aisling McDonough, Policy Coordinator; Meghan Mullon, Staff 
Assistant; Alivia Roberts, Press Assistant; Rebecca Tomilchik, 
Staff Assistant; Kimberlee Trzeciak, Chief Health Advisor; C. 
J. Young, Press Secretary; Margaret Tucker Fogarty, Minority 
Legislative Clerk/Press Assistant; Theresa Gambo, Minority 
Financial and Office Administrator; Peter Kielty, Minority 
General Counsel; Ryan Long, Minority Deputy Staff Director; J. 
P. Paluskiewicz, Minority Chief Counsel, Health; and Kristin 
Seum, Minority Health Counsel.
    Ms. Eshoo. The Subcommittee on Health will now come to 
order.
    Good morning to all of my colleagues, to the witnesses that 
are here today. We are grateful to you for being here and to 
everyone else in the audience that has joined us.
    The Chair now recognizes herself for 5 minutes for an 
opening statement.

 OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Smoking kills. It is the leading cause of preventable death 
in the United States. Cigarette smoking is responsible for more 
than 480,000 deaths in the United States each year, and more 
than 16 million Americans are living with a disease caused by 
smoking.
    These health problems cost our country more than $300 
billion, with a B, a year. But despite knowing the consequences 
of smoking for over half a century, we are still raising 
children who smoke.
    In 2018, 4.9 million middle and high school students were 
current users of some type of tobacco product or e-cigarettes. 
Many of those children will be lifelong smokers.
    Over 90 percent of adult smokers began smoking before they 
turned 21. The tobacco industry knows the best way to continue 
their business to aggressively target children with their 
addictive products so that they will have guaranteed customers 
for decades.
    That is why 10 years ago, along with both Republican and 
Democratic members of this committee, we voted for the Family 
Smoking Prevention and Tobacco Control Act of 2009.
    This law restricted marketing tobacco products to children 
and banned most of the flavored cigarettes made to appeal to 
children.
    After that law passed, youth tobacco use declined. But the 
rise of e-cigarettes reversed that trend. For the first time in 
decades, the CDC reports that youth tobacco use is 
significantly rising.
    Because of e-cigarettes, 1.5 million more youth used a 
tobacco product in 2018, compared to the year before, 2017. 
High school e-cigarette users are four to seven times more 
likely to start smoking traditional cigarettes than their 
nonvaping peers.
    Our work to end tobacco use and nicotine addiction in the 
United States is really at risk. We have been caught flat-
footed by the popularity of e-cigarettes among young people.
    And now, in the midst of the youth e-cigarette epidemic, we 
are seeing an outbreak of a vaping-related illness, with nearly 
1,300 cases and 26 deaths.
    This illness is affecting children. Thirty-six percent of 
the patients are under 20 years old. Just last month, the FDA 
Acting Commissioner told our Oversight Subcommittee that the 
FDA, quote, ``should have acted sooner,'' unquote, to rein in 
e-cigarettes.
    Despite the lessons from the Tobacco Control Act of 2009, 
we haven't extended its bipartisan restrictions to e-
cigarettes.
    The bill we are considering today, Chairman Pallone and 
Representative Shalala, who is here with us this morning right 
in the front row--former Secretary of HHS, now happily a member 
of the House of Representatives, she came very often to testify 
before this subcommittee--her legislation fixes the problem I 
just described.
    The bill extends tobacco marketing, sale, flavor 
restrictions, and fees to e-cigarettes while also making the 
landmark change of raising the minimum age to buy tobacco 
products to 21 years.
    This bill will save lives. Raising the tobacco age to 21 
will result in a quarter of a million fewer premature deaths 
for those born between 2000 and 2019.
    It is comprehensive legislation that will reverse youth e-
cigarette use and drive down youth tobacco use overall. We 
cannot allow young Americans to be ensnared in nicotine 
addiction.
    It is time to do everything we can to end youth tobacco 
use. I look forward to working with all of my colleagues on a 
bill to do just that.
    [The prepared statement of Ms. Eshoo follows:]

                Prepared Statement of Hon. Anna G. Eshoo

    Smoking kills. It is the leading cause of preventable death 
in the U.S.
    Cigarette smoking is responsible for more than 480,000 
deaths in the U.S. each year and more than 16 million Americans 
are living with a disease caused by smoking. These health 
problems cost our country more than $300 billion a year.
    But despite knowing the consequences of smoking for over 
half a century, we're still raising children who smoke.
    In 2018, 4.9 million middle and high school students were 
current users of some type of tobacco product or e-cigarette. 
Many of those children will be life-long smokers. Over 90% of 
adult smokers began smoking before they turned 21.
    The tobacco industry knows the best way to continue their 
business is to aggressively target children with their 
addictive products, so that they'll have guaranteed customers 
for decades.
    That's why 10 years ago, I was proud to vote, along with 
both Democratic and Republican members of this committee, for 
the Family Smoking Prevention and Tobacco Control Act of 2009. 
This law restricted marketing tobacco products to children and 
banned most of the flavored cigarettes made to appeal to 
children.
    After that law passed, youth tobacco use declined.
    But e-cigarettes reversed that trend. For the first time in 
decades, the CDC reports youth tobacco use is rising 
significantly. Because of e-cigarettes, 1.5 million more youth 
used a tobacco product in 2018 compared to 2017. High school e-
cigarette users are 4 to 7 times more likely to adopt 
traditional cigarette use than their nonvaping peers.
    Our work to end tobacco use and nicotine addiction in the 
U.S. is at risk.
    We've been caught flat-footed by the popularity of e-
cigarettes among young people. And now, in the midst of the 
youth e-cigarette epidemic, we're seeing an outbreak of a 
vaping-related illness with nearly 1,300 cases and 26 deaths. 
This illness is affecting children--36% of the patients are 
under 20 years old.
    Just last month, the FDA Acting Commissioner told our 
Oversight Subcommittee that the FDA ``should have acted 
sooner'' to rein in e-cigarettes.
    Despite the lessons from the Tobacco Control Act of 2009, 
we haven't extended its bipartisan restrictions to e-
cigarettes.
    The bill we're considering today, Chairman Pallone and 
Representative Shalala's Reversing the Youth Tobacco Epidemic 
Act, fixes that problem. The bill extends tobacco marketing, 
sale, flavor restrictions and fees to e-cigarettes, while also 
making the landmark change of raising the minimum age to buy 
tobacco products to 21 years.
    This bill will save lives. Raising the tobacco age to 21 
will result in a quarter of a million fewer premature deaths 
for those born between 2000 and 2019. It is comprehensive 
legislation that will reverse youth e-cigarette use and drive 
down youth tobacco use overall.
    We can't allow young Americans to be ensnared in nicotine 
addiction. It's time to do everything we can to end youth 
tobacco use. I look forward to working with all my colleagues 
on a bill to do just that.

    Ms. Eshoo. The Chair now recognizes Dr. Burgess, the 
distinguished ranking member of the subcommittee, for his 5 
minutes for an opening statement.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE 
              IN CONGRESS FROM THE STATE OF TEXAS

    Mr. Burgess. And I thank the Chair, and I want to thank our 
witnesses for being with us this morning. I will just note 
there have been over a thousand confirmed and probable cases of 
lung injury reported to the Centers for Disease Control, 
reaching almost every State and U.S. Territory.
    Eighty percent of these cases involve individuals under the 
age of 35. Vaping and e-cigarettes acutely affect the youth 
population in the United States, which is why there has been 
such great national attention by the news media and, indeed, by 
the Congress.
    The CDC continues to work closely with State and local 
authorities together and to analyze the information from across 
the country.
    So both the Trump administration and Congress have taken 
steps to try to further understand and combat this lung injury 
outbreak. Action is needed, but we do need to first understand 
the issue at hand to devise the best solution.
    When it's an issue of public health at stake, it is 
critical that Congress work with the agencies, including the 
Food and Drug Administration and the CDC, to gather as much 
information as possible and act within appropriate authorities 
to protect the public.
    When this investigation began, the CDC issued a warning 
that consumers should avoid using any and all vaping products, 
including nicotine, THC, and hybrid products.
    Since the investigation has progressed, the CDC has perhaps 
refined their warning a bit to just avoid using these products, 
particularly those containing THC.
    Most affected patients reported a history of using THC-
containing products, confirming the findings that the THC has 
played a role in the outbreak.
    As more information becomes known and understood about e-
cigarettes, we should ensure that our legislative solutions 
tackle the true underlying cause of the issue.
    Throughout this conversation we do have to keep in mind 
that the nicotine in e-cigarettes is still highly addictive. E-
cigarettes do provide an alternative to traditional cigarettes 
for adult smokers who are trying to quit.
    Traditional cigarettes remain the leading cause of 
preventable death in the United States, claiming an estimated 
480,000 lives or more each year.
    This is personal for me because both of my parents were 
part of that 480,000 statistic a few years ago.
    According to the CDC, an estimated 34 million adults in the 
United States currently smoke cigarettes, and more than 16 
million Americans live with a smoking-related disease.
    I am certainly concerned about the effect of e-cigarettes 
on youth, but we do need to remember there is a large adult 
population with a whole host of health problems related to 
tobacco.
    This legislative hearing today is about Mr. Pallone's bill, 
H.R. 2339. The bill includes some policies similar to President 
Trump's Executive order banning flavored e-cigarettes and some 
similarity to Senator McConnell's Tobacco-Free Youth Act that 
raises the minimum age for purchasing tobacco to age 21.
    While H.R. 2339 overlaps with some good policy coming from 
the administration and the Senate, there are provisions in the 
bill that are concerning should this become law.
    There is potential infringement on the First Amendment by 
requiring graphic health warnings on cigarette labels and 
advertising.
    There are other ways to educate individuals, particularly 
the youth population, of the harmful effects of smoking and 
reduce youth smoking rates without being detrimental to the 
freedom of speech.
    For example, Mr. McConnell's Tobacco-Free Youth Act, which 
has bipartisan support and in fact was included in a bipartisan 
package that passed out of the Health, Education, Labor, and 
Pensions Committee over in the Senate, S. 1895, and that is a 
bill that directly addresses youth smoking by raising the age 
to purchase without problematic and overreaching provisions.
    A bill such as 2339 includes some policies that may be 
helpful, but there are problematic provisions and lack of full 
understanding of the causes of this lung injury epidemic.
    Reducing youth tobacco rates is essential to a healthy 
America. So I am certainly glad that we are having this 
discussion today.
    Again, thanks to all of our witnesses for being part of 
this important conversation this morning, and I look forward to 
hearing your testimony and the question portion of the hearing.
    I yield back.
    [The prepared statement of Mr. Burgess follows:]

             Prepared Statement of Hon. Michael C. Burgess

    Thank you, Madame Chair and to our witnesses for being here 
today. There have been over 1,000 confirmed and probable cases 
of lung injury reported to the Centers for Disease Control and 
Prevention, reaching almost every State and even a U.S. 
Territory. Approximately 80 percent of these cases involve 
individuals under 35 years of age. Vaping and e-cigarettes 
acutely affect the youth population in the United States, which 
is why there has been such great national attention by the news 
media and by Congress.
    The CDC continues to work closely with State and local 
authorities to gather and analyze information from across the 
country.
    We must continue investigating this very concerning 
outbreak among our Nation's youth.
    Both the Trump administration and Congress have taken steps 
to try to further understand and combat this lung injury 
outbreak. While action is needed, we must first understand the 
issue at hand so that we can devise the best solution. With an 
issue of public health at stake, it is critical that Congress 
work with agencies, including the Food and Drug Administration 
and the CDC, to gather as much information as possible and act 
within appropriate authorities to protect the public.
    When this investigation began, the CDC issued a warning 
that consumers should avoid using any and all vaping products, 
including nicotine, tetrahydrocannabinol (THC), and hybrid 
products. Since the investigation has progressed, the CDC has 
refined their warning to avoid using these products, 
particularly those containing THC.
    Most affected patients reported a history of using THC-
containing products, confirming the findings that THC has 
played a role in the outbreak. As more information becomes 
known and understood about e-cigarettes, we should ensure our 
legislative solutions tackle the underlying causes of this 
issue.
    Throughout this conversation, we should also keep in mind 
that the nicotine in e-cigarettes is still addictive. However, 
e-cigarettes do provide an alternative to traditional 
cigarettes for adult smokers who are trying to quit.
    Traditional cigarettes remain the leading cause of 
preventable death in the U.S., claiming an estimated 480,000 
lives or more each year. This is a personal issue for me, as I 
lost both of my parents to tobacco-related illness.
    According to the CDC, an estimated 34 million adults in the 
United States currently smoke cigarettes and more than 16 
million Americans live with a smoking-related disease.
    While I am certainly concerned about the affect of e-
cigarettes on our youth, we do need to remember that there is a 
large adult population with a whole host of health problems 
related to tobacco.
    This legislative hearing is about Mr. Pallone's bill, H.R. 
2339. This bill includes some policies similar to President 
Trump's Executive order banning flavored e-cigarettes and to 
Senator McConnell's Tobacco-Free Youth Act (S. 1541) that 
raises the minimum age for purchasing tobacco products to 21 
years old.
    While H.R. 2339 overlaps with some good policy coming from 
the administration and the Senate, there are concerning 
provisions that could hinder this bill becoming law.
    There is potential infringement on the First Amendment by 
requiring graphic health warnings on cigarette labels and 
advertising. There are other ways to educate individuals, 
particularly the youth population, of the harmful effects of 
smoking and reduce youth smoking rates without being 
detrimental to the freedom of speech. For example, Mr. 
McConnell's Tobacco-Free Youth Act, which has bipartisan 
support and has been included in bipartisan HELP drug cost 
package (S. 1895), is a bill that directly addresses youth 
smoking by raising the age to purchase without problematic and 
overreaching provisions.
    A bill such as H.R. 2339 includes some policies that may be 
helpful in combating the youth tobacco rates in the U.S.; 
however, there are problematic provisions and a lack of a full 
understanding of the causes of this lung injury epidemic. 
Reducing youth tobacco rates is essential to a healthy America, 
and I am glad we are discussing this issue today.
    Again, I would like to thank all our witnesses for being 
part of this important conversation today. I yield back.

    Ms. Eshoo. The gentleman yields back.
    The Chair now recognizes Mr. Pallone, the chairman of the 
full committee, for his 5 minutes of an opening statement.

OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Chairwoman Eshoo.
    This committee takes another important step in protecting 
our youth from a life of chronic disease, disability, and death 
from tobacco products and nicotine.
    We will consider H.R. 2339, the Reversing the Youth Tobacco 
Epidemic Act of 2019, which is a bipartisan bill that I 
introduced with Representative Donna Shalala, aimed at reducing 
the number of kids using tobacco products in the United States.
    And I did want to mention, Congresswoman Shalala, when 
you--Madam Chair, when you said ``happily,'' I was thinking 
about that because it's true. She's always happy and yet she's 
always substantive at the same time.
    It's a rare combination, and it's also rare that somebody 
is the Secretary of a major agency and comes back to Congress.
    But I think it's that--you know, I was thinking about what 
Chairwoman Eshoo said, and I think that you are just very 
optimistic and you always think that we can do things and it's 
a day--you know, oftentimes she'll come to the floor and say 
``I have a new idea'' and be all excited about it, which is 
such a great thing. So I just wanted to mention that.
    Let me say that 55 years ago, the Surgeon General warned of 
the dangerous health effects of smoking cigarettes. Yet, five 
decades later, smoking remains the leading cause of preventable 
death.
    The use of tobacco and nicotine has evolved since that 
first Surgeon General's report. A quick Google search will lead 
you to an array of products online, including cigarettes, 
cigars, smoking pipes, and the most recent addition, e-
cigarettes, and these e-cigarettes are now available in many 
flavors, and studies show that flavored choices like mint, 
candy, fruit, or chocolate draw the interests of teens in 
middle school and high school.
    Unfortunately, while combustible cigarette use among teens 
have declined over the past two decades, there is a widespread 
and false perception that e-cigarettes are safe, and I have to 
say I have been to some of my middle schools, and that's what I 
would get until recently from the students, that, ``Oh, they 
are safe, there's not a problem here.''
    And this false belief threatens the progress we have made 
in combating this public health threat. Compounding this 
alarming reality is the fact that nearly all tobacco use begins 
during youth and young adulthood, which is a crucial period for 
the development of the human brain.
    Recent data shows that over 3.6 million youth used e-
cigarettes in 2018, making this product the most commonly used 
tobacco product on the market.
    Last month, our Oversight and Investigations Subcommittee 
held a hearing on the public health threats of e-cigarettes, 
and I remain deeply concerned about the outbreak of lung 
illnesses associated with e-cigarette use and vaping products.
    The most recent report from the CDC confirmed 26 deaths in 
21 States, and at our Oversight hearing, CDC stated that they 
expect the number of cases to increase by the hundreds.
    So I firmly believe that the youth vaping epidemic we face 
today could have been addressed if the FDA had moved forward 
with reviewing all e-cigarettes on the market when the agency 
first had the chance 2 years ago.
    And while I appreciated the administration's announcement 
to ban flavored vaping products, we have yet to see that 
promise come to fruition.
    Ten years ago, Congress took significant bipartisan action 
when we passed the Family Smoking Prevention and Tobacco 
Control Act, which gave the FDA regulatory authority to 
regulate tobacco products, and that was a strong step.
    But now, given the shocking increases in the number of 
teens and young people using e-cigarettes, our bill takes this 
authority a step forward. It extends FDA regulation on the sale 
and distribution of tobacco products, including e-cigarettes.
    The bill raises the minimum age for purchasing tobacco to 
21 and makes it unlawful for any retailer to sell a tobacco 
product to any person younger than 21, and the bill also 
prohibits non-face-to-face sales of all tobacco products and 
bans all flavors of tobacco products, including mint and 
menthol.
    Now, this bipartisan bill has widespread support from 
groups like the African American Tobacco Control Leadership 
Council, American Academy of Pediatrics, American Cancer 
Society, American College of Cardiology, American Heart 
Association, American Lung Association, American Thoracic 
Society, Campaign for Tobacco-Free Kids, March of Dimes, and 
the National African American Tobacco Prevention Network.
    These groups say loud and clear we are facing a serious 
problem that needs a comprehensive solution, and as the 
committee responsible for protecting the Nation's public 
health, we have to act.
    It is my intention to advance this legislation this fall, 
and I hope we can do so with strong bipartisan support because 
we simply can't lose another generation to a lifetime of 
nicotine addiction.
    And I want to thank the witnesses for being here today and 
look forward to our committee's discussion on this important 
bill, Madam Chair.
    Thank you, and I yield back.
    [The prepared statement of Mr. Pallone follows:]

             Prepared Statement of Hon. Frank Pallone, Jr.

    Today, this committee takes another important step in 
protecting our youth from a life of chronic disease, 
disability, and death from tobacco products and nicotine 
addiction. We will consider H.R. 2339, the Reversing the Youth 
Tobacco Epidemic Act of 2019, a bipartisan bill that I 
introduced with Representative Donna Shalala aimed at reducing 
the number of kids using tobacco products in the United States.
    Fifty-five years ago, the Surgeon General warned of the 
dangerous health effects of smoking cigarettes. Yet, five 
decades later smoking remains the leading cause of preventable 
death.
    The use of tobacco and nicotine has evolved since that 
first Surgeon General's report. A quick Google search will lead 
you to an array of products online, including cigarettes, 
cigars, smoking pipes, and the most recent addition--e-
cigarettes. These e-cigarettes are now available in many 
flavors and studies show that flavor choices like mint, candy, 
fruit, or chocolate draw the interest of teens in middle school 
and high school.
    Unfortunately, while combustible cigarette use among teens 
has declined over the past two decades, there is a widespread--
and false--perception that e-cigarettes are safe. This false 
belief threatens the progress we have made in combatting this 
public health threat. Compounding this alarming reality is the 
fact that nearly all tobacco use begins during youth and young 
adulthood--which is a crucial period for the development of the 
human brain. Recent data shows that over 3.6 million youth used 
e-cigarettes in 2018, making this product the most commonly 
used tobacco product on the market.
    Last month, our Oversight and Investigations Subcommittee 
held a hearing on the public health threats of e-cigarettes. I 
remain deeply concerned about the outbreak of lung illnesses 
associated with e-cigarette use and vaping products. The most 
recent report from the CDC confirmed 26 deaths in 21 States, 
and at our oversight hearing, CDC stated that they expect the 
number of cases to increase ``by the hundreds.''
    I firmly believe that the youth vaping epidemic we face 
today could have been addressed if the FDA had moved forward 
with reviewing all e-cigarettes on the market when the agency 
first had the chance 2 years ago. And while I appreciated the 
administration'sannouncement to ban flavored vaping products, 
we have yet to see that promise come to fruition.
    Ten years ago, Congress took significant bipartisan action 
when we passed the Family Smoking Prevention and Tobacco 
Control Act, which gave FDA regulatory authority to regulate 
tobacco products. That was a strong step, but now, given the 
shocking increases in the number of teens and young people 
using e-cigarette, my bill takes this authority a step forward. 
It extends FDA regulation on the sale and distribution of 
tobacco products, including e-cigarettes. My bill raises the 
minimum age for purchasing tobacco to 21 and makes it unlawful 
for any retailer to sell a tobacco product to any person 
younger than 21 years of age. My bill also prohibits non-face-
to-face sales of all tobacco products. It also bans all flavors 
of tobacco products, including mint and menthol.
    This bipartisan bill has widespread support from groups 
like the African American Tobacco Control Leadership Council, 
American Academy of Pediatrics, American Cancer Society Cancer 
Action Network, American College of Cardiology, American Heart 
Association, American Lung Association, American Thoracic 
Society, Campaign for Tobacco-Free Kids, March of Dimes, and 
National African American Tobacco Prevention Network.
    These groups say loud and clear: We are facing a serious 
problem that needs a comprehensive solution. As the committee 
responsible for protecting the Nation's public health, we must 
act. It is my intention to advance this legislation this fall, 
and I hope we can do so with strong bipartisan support.
    We simply cannot lose another generation to a lifetime of 
nicotine addiction.
    I thank the witnesses for being here today and I look 
forward to our committee's discussion on this important bill.
    Thank you, and I yield back.

    Ms. Eshoo. The gentleman yields back.
    The Chair now recognizes Mr.--is Mr. Walden here?
    Mr. Burgess. In Mr. Walden's absence, may I ask unanimous 
consent that we recognize the gentleman from North Carolina?
    Ms. Eshoo. So ordered. The gentleman from North Carolina is 
recognized.

 OPENING STATEMENT OF HON. RICHARD HUDSON, A REPRESENTATIVE IN 
           CONGRESS FROM THE STATE OF NORTH CAROLINA

    Mr. Hudson. I thank the chairwoman.
    I appreciate the opportunity to speak today, and I share 
the concerns about youth initiating the nicotine products. But 
I want to make one thing clear: There is only one youth 
epidemic right now, and it is in e-cigarettes.
    I have serious concerns with the proposed legislation today 
and the intended and unintended consequences that could result 
from its enactment.
    My biggest concern is the total flavor ban for all tobacco 
products included in this legislation. While we have seen 
pronounced increases in youth initiation rates for e-
cigarettes, we have not seen the same increases in traditional 
tobacco products such as combustible cigarettes and smokeless 
tobacco.
    In fact, these products have seen declining usage rates for 
the past 20 years, according to the National Youth Tobacco 
survey and the Monitoring the Future survey.
    Now, looking at the larger issue of flavors as they relate 
to youth initiation, the Monitoring the Future survey notes 
that youth are almost four times as likely to use illegal drugs 
and alcohol as they are to smoke cigarettes. The percentage is 
even lower for menthol cigarettes.
    Right now, you can buy alcohol in any number of flavors, 
including whipped cream, peach, mango, black cherry, and so 
forth.
    Alcohol is responsible for 4,300 deaths and 119,000 
emergency room visits for people aged 12 to 21. Additionally, 
you can purchase marijuana-infused edibles such as gummy bears 
in any number of flavors appealing to children.
    Marijuana is a federally controlled substance and is being 
marketed to children. Yet, we are discussing banning legal 
products that have declining usage rates among youth.
    The Tobacco Control Act specifically provides the authority 
for the FDA to adopt additional product standards. Given the 
FDA already has the authority to ban menthol and other flavored 
products through a law that is now almost 10 years old, we 
should focus this hearing on the issue at hand--youth vaping, 
and how we can control and stem its occurrence.
    I agree this youth epidemic requires congressional 
attention, and I want to make sure our children are not 
initiating nicotine products that can lead to lifelong 
addictions.
    But let's make sure the tools already in statute are being 
used before we engage in knee-jerk reactions and add additional 
layers of statute on top.
    Thank you, and I will--if anyone wants me to yield to them, 
I am willing to do that. If not, Madam Chair, I'll yield back.
    [The prepared statement of Mr. Hudson follows:]

               Prepared Statement of Hon. Richard Hudson

    Thank you Mrs. Chairwoman.
    I appreciate the opportunity to speak today and I share the 
concerns about youth initiating in nicotine products but I want 
to make one thing clear, there is only one youth epidemic right 
now and it is in e-cigarettes. I have serious concerns with the 
proposed legislation today and the intended and unintended 
consequences that could result from its enactment.
    My biggest concern is the total flavor ban for all tobacco 
products included in this legislation. While we have seen 
pronounced increases in youth initiation rates for e-
cigarettes, we have not seen the same increases in traditional 
tobacco products such as combustible cigarettes and smokeless 
tobacco. In fact, these products have seen declining usage 
rates for the past 20 years according to the National Youth 
Tobacco Survey and the Monitoring the Future survey.
    Further, looking at the larger issue of flavors as they 
relate to youth initiation, the Monitoring the Future survey 
notes that youth are almost 4 times as likely to use illegal 
drugs and alcohol as they are to smoke cigarettes. The 
percentage is even lower for menthol cigarettes. Right now, you 
can buy alcohol in any number of flavors, including whipped 
cream, peach, mango, black cherry, and so forth. Alcohol is 
responsible for 4,300 deaths and 119,000 emergency room visits 
for people aged 12-21. Additionally, you can purchase marijuana 
infused edibles such as gummy bears in any number of flavors 
appealing to children. Marijuana is a federally controlled 
substance and is being marketed to children, yet we're 
discussing banning legal products that have declining usage 
rates among youth.
    The Tobacco Control Act specifically provides the authority 
for the FDA to adopt additional product standards if scientific 
evidence warrants action. Given the FDA already has the 
authority to ban menthol and other flavored products through a 
law that is now almost 10 years old, we should focus this 
hearing on the prominent issue at hand--youth vaping and how we 
can control and stem its occurrence.
    I agree this youth epidemic requires congressional 
attention and I want to make sure children are not initiating 
nicotine products that can lead to lifelong addictions, but 
let's make sure the tools already in statute are being used 
before we engage in knee-jerk reactions and add additional 
layers of statute on top.
    Thank you and I yield back the balance of my time.

    Ms. Eshoo. The gentleman yields back.
    The Chair reminds Members that, pursuant to committee 
rules, all Members' written opening statements shall be made 
part of the record.
    I now would like to introduce our witnesses for today's 
hearing.
    First, Mr. Myers is the president of the Campaign for 
Tobacco-Free Kids. Thank you for being with us here today.
    Ms. Dorian Fuhrman--she is the cofounder of Parents Against 
Vaping e-Cigarettes. Thank you for being with us.
    Dr. Tanski is a member of the American Academy of 
Pediatrics. Thank you to you for the testimony that you're 
going to provide.
    We have Dr. Gardiner. He is the senior program officer of 
the Tobacco-Related Disease Research Program at the University 
of California, in my view the greatest public university in the 
world. How is that?
    And last but not least, Dr. Michael Siegel. He's a 
professor, Department of Community Health Sciences at the 
Boston University School of Public Health. Thank you to you as 
well.
    So, at this time, I am going to recognize each witness for 
5 minutes to provide your opening statement. I think you know 
what the--you need to have your microphones on. Get close to 
them because we don't want to miss a word. It'll be green and 
it'll turn yellow and you know what red means.
    So, with that, Mr. Myers, you have 5 minutes for your 
opening statement.

    STATEMENTS OF MATTHEW L. MYERS, PRESIDENT, CAMPAIGN FOR 
 TOBACCO-FREE KIDS; DORIAN FUHRMAN, COFOUNDER, PARENTS AGAINST 
VAPING e-CIGARETTES (PAVe); SUSANNE E. TANSKI, M.D., ON BEHALF 
   OF THE AMERICAN ACADEMY OF PEDIATRICS; PHILLIP GARDINER, 
    D.P.H., SENIOR PROGRAM OFFICER, TOBACCO-RELATED DISEASE 
RESEARCH PROGRAM, UNIVERSITY OF CALIFORNIA; AND MICHAEL SIEGEL, 
   M.D., PROFESSOR, DEPARTMENT OF COMMUNITY HEALTH SCIENCES, 
           BOSTON UNIVERSITY SCHOOL OF PUBLIC HEALTH

                 STATEMENT OF MATTHEW L. MYERS

    Mr. Myers. Thank you, Chairman Eshoo, and Dr. Burgess and 
members of the committee. We very much appreciate the 
opportunity to testify on H.R. 2339, the Reversing the Youth 
Tobacco Epidemic Act.
    My name is Matthew Myers. I am the president of the 
Campaign for Tobacco-Free Kids. The campaign strongly supports 
this bill because we have a genuine crisis of youth e-cigarette 
use that is growing worse by the day, and this is the piece of 
legislation that addresses all of the leading drivers of youth 
tobacco use and tobacco-related health disparities: the use of 
sweet flavors, the use of marketing that appeals to kids, and 
the easy access to tobacco products for our Nation's children.
    Make no mistake, we do have a crisis. The use of e-
cigarettes by our youth has skyrocketed. Newly released data 
shows that it has grown even worse over the last year. Today, 
roughly, 27.5 percent of our high school students--an increase 
of 3 million in just the last two years--use e-cigarettes.
    It's also critical to understand these kids are not just 
experimenting. More than a quarter of high school e-cigarette 
users are frequent users. That means they are using them more 
than 20 days a month--a clear sign of addiction.
    If you want a point of comparison, that is three to five 
times the number of e-cigarette users who use them with a 
frequency to demonstrate addiction than we see with cigarettes.
    For decades we have been concerned about how rapid kids 
become addicted to cigarettes. E-cigarettes are an addiction 
that is more intense, more rapid, and is affecting more of our 
children than we have seen in two decades in the United States.
    There is also reason for additional concern. The evidence 
shows that kids who use e-cigarettes--nonsmoking kids who use 
e-cigarettes--are far more likely to go on to become regular 
cigarette smokers. One study demonstrates it increases the risk 
by three to four times.
    Put it in context. The kids who are using e-cigarettes are 
by and large not kids who are most at risk for cigarette 
smoking. So what we are not doing is we are not replacing kids 
who might have smoked with e-cigarettes. We are adding a whole 
generation of young people.
    The use of e-cigarettes by our kids has both short- and 
long-term health consequences. The use of products that deliver 
massive doses of nicotine have a direct effect on the 
developing brain.
    They harm kids' memory, attention span, learning. The tales 
of kids who are dropping out of sports, who can't pay attention 
in the class, who are being--who are so addicted that they have 
to go to in-patient therapy are legion.
    What we are facing is a true crisis of addiction, and we 
don't know the long-term health effects of these products.
    Now, Dr. Burgess, you correctly said--and we are all 
concerned--about the need to do more to help adults quit. We 
are also concerned about not chasing false gods.
    The reality is that the scientific evidence about e-
cigarette use and cessation is far weaker than it has been 
presented in most circumstances.
    Let me quote the prestigious journal--medical journal--The 
Lancet, just this last week: ``Manufacturers of e-cigarettes 
and some public health advocates have supported their use as a 
smoking cessation tool and a safer alternative to cigarettes, 
something we would all support.''
    The journal goes on to say, ``However, the evidence of both 
of these claims is weak. The positioning of e-cigarettes as a 
viable cessation aid is vastly overstated.''
    Every public health authority in the United States that has 
examined the evidence has found that the evidence is too weak 
to conclude that these are effective tobacco cessation tools.
    Our adult smokers need effective tobacco cessation tools. 
They don't need to be misled. And we shouldn't be surprised. 
Let me quote a senior executive from JUUL.
    Quote, ``We don't think a lot about addiction here because 
we are not trying to design a cessation product at all,'' he 
said, later noting, ``Anything about health is not on our 
mind.''
    So we need to understand. We need to help adult smokers 
quit. We need the FDA to do more to assist and to identify 
products that will be effective to doing so. But we are not 
helping adults when we allow them to be misled by claims going 
on.
    At the heart of the industry--at the heart of the problem 
is in fact the use of flavors. Nearly 97 percent of current e-
cigarette youths have used a flavored e-cigarette in the past 
month. Seventy percent say they use them because of the 
flavors. The tales are legion.
    And make no mistake, mint and menthol are flavors that 
appeal to kids. We have seen the use of those----
    Ms. Eshoo. Mr. Myers, your time has expired.
    Mr. Myers. Sure. Let me just finish this sentence. We have 
seen the use of those two flavors go from 41 percent to 53 
percent to 64 percent over the last 3 years. We need to address 
that issue.
    [The prepared statement of Mr. Myers follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you very much.
    I now would like to recognize Ms. Fuhrman for her 5 minutes 
of testimony. Welcome again.

                  STATEMENT OF DORIAN FUHRMAN

    Ms. Fuhrman. Good morning, and thank you, Chairwoman Eshoo, 
Ranking Member Burgess, Chairman Pallone, and members of the 
Subcommittee on Health.
    My name is Dorian Fuhrman, and I am one of the cofounders 
of Parents Against Vaping e-Cigarettes, a national grassroots 
organization founded by three moms in response to the youth 
vaping epidemic, the worst adolescent public health crisis we 
have seen in decades.
    We founded PAVe in 2018, and today we have 13 chapters in 
10 States. In late 2017, we became aware of a new trend called 
JUULing. The real catalyst for us to form PAVe came in 2018 
when JUUL sent a representative into our son's ninth-grade 
class for an addiction and mental health talk. We testified 
about this in July in the congressional Oversight Subcommittee.
    After the talk, our boys went to speak with the presenter. 
When asked what to do if a friend was addicted to nicotine, the 
presenter pulled out his JUUL, showed the boys how it worked, 
and called it the iPhone of vapes.
    We discovered that these predatory companies targeted our 
kids where they live, on social media with slick ads, 
influences, and promotions.
    We were contacted by parents who discovered these companies 
advertising on homework websites. Yes, homework websites.
    We knew it was important to educate parents about the 
dangers of flavored e-cigarette products. We launched our 
website that fall and immediately began to get emails from 
parents around the country who were struggling with their kids' 
severe nicotine addiction.
    These kids were vaping in record numbers, and the physical 
and emotional effects of their nicotine addiction were 
stunning, and it was tearing families apart--the extreme, 
explosive anger, the inability to concentrate and focus in 
school, the extreme anxiety and mood swings.
    We learned that nicotine rewires the developing adolescent 
brain, not only priming it for further addiction but affecting 
cognitive development, mood, and impulse control.
    We learned that kids' lungs continue to develop until the 
age of 25, just like their brains. These unknown, unregulated, 
proprietary flavorings may be safe for consumption but are not 
safe to be heated at high temperatures, combined with other 
chemicals and particles of metal, and inhaled deep into 
healthy, developing lungs, and extremely high levels of a new 
patented nicotine salt, higher than any nicotine we have seen 
before, are absorbed so efficiently into a teen's blood and 
brain that the effects are immediate and the addiction is 
immediate.
    Kids report vaping 24/7, and it's easy. Today's vapes leave 
no harsh smell and create very little smoke. Kids sleep with 
their JUUL under their pillow or tape them to the night stand 
so they can vape in the middle of the night and first thing 
when they wake up.
    Now kids have dozens of brands to choose from, each with 
their own multitude of proprietary flavors. Kids do not 
perceive harm in a product that is flavored like vanilla or 
cotton candy.
    JUUL and other pod-based devices hide in plain sight on 
kids' desks. Now new disposable brands like STIG are even 
smaller with sweet, often mentholated flavors and can easily be 
hidden in a child's small hand.
    These disposable plastic vapes, a new favorite among kids, 
are quickly replacing JUUL. They can cost as little as $3--$3 
for a sweet vape with more nicotine than a pack of cigarettes. 
Kids can then easily dispose of the evidence.
    The emails from desperate parents and families continue to 
move us the most. They are desperately seeking resources, 
information, and treatment for their e-cigarette-dependent, 
nicotine-addicted kids.
    The truth is that currently there is no FDA-approved 
treatment for teen e-cigarette nicotine addiction. For 
instance, we got an email from Kelly Kinard of North Carolina 
whose son, Luka, experienced seizures and had an addiction so 
severe he went to rehab for 39 days.
    There was a New York mom who wrote us when her 12-year-old 
was expelled from school for JUULing. Twelve. There was Geri 
Sullivan from Pennsylvania, whose only son was hospitalized for 
vaping-related illness and now cannot play football in his 
senior year of high school.
    There was the dad whose son is a DI baseball player, and 
the entire team was vaping. Now they use tobacco pouches, a 
new--actually, nicotine pouches, excuse me--a new flavored 
product.
    Ruby Johnson's daughter, Piper, was hospitalized on her way 
to freshman year in college. Piper's out of the hospital, and 
Ruby has joined PAVe. The mom who read about Ruby and brought 
her own daughter to the hospital after recognizing the symptoms 
now credits Ruby for saving her daughter's life.
    The list goes on. We get so many letters, and it's hard to 
answer them all. And that friend who was addicted to nicotine? 
That was my 14-year-old son.
    I later found out that my son had been handed a mint JUUL, 
a teen favorite, at the end of eighth grade by another eighth-
grader. It had become the new social norm. Suddenly, when kids 
met someone new, the first question was, ``What's your 
flavor?,'' not ``What school do you go to?'' or ``What's your 
favorite sport?''
    Thankfully, my son was able to stop JUULing with a lot of 
support. Every day, more scientific evidence emerges that 
vaping causes harm to the heart and lungs, the cardiovascular 
system, and now, possibly, cancer, and that means we are in a 
race against time to protect our kids from becoming not only an 
entire generation of nicotine addicts but human guinea pigs for 
the vaping experiment overall.
    I am here today representing PAVe and families around the 
country to support the legislation to reverse the youth tobacco 
epidemic and a full ban on flavored tobacco, which has been 
addicting our kids.
    The FDA banned flavored cigarettes in 2009 under the Family 
Smoking Prevention and Tobacco Act except menthol, and now we 
must ban all flavored tobacco products, including e-cigarettes 
and menthol cigarettes, to protect an entire generation of 
young Americans.
    The FDA themselves and the Surgeon General called this a 
youth vaping epidemic last year. The numbers are even higher 
today. Let's stop these numbers from rising, together.
    [The prepared statement of Ms. Fuhrman follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you very much, Ms. Fuhrman.
    Could the committee staff get the samples that Ms. Fuhrman 
has so that all of the Members can hold them in their hands, 
view them, and have a sense of what we are talking about here? 
I think that would be a good idea.
    There's the young man.
    Ms. Fuhrman. I did not bring a JUUL because I assumed 
everyone knew what a JUUL was. This is--this might look like a 
highlighter. It's a vape I've been holding in my hand.
    Ms. Eshoo. Thank you.
    I now would like to recognize Dr. Tanski and welcome her. 
You are recognized for 5 minutes for your testimony.

              STATEMENT OF SUSANNE E. TANSKI, M.D.

    Dr. Tanski. Thank you.
    Good morning, Chairwoman Eshoo, Ranking Member Burgess, 
Congresswoman Shalala, and members of the subcommittee.
    It's my pleasure to be here today to address the national 
youth tobacco epidemic, an urgent matter that requires 
Congress's prompt action.
    My name is Dr. Susanne Tanski. I am a practicing 
pediatrician and tobacco control expert with over 17 years of 
experience researching tobacco issues and counseling youth who 
use a wide range of tobacco products, including cigarettes, 
cigars, and e-cigarettes.
    I am here today representing the American Academy of 
Pediatrics, a professional medical organization with over 
67,000 pediatricians.
    The AAP strongly supports the Reversing the Youth Tobacco 
Epidemic Act. Pediatricians are on the front lines of 
counseling youth and young adults about the harms posed by 
tobacco products.
    Unfortunately, we call tobacco use a pediatric disease 
because virtually everybody started using before the age of 18. 
The latest data, as mentioned, from the National Youth Tobacco 
Survey shows that 27.5 percent of our high school students are 
current e-cigarette users.
    This shocking number is a 2\1/2\-fold increase since 2017. 
As a pediatrician, I see all too often how nicotine addiction 
takes hold in my teenage patients who use e-cigarettes.
    Biologically, the brain is more susceptible to nicotine 
addiction during adolescence, and symptoms of dependence begin 
within days to weeks of occasional use and well before daily 
use.
    Nicotine dependence impacts reward pathways and areas of 
the brain that control executive function, memory, and mood. At 
low doses, it acts as a stimulant, leading to a feeling of 
pleasure and a reversal of unpleasant withdrawal symptoms, such 
as irritability and anxiety.
    With repeated exposure, tolerance develops quickly and 
leads to needing more nicotine to even just feel normal. 
Importantly, for many young people, this is not sporadic use, 
but it is consistent, frequent, and dependent use.
    Recently, a colleague asked me if I had heard of teens 
getting up in the middle of the night. I said I hadn't. This is 
a sign of intense nicotine addiction.
    But I quickly realized that it's just because I wasn't 
asking the right question, and repeatedly since then, in 
speaking with my patients, they admit they are indeed vaping 
throughout the night.
    This is something I've not seen with adolescent cigarette 
users. The teens I see in my practice and in my community are 
using a variety of e-cigarette devices, but most often JUUL and 
the small devices like you see here today--small and discreet.
    One JUUL pod contains the nicotine content as an entire 
pack of cigarettes. I have adolescents reporting using a pod or 
more a day.
    These pods lack any cues for how much has been used, 
meaning adolescents have no idea how much nicotine they're 
getting. With high levels of nicotine delivery, our adolescents 
simply don't have a chance.
    What's more, studies to date have shown that previously 
never-smoking e-cigarette users are three times more likely to 
progress to smoking initiation with cigarettes.
    Beyond nicotine addiction, as mentioned, there are serious 
concerns about vaping and lung health. As of last week, there 
have been about 1,300 cases of vaping-associated lung injury, 
with 36 percent of those cases occurring in kids under the age 
of 21.
    Twenty-six deaths have been reported, with the youngest 
being 17 years old. This outbreak has called attention to the 
acute dangers of e-cigarette aerosol inhalation.
    And while some have been quick to explain that this is only 
due to vaping THC, which is the psychoactive ingredient in 
marijuana, this has not yet been determined, and the CDC 
reports nicotine use in almost 60 percent of cases and 
exclusive nicotine at 13 percent.
    In light of these health concerns, it is critical to limit 
the appeal and access of these products to youth. The Reversing 
the Youth Tobacco Epidemic Act will institute a prohibition on 
all flavored tobacco products, including e-cigarettes, menthol 
cigarettes, and flavored cigars.
    This is the single most important policy that Congress can 
pass to address the youth tobacco epidemic and a step that 
Congress took years ago for other flavored cigarettes.
    The body of evidence is clear. Flavors in tobacco products 
attract young users and hook kids. The flavors help mask the 
harsh taste of nicotine, making repeated use more likely and 
thereby increasing the likelihood of developing addiction.
    It's important to include menthol, as this is well known to 
promote and sustain tobacco use. People are more addicted and 
sicker because of menthol in tobacco.
    This legislation will also raise the tobacco sales to age 
21, a key policy that successfully reduces teen access to 
tobacco products. This works in part by getting tobacco 
products out of high schools, cutting off a social pipeline.
    The bill also, importantly, prohibits tobacco sales 
online--another source of youth access--and it holds e-
cigarettes to the same marketing restrictions as traditional 
cigarettes, preventing the use of tried-and-true tobacco 
company marketing tactics aimed at youth that have been 
designed to mislead the public about tobacco.
    We have made significant progress over the years in 
reducing adolescent tobacco use to reduce cigarette smoking. 
But that progress has been jeopardized by a tobacco industry 
that is constantly innovating in the business of addicting 
young people.
    The Reversing the Youth Tobacco Epidemic Act will help 
prevent youth from starting tobacco in the first place, and we 
urge Congress to quickly advance this very important 
legislation.
    Thank you very much.
    [The prepared statement of Dr. Tanski follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you, Dr. Tanski.
    I now would like to recognize Dr. Gardiner for your 5 
minutes for testimony, and welcome again.

             STATEMENT OF PHILLIP GARDINER, D.P.H.

    Dr. Gardiner. Thank you, and thank you for having me here 
this morning.
    I am Dr. Phillip Gardiner. I work at the University of 
California Office of the President Tobacco-Related Disease 
Research Program, and have worked there for 23 years.
    I am also the cochair of the African American Tobacco 
Control Leadership Council, from which I am speaking here 
today.
    Let me just read my opening paragraph statement that I sent 
to the committee earlier.
    The African American Tobacco Control Leadership Council 
strongly encourages the Subcommittee on Health of the Energy 
and Commerce Committee to adopt Representatives Pallone and 
Shalala's bill, Reversing the Youth Epidemic Act of 2009, H.R. 
2339.
    From our reading, this bill is the most comprehensive 
tobacco legislation proposed in years, especially because it 
would prohibit the manufacture of menthol and all 
characterizing flavors in tobacco products, including e-juices.
    Support for the bill now is extremely important, given the 
vaping lung injury crisis that is sweeping our Nation today. 
But also, this bill would finally get menthol flavorings out of 
cigarettes, little cigars, and all other tobacco products, 
something the FDA has failed to do for the past 10 years.
    The predatory marketing of these products must be stopped, 
and we all should recognize this as a social injustice issue, 
an issue that disproportionately impacts poorer communities, 
marginalized groups, youth, and communities of color.
    Be appraised that 85 percent of African-American adults and 
94 percent of Black youth who smoke are using menthol products. 
These striking statistics come from the predatory marketing of 
these products.
    There is more advertising for menthol cigarettes in the 
African-American community, there are more lucrative promotions 
for these products, and I guess what pisses me off the most, 
these products are cheaper. We have nationalwide data as it 
relates to that.
    So let's just take a look at this for a minute. I would 
suggest to you that menthol is the ultimate candy flavor and 
helps the poison to go down easier.
    Menthol masks the harsh taste of smoking. It activates cold 
receptors in the lungs and in the branchia, it activates taste 
buds, it produces an anaesthetic effect that allows easier and 
deeper inhalation.
    The deeper you inhale, the more toxins and nicotine you 
intake. The more nicotine and toxins you intake, the more 
addicted you become. The more addicted you become, the harder 
it is to quit.
    It also inhibits--menthol also inhibits metabolism of 
nicotine. It slows it down, essentially, allowing for nicotine 
to stay in the body longer.
    It activates more nicotinic receptors, and not to get too 
technical, it produces more dopamine expression in the body, 
meaning they are more pleasurable. You like them more. That's 
why it's harder to quit.
    In chewing tobacco, if you have menthol in it, it cross the 
gum barrier much more effectively than if it isn't in there. 
And last but certainly not least, menthol in cigarettes 
increases the ability of smoke to penetrate cell membranes much 
more effectively.
    Some have argued that this is discriminatory since black 
people use menthol cigarettes more, and this--we should protect 
their product. However, I would suggest to you it's just the 
opposite.
    It's the discriminatory practices of the tobacco industry 
that led to the disproportionate use of these products by 
folks.
    Look at it this way. In 1952, only 5 percent of Blacks used 
menthol cigarettes. By 1968, it almost tripled to 14 percent. 
By 1976, it had tripled again to over 44 percent and by 2000 we 
are into the 80 percent with this thing.
    Other people would also like to suggest to you that, if you 
were to ban this product, this will lead to the criminalization 
of young Black youth.
    I've worked on this subject for the last 10 years. We've 
gotten bills passed in 26 cities that restrict the sale of 
menthol overall. No one's been arrested.
    This bill is about--not about possession. It's about--in 
the Pallone bill it's about manufacturing, but at the local 
level it's been about sale.
    Let me tell you, we should strike while the iron is hot. 
Six States have already outlawed these flavors in some form or 
another.
    I don't want to wait on the FDA to act or wait on the Trump 
administration to act. Let's have the Congress act. Let's have 
somebody act on this.
    I would suggest to you that the most fundamental health 
thing that could go down--and my colleagues have all pointed 
out it's the number-one killer in the United States--let's take 
some action on it.
    Let's get flavors out of cigarettes. Let's get flavors out 
of the e-juices. Let's protect our youth.
    Thank you very much.
    [The prepared statement of Dr. Gardiner follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you, Dr. Gardiner, for all the years that 
you have given of your life to this subject matter.
    And the Chair would now like to recognize Dr. Siegel. You 
have 5 minutes for your testimony. Thank you, again, for being 
here today.

               STATEMENT OF MICHAEL SIEGEL, M.D.

    Dr. Siegel. Thank you, Chairwoman Eshoo, and members of the 
subcommittee.
    My message today is simple. H.R. 2339 has the potential to 
help curtail the youth vaping epidemic. But first you must 
eliminate one subsection that, if enacted, will have severe 
negative public health consequences.S
    Subsection (d) of section 103, which bans flavored 
electronic cigarettes, will result in a public health disaster.
    As you know, we are in the midst of an outbreak of severe 
acute respiratory disease that has affected more than 1,000 
people and has resulted in more than 20 deaths.
    Can we prevent these tragic deaths by banning the retail 
sale of vaping products? The answer is no. In the vast majority 
of cases, the victims were not purchasing vaping products from 
retail stores.
    Instead, they were obtaining vape cartridges from the 
completely unregulated black market. These products originate 
from illegal drug operations that are producing tens of 
thousands of contaminated THC, not nicotine vape cartridges.
    So, in a sense, the cause of this outbreak is not the fact 
that youth are buying vaping products from stores but the fact 
that they are not buying their vaping products from stores.
    The lesson that this outbreak should teach us is that the 
greatest danger to our youth is not store-bought vaping 
products but those purchased from friends, on the street, or 
over the internet from the black market.
    A ban on flavored e-cigarettes would create a public health 
disaster because it would create a new black market for 
flavored e-liquids. It is nearly certain that we would see more 
outbreaks similar to what we are experiencing now with these 
tainted THC vape cartridges.
    Banning flavored e-liquids is not going to do anything to 
curtail this respiratory disease outbreak. But it may make the 
outbreak worse.
    Why? Because the supply of e-liquids that youth are vaping 
is going to transition from one dominated by nicotine products 
to one dominated by THC products, exactly the products that are 
causing this outbreak.
    There's a second reason why banning e-liquid flavors would 
have devastating health consequences. More than 2 million adult 
smokers in the U.S. have quit smoking completely by switching 
to flavored electronic cigarettes.
    If these products are banned, many of these ex-smokers will 
return to cigarette smoking. Most of those who don't will turn 
to a new, potentially dangerous black market that will be 
created by this legislation.
    I want to suggest to you today that the way to address the 
problem of youth e-cigarette use is not to ban these products 
but to strictly regulate them, and second, that we must focus 
on the aspect of e-cigarettes that is actually causing harm to 
our youth.
    The real danger of e-cigarette use is not the flavors. It's 
not the flavors that are causing the harm. It's the high levels 
of nicotine and the special nicotine formulations being used in 
some of these products that are resulting in youth addiction to 
vaping.
    For example, prior to the introduction of JUUL, three-
fourths of nonsmoking youth vapers reported using e-cigarettes 
no more than once a week, and only 4 percent used them every 
day.
    But by 2018, 12 percent of nonsmoking youth used e-
cigarettes every day, a tripling of the percentage of youth e-
cigarette users who were addicted, and less than half of 
nonsmoking youth vapers use e-cigarettes less than once a week.
    This change is what has created a public health crisis. So 
what explains this change? What changed is that products like 
JUUL, Suorin, SMOK, and Phix entered the market and quickly 
became popular among teenagers.
    All of these brands use a different nicotine formulation 
from virtually all other e-cigarettes. They use a nicotine salt 
at very high concentrations. The use of nicotine salts allows 
nicotine to be absorbed into the bloodstream much more quickly, 
simulating the pattern that you get with a real cigarette.
    That is why so many youth are now addicted to vaping. It's 
not the flavors. It's the nicotine. Regulating the nicotine 
formulations and levels allowable in e-liquids is the single 
most effective step you can take to help reverse the youth e-
cigarette epidemic.
    In summary, the broad stroke of prohibition is going to 
make this crisis worse, not better. Instead of regulating e-
cigarette flavors, I recommend that you regulate the nicotine 
content in e-cigarettes.
    This will allow you to balance the need to reverse the 
epidemic of youth vaping and the need to keep flavored e-
cigarettes available to adults who have quit smoking or are 
trying to quit smoking.
    The art of public health and public policy is being able to 
balance competing objectives. I think we can do that in a way 
that protects the health of both youth and adults.
    Thank you.
    [The prepared statement of Dr. Siegel follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you, Dr. Siegel.
    We've concluded opening statements. We are now going to 
move to Members' questions. Each Member will have 5 minutes to 
ask questions of our witnesses, and I will start by recognizing 
myself for 5 minutes.
    Do each of our witnesses support raising the minimum 
tobacco age to 21? Everyone agree?
    [Chorus of yes.]
    Ms. Eshoo. OK. Terrific. Do you support extending the 
current restrictions on sales and advertising of traditional 
cigarettes to e-cigarettes?
    [Chorus of yes.]
    Ms. Eshoo. Everyone? Good.
    Do you support prohibiting non-face-to-face sales of 
tobacco products so that children can't buy tobacco products 
online?
    [Chorus of yes.]
    Ms. Eshoo. Everyone agrees? Wonderful.
    All right. So we, obviously, are in agreement about major 
portions of the bill we are considering today.
    Now I want to talk about the provision that bans flavors. I 
was going to start with Mr. Myers, but I want to go to Dr. 
Siegel.
    What kind of candy do you like?
    Dr. Siegel. Well----
    Ms. Eshoo. What's your favorite candy?
    Dr. Siegel. Bubble gum.
    Ms. Eshoo. Bubble gum. And you like the flavor of bubble 
gum, right?
    Dr. Siegel. I do.
    Ms. Eshoo. Yes. So I think that if you take the attraction 
to the flavor, that that's your gum of choice. You're attracted 
to it because of the flavor.
    Now, that--I would draw a parallel from that to--and I 
disagree with what you said in your testimony, that flavor 
doesn't have anything to do with anything.
    Well, you know, I love Italian food, so I go to Italian 
restaurants. Flavor is very attractive. It really drives our 
eating habits and other habits. So I just want to get that on 
the record.
    Mr. Myers, do you know whether e-cigarettes' sweet flavors 
have contributed to youth tobacco use?
    Mr. Myers. All of the evidence is that they're the driving 
force of that, and that it has gotten worse over the last 4 
years.
    Ms. Eshoo. And do you know whether e-cigarettes' sweet 
flavors have contributed to adults quitting tobacco use?
    Mr. Myers. Well, what's extraordinary, and I have a chart I 
would be happy to provide the committee, that over the last 4 
years we've seen this meteoric rise in youth use of these sweet 
flavors.
    The percentage of adults who have used e-cigarettes during 
the time the flavors have been so prominent hasn't increased at 
all. It's hovered straight about 3 percent and not gone up.
    So what it shows is the introduction of all these flavors 
has fueled a youth epidemic, but it had no impact whatsoever--
indeed, before JUUL was introduced the most popular e-cigarette 
flavor was tobacco.
    So for smokers who want to quit, that was a viable option 
until JUUL changed the market.
    Ms. Eshoo. That's interesting. Thank you.
    Dr. Tanski, you spoke about the large amount of nicotine 
that e-cigarettes deliver--and thank you, Ms. Fuhrman, for the 
samples because I noted on the various packages the percentage 
of nicotine that they contain. A single e-cigarette pod--this 
is really stunning--can have as much nicotine as a pack of 
cigarettes, and, as you said, some young people report smoking 
more than one pod a day.
    Should we consider legislation to restrict the amount of 
nicotine in a pod?
    Dr. Tanski. That's actually a little bit of a complicated 
question. As Dr. Siegel was mentioning, the technology really 
changed with the addition of nicotine salts to the industry, 
and there were differences in PH that were introduced by that, 
and every pod is also a different size. So these are--you have 
a disposable one here, but there are some that Dr. Siegel was 
also mentioning where the pod size is 3 milliliters rather than 
just .7 or 1 milliliter. So there's a lot more quantity that 
can go in there.
    So this is a fairly complicated chemistry equation as well 
because, depending on the voltage of the device, it also 
changes delivery.
    So someone who's using one of those big pod devices, they 
can use a very low nicotine----
    Ms. Eshoo. I understand the complication.
    Dr. Tanski. Yes.
    Ms. Eshoo. But we deal with complex things here.
    Dr. Tanski. But so let me finish my thought.
    Ms. Eshoo. Yes.
    Dr. Tanski. It will show why a number of----
    Ms. Eshoo. I only have 56 seconds left. So----
    Dr. Tanski. OK. Sorry. So the amount of nicotine in it is 
insufficient because the voltage can change delivery, so you 
have a 1 percent nicotine solution in a high-voltage device 
that will----
    Ms. Eshoo. Do you think we should look for a way to 
restrict the amount of nicotine in a pod? Yes or no.
    Dr. Tanski. Yes. FDA needs to look at the science, though--
--
    Ms. Eshoo. OK. Thank you.
    Dr. Tanski [continuing]. Because we can't just say a number 
because of a knee-jerk reaction.
    Ms. Eshoo. I understand. I understand.
    How can we require e-cigarettes to better warn people about 
the amount of nicotine they're ingesting?
    Dr. Tanski. A warning label will go a long way, and making 
it very clear what the numbers mean. The numbers are very 
confusing on the packaging. Some people don't know what the 
numbers mean--
    Ms. Eshoo. I think it should state it's equal to one pack 
of cigarettes, equal to two packs of cigarettes. That's pretty 
clear.
    Dr. Tanski. Exactly. I think the other piece, it has to be 
as delivered as opposed to what's the content because there's a 
difference between what's delivered and the content that's in 
the device.
    And, again, that's complicated nuance. But it really is 
critically important because, again, our young people have no 
idea how much nicotine they're getting when they use these 
devices.
    Ms. Eshoo. Thank you. My time has expired.
    Dr. Tanski. Sorry.
    Ms. Eshoo. Thank you to each one of you.
    The Chair now recognizes Dr. Burgess, the ranking member of 
our subcommittee, for his 5 minutes of questions.
    Mr. Burgess. Thank you, and this is fascinating, about 
regulating the amount of nicotine in these devices.
    I actually remember in 2008 or 2009, when we did the 
Tobacco Control Act, and for reasons I did not understand, 
written into statute was a prohibition that the FDA could not 
require a 0 milligram cigarette to be produced.
    I thought that was odd, and I thought that was wrong. So I 
had an amendment that the FDA could require a 0 milligram 
cigarette to be produced.
    I actually lost that battle. That language, I think, 
endures to this day. But to Dr. Siegel's point, the nicotine is 
the culprit here.
    People may like the flavor of bubble gum or dark chocolate, 
but it is the nicotine that keeps you coming back, and it is 
the nicotine that you cannot live without. If someone said, 
``Well, you can't have your bubble gum today,'' the world would 
not come to an end.
    But if someone says--someone who is heavily nicotine 
addicted--deprivation of nicotine actually incites a fairly 
significant physiological and psychological response, and it is 
unpleasant enough that people will do--just like with other 
addicting substances, people will do whatever is required to 
the exclusion of everything else to fulfil that need.
    I am not a psychologist, but I think that's kind of the 
definition of addiction. I don't like to use that because 
people then apply it to coffee, which I don't think we should 
outlaw.
    But this is an area where--and Dr. Gardiner, I appreciate 
your call to action and your enthusiasm with that call to 
action. But the way our system is set up, we can legislate, and 
we do legislate all the time.
    But we do require the administration--we do require the 
Federal agencies for the implementation of that and, indeed, 
one of the, perhaps, the failings of the Tobacco Control Act 
was the fact that this committee has not had many oversight or 
implementation hearings on that activity, and I think we heard 
the acting FDA Director kind of admit that they've fallen 
behind the curve, and maybe had Congress exercised its 
oversight authority in that regard a little more stringently, 
perhaps we wouldn't be at this place.
    But, Dr. Siegel, we saw the devices that Ms. Fuhrman 
supplied to us. But your contention is, or Dr. Tanski, I guess, 
your contention is that it wouldn't matter--the 6 percent, 5 
percent, 2 percent devices--mandating that level, because of 
the differences in bioavailability of different nicotine salts 
and delivery devices alters what a person actually absorbs?
    Dr. Siegel. So the nicotine salt formulation that JUUL 
introduced and which has now been copied by several companies, 
essentially the nicotine is absorbed much more rapidly into the 
body, and that's what creates the addiction.
    That is why kids are addicted to JUUL. It's not just the 
amount. It's the formulation, and the cigarette companies have 
perfected this method of getting nicotine into the blood.
    So I think that--what I think needs to be done is to have a 
certain nicotine level that's allowable for all e-cigarettes, 
and then a lower nicotine level that would be the maximum for 
nicotine salt formulations.
    I think a 20 milligram per milliliter limit for electronic 
cigarettes would be very reasonable, and I would make it half 
of that for nicotine salt formulations.
    It's important to recognize that in the U.K. they do have a 
level. They have a 20 milligram per milliliter level, and 
that's the maximum. They have JUUL there, but JUUL comes in at 
17 milligrams per milliliter in the U.K., not 50 like they do 
in the U.S.
    So I think regulating that at a level of 20 would help to 
solve this problem with youth addiction.
    Mr. Burgess. And what about, as Dr. Tanski pointed out, 
creating some--like with opiates, we have milligrams of 
morphine equivalence, the MME that has become so famous. Is 
there any way to apply that to the nicotine delivery devices?
    Dr. Siegel. Yes, absolutely. I think, as Dr. Tanski 
mentioned, if we require companies to reveal the nicotine 
delivery of the product, that that will inform the user of 
exactly what they're getting, and I think it's easily possible 
to do that.
    Mr. Burgess. Well, again, fascinating topic, and you have 
given us a lot of additional information. You know, we do have 
to get this right, and over and above everything.
    So I thank you for your testimony, and I will yield back.
    Ms. Eshoo. The gentleman yields back.
    The Chair now recognizes--is Mr. Pallone here?
    Mr. Butterfield, the gentleman from North Carolina, for his 
5 minutes of questioning.
    Mr. Butterfield. Thank you very much, Madam Chair, and 
thank you to the five witnesses for your testimony. I have 
stayed throughout the hearing, because I wanted to hear from 
each one of you because this issue is very important to me.
    As many of my colleagues know, I represent a tobacco 
district. At one time, it was the largest tobacco district in 
the United States of America.
    I think it may have slipped to number two or three now, but 
we are a tobacco-producing district, and so whenever I hear the 
word ``tobacco,'' my ears perk up just as those from New York, 
you know, when you hear ``financial,'' your ears may perk up. 
When you hear ``sugar,'' then you pay extra attention if you're 
from a sugar district. And so that's where I am coming from 
today.
    My phone has been ringing for the last few days. Some have 
even asked me, ``Does Congress have a legitimate interest in 
regulating these products?'' And my position is--and I've said 
it to anyone who's willing to listen--we do have a legitimate 
interest as Congress in addressing public health concerns and 
the recent spike in the use of electronic cigarettes.
    No one in this room, I would hope, disagrees that a youth 
vaping epidemic is underway. We need to address it. And so I 
thank the chairman for meeting this epidemic head on and 
wholeheartedly support his efforts to stem youth vaping.
    However, I have very real concerns with the unintended 
consequences that could result if this bill were to become law.
    We all know that nicotine is harmful. We have heard that 
throughout the hearing. It's harmful to young people and can 
have a lasting impact on their developing brains.
    The CDC reports that there is evidence to indicate that 
flavorings such as fruit and candy in e-cigarette products can 
make them more appealing to youth, and in fact they are the 
primary reason that youth report using e-cigarettes.
    Flavors such as these are already banned in cigarettes. I 
was on this committee when we enabled and authorized that. They 
are already banned, but these types of flavors are not 
currently prohibited in e-cigarettes.
    The bill before us seeks to address the disturbing youth 
vaping trend in two ways. First, the bill raises the age to 21, 
and we all agree with that. I am 100 percent supportive of 
raising the age.
    The second shift in--monumental shift in--the bill is a ban 
on characterizing flavors including menthol for all tobacco 
products.
    While a ban on flavors in e-cigarettes that appeal to youth 
may be an appropriate public policy response to vaping, I am 
concerned that extending that ban to existing tobacco products 
on the market, such as menthol and flavored smokeless tobacco 
and cigars, could have unintended consequences.
    Menthol cigarettes are one-third of the U.S. market. In the 
African-American community, the preferred cigarette is menthol. 
Eighty percent of African Americans who smoke prefer to use 
menthol cigarettes. In other communities, the preferred 
cigarette is nonmenthol.
    So I want us to think about that, my colleagues. Think 
about that. This bill does not address tobacco use in two-
thirds of the U.S. market. Instead, it targets one-third of the 
market that just happens to be African-American.
    The fact is that banning menthol cigarettes will lead to 
users migrating to nonmenthol cigarettes. It will not lead to 
cessation of using tobacco products.
    So a flavor ban on existing tobacco products does not solve 
the problem that we all agree needs to be addressed. Instead, 
this bill makes the manufacturer of menthol tobacco products 
illegal and retains legal status for nonmenthol.
    My fear, shared by the National Organization of Black Law 
Enforcement Executives and Law Enforcement Action Partnership, 
is that such a ban will inevitably lead to the creation of a 
black market for mentholated products.
    According to these groups, there is already an illicit 
market for cigarettes, and a ban on menthol could encourage 
more criminal activity as groups look to bring in mentholated 
cigarettes from outside of the country or make them on their 
own.
    In conclusion, if we really--my colleagues, if we really 
want to address tobacco cessation, someone just put a bill on 
the table that will ban the manufacture, sale, and use of 
tobacco, period.
    If you want to stop the use of tobacco, let's present a 
bill that will prohibit the manufacture and use of tobacco. It 
is naive to think that a prohibition of flavors for existing 
tobacco products like menthol will not have unintended 
consequences.
    I urge my colleagues to think about these things and to 
realize that you are targeting a specific community at the 
exclusion of another community.
    Thank you. I yield back.
    Ms. Eshoo. The gentleman yields back.
    It's a pleasure to recognize the gentleman from Illinois, 
Mr. Shimkus, for his 5 minutes of questions.
    Mr. Shimkus. OK. Thank you, Madam Chairman, and you took me 
by surprise. I thought Mr. Upton was going to be before me. But 
let me just go to a couple questions.
    And we've had these debates before, but not in this venue, 
of the e-cigarette. So this is, I think for those of us who 
have been able to stay--we've got two hearings going on at the 
same time--the interesting one down below on the first floor is 
the Telecommunications and whatever the other committee is and 
it's unimportant because I am not on it. But----
    Ms. Eshoo. Technology.
    Mr. Shimkus. Technology--whatever it is.
    Ms. Eshoo. It's not whatever. It's----
    Mr. Shimkus. Whatever, and you're wasting my time, Madam 
Chairman. So, but the other--but the point is that what we are 
trying to address in the e-commerce world is do the providers 
and the stewards of that information--do they have some legal 
authority to police that?
    And it's interesting, in one of the court cases two people 
were brought to court. The one that tried to police lost the 
case. The one that allowed free information did not lose the 
case.
    So this kind of goes to Dr. Siegel, and some of the 
comments made on black-market issues that we have to really be 
concerned about, and also regulation.
    Let me--the deaths that we have seen are--I've been told 
and what I've read is that they are black-market pods that had 
THC and oils like Vitamin E, and I think most people, even 
though I am not--Dr. Bucshon is a cardiothoracic surgeon--I 
hope I am here to listen to his questions if he gets a chance 
to do that.
    I mean, you can't put oil on your lungs. That's--because if 
you just know anything about lungs and how they operate, you 
just can't coat them with oil because that's why people end up 
dying.
    Dr. Siegel, Congressman Butterfield raised this issue, and 
we were here for this last debate on menthol, and Dr. 
Gardiner--it's kind of interesting because your testimony 
identifies we are targeting the African community by allowing 
this.
    But my colleague would say we are targeting the community 
by if we attack menthol aspect. So there is this--this is the 
same debate we had here.
    Is it tar that creates the build-up of--tar in lungs that 
creates either lung disease in a regular smoker, and cancer? 
Can anyone answer that question?
    I think the--anyone? I think the answer is yes, the build-
up of tar--we used to hear tar in nicotine, right? So an e-
cigarette takes away the tar out of this equation, and I would 
propose that as we move forward we look at FDA's involvement 
and proper regulation of what is a healthy application of this, 
because I do think there's a credible argument about those who 
are in minority communities who are smoking menthol cigarettes 
who now are trying to move to e-cigarettes to decrease their 
risk of cancer, right.
    If it's readily regulated in ways delivered that--that 
should not be discounted. Does anyone disagree with that?
    Go ahead. Yes, sir.
    Mr. Myers. Just a couple facts I think are really important 
to understand here. First of all, delivering of nicotine, 
particularly to adolescent brain, is itself harmful. So----
    Mr. Shimkus. Oh, yes. I know. But we've talked about, first 
of all, aids. I am not--I am not talking about just doing the 
aids. I am talking about the issue of cigarettes and e-
cigarettes and cancer and tar.
    Mr. Myers. So a couple other things are important. We don't 
know the long-term health effects of e-cigarettes because they 
haven't been studied and they haven't been regulated.
    Mr. Shimkus. And that's why we have the Food and Drug 
Administration that properly vets the science and makes 
regulations on the safety and efficacy of products.
    Mr. Myers. But it's also a reason we should be concerned 
about the youth epidemic, and what we have seen is that, while 
the nicotine keeps them coming back, it's the flavors that get 
them in the first place.
    Mr. Shimkus. But if you regulate the nicotine at a level--
and I understand the chairman's point about flavors are 
important.
    But, Dr. Siegel, your point was it's the nicotine and the 
addiction that keeps them coming back, not the flavor. Is that 
correct?
    Dr. Siegel. Exactly. Exactly.
    Mr. Myers. But in the interim, what we have is we have a 
million and a half new kids each year----
    Mr. Shimkus. So we should regulate the--I think the answer 
is the FDA if we want to help people save themselves from 
cancer, transition, and deal with the pods.
    Thank you, Madam Chairman. I yield back.
    Ms. Eshoo. The gentleman yields back.
    I am pleased to recognize the gentleman from Maryland, Mr. 
Sarbanes, for his 5 minutes of questions.
    Mr. Sarbanes. Thank you, Madam Chair. Thanks to the panel. 
I am proud to be a co-sponsor of the bill that we are talking 
about today.
    I am mostly just terribly confused by this conversation 
because I remember this gigantic tobacco settlement that we had 
a few years ago, and I remember aspects of it being how to 
limit marketing to young people in all different kinds of ways.
    And it just seems like the industry has found this gigantic 
loophole for going back and creating that whole public health 
crisis all over again.
    And I am interested in hearing again some of these 
statistics because I think I am understanding that the pace at 
which young people--middle school age, high school age, maybe 
younger, if you want to describe that--the pace at which they 
are--the uptake of the e-cigarettes may be like nothing we've 
ever seen when you look at the period of time and the numbers 
that we are talking about.
    And if that is what begins the addiction to nicotine that 
then leads to use of the product over time, then we are kind of 
right back where we were 15 years ago on this.
    It's staring us in the face. It's bearing down on us. So 
could you describe the statistics that way in terms of--whoever 
is in the best position to do it, and maybe compare it 
historically to other periods when there was a significant 
acceleration in use among youth of tobacco products and comment 
on how it's new and different and scary.
    Mr. Myers. Let me defer to Dr. Tanski. But the increase in 
e-cigarette use between 2017 and 2018 is the single largest 
increase in use of any substance that has been studied in the 
last 43 years.
    So when you say that it's unprecedented, it is genuinely 
unprecedented, and what's more frightening is that between 2018 
and 2019 the absolute numbers of new kids using these products 
grew by the exact same number.
    We haven't seen an epidemic come on us this quickly, this 
intensely at any point in the last 50 years.
    Let me refer to Dr. Tanski.
    Dr. Tanski. Yes, I completely agree. This is, indeed, 
unprecedented. In 2017, it was 11.7 percent of our high school 
kids were using e-cigarettes in the last month, and now it's 
27.5 percent, and that's just exponential.
    And if you look back and you look at kind of the rates of 
cigarettes rising year over years, cigarettes never did this 
this quickly. So this really is uncharted territory.
    And to your point about marketing, you're right. Marketing 
really influences kids, and there is implicit marketing and 
explicit marketing, and sometimes they--what the packaging says 
or what the ad says, the kids read it in a very different way.
    And there's topics of freedom and there's this image of 
healthiness, and kids respond to that. And we know that 
marketing works, and that's why marketing was restricted so 
profoundly with all the previous acts that we've had around 
other tobacco products.
    Mr. Sarbanes. Could you speak to whether there's any 
effective countermarketing, or I would call it education, going 
on in schools that is equipping young people to resist this 
temptation?
    What are some programs you have seen or education efforts 
that you consider to be particularly effective, even if right 
now they're not really competing that well with what's coming 
from the other direction?
    Dr. Tanski. That's a great question. The FDA actually has a 
very strong program that is in the schools. They actually have 
posters in the bathrooms that say ``People actually use the 
bathroom here, too,'' trying to counteract the idea that now 
the rest rooms in some of the high schools and middle schools 
are used for--that's where people go to vape.
    So they're really trying to get in where the kids are and 
directly countermarket, if you will. The Truth Initiative also 
has some excellent countermarketing where they're really trying 
to work with the kids.
    They've done testing on the messages to make sure that 
they're actually being received the right way. So we are 
trying. But the issue is that the overwhelming pressure that 
kids are getting from either marketing that is explicitly from 
these industries or that social marketing and social media-
related, it's very difficult to break through that.
    Mr. Sarbanes. Thank you.
    Dr. Tanski. Thank you.
    Ms. Eshoo. The gentleman yields back.
    I now would like to recognize the gentleman from Virginia, 
Mr. Griffith, for his 5 minutes of questions.
    Mr. Griffith. Thank you all very much for being here today.
    The e-cigarette problem is a significant problem that we 
have to deal with and, you know, it always amazes me how people 
can do things that ought to just--your instincts ought to tell 
you there's something wrong with them.
    I know the history books when I was growing up had lots to 
be desired, but one of the stories that they told in our 
Virginia history books was that the first person or one of the 
first people who was smoking a cigar on the streets of London, 
somebody ran into the store, grabbed the bucket that was there 
for fire, and put it in their face because, clearly, there was 
smoke coming out of them, they were on fire, and that couldn't 
be healthy.
    I don't know why we don't realize that. So I recognize 
that. And my wife is a juvenile judge, and she is constantly 
talking about all the problems they're having in the schools 
because they are so small, Ms. Fuhrman, the devices are so 
small the kids can take them to school. It's not like a 
cigarette where you immediately smell the smoke and you can 
see, you know, generally where it's coming from, or if there's 
people in the bathroom.
    No, it leaves no tell-tale sign and then can actually do it 
in the classroom while the teacher is trying to teach, and so 
it is a significant problem, and we need to do something.
    The question is, is this the bill? Now, I don't have a 
problem with raising the age to 21. But then we get into these 
other issues.
    And to me--and I am not trying to chastise you all--I think 
the American public have to suddenly realize we have some kind 
of split personality thing going on because, you know, as my 
colleague said in his opening statement from North Carolina, 
you can get gummy bears with marijuana in them. You can get 
brownies with marijuana.
    A staffer brought me cannabis-infused honey sticks, and it 
says anyone from small children with severe seizures to old men 
with Alzheimer's disease can benefit from taking marijuana or 
CBD supplements. And ``We do have a physical store in the U.S., 
but if you want us to ship to you, we are happy to do so.''
    Now, my problem is I've always been for medicinal use of 
marijuana since the '90s. I think that makes sense. I don't 
know why we haven't been studying it more.
    But, Mr. Myers, you said in relationship to e-cigarettes, 
we don't know what the long-term effects are.
    But the American public is demanding that we make 
recreational marijuana legal. It's been illegal for decades, 
and while I support medicinal marijuana I've never been 
convinced on recreational, and part of it is exactly what you 
said. I don't know what the long-term effects are on the 
public.
    So I am going to ask you all, not because I am trying to 
make any huge point other than we have to sort this out as a 
society. Laws don't solve all the problems.
    But do any of you all support recreational use of marijuana 
being legalized in the United States?
    Mr. Myers.
    Mr. Myers. Let me not avoid your question but say we have a 
lot of problems in this country.
    There's some we do know how to solve, and this is one we 
can solve so that there are clear pathways to deal with the 
increased use of nicotine by kids.
    Mr. Griffith. And I don't disagree there are things we can 
do. I don't disagree with that. But I am trying to find out----
    Mr. Myers. And we shouldn't----
    Mr. Griffith [continuing]. And I don't think you all--I was 
expecting a quick answer on this--I don't think you all have 
that split personality that the public has.
    I think because of the long-term risks that are unknown, 
and because particularly on smoking anything, whether it's 
tobacco or marijuana, it's got to be harmful, particularly on 
those young brains.
    And when you're talking about eliminating flavored 
cigarettes, then should we not be looking at eliminating in 
those States that say it's legal, notwithstanding the fact it's 
still illegal federally, brownies and honey sticks?
    What say you, Mr. Myers?
    Mr. Myers. There is a broader question, but our issue 
focuses on there's something we could do about this issue now 
and there's a solution to it.
    Mr. Griffith. My problem is I see them as being similar 
issues, and I am with you on one. But if you're for smoking 
recreational marijuana, I am not sure I am with you until we 
know the results.
    Ms. Fuhrman, what say you?
    Ms. Fuhrman. Well, I would say that eating a brownie and 
vaping a strawberry THC pod are very different. So yes, I do 
not--I do not believe in legalizing recreational marijuana, 
especially when it's in a vape which, obviously, attracts kids 
and the flavors--a lot of these THC vapes are also flavored.
    Mr. Griffith. I understand that. Yes, ma'am. Absolutely.
    Dr. Tanski.
    Dr. Tanski. Smoking anything is likely to shorten your 
life, period.
    Mr. Griffith. Yes, ma'am. Burning material in your lungs is 
not a good thing, in my opinion.
    Dr. Gardiner.
    Dr. Gardiner. Let me suggest to you that you can--in 
California marijuana has been legalized--I am sorry--marijuana 
has been legalized in California.
    I think what would be great at the national level is the 
decriminalization of it such that you aren't going around 
arresting people for this.
    Smoking anything is bad for you. There's a period after 
that. How you legalize it--it didn't have to get legalized 
where you have billboards all over California like you have. It 
could have been legalized another way. I would suggest at the 
Federal level that there's a way to do both things. Legalize 
it, decriminalize it, not promote it.
    I need to say this. We had a conference 4 years ago at 
UCSF--University of California San Francisco--on the 
legalization of this.
    We came out with two conclusions. One conclusion is that it 
should be decriminalized. The second conclusion is it should be 
denormalized.
    Mr. Griffith. I know I am out of time, Madam Chairman.
    Dr. Siegel, answer quickly.
    Dr. Siegel. Sure. I think you're making a great point. I 
think that flavored alcoholic beverages are causing major havoc 
among youth. We know that it's a gateway to liquor use. It's 
causing tens of thousands of deaths.
    We know that flavored THC products are causing this 
outbreak. But nobody has called for a ban on flavored alcoholic 
beverages. Nobody has called for cracking down on flavored THC.
    Mr. Griffith. And my time is up, so I am going to have to 
yield back.
    Thank you, Madam Chair.
    Ms. Eshoo. The gentleman yields back.
    It's a pleasure to recognize the gentleman from New York, 
Mr. Engel, for his 5 minutes of questioning.
    Mr. Engel. Thank you, Madam Chair.
    In my home State of New York there's been a 160 percent 
increase in the number of teens using e-cigarettes between 2014 
and 2018.
    Many of these children use e-cigarettes in schools, and 
I've even heard from schools in my district that they are 
installing vape detectors in the bathrooms to catch students 
vaping.
    Teachers, principals, and school administrators have been 
thrust to the forefront of this epidemic, but schools, 
unfortunately, are not equipped to handle these types of public 
health cases.
    To that end, I've introduced the bipartisan, bicameral 
Smoke-Free Schools Act, which would ban vaping in schools and 
child care facilities. Schools should be places that promote 
healthy childhood development. But tobacco use jeopardizes 
their health.
    Dr. Tanski, I want to ask you, could you please describe 
how tobacco use hinders a child's brain development and how it 
can impact a child's ability to succeed in the classroom?
    Dr. Tanski. Thank you for the question.
    So as I mentioned in my testimony, we know that the 
adolescent brain is really quite uniquely susceptible to 
nicotine addiction, and if you think very simplistically things 
kind of develop from the back to the front, and one of the 
final things that develops is our executive function and our 
ability to put brakes on our own behavior.
    The pleasure center lights up first. So we know what feels 
good, and so that's why the adolescent brain is more likely to 
be addicted. We know it feels good. They try it. It feels good, 
and they don't have the brakes to stop their own behavior.
    So addiction is very prevalent in adolescents and in 
younger people, and we know that it impacts on their executive 
function. We know that nicotine can impair the way people kind 
of process and prioritize things.
    So, indeed, it can make a big difference on school success. 
So someone who is struggling with either nicotine addiction or 
withdrawal, so if someone is withdrawing from nicotine during 
the classroom because they don't--they can't vape in the 
school, or because they don't have a vape, or they put good 
restrictions on, they're distracted.
    They're irritable. They're anxious. They don't feel good, 
and so that also is going to impair their ability to be 
successful in a classroom.
    Mr. Engel. Thank you very much.
    The science is settled and nicotine certainly has short-
term and long-term health consequences for children, and it's 
my understanding that many e-cigarettes on the market today are 
much more efficient delivering nicotine than traditional 
cigarettes, delivering nicotine at substantially higher levels 
and making these e-cigarettes potently addictive.
    In some cases, JUUL pods deliver around 200 puffs, which 
provides the same amount of nicotine as a pack of 20 
cigarettes.
    And what's more concerning is that research has shown that 
many young JUUL users are unaware that these e-cigarettes 
contain nicotine.
    JUUL threatens the tremendous progress we've made in 
reducing teen smoking rates to what was an all-time low of 10 
percent.
    Mr. Myers, let me ask you, what enables the JUUL devices to 
deliver higher levels of nicotine than cigarettes?
    Mr. Myers. I think this is an issue on which we all agree. 
JUUL developed the science of using benzoic acid to turn 
nicotine into nicotine salts that delivers nicotine more 
efficiently, more rapidly, and allows smokers and young people 
to inhale more intensely because it eliminates the harshness.
    So what it means is that we have the double whammy. We have 
sweet flavors that attract kids to get them to try it, and then 
we have new technology that addicts kids more rapidly and more 
intensely than we've had before.
    Mr. Engel. Thank you.
    Ms. Fuhrman, let me ask you. In 2009, I helped pass the 
Family Smoking Prevention and Tobacco Control Act as a member 
of this committee. This legislation banned flavors in 
cigarettes, since they were being used to attract kids.
    In the current e-cigarette epidemic, we are seeing a repeat 
of this industry tactic. In fact, nearly 97 percent of teen e-
cigarette users reported using a flavored product in the last 
month.
    Last year I was one of the first House members to call on 
the FDA to ban flavored e-cigarettes, and I am pleased to co-
sponsor Chairman Pallone's Reversing the Youth Tobacco Epidemic 
Act, which would ban flavors in e-cigarettes.
    Ms. Fuhrman, in addition to flavors, what other marketing 
tactics have e-cigarette makers used to target children?
    Ms. Fuhrman. That's a great question. There are many.
    Flavors are the primary marketing tactic because it 
prevents the kids from perceiving harm. They don't think that 
there's anything harmful with gummy bear.
    They've also been targeting the kids on social media. They 
have hashtag vape tricks. The kids actually now have started 
taking over now that JUUL has banned--has stopped their own 
social media accounts. Now there are hundreds and thousands of 
kids who actually do their own vape tricks.
    The size--the fact that they're deceptively innocuous. You 
can have them on a desk and they look like a highlighter or a 
flash drive. So all of these marketing tactics.
    And the fact that they can get them over the counter, 
they're available online with no age verification. JUUL has a 
very strong age verification now, but many brands, like 
Eonsmoke, does not. So kids can order them and get them in two 
days, or they can go to the corner store.
    Mr. Engel. Social media, YouTube videos, and teen-oriented 
magazines--the sky is the limit with this.
    Ms. Fuhrman. Exactly. And homework websites, as I said. 
Homework websites, social interaction apps, and games--they all 
advertise on those as well.
    Mr. Engel. Thank you. Thank you, Madam Chair.
    Ms. Eshoo. The gentleman yields back.
    Now I would like to recognize the gentleman from North 
Carolina, Mr. Hudson, for his 5 minutes.
    Mr. Hudson. Thank you, Madam Chairwoman.
    First, I would like to echo the sentiments of my colleague, 
Representative Butterfield, and I would like to ask unanimous 
consent to insert for the record the two letters he referenced 
from the National Association of Black Law Enforcement 
Executives and the Law Enforcement Action Partnership.
    Ms. Eshoo. So ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Hudson. And I share his concerns that, if we outlaw 
specific tobacco products such as menthol, it'll lead to 
illicit trade of tobacco products.
    I have a bipartisan bill with Representative Sheila Jackson 
Lee aimed at curbing this very practice around the globe. 
According to the Department of State report, the illicit trade 
in tobacco products funding for criminal activities included 
money laundering, bulk cash smuggling, and the trafficking of 
humans, weapons, drugs, antiquities, diamonds, and counterfeit 
goods.
    I do not believe it is good policymaking to ban legal 
products unless it is the last viable option because of these 
concerns. If we deny consumers access to products, they may 
turn to the black market to find their desired product and 
drive consumers away from regulated tobacco products.
    Dr. Siegel, I've read your testimony and I would like to 
hear a little bit more from you on, you know, our shared goal. 
I think everyone here agrees there is an epidemic with youth 
using e-cigarettes. We all agree we want to combat that.
    Could you just talk a little bit more about what you think 
are the most effective ways to achieve that goal of stopping 
youth from using e-cigarettes?
    Dr. Siegel. Sure. I think that the key is to make these 
products nonaddictive. I think that's the key, because prior to 
JUUL, we didn't have a problem of addiction.
    Kids were using these products socially, at parties, only 
on occasion, and it's only after JUUL and its copycat products 
that we start to see addiction.
    And so I think regulating the nicotine level and regulating 
the nicotine salt formulations can make these products so that 
they're not addictive to kids.
    I think we are being naive if we think that, if we ban 
flavored e-liquids, kids are going to stop vaping. They're not 
going to. They're going to continue vaping, but they're going 
to change what they vape, and what they're going to vape is 
going to be more and more THC.
    And one thing that hasn't been said today but is a key 
statistic that I think everyone needs to understand is that, of 
regular vapers--kids who regularly vape e-cigarettes--70 
percent of them have reported vaping THC.
    And I think that kids are incredibly resourceful, and they 
will use what products are available, and I think prohibition 
is going to be a disaster because kids are just going to use 
what's available, and what is going to be available are the 
black-market products.
    And right now, you can go right on the internet, go to 
dankvapes.com, say you're 21, and you can get Apple Jacks, 
Banana, Birthday Cake, Blackberry, Blue Dream, Candyland, 
Cherry Pie, Cotton Candy, Bubble Gum.
    We talked about bubble gum before. Bubble gum vapes are not 
really killing anyone. But bubble gum THC products are, and 
that's where we need to focus our attention.
    Don't create a new black market. Strictly regulate these 
products like we do all other dangerous products on the market.
    Mr. Hudson. I think you make a good point, especially in 
light of what I mentioned in my opening statement. According to 
Monitoring the Future, youth are four times more likely to use 
alcohol and illegal drugs than they are to use e-cigarette 
products.
    Are there any additional tools, in your opinion, that we 
need to give to FDA to help regulate this?
    Dr. Siegel. I think that what we need to do is to require 
the FDA to set standards, and I think that your legislation 
that you had proposed, I believe, last year would have required 
them to do that.
    I think the problem is that the FDA has been sleeping on 
this issue for 10 years. They've had authority, but they 
haven't passed any actual safety standards.
    Instead, they have been essentially taking a prohibitionist 
approach. It's all or nothing. You have to put in an 
application, and either you're approved or not approved.
    That's not the way we regulate dangerous products. The way 
we regulate them is actually passing safety standards. Had they 
implemented safety standards back in 2013 when I was first 
calling for it, we would have had limits on nicotine levels, 
and JUUL would never have occurred. We need the FDA to be 
forced to immediately, without delay, set safety standards for 
these products as you had requested.
    Mr. Hudson. Yes, that makes a lot of sense. And, you know, 
you look at alcohol. Prohibition didn't work. The percent of 
alcoholics in America is more than before Prohibition now.
    But we do regulate alcohol at point of sale, and I think 
ideas like point-of-sale regulation for tobacco products makes 
a lot of sense as a way to keep these out of the hands of kids.
    So I appreciate your testimony, and Madam Chair, I yield 
back.
    Ms. Eshoo. The gentleman yields back.
    I think it's important for everyone to understand that THC 
is prohibited by the Federal Government. So if there's any 
product that's carrying this poison in it, we have--enforcement 
is really essential in this.
    I now would like to recognize the gentlewoman--and she is a 
gentlewoman--from California, strengthful and gentle, Ms. 
Matsui, for her 5 minutes.
    Ms. Matsui. OK. Thank you very much, my friend, Madam 
Chair.
    Thank you for calling this important hearing, and I am 
really pleased that we are examining a truly comprehensive bill 
to address the epidemic of youth smoking and e-cigarette use.
    While we know the Tobacco Control Act of 2009 was a 
historic piece of legislation that finally gave FDA regulatory 
authority over tobacco products, the current epidemic shows we 
have lots more work to do.
    One area this committee must address is youths' ability to 
purchase tobacco products online. A simple web search shows 
that there are thousands of websites selling tobacco products 
via the internet, often with different standards for how they 
verify the age of their customers.
    If we decide to raise the tobacco purchasing age to 21 but 
any child can go online and purchase e-cigarettes, we risk 
exposing millions more children to these dangerous and 
addictive products.
    I understand that there are existing requirements for 
selling tobacco products online but that current age 
verification practices have not solved the problem.
    Mr. Myers, can you describe how the current online age 
verification for tobacco works and how it fails to prevent all 
youth from accessing tobacco products, including e-cigarettes 
and e-cigarette accessories via online sales?
    Mr. Myers. Certainly, and it's a very important issue 
because the data shows that the number of e-cigarettes sold 
online is equivalent to the number sold in vape shops. So it's 
a substantial number.
    We have, as we know, a wide variety of rules governing this 
issue, so that even if one company has good age verification 
rules, many companies do not----
    Ms. Matsui. Right.
    Mr. Myers [continuing]. And they're equally circumvented 
with regard to it. It's one of the reasons why with cigarettes 
we looked at both restricting online sales and working with 
those who deliver them to do it.
    It's an incredibly important issue, and it's 
extraordinarily difficult to get to as long as you allow any 
online sales.
    Ms. Matsui. Any online sales. OK.
    Late last year, FDA announced they'd take new steps aimed 
at curtailing illegal underage use of e-cigarettes by 
implementing soon-to-be-announced heightened age verification 
measures for online sales.
    We are still waiting on such explicit direction from the 
FDA, and I am curious if regulatory threat and public pressure 
alone have been enough to crack down on illicit online sales.
    Ms. Fuhrman, you mentioned that your son was able to 
purchase his e-cigarette on eBay, which does not require any 
age verification, and that he was able to find other websites 
that sell e-cigarettes without any age verification.
    Can you explain how kids and teens are finding these 
websites?
    Ms. Fuhrman. It's very easy. You just do a Google search.
    Ms. Matsui. Mm-hmm. OK.
    Absent Federal action, States like California have taken 
their own initiative to increase age verification requirements 
for purchasing vaping products online, and it's clear that 
there remains an urgent need for Federal action, and I really 
believe that Mr. Myers is saying what nobody wants to talk 
about but might be really required here.
    FDA has already found that menthol cigarettes likely pose a 
greater public health risk than regular cigarettes. But the 
agency has not moved forward with an outright ban on these 
products.
    Dr. Gardiner--and I appreciate you're from University of 
California. I am an alum. Thank you very much. I want to thank 
you for shining a spotlight on the social injustice issue at 
hand wherein menthol disproportionately impacts poorer 
communities, marginalized groups, youth, and communities of 
color.
    Dr. Gardiner, what have we learned about the impact of 
local restrictions on selling menthol products? In your 
opinion, how should these lessons inform Federal regulatory 
decisions, moving forward?
    Dr. Gardiner. I mention it in part in my testimony, and 
thank you for the question.
    There have been over 221 local flavor restrictions around 
the country, 26 of them specifically restricting the sale of 
menthol all around. It hasn't led to any criminalization or 
increased arrests of anybody. None of that has taken place.
    As we actually speak there last week, the Fremont City 
Council in California passed comprehensive legislation. Of 
course, San Francisco has passed legislation about this.
    Let me just take a moment and say that the suggestion that 
somehow this is a Black cigarette or that disproportionately 
affecting, it would be bad for African Americans--it's been the 
predatory marketing of these things that have led to that 
problem.
    Ms. Matsui. Mm-hmm. Right.
    Dr. Gardiner. I didn't mention this in my testimony, but 
African Americans die disproportionately of tobacco-related 
diseases--heart disease, lung cancer, and cerebral vascular 
disease or stroke.
    So that's why we want to get it off the market. It has 
nothing to do with this.
    And lastly, the National Organization of Black Law 
Enforcement Officials and its counterpart, LEAP, are all funded 
by the tobacco industry. Let's make no mistake about that.
    Ms. Matsui. OK. Well, thank you very much for your 
testimony, and I yield back.
    Dr. Gardiner. Thank you, Madam.
    Ms. Eshoo. The gentlewoman yields back.
    It's now a pleasure to recognize the gentleman from 
Oklahoma, Mr. Mullin, for his 5 minutes of questions.
    Mr. Mullin. Thank you, Madam Chair, and thank you for the 
panel that's willing to take their time and come up here to 
Capitol Hill and give your testimony. We appreciate that.
    I want to make it very clear I have no dog in this fight. I 
don't drink. I don't use any drugs, never have. I don't use any 
tobacco products.
    But I do believe that it's the role of this body to create 
an environment for entrepreneurs to be able to perceive their 
dreams and consumers to have choice.
    I also think it's very hypocritical that in one hand we are 
talking about banning flavored e-cigarettes and on the other 
hand most of the people that are for banning are also for 
legalizing marijuana.
    I mean, if you're talking about targeting kids, let's talk 
about the whole product and what is actually being targeted. If 
we are going to talk about this, let's have an open and fair 
conversation about it.
    What brought this into a hearing to begin with was because 
of the death and sickness that e-cigarettes has brought. But 
what hasn't been discussed is that most of those individuals 
were buying illegal cartridges laced with THC.
    So why is it that we are just focusing on one area? I don't 
like any of it. I choose not to use any of it. But we are a 
free and balanced country that allows consumers to make the 
decision, and we are old enough to make those decisions.
    We talk about in this bill from age limits or an age limit 
to 21. As I said, I don't have a dog in this fight. But we 
allow men and women to choose to die for this country at 18, 
and now we are saying they're not smart enough to decide if 
they're going to smoke or not.
    I get the point, but there's some hypocrisy that goes alone 
with this, and I just have a hard time understanding it from 
the onset. We need to have the full conversation.
    We want to take these products and we want to put them off 
the reach of the children, but we already know they're able to 
get THC-laced cartridges online.
    Do you think that's going to stop them? Do we think that's 
not going to happen? Do we not think that's where the products 
are going to move to, and then there's going to be absolutely 
no oversight of it?
    They're still going to be inhaling it, and it's still going 
to go into their lungs.
    Let me ask--Mr. Myers, let me ask you a question. Have we 
seen sales increase or decrease on the black market with the 
THC cartridges?
    Mr. Myers. We actually don't track, because we don't have 
an ability to track THC. But the issue you raised is important 
in two different ways. Let me address it.
    Because I don't believe most of the tobacco control 
advocates out there do support legalization of marijuana. With 
regard to----
    Mr. Mullin. No, I am talking about--I am talking about the 
people on the bill. I am talking about on this bill. The 
people--most of the people that are sponsoring this bill are 
for legalizing marijuana. Not all, but most.
    Mr. Myers. But, you know, there is--it's important not to 
confuse two separate issues. One is we have an epidemic of e-
cigarette use among our kids, and two, we----
    Mr. Mullin. No, Mr. Myers--excuse me. It is important to 
have a full and fair conversation about all of it.
    Mr. Myers. We totally agree.
    Mr. Mullin. If you're going to--if you're going to focus on 
one area, focus on all of it. It still has to do with getting 
people addicted to a product.
    It still is called dependency.
    Mr. Myers. So we agree with you. One of the critical 
factors and one of the reasons we are concerned is that the 
availability of flavored e-cigarettes has so dramatically 
increased the number of kids who are addicted to any substance 
and the----
    Mr. Mullin. So has the availability of marijuana, too, and 
go back and look at the States that have legalized it.
    Mr. Myers. Right. But----
    Mr. Mullin. And I am not trying to make this about 
marijuana versus anything else. I am just saying that we got to 
have a full conversation about all this.
    I am not trying to focus on it. I know that's what it 
sounds like. But I am just pointing out that we are only 
focusing on one area. If we are going to talk about kids, then 
let's have a conversation.
    I've got six at home, ranging from 16 to 8. I don't want to 
see any of these products either, and one of the biggest issues 
we have in our schools is that they're going in and they're 
smoking in the boys' room--ha, ha, song there--and we are 
having an issue with it where they're having to take the stalls 
off the doors.
    And I don't want this product available to anybody. I 
don't. But we got--we can't be kidding ourselves that we think 
if we just ban this that it's just going to go away--that the 
problem is just going to go away. It is absolutely not.
    Dr. Siegel----
    Mr. Myers. Can I just----
    Mr. Mullin [continuing]. Where is most of--where has most 
of the sales of THC taken place? The underage--the underage 
kids, where are they getting the majority of their cartridges 
for these e-cigarettes to begin with?
    Dr. Siegel. They're coming off the black market and they're 
coming from large drug dealers who are producing hundreds of 
thousands of these completely unregulated, and people are 
buying them off the internet, getting them off the street, and 
those are being distributed in our schools.
    And just to be clear--you made this point--that's what's 
causing this outbreak, not nicotine products that people are 
buying at stores.
    Mr. Mullin. So if you--so if you think----
    Dr. Gardiner. The CDC has been very clear about that----
    Mr. Mullin. Hold on. I didn't ask you a question, sir.
    Dr. Gardiner. Since you've been doing this longer----
    Mr. Mullin. I didn't--I didn't ask you a question.
    Ms. Eshoo. The gentleman's time has expired.
    Dr. Gardiner. Seventy-eight percent of it, not always.
    Mr. Mullin. Ma'am--Madam Chair, with all due respect, 
everybody else--everybody else's went over quite a bit.
    Ms. Eshoo. They haven't gone over by 20 seconds. So you can 
finish your answer and then we need to move on. Who was giving 
the answer?
    Mr. Mullin. Dr. Siegel was.
    Dr. Siegel. Yes. I concluded, basically saying--yes.
    Ms. Eshoo. Good. OK. The gentleman yields back.
    Mr. Mullin. Thank you.
    Ms. Eshoo. I would like to now recognize the gentlewoman 
from Florida, Ms. Castor, for her 5 minutes of questioning.
    Ms. Castor. Well, thank you, Chairwoman Eshoo, for calling 
this important hearing and thank you to all of the witnesses 
for all of your work.
    We have a very serious problem in America with this growing 
epidemic of vaping and e-cigarettes, and I've seen it.
    My daughters are just in their early 20s, and over the past 
decade I watched among all of their friends groups and kids all 
across middle school and high school as their behavior changed 
substantially with the uptake of the JUUL and the e-cigarettes, 
and this is borne out by the Florida Youth Tobacco Survey run 
by our Department of Health found that from 2012 to 2018 there 
was a 361 percent increase in kids age 11 to 17 who tried 
electronic vaping and a 582 percent increase in kids that 
actually continued to use the vapes.
    And we all know that nearly all tobacco use begins when 
kids are in middle school and high school. So that--this area 
of what they do to target children to--and then get them hooked 
through nicotine and other habit-forming characteristics I 
think is ripe for us to do so much more.
    Now, this bill, Reversing the Youth Tobacco Epidemic Act, 
includes language making it unlawful to market, advertise, or 
promote any e-cigarette products to individuals under the age 
of 21.
    Is this strong enough, the language in the bill, and it 
gives the FTC enforcement ability and they can come up with 
penalties? But I don't know if we are doing all that we need to 
do.
    I would like to have you all go down, real quick, and just 
say it's not strong enough, it is strong enough. We had Dr. 
Schuchat here from CDC and Dr. Sharpless from FDA. They called 
it an epidemic. They're doing some things with--online and 
social media.
    But I continue to think it's not strong enough. What else 
would you do?
    Mr. Myers. It's a very good start. FDA has authority to 
regulate e-cigarette marketing up to the limits of the First 
Amendment. They haven't done so.
    So the kind of social media marketing, which has fueled 
this epidemic, needs to be the subject of very clear rules to 
prevent it from happening.
    Ms. Castor. Thank you.
    Ms. Fuhrman. I would echo that--it's a great start. I think 
the problem now is that kids are marketing it among themselves. 
So that's also another issue that's going to be hard to follow.
    And I think that we are talking about reversing the 
epidemic--the youth epidemic. But once--if you ban flavors and 
you slow down the uptake of new kids starting to vape, you 
still have 5 million kids who are potentially addicted to 
nicotine, and there's no approved method of cessation. So 
that's what the next focus should be.
    Dr. Tanski. One of the aspects I really like about this 
bill is that it restricts sponsorships, and that's a big thing 
that was restricted with the 2009 tobacco control.
    So it's that Marlboro could no longer sponsor the Indy 500 
NASCAR. But right now, e-cigarette vendors can, and so that's 
one very important thing to clamp down on.
    So it's a great start, and in particular, the sponsorship 
and avoiding all that is going to be critical.
    Dr. Gardiner. I think the greatest part of--and thank you--
I think the greatest part of the bill is that it, for the first 
time in 10 years, takes up the question of menthol and 
prohibits its manufacture and promotion. We know that it's one 
of the leading causes of death in the African-American 
community.
    Let me also say, Ms. Eshoo, I am sorry for my interruption.
    There's just been so much discussion about marijuana that 
we should at least have the facts right--that 78 percent of the 
cases have identified marijuana, but 22 of the cases haven't. 
If we want to have a full discussion about it, then let's have 
a scientific discussion about it and not make generalizations.
    Dr. Siegel. So in answer to your question about the age 21, 
I don't think it goes far enough. I think what needs to be done 
is to not only raise the age of sale to 21 but to prohibit the 
sale of all tobacco products, including e-cigarettes, to stores 
that are only open to people who are 21 and older.
    I don't think there's any reason in 2019 that any kid can 
walk into a grocery store, a convenience store, a drug store, 
and buy a pack of Marlboros. I just don't think that in 2019 
that makes any sense.
    I think these should be restricted to tobacco or vape 
shops. That's where they should be sold, and you can't go in 
there unless you're 21.
    Ms. Castor. Thank you. I yield back.
    Ms. Eshoo. The gentlewoman yields back.
    It's a pleasure to recognize Dr. Bucshon from the great 
State of Indiana.
    Mr. Bucshon. Thank you. I appreciate the recognition.
    Look, I am a conservative Republican. I am not normally for 
government putting in more regulations.
    But on the other hand, as a doctor, looking at the data 
it's pretty clear we need to do something about the e-cigarette 
epidemic in grade schools and high schools.
    I have four kids. I was a cardiovascular and thoracic 
surgeon. Most of my patients came to me because of the end 
results of cigarette use, honestly, and my daughter, who's in 
high school, tells me it's pretty pervasive in her school.
    I am deeply troubled by the increasing rate of e-cigarette 
use amongst children. The long-term negative health 
implications of nicotine use on the heart and lungs are well 
known, and enticing flavors are attracting teens who might not 
otherwise have exposure to nicotine.
    The fact is high school and middle school students are 
getting their hands on these products, setting them up for a 
lifetime of addiction and negative health side effects and 
it's--they're not actually going to a legitimate marketplace 
and buying them.
    They're buying them from, honestly, high school and grade 
school dealers and their own colleagues in their classes who 
are selling these at their schools.
    In 2018, more than 3.6 million U.S. youth, including one in 
five high school students and one in 20 middle school students, 
reported to have used e-cigarettes, and this number is rising, 
as has been pointed out by multiple witnesses.
    Two-thirds or more of the students don't even realize 
there's nicotine in the product--a high percentage. The focus 
of this issue must be on the health of our children. I think 
it's important not to lose sight of this by using this epidemic 
to impose excessive and overreaching government regulation 
broadly.
    That is why I have supported the Trump administration's 
proposal to combat the epidemic of youth e-cigarette use by 
banning flavored options from the marketplace by removing all 
flavored e-cigarettes from the marketplace until the FDA can 
properly review and approve them. If they can, we can get ahead 
of the epidemic before it's too late.
    I hope that this committee can continue to build on the 
leadership of the administration and work together to address 
this epidemic head on so that children never need to find out 
the long-term negative health implications of nicotine and find 
it out the hard way. Nicotine is extremely addicting. It's 
almost impossible to get rid of the addiction.
    In that vein, Dr. Tanski--there you are--if adults want to 
quit--help quit smoking, they have a number of resources 
available to them. For example, there are several FDA-approved 
tobacco cessation medications that have been proven to help 
adults quit.
    But for kids, this doesn't seem to be the case. What common 
treatment options do you recommend to your patients who are 
addicted to e-cigarettes, and are any tobacco cessation drugs 
or nicotine replacement therapies proven effective with kids?
    Dr. Tanski. Dr. Bucshon, I really appreciate the question, 
and unfortunately the answer is we don't have a lot of evidence 
as to what works well for cessation for adolescents.
    And with regards to vaping devices, we have no evidence at 
all because there have not been any studies looking at how to 
get young people or anybody to quit vaping devices.
    So we are in uncharted territory. We actually dramatically 
and desperately need research and some evidence to support what 
we are trying to do.
    We are using our best practice at the moment, and so we are 
using all the tools that we used for adolescent smoking 
cessation, including counseling, group counseling.
    We are using nicotine replacement therapies off label 
because we know that some of our young people have very high 
levels of addiction, and that is a huge area of concern.
    Kids are suffering. They're withdrawing in class. They're 
feeling really horrible, and they're getting that bloom of 
anxiety and irritability, and they're having a really hard time 
getting through the day.
    So we do have a big problem. And to your point as a 
cardiovascular surgeon, my husband is a vascular surgeon. We 
joke that I am trying to put him out of business.
    We can't avoid the cardiovascular impacts of these devices, 
and it took us 40 years to figure out COPD and 40 years to 
figure out lung cancer, and I am confident, unfortunately, that 
we are going to see cardiovascular impacts from our--these 
use--our youth using these products.
    Mr. Bucshon. I would agree, and I want to yield the last 
minute of my time to Ranking Member Burgess.
    Mr. Burgess. Thank you, Dr. Bucshon.
    Dr. Siegel, you had made mention just a few minutes ago 
about FDA perhaps missed an opportunity in 2013 to regulate the 
amount of nicotine.
    I just want to point out to the committee much has been 
made about the passage of the Tobacco Control Act. But 
remember, Tobacco Control Act contained a user fee, and so the 
FDA cannot say that it was resource constrained because, since 
the inception of the Tobacco Control Act, they've collected 
over $5.5 billion, and I don't know that we have good oversight 
as to how that money has been spent.
    But it certainly could have been spent in some of this 
activity. I realize that vaping doesn't have the user fee. But 
if the purpose of the FDA and the Tobacco Control Act is to 
regulate nicotine, they had the money to do so. I will make 
this available for the record, and I will yield back.
    Ms. Eshoo. The gentleman yields back.
    Mr. Bucshon. I yield back.
    Ms. Eshoo. I would like to just make a suggestion, that as 
the ranking member and the chair of the subcommittee that we 
write to the FDA and inquire as to how those dollars are 
being--have been used and continue to be used.
    I now would like to--you know, I would like to ask--just 
circle back for a moment. I did not hear Dr. Gardiner--you said 
something about the organizations when I said ``so ordered'' 
that the letters be placed in the record, and you made a 
comment but I didn't catch it. Can you restate what you said?
    Dr. Gardiner. I didn't say it directly at the time, but 
what I said is that the organizations--the National 
Organization of Black Law Enforcement Executives and LEAP, and 
I am not familiar with their terminology--both take money from 
the tobacco industry and actually have for a number of years.
    Ms. Eshoo. Thank you very much.
    I now would like to recognize the chairman of the full 
committee, Mr. Pallone of New Jersey.
    Mr. Pallone. Thank you, Chairwoman Eshoo.
    Whether it's mango, mint, bubble gum, or gummy bear, the 
wide variety of kid-friendly flavors of cigarettes rival any 
ice cream shop or candy store, and as we've heard from our 
witnesses today, that's by design.
    Tobacco manufacturers know that, to attract youth use 
early, there's no better way than to give them new sweet 
flavors to try, and once you have got them hooked, you might 
just have a customer for life.
    So it's not just me saying this. Children themselves report 
that these flavored products are what they use, according the 
National Youth Tobacco Survey conducted by the CDC and the FDA.
    Twenty-eight percent of high school students use e-
cigarettes 20 or more days per month, and nearly 70 percent of 
those students report using flavored products.
    So I want to ask some of you--let me start with Dr. Tanski. 
In your testimony you described the physical and psychoactive 
harms that can come from nicotine use, and you described how 
nicotine affects the developing adolescent brain.
    Can you describe how flavors combined with nicotine might 
influence the drug's addictive properties, and the impact this 
has had for youth users?
    Dr. Tanski. Well, I don't know the specific research about 
it, but it is kind of intuitive that we know that flavors also 
light up the pleasure systems in your brain. So it's kind of 
intuitive to assume that, if we combine yummy flavors with 
nicotine, that might be a double whammy.
    I don't know about the specific research on that topic. 
That is my hypothesis, and it's supported by anecdote by seeing 
so many of my young patients start with flavored products.
    Mr. Pallone. So let me----
    Dr. Gardiner. But we do have data on the impact of flavors 
on other parts of the body. Cinnamaldehyde we know is very bad 
for your lungs. We know that diacetyl is also bad for your 
lungs. These are things that are put into e-cigarettes. There's 
a whole list of them.
    One thing we didn't talk about in this hearing is that 
there's a multiplicity of cardiovascular effects associated 
with smoking e-cigarettes. How they relate to youth, I am not 
really sure.
    But we know that platelet formation, you know, in plants--I 
use the example if you cut yourself what happens, and the 
students all say you bleed. Well, internally, you actually 
develop platelets. You actually develop--that's the mechanism 
to stop the bleeding externally. Internally, it leads to 
blockage of arteries.
    We know that e-cigarettes do that. So, and I appreciate 
what's been going on. At some point we do need to have a full 
discussion about this. I mean, we are kind of at the surface of 
this, and I am sorry to take all your time.
    Mr. Pallone. No, that's OK. Let me ask Ms. Fuhrman, though. 
Some people have argued that a flavor ban for e-cigarette 
products should contain an exception for mint- and menthol-
flavored e-cigarettes, as these products may not be as kid-
friendly as fruit-flavored products.
    But as the parent of a child currently in schools, what are 
your thoughts on that suggestion? Is it true that teenagers and 
youth are not using mint- or menthol-flavored tobacco products?
    Ms. Fuhrman. No. No. It's not true at all. Actually, some 
of the samples I brought were different flavors of mint chewing 
gum, or Mighty Mint.
    Mint is one of the preferred flavors of teens, and if you 
look at JUUL sales, JUUL sales of mint and menthol are now over 
80 percent of their total sales. So it's very important.
    What I think is also important to recognize is that there 
are other flavors coming out on the market. For instance, STIG 
has a mentholated mango. So they're combining flavors now.
    To what Mr. Gardiner said, the menthol makes it easier to 
absorb, easier for the lungs to absorb, easier to addict. So 
they're adding that mentholated to flavors that are already, 
you know, commonplace.
    Mr. Pallone. Thank you.
    You know, I was pleased to see the FDA's announcement that 
they would soon be conducting some level of enforcement on 
flavored e-cigarette products that would lead to their removal 
from store shelves and e-commerce, and more than a month later, 
though, we still have not seen details of that proposal, and I 
am concerned about possible loopholes in the proposed guidance.
    So, Mr. Myers, can you explain why legislation provides a 
more complete solution for addressing concerns about flavored 
products?
    Mr. Myers. Sure. It's very important for multiple reasons.
    First of all, we have not yet seen a proposal out of the 
administration to finally implement. Our hope is that we will 
see one very soon, and it will be complete.
    Second, the tobacco industry inevitably will sue the FDA as 
soon as it files any such rule. They have done that in every 
case. We need to be certain that this actually becomes the law 
of the land.
    Third, a rule adopted is a rule that can be changed. We 
banned the sale of flavored cigarettes because we knew they 
attracted kids. It's worked. It hasn't produced a black market.
    It has helped us reduce cigarette use. We should do the 
same thing here and be sure that it's not something we have to 
look back on 10 years from now.
    Mr. Pallone. Thank you.
    One more question. Dr. Gardiner, you talk in depth about 
menthol in your testimony, and you say we should recognize the 
marketing of menthol products as a social injustice issue.
    Would you just elaborate on that? What's driving the 
increase in the use of menthol?
    Dr. Gardiner. It has been going on for decades that prices 
of cigarettes in the Black community, particularly menthol 
cigarettes, are cheaper. There are more advertisements, and 
promotions are much more lucrative. That's what has gone on for 
the last 50 years.
    That is why 85 percent of African Americans smoke these 
products. That's why the majority of African Americans who die, 
die of tobacco-related diseases.
    Mr. Pallone. Thank you, Madam Chair.
    Ms. Eshoo. The gentleman yields back.
    A pleasure to recognize the gentleman from Kentucky, Mr. 
Guthrie, for his 5 minutes.
    Mr. Guthrie. Thank you very much, and thank you for being 
here today. This is very important. I am the ranking member of 
this Subcommittee on Oversight and Investigations, and we had a 
hearing right before the break on the deaths--the lung deaths 
coming from vaping--and it seems to be two specific issues that 
both need to be addressed.
    One is the flavors and young people becoming addicted to 
the flavors. I think that is a real problem that needs to be 
addressed. The second is the THC--that, of the 26 deaths in 21 
States, many are due to products containing THC.
    And even right before the break, we passed a bill to make 
it easier to bank marijuana. I mean, that's the thing. So, as 
we are trying to restrict access to nicotine products, which I 
agree with, we also seem to be not restricting access to 
marijuana-laced products.
    And so, Dr. Siegel or Dr. Tanski, maybe this might be--do 
you have--and then flavors. I understand you can buy marijuana 
gummy bears. I don't know if that's true or not. But if you're 
saying that the pleasure from flavor and the pleasure from 
getting intoxicant is combined, then it's combined in that. So 
maybe we should be looking at banning those products too 
instead of expanding the access to them.
    But to Dr. Siegel and Dr. Tanski, do you have concerns 
about the effects of adolescent brains and their behavior--the 
development of their brains and behavior from vaping THC?
    Dr. Tanski. Go ahead. You go first.
    Dr. Siegel. Absolutely. Absolutely.
    I know that we've been testifying that this is an 
unprecedented increase in what we are seeing. But in reality, 
there was another unprecedented increase.
    Just last year, marijuana use among college students rose 
to its highest level in 35 years. Forty-nine percent of college 
students admitted that they use marijuana.
    We have--the legalization of marijuana has led to the 
perception among young people that it's just not harmful. The 
policies that we set in society are what tell kids what's 
harmful and what's not. When they see that this is legalized, 
their perception of harm is decreased.
    And that's what has gotten us into this mess with the 
deaths from respiratory illness because kids--the increase in 
marijuana has now transferred into vaping.
    They've gone from smoking it to vaping it, and because 
they're vaping it and because they're buying products on the 
black market that have been contaminated, that's why kids are 
dying.
    And I think we cannot ignore that problem, and I think it's 
naive to think that if we just ban flavored e-liquids 
everything is going to be fine. It's not.
    Kids are getting these products from dealers--from drug 
dealers in their schools who are getting them from actual drug 
dealers.
    And they're going to continue getting vaping products. 
They're not going to stop vaping just because the Government 
says you can't sell flavored e-liquids. They're just going to 
shift over to what's available, which is going to be THC.
    Mr. Guthrie. OK.
    So, Dr. Tanski, do you have a view on the THC, or anybody 
here on the panel?
    Dr. Tanski. Yes. So a couple comments on the THC.
    I will comment that it is still federally illegal. So that 
is completely an illicit product and there is no--in my State, 
there is no legal sale of recreational THC in the State of New 
Hampshire.
    Mr. Guthrie. But Congress has voted to make it easier to 
bank. I mean, not--the House did, not--Congress hasn't passed--
so we are moving in that direction.
    Dr. Tanski. I am not familiar with the bill----
    Mr. Guthrie. And I am just saying, so we are going down 
that pathway much more.
    Dr. Tanski. So, but to the point, THC is an intoxicant. It 
is something that makes people higher longer, and it impairs 
their ability to learn. People get high, and it's not a two-
minute head rush. It's a long-day thing.
    So I think that, indeed, we are seeing kind of another 
epidemic. There are two separate epidemics, and I think we need 
to think about them in two separate ways----
    Mr. Guthrie. Need to do it with both, yes.
    Dr. Tanski [continuing]. Because they really are two very 
different drugs and there is no legal recreational marijuana, 
at least in my State and at the Federal level, whereas nicotine 
is legally available.
    Mr. Guthrie. Well, is THC as addictive as nicotine, or--do 
you know? Nicotine is very addictive. I know that----
    Dr. Tanski. Nicotine is very addictive. I am not an 
addiction specialist----
    Mr. Guthrie. You're not an expert in that area?
    Dr. Tanski [continuing]. To be able to compare the two. So 
I don't have----
    Mr. Guthrie. Anybody here? Dr. Siegel?
    Dr. Gardiner. It's definitely addictive.
    Dr. Tanski. It is addictive, but----
    Dr. Gardiner. That's not--that's not the question. There's 
very few things as addictive as nicotine, though, and I guess 
that's the issue.
    You opened your statement with the deaths around the--and I 
just want to reassert this. Seventy-eight percent of the people 
with the lung illness have reported THC use. Another 22 percent 
have not. They said they've only used nicotine. So we are going 
to have to look into the interaction of what's in the actual e-
cigarette.
    Mr. Guthrie. So yes, eight out of 10 have said--reported 
THC, and they would say that it's been self-reporting, so 
they're not sure if other--does not have THC as well, but 
that's helpful.
    Dr. Gardiner. So let's even take it a step further. If 
you're mixing flavors, as Matt has pointed out, with some legal 
products can't you imagine that there are flavors being mixed 
with the THC?
    Mr. Guthrie. Well, I would imagine so. But THC seems to be 
common, and most of it is----
    Mr. Myers. Can I make just one short point, too, that 
relates to this? One of the reasons we are so concerned about 
flavors hooking kids on e-cigarettes is the data shows that, 
even if these are kids who otherwise wouldn't have smoked or 
used other products, it increases their likelihood of moving on 
to other products. So----
    Mr. Guthrie. Like THC gummy bears would be in the same 
category.
    Mr. Myers. Well, you know, I don't have specific data on 
THC. But what it does is, it demonstrates that there's an 
increased risk those kids will go on to use other products. So 
if you're concerned about other addictions----
    Mr. Guthrie. Absolutely.
    Mr. Myers [continuing]. Stopping this one helps across the 
board.
    Mr. Guthrie. That one, and not for Congress to move down 
the path that----
    Ms. Eshoo. The--yes, the gentleman's time has expired.
    Mr. Siegel, you--I just want to--you spoke about many 
issues in one of your answers, but you didn't demonstrate any 
data that supports it.
    So would you please get that to us? Otherwise, it's--
they're sentences with lots of words in them, but we need 
factual--we need data here.
    Dr. Siegel. Well, I can give you the data.
    Ms. Eshoo. Yes. OK. That's what I am asking for. If you 
would, please.
    Dr. Siegel. Absolutely.
    Ms. Eshoo. Not now. In writing to me, please.
    Dr. Siegel. Sure. Sure.
    [The information follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Now I would like to recognize the very 
distinguished gentleman from Massachusetts. It's so wonderful 
that we have a Kennedy in the Congress.
    Mr. Joseph Kennedy.
    Mr. Kennedy. Thank you, Madam Chair. Thank you to our 
witnesses for being here for this important hearing.
    A few weeks ago, I asked the acting head of the FDA what 
caused a catastrophic regulatory failure that we are seeing 
play out in our schools and our neighborhoods and our hospitals 
all over our country.
    Just a week ago, Massachusetts experienced our own--the 
first death that we have had in a vaping-related death. More 
than a thousand people of all ages are currently sick with a 
mysterious disease, and our Government still cannot diagnose 
its roots.
    Our Federal Government's failure to adequately and 
proactively address this crisis has had devastating and 
immediate and long-term impacts which, again, we don't fully 
understand.
    Right now, however, patients are sick. Legally operating 
businesses in Massachusetts are being forced to shutter, with 
small business owners facing bankruptcy, and our Government is 
scrambling to do what it should have done an awful long time 
ago.
    So, to each of our witnesses, with the benefit of 
hindsight, what is the one most important regulatory protection 
that must be put in place immediately?
    Dr. Siegel, we'll start with you.
    Dr. Siegel. I think it's regulating the nicotine levels. I 
don't think that the nicotine levels in e-liquids should be 
allowed to be more than 20 milligrams per milliliter, and I 
think if your formulation is a nicotine salt it should be even 
lower than that, probably half of that.
    Mr. Kennedy. Thank you.
    Dr. Gardiner.
    Dr. Gardiner. Let me speak to that. Mike has mentioned that 
a couple of times. There has been a proposal before the FDA to 
gradually lower the limit of nicotine in cigarettes. So I think 
it's on the table and it needs to be done, and I will just 
reiterate what I came to testify about.
    I think the single most public health benefit that we could 
get in terms of regulation is getting menthol products off the 
market. I will just leave it there.
    Mr. Kennedy. Thank you, sir.
    Dr. Tanski. So we are looking at the retrospective scope, 
right. We are going into the Wayback Machine, and in hindsight 
what should we have done when e-cigarettes came on the market? 
Is that the question?
    Mr. Kennedy. Yes, what should we--well, what should we have 
done, but what should we do now?
    Dr. Tanski. So I think this bill goes a long way towards 
addressing what we need to do now. By putting strict regulation 
on these products and addressing age limits and addressing 
flavors. I think those are absolutely critical.
    I think that 15 years ago, when these first came on the 
market, we made a lot of mistakes by allowing them to come in 
as a consumer product and being completely unregulated and 
allowing these unfettered flavors and access to our kids.
    Mr. Kennedy. Thank you, Doctor.
    Ms. Fuhrman.
    Ms. Fuhrman. I would say that the biggest mistake we made 
was not banning menthol cigarettes, and today I think we should 
ban all flavors.
    If we leave menthol cigarettes out of the equation and we 
ban flavored e-cigarettes, it will allow not only multiple 
generations of young people to start smoking regular cigarettes 
with menthol, but it will also create a loophole and a 
precedent to exempt menthol e-cigarettes from the bill. So----
    Mr. Kennedy. Thank you.
    Mr. Myers. Let me echo Dorian. I think the critical issue 
is flavors is what brings people to it. Flavors is how the 
tobacco industry has addicted generations of people in the 
African-American community.
    We need to turn off the on ramp, and the best way to do it 
is to eliminate the flavors that appeal to them. But, 
simultaneously, long term we need to look at reducing nicotine 
in combusted tobacco products so that we ratchet that down, 
clearly.
    And in the interim we have to make it a priority to figure 
out how to help young people who are addicted to quit.
    So it's three things, but you really have to do them all.
    Mr. Kennedy. So building off your comments there, Dr. 
Tanski, can you tell a little bit about--tell me a little bit 
about what nicotine does to a young, developing brain, 
particularly when it's vaped?
    Dr. Tanski. So it hits the brain very quickly, particularly 
the new products where there's--the features of the nicotine 
get introduced to the brain very, very quickly, kind of 
analogous to a combusted tobacco cigarette, and it induces this 
feeling of pleasure.
    And there's two things that happen. If someone has been 
using nicotine for a long time, when you don't have nicotine in 
your body, you feel poorly. You have withdrawal systems. You 
get irritable. You get anxious. You have trouble feeling 
pleasure. And so you also vape or smoke to avoid withdrawal 
because otherwise you don't feel normal.
    So it's this kind of self-fulfilling need. You start with 
nicotine innocently. You don't think it's going to do anything. 
You think--you're a teenager--you think nothing bad is going to 
happen to you.
    But you start, you get hooked, and then you're stuck in 
this trap, and you don't feel well until you have more nicotine 
in your brain. And so that's what addiction is. That's what 
dependence is and, unfortunately, these products that are in 
our kids' schools and in our kids' lives have perpetuated 
significant addiction to nicotine.
    Mr. Kennedy. And just fleshing that out in the last 15 
seconds here, why is that more--why are younger brains or 
brains that are not fully developed more susceptible to 
nicotine?
    Dr. Tanski. It's a great question. It's a developmental 
pattern, and it's--the pleasure centers kind of become mature 
before the inhibitory centers become mature. So they are much--
the addictive potential is much higher with any product in an 
adolescent brain.
    Whether it's nicotine, THC, anything, the adolescent brain 
is in this unique developmental period. It's not to do with 
law. It's not to do with people going off to war. It's to do 
with brain development, and it's a tempo that doesn't finish 
until the mid-20s.
    Mr. Kennedy. Thank you.
    Dr. Tanski. Thank you.
    Mr. Kennedy. Yield back.
    Ms. Eshoo. Thank you. The gentleman yields back.
    It's a pleasure to recognize my friend, the gentlewoman 
from Indiana, Mrs. Brooks, for her 5 minutes.
    Mrs. Brooks. Thank you, Madam Chairwoman, and thank you for 
holding this incredibly important hearing.
    While Massachusetts has just had its first vaping death, 
Indiana, sadly, has had three--three of the 26 that have 
occurred, as far as I know, across the country.
    In the 2018 Indiana Youth Tobacco Survey, nearly 1 in 5 
high school students and 1 in 12 middle schoolers said they 
were using e-cigarettes.
    And I was at an American Cancer Society event while I was 
home the last the two weeks and Dr. Sarah Bosslet, a 
pediatrician, said that it is something that she is having 
regular conversations with and she is overwhelmed by the number 
of kids, which is what I am curious about, Dr. Tanski and Ms. 
Fuhrman, is it's interesting to me that the kids are actually 
sharing with you that they are vaping.
    They are not hiding it. They might hide it in school 
because they can get in trouble for it in school. But I want to 
talk a little bit more about where are the kids getting it.
    I just came from a hearing downstairs on fostering the safe 
internet--and when I looked up a product online as we were 
passing it out, it asked you the question, ``Are you 21, or are 
you legal or not legal''--``Are you 21 or not legal?''
    So, truly, where are--having come from law enforcement 
background, where are the kids getting it? Is it over the 
internet?
    Is it--how are middle school kids getting it from black 
markets? Share with me what you know. And, Mr. Myers, I want to 
ask you very briefly about the marketing specifically to the 
kids.
    Ms. Fuhrman.
    Ms. Fuhrman. Well, I think when you say on--when you go 
online and it says, ``Are you 21 or are you not?,'' you click 
21, that's it.
    Then you can go through and then you can purchase anything. 
So there's really no verification beyond that, except on very 
few other websites. So they can do it that way.
    They can get it at a gas station. They can get it at the 
corner store, and a lot of----
    Mrs. Brooks. Are they not required to provide an ID at a 
gas station?
    Ms. Fuhrman. They don't ask. A lot of the clerks don't ask, 
and a lot of the kids have fake IDs. But most of them don't 
ask. And then a lot of those kids will then purchase them and 
go to school and sell them to other kids.
    Mrs. Brooks. And what are they selling them for? How much, 
roughly?
    Ms. Fuhrman. You know, before when you could--when you 
could purchase bulk online, they were--the pack of four pods is 
$16, and you could break it up and they would sell a pod for 
$10.
    Mrs. Brooks. Dr. Tanski?
    Ms. Fuhrman. Now you can buy them for--I just passed around 
a thing--you can buy--the pack of four pods is $7.
    Mrs. Brooks. Dr. Tanski, the pediatricians you're 
representing, can you share with us what kids are--what they 
are sharing with them about availability and why they believe 
they're safe?
    Dr. Tanski. So I think the flavors go a long way towards 
this halo effect that it must be safe, because why would 
something called ``gummy bear'' be harmful to you?
    And interestingly, a lot of the young people don't think 
that they're vaping nicotine. When you ask kids, ``Are you 
vaping stuff with nicotine?'' they'll say, ``I am only vaping 
flavors.'' But when you actually look at the product or you dig 
down deeper, you find that, indeed, they are vaping nicotine, 
and they just don't know.
    And it is the social pipeline where a lot of the kids are 
getting these. The middle schoolers are getting them from their 
older brother and sisters in the high school, and an 18-year-
old high school senior in most States is currently legal to buy 
vaping products.
    My son turned 18 at Christmas in his senior year of high 
school, and on the day of his birthday people say, ``Hey, will 
you buy me some vapes?'' Thankfully, he said no. Otherwise, we 
would have had some family problems.
    But this social pipeline needs to be shut off, and that's 
where Tobacco 21 can be one part of the solution. But the 
flavors are another critical piece of the solution because the 
kids don't perceive something that's labeled as cotton candy or 
gummy bears as being something that could possibly be harmful.
    Mrs. Brooks. So Governor Holcomb of Indiana and our State 
health commission are investing $2 million in a public 
relations campaign to educate schools and kids and so forth.
    Mr. Myers, can you talk to us about what kind of marketing 
are you seeing that has made the big--why do the kids believe 
it's safe? Aside from flavors, how is it that there is nothing 
that indicates that it's filled with nicotine?
    Mr. Myers. It's the perfect question. It's because the FDA 
rules on advertising have not been applied to e-cigarettes--
that this industry, which comes out of Silicon Valley, figured 
out that, if you use social media, we adults wouldn't see it 
until long after our children saw it.
    They went back and researched and used the exact same 
imagery that the cigarette industry used in the '50s and '60s 
to make it look like it was cool, it's what you needed to be 
socially successful, happy, independent, and healthy--all of 
those things.
    And so everybody in their ads, everybody in the events that 
they sponsored looks like they are the quintessential most 
healthy, happiest, most successful person in the world.
    You want to be a--figure out how you reach a teenager? They 
took the tobacco industry playbook, and they applied it to 
precision.
    Mrs. Brooks. Thank you. I yield back.
    Ms. Eshoo. The gentlewoman yields back.
    A pleasure to recognize the gentleman from California, Mr. 
Cardenas, for his 5 minutes.
    Mr. Cardenas. Thank you very much, Madam Chair. Appreciate 
the opportunity for us to have this open and public discussion 
about this important issue.
    I will quote the U.S. attorney general--excuse me, the U.S. 
Surgeon General: ``The evidence is sufficient to conclude that 
advertising and promotional activities by the tobacco companies 
cause the onset and continuation of smoking among adolescents 
and young adults,'' end quote.
    So it appears that the U.S. Surgeon General agrees that 
there is evidence by his statement that this epidemic is 
something that we should do something about to protect not only 
our children but families as a whole.
    Dr. Tanski, you have devoted a significant portion of your 
research to the effects of marketing tobacco products to youth.
    Can you expand on how tobacco companies historically 
targeted youth in advertising and why youth might be very 
susceptible to tobacco marketing?
    Dr. Tanski. Thank you for the question.
    So yes, I've done quite a bit of research on marketing and, 
specifically, media mentions and product placement.
    So back in the '50s, '60s, '70s, even earlier, tobacco 
companies would actually pay film companies for product 
placement. So there's no such thing as a Marlboro truck, but 
there was in the ``Superman'' movie, and the little creepy guys 
from ``Men in Black,'' they smoked Marlboro cigarettes.
    Those were product placements that were, in the first case, 
paid for. There were things that were--documents that were 
signed. But what that does when things are placed in media, it 
creates this halo effect.
    You associate cool characters with the product that they're 
trying to sell, and movies and media are kind of a super peer, 
and it's a life that you may not live, but it's out there and 
it's very attractive.
    So marketing and media placements are very effective at 
changing social norms and moving people towards behavioral 
willingness, which is a term we use to say when people--maybe 
they thought they weren't going to do it, but now they've seen 
it often enough or they've heard about it often enough, maybe 
now ``I will try it.''
    They try it because of the flavors or their friend giving 
it to them. Then they get hooked, and now we've got a new 
patient who is addicted to nicotine.
    Mr. Cardenas. Most of what you described in those practices 
by the tobacco industry is predigital media. What tactics do 
they seem to be using today?
    Dr. Tanski. They use a lot of similar tactics, and they 
also hire social influencers. Influencers are--we are all 
familiar with what they look like. They're the cool people and 
they use the products, and then they're basically advertising 
that product. There are supposed to be rules about them 
disclosing that, they're getting funding for talking about or 
promoting those products.
    That doesn't always happen. But that is a place where we 
know that the tobacco industry and the vaping industry has put 
some of their effort to try to get these influencers to get 
their product and the word about their products out.
    Mr. Cardenas. OK.
    Ms. Fuhrman, what types of marketing do you see or that you 
think parents are having to contend with?
    Ms. Fuhrman. Well, as I said, there's a lot of peer-to-peer 
marketing now. The influencers who used to be paid, who may 
still be paid or not, they have hundreds of thousands of views 
on their vape tricks--#vapetricks. So there's a lot of that 
peer-to-peer marketing.
    And then, you know, concerts and events, you see a lot of 
the placement there. And then, as I said before, homework 
websites or apps and games that, you know, middle schoolers are 
playing. So it's prevalent.
    Mr. Cardenas. OK. I probably would get voted out of office, 
but I don't have a problem with increasing the legal age to 25, 
26 because, back in the day, we didn't realize as human beings 
that the human brain is not fully developed until you're in 
your mid-20s. And now that we have those stats, maybe we should 
have policy follow the facts and the science.
    Mr. Myers, President Trump made some kind of claim on this 
matter. What's the status of that implementation with the 
administration when it comes to actual actions?
    Mr. Myers. Yes, on September 11th President Trump and the 
White House announced that they were going to take action 
within a few weeks to ban the sale of all flavor----
    Mr. Cardenas. So that statement was more than a few weeks 
ago?
    Mr. Myers. September 11th. We can--I will do--about 5 weeks 
ago now.
    Mr. Cardenas. OK.
    Mr. Myers. Within a few weeks of that they would announce a 
policy to ban the sale of all flavored e-cigarettes that had 
not been reviewed by the Food and Drug Administration.
    Our hope is that they will move and do that as fully and as 
completely as they said. But they haven't done it yet.
    Mr. Cardenas. So the President said in a few weeks they 
were going to come out with something, and it's been more than 
a few weeks. So it's been at least 5 weeks, and they haven't 
come out with something.
    Does anybody at the table know when they are making a 
harder claim of when that date's coming?
    Mr. Myers. We don't believe that they've announced any hard 
date.
    Mr. Cardenas. Well, I personally believe that, once again, 
we were duped by this President, because I actually ran into 
somebody in my district who said, ``Oh, the President's going 
to do something about it.'' I said, ``No, he just said 
something.''
    I personally doubt it. I hope for the best, but I 
personally doubt it that there would be follow through. Yet, we 
haven't seen that follow through.
    Ms. FuhrmanS.
    Ms. Fuhrman. One thing. The First Lady last week met with a 
group of kids from the Truth Initiative to discuss the youth 
vaping epidemic. So we are very hopeful that the First Lady and 
the President will fulfill their promise and----
    Mr. Cardenas. And she's trying to end bullying as well. 
Thank you.
    Ms. Eshoo. The gentleman yields back.
    Now I would like to recognize the gentleman from Georgia, 
the House of Representatives' only pharmacist----
    Mr. Carter. Thank you.
    Ms. Eshoo [continuing]. For 5 minutes.
    Mr. Carter. Thank you, Madam Chair, and thank all of you 
for being here. Obviously, a very important subject--something 
that we are all concerned with.
    Dr. Siegel, you mentioned in your testimony that the supply 
of e-liquids that the youth are vaping is transforming more to 
the THC products, and can you elaborate on that some and tell 
us what you see happening here?
    Dr. Siegel. Yes. So I think what's happened is that youth 
discovered that you can use THC in these devices, and once they 
discovered that it became incredibly popular because you can't 
tell that someone is using it.
    If you're smoking pot, you can smell it. You can't do that 
in the school and not get caught. But you can vape THC all you 
want. The vapor just dissipates immediately and nobody can 
tell.
    In addition----
    Mr. Carter. Are you--I never knew that. That's one of the 
most disgusting smells, is the smell of marijuana, that I can 
imagine. So thank goodness, at least we've gotten something 
done about that.
    Dr. Siegel. So, you know, because the vaping is heating the 
liquid it's not--it's not burning it. So that's why it doesn't 
create a smoke and you can't smell it.
    The other thing is that you can't look at the e-liquid and 
tell whether it's a nicotine e-liquid or a THC e-liquid. And so 
that's why this is so--becoming so popular, because it's 
discreet.
    Nobody knows what they're doing and they're able to get a 
high without actually having to risk anyone knowing that 
they're using an illicit substance.
    Mr. Carter. Unbelievable. Can I ask you, have you read this 
bill? Have you reviewed this bill that--before us today?
    Dr. Siegel. I have.
    Mr. Carter. Do you--is it your understanding that the 
proposed ban on flavored products would apply to just tobacco-
vaping products, or is it your understanding it would also 
apply to CBD and to THC products?
    Dr. Siegel. No, just nicotine-containing tobacco products.
    Mr. Carter. That's exactly right. You know, it appals me. I 
am going to do something I don't normally do, but I would like 
to ask each one of you a yes or no question, OK, just like they 
ask you.
    First of all, I will start with you, Mr. Myers. Do you 
think we had sufficient research on public safety before 
allowing flavored e-cigarette products to enter the market?
    Just yes or no. Do you think we had proper research?
    Mr. Myers. No.
    Ms. Fuhrman. No.
    Dr. Tanski. Not yet. No.
    Dr. Gardiner. No.
    Dr. Siegel. No.
    Mr. Carter. All five of you said no. And yet, here we are, 
the Federal Government, whether it be the FDA--and by the way, 
Dr. Scott Gottlieb wrote an op-ed in the Wall Street Journal 
last week about the pot legalization makes vaping deadly, about 
the--just what you were talking about, Dr. Siegel--Mr. Siegel--
about the fact that they were using THC and how this is killing 
people--killing our youth.
    And yet, here we are. In this bill--and the Federal 
Government, we don't even mention THC in this bill. We mention 
flavored tobacco, but we don't mention THC. We don't regulate 
THC. I mean, it's amazing to me, and if you can't tell, this is 
one of my pet peeves.
    I am adamantly opposed to recreational use of marijuana and 
just think it's awful. And here we have an example of where the 
inaction of the FDA, of Congress, of not reclassifying 
marijuana like we should so that research can be done on it. 
Here we have a national crisis on our hands as a result of 
that.
    Any comments?
    Dr. Siegel. I think that you make a great point, and I 
think that, as Dr. Gottlieb wrote in that op-ed, we need to 
reclassify marijuana so that it can be regulated and so that we 
can prevent these tragic deaths from occurring.
    I think part of the problem is that everyone is talking 
about e-cigarettes--nicotine e-cigarettes--and because of that, 
kids have completely lost sight of the fact that the THC 
cartridges are the ones that are causing the deaths, and 
because of that the public's perception is completely wrong.
    If you ask the public in surveys, they say that they think 
this is due to nicotine e-cigarettes, not THC. Very few 
understand that THC is even involved. I think our 
communications have to be a lot more specific and, rather than 
THC vaping being the kind of elephant in the room that nobody 
is talking about, I think we have to directly address that 
problem.
    Mr. Carter. Anyone else want to comment on that?
    Mr. Myer.
    Mr. Myers. I just think it's important to recognize we have 
two separate issues. We have an e-cigarette youth epidemic----
    Mr. Carter. And I am not denying that.
    Mr. Myers [continuing]. And everybody, I think, agrees that 
we need to do something about that issue. The THC issue and the 
lung deaths bring greater urgency to have as few kids using any 
of these products as possible, whatever their link is.
    Mr. Carter. And I understand that. It just amazes me that 
we in Congress continue to ignore the fact that we need to 
reclassify marijuana--that Federal law says that it is against 
the law, and States are approving it. Amazing.
    Ms. Eshoo. The gentleman's time is expired.
    Mr. Carter. I yield back.
    Ms. Eshoo. I think it's important to restate again that THC 
is prohibited by the Federal Government. It's not just out 
there floating around that we need to get our arms around. It 
already is a prohibited substance so----
    Mr. Carter. It is prohibited, but there are States that are 
legalizing it.
    Ms. Eshoo. Well, I said earlier before you came back into 
the room that we need enforcement of the laws that we have on 
the books when it comes to THC.
    But I think that it is a conflation to keep referring to it 
as if it's the newest shiny object that we have to go after. I 
think we need to in terms of enforcement.
    But we have an epidemic on our hands, and people are dying. 
So I appreciate the gentleman's questioning and his 
participation today.
    I now would like to recognize Dr. Ruiz from the Golden 
State of our Nation, California.
    Mr. Ruiz. Thank you, Madam Chair.
    As a physician, I am all too familiar with the devastation 
caused by addiction to nicotine. I've seen firsthand a health 
decline in individuals who tried tobacco as teenagers, got 
addicted, and never quit.
    And there's also reports in the Emergency Department--I am 
an emergency physician--of new cases of cardiac pediatric 
arrhythmias caused by nicotine overdose in much higher 
frequency than before.
    While in recent years smoking cigarettes among teens has 
continued to decline to the lowest level in decades, on the 
other hand, vaping rates have skyrocketed. OK.
    In fact, according to a 2016 report by the Surgeon General, 
there was a 900 percent increase in teens vaping from 2011 to 
2015--900 percent increase.
    Part of the problem is that many teens and adults think 
that vaping is harmless, or because the vaping industry want to 
take addicted cigarette smokers to become addicted vaping 
smokers, basically increasing their profit share, then people 
think that it's not as bad, right, and therefore it's safer--
i.e., safe to smoke, and I've spoken about this before.
    But perhaps it may be slightly safer. It is certainly not 
good for you to smoke, and it can still injure your lungs. It 
can still cause cancer. There are carcinogens in vaping 
products that can cause cancer, period.
    You know, there's research done on many different types of 
plant-based kind of properties, and some may have some 
therapeutic properties, right. There has been research on 
cannabis, and maybe there's some benefit, medically speaking. 
But there's no benefit for nicotine.
    I haven't found that research yet to say that nicotine is 
good for any particular ailment, and it's definitely addictive. 
It's addictive.
    So it's devastating that so many young people and many of 
their parents are operating under an assumption, oh, that these 
products are harmless when, clearly, there are significant 
health risks that we know about as well as many that we still 
yet don't know about, OK, and it is our job to weigh the 
potential benefits of vaping for people trying to quit nicotine 
use against the cost, particularly as more teens are using and 
getting addicted to these harmful products.
    So, as we tackle this issue, we need to do everything in 
our power to decrease access to these products to underage 
teens. And, while it is certainly common for high school 
students to get vaping and tobacco products from their friends, 
many are buying them directly.
    So we need to get tough on those who are selling to 
underage teens. Clearly, the current punishment isn't enough to 
stop retailers from selling to kids. So that means we need to 
increase the penalties, and I am working on legislation that 
would require the FDA to issue a fine for the first offense.
    Right now it's just a slap-on-the-hand letter that you get, 
and then for the fines that are already in place, we are 
doubling them, and my bill will also require the CDC to conduct 
much-needed research on the long-term effects of vaping.
    So if e-cigarettes can be used in specific, narrow cases as 
a tool to help smokers quit combustible cigarettes--quit 
nicotine, period--it makes sense that we should ensure there is 
perhaps some safe pathways for smokers to use these devices to 
end their addiction to nicotine, not transfer the product for 
their addiction.
    So, like other policies that affect public health, we must 
let the science be our guide. The first question I think we 
need to answer is, do e-cigarettes really actually work as a 
safe tool to encourage smoking and nicotine use cessation?
    I will start with you, Mr. Myers.
    Mr. Myers. The answer is the evidence is weak on that 
point. More than 60 percent of all e-cigarette adult users also 
continue to smoke cigarettes, and they don't reduce their risk 
of disease at all.
    Mr. Ruiz. In those cases, had there been any literature 
showing that e-cigarettes can be better than a nicotine patch 
or the nicotine gums for actually ending the use of nicotine?
    Mr. Myers. There are one or two studies. There are also a 
number of studies that many e-cigarettes actually decrease your 
likelihood of success.
    The failure of any e-cigarette manufacturer to submit 
evidence to the FDA to be objectively evaluated is why we don't 
know the answer and why, frankly, the failure of FDA to act is 
hurting smokers as well as kids.
    Mr. Ruiz. I've run out of time.
    Ms. Eshoo. The gentleman yields back.
    Pleasure to recognize the gentleman from Montana, Mr. 
Gianforte.
    Mr. Gianforte. Thank you, Madam Chair, and thank you to all 
the witnesses for being here today.
    This is a very important topic that's getting an awful lot 
of attention. I hear about it back home all the time.
    The bill before this committee is supposed to deal with the 
ongoing public health concerns about vaping, particularly among 
children, and I am pleased that there's bipartisan agreement on 
this committee that we don't want children vaping or smoking.
    There's also bipartisan agreement on this committee that we 
don't want vapers harmed by dangerous or adulterated substances 
sold on the black market.
    The proposed legislation we consider today, however, goes 
beyond what has been a bipartisan agreement on this committee.
    Those bipartisan measures included raising the legal age 
for tobacco use to 21, addressing online sales--to prohibit 
them--and ensuring a known and evaluated product is on sale. We 
agree on that.
    Small business owners I talk to back in Montana have told 
me they're fine with raising the legal age to 21. They 
supported a similar measure before our State legislature just 
this year.
    What concerns them is the effort to ban flavors. We've seen 
efforts in a handful of places, including Los Angeles, New 
York, and even Montana, to ban flavors.
    Shop owners I have talked to worry that, even though 
they're selling products from a known and evaluated supply 
chain, they'll be put out of business.
    Furthermore, I worry that efforts to ban flavors will lead 
to stronger illegal markets with unhealthy, unregulated 
products--exactly what we aim to avoid in the first place.
    There's a balance we have to strike here as we responsibly 
promote public health. I want to get the answers, and I want to 
hear from the experts, and I want to rely on sound science to 
make these decisions.
    We were getting there with our bipartisan work and, 
personally, I think we should get back to that bipartisan work 
where we have agreement. I would like to direct my first 
question to Dr. Siegel.
    What evidence is there of cadmium and other heavy metals 
being involved in the cases of severe vaping-related lung 
injuries?
    Dr. Siegel. Right now there is none. The most likely cause 
of this outbreak is tainted THC cartridges that have been laced 
with Vitamin E acetate, which is a new thickening agent that 
just started to be used by the black-market producers late last 
year. And either the oil itself or something in it is what's 
likely causing this outbreak.
    Mr. Gianforte. So--and are these products available in 
shops that are down on Main Street?
    Dr. Siegel. No. These are black-market products that can 
only be obtained through illegal sources.
    Mr. Gianforte. So you believe the challenges we've seen 
with the cases that have been reported are not from legitimate 
products that have been provided through a legal supply chain?
    Dr. Siegel. I think there is absolutely no evidence that 
that's the case. I think that these are coming from the black 
market. They are counterfeit, bootleg, illicit products that 
are causing this, not products that are sold in retail stores.
    Mr. Gianforte. OK. So what--I heard some of your testimony 
earlier, but just to put a bow on it, Dr. Siegel, what advice 
would you have for this committee on ways to improve the 
legislation we have in front of us?
    Dr. Siegel. Well, I think that banning the flavors--I think 
every aspect of the legislation is reasonable except for 
banning the flavors.
    I think you need to consider what's going to happen if you 
ban e-cigarette flavors. The first thing that's going to happen 
is you're going to be putting 16,000 small businesses out of 
business. You have got to consider that effect.
    The second thing that's going to happen is you're going to 
be having--forcing 2 million ex-smokers who have already quit 
smoking using these products to go back to--either go back to 
smoking, which is a disaster, or to turn to an illicit black 
market, which is also a disaster.
    And the third thing you're doing is you are causing more 
youth to turn to THC products. Those are the only ones that are 
going to be available, and you are actually increasing the risk 
of more cases of this outbreak.
    But you're doing nothing to actually address respiratory 
disease that is occurring. You're doing nothing to prevent 
deaths. You're just putting a lot of people out of business and 
forcing a lot of ex-smokers to go back to smoking.
    Mr. Gianforte. OK, and thank you for that.
    And, Madam Chair, I would just encourage this whole 
committee, let's get the facts and make decisions based on 
public health.
    And with that, I yield back.
    Dr. Tanski. May I make a comment in the last couple 
seconds?
    Oh, sorry.
    So one of the things that you mentioned is that we need 
known and evaluated e-cigarettes, and flavors have not been 
proven safe, and I think that's something that we need to 
really wrap our hands around.
    Many of the flavors are known to be--to cause harm and 
cause tissue damage and direct tissue damage to the lung, and 
we have young people who are inhaling them directly into their 
lungs over and over again every day, and we don't know what the 
effects are.
    So known and evaluated is not actually true, and tobacco 
flavor is still available, yes.
    Ms. Eshoo. Thank you. The gentleman has yielded back.
    I now would like to recognize the gentlewoman from 
Illinois, Ms. Kelly, for her 5 minutes of questioning.
    Ms. Kelly. Thank you, Madam Chair, and thank all of you for 
your testimony today.
    In addition to my role in this committee, I am also chair 
of the Congressional Black Caucus Health Braintrust. Because of 
this, I am invested in working to improve the health of all 
communities and reducing health disparities, especially for 
vulnerable and minority populations.
    Dr. Gardiner, in your testimony you mentioned the impact of 
predatory marketing and how it disproportionately impacts 
minority communities. We know that the majority of African-
American smokers are using menthol products.
    Not only is the youth tobacco epidemic a crisis, but 
predatory practices have led to severe disparities in health 
outcomes, including increased rates of various morbidities such 
as lung cancer and heart attacks among minority populations.
    Can you expand upon the extent of these disparities and its 
impact on communities of color?
    Dr. Gardiner. Thank you very much for the question.
    The impact is actually larger than just the statistics 
show. We are talking about kids losing parents at an early age 
in a poor community that doesn't necessarily have healthcare.
    So you have to look at--when we talk about unintended 
consequences, the unintended consequences of the tobacco 
epidemic in the African-American community, frankly, has been 
somewhat overwhelming and has been going on for years.
    I want to encourage this committee. The last question about 
the black market occurring there--in the 26 cities where this 
has been done, there's no black market that has occurred.
    And in terms of these folks going out of business, a great 
study was done--we should share it with the committee--that was 
done in Minneapolis where--what was the impact? Not one person 
went out of business. Their sales went down--this is true--but 
they didn't go out of business.
    So all this discussion about we need to get the science 
right and we need to get this right, I want to encourage that.
    But I appreciate your question because we know the facts 
disproportionately affect Black people. When you look behind 
it, kids are losing parents at an early age. This is leading to 
folks going to jail for other--the impact is overwhelming, 
frankly.
    Ms. Kelly. And I know the top 10 diseases that Americans 
die from, African-Americans are number one, I believe, in eight 
of the----
    Dr. Gardiner. Eight of the 10. Right.
    Ms. Kelly. Eight of the 10 diseases.
    This is personal for me, too, because my son was a smoker 
and he vapes. But he's not a kid. He's 35 years old. So we go 
back and forth with him, and it has helped him, you know, stop 
smoking. Even I bug him every day, every time I hear of 
something going on.
    But he differentiates between what he does and what he 
believes these young folks are dying from or their throats are 
being messed up, from what he uses. But I still don't get what 
he's--I don't have the argument back for him.
    Dr. Gardiner. The distinction that is trying to be made is 
that vaping heats the oil or heats the something and--while 
smoking a cigarette or smoking a joint burns it. and you're 
going to have different chemical reactions. My suggestion to 
the committee: They both have a specific chemical footprint, 
and that footprint is different, and that does not necessarily 
mean that one is healthier than the other.
    There is still science to be done. I want to encourage if 
we are going to really look into the science to look into when 
you--you said it best--when you inhale flavors over a long 
period of time, what is that going to mean for your lungs?
    And then the latest data out on the deaths is not so much 
the concentrated juice. There's actually the scarring that's 
been identified in the lung, and that--now, that be other 
causes.
    And one thing we know is that flavors are aldehydes, and 
aldehydes are irritants, and that may be leading to the 
scarring. So----
    Ms. Kelly. And I don't think he uses flavors but--and, you 
know, he says to me, ``Do you want me to go back to smoking?,'' 
and I said, ``No, but you want to slow down----''
    Dr. Gardiner. Do you know--do you know he doesn't use 
flavors?
    Ms. Kelly. Yes, I don't--yes, because he's done it at my 
house, so I should be able to smell it, right? Or no?
    Dr. Gardiner. No.
    [Laughter.]
    Ms. Kelly. I can't? Oh.
    Mr. Myers. One of the--one of the diabolical----
    Ms. Kelly. I mean, he's not going to lie. He doesn't have 
to lie to me.
    Mr. Myers. One of the diabolical genius parts about this is 
they've created a mechanism so that you can't smell it on their 
breath or on their clothes, which is why kids are able to do it 
in school and not get caught. I mean, it is really troubling.
    You know, the other issue we don't talk about with menthol 
that is really important is that menthol is a starter product 
for kids all across the country.
    More than 50 percent of kids who become addicted to 
cigarette smoking start using menthol products. So if we care 
about kids all across the board, that's part of the issue.
    Ms. Kelly. Thank you.
    Ms. Eshoo. The gentlewoman yields back.
    I now would like to recognize the gentleman from Florida, 
Mr. Bilirakis, for his 5 minutes.
    Mr. Bilirakis. Thank you, Madam Chair. I appreciate it. I 
really appreciate you holding this hearing. It's so very 
important and timely, and of course, we have to get it right.
    But let me be clear: Under no circumstances should youth 
have access to tobacco products, period. That's the way I feel, 
and I think most people feel the same way.
    So, while this committee and the FDA are working to address 
the real epidemic of youth use of tobacco products and lung 
injuries linked to illicit black-market vaping products, we 
should also be sure we are not creating unintended consequences 
that will lead to a future public health crisis or exacerbate 
the current one.
    I remain committed, of course, to working with the Chair 
and all my committee members on both sides of the aisle.
    Dr. Siegel, CDC recently highlighted data showing that 
cigarette smoking has fallen to historic lows. That's been 
mentioned in this committee.
    This is a positive advancement for public health, and we 
should be providing current adult smokers with more tools. Not 
necessarily e-cigarettes but, you know, that's why we are 
having this hearing--to get the facts from the experts.
    So, but we don't--we want to provide them more tools if 
they're less harmful to quit and transition to low-risk 
products.
    Congress is no stranger to unintended consequences, 
unfortunately. Could this bill make it harder for current adult 
users of traditional combustible tobacco products to transition 
to a modified-risk tobacco product?
    And then let me ask--first of all, can you answer that 
question, please, sir?
    Dr. Siegel. Yes. This bill, if enacted as it is with the 
flavored e-cigarette ban, is going to wreak havoc with smokers. 
It's going to make it incredibly difficult for them to quit 
smoking by using flavored e-liquids, and it's also going to 
force many ex-smokers who have already quit to go back to 
smoking.
    We know that e-cigarettes are the most effective smoking 
cessation tool using nicotine. They outperform nicotine patches 
by double.
    So the New England Journal of Medicine published a clinical 
trial--published earlier this year--which showed that switching 
to vaping e-cigarettes is twice as effective as a nicotine 
patch in helping smokers quit.
    So this is currently the best option we have for smokers to 
quit. Two million of them have quit using flavored e-
cigarettes. Why would we want to take that away from them?
    Mr. Bilirakis. Yes, but we don't want--yes, I agree with 
that. But, again, I don't want my kids or, you know, youth 
vaping.
    I understand, and we heard it today--I've heard it several 
times over the last few years that, what is it, the nicotine--
the amount of nicotine is equivalent to--in one e-cigarette or 
JUUL, what have you--a pack of cigarettes. I mean, that's 
terrible, and then our kids are being addicted, and I just 
don't see--I think that there's going to be a rise in the 
future, and we've got to do something about it.
    But I want to do the right thing. I don't want to just pass 
a bill and then--and have the unintended consequences or pass a 
bill and we pat ourselves on the back and say we've solved the 
problem when we really didn't.
    So Dr. Siegel, with recent reports of patients, especially 
youth, being hospitalized with lung injuries associated with 
vaping illicit black-market THC and flavored nicotine home 
brews, does this bill address this public health concern?
    And I think I know the answer to that. You have testified. 
But if you want to elaborate, that would be good.
    Dr. Siegel. It doesn't. It doesn't. This is going to outlaw 
the legal sale by retail stores of electronic cigarettes--of 
flavored products. These are not the products that are causing 
the terrible deaths and severe respiratory failure that we are 
seeing.
    And, in my opinion, it's actually going to make the problem 
worse because I think when youth are no longer--no longer have 
access to flavored e-liquids, what the suppliers are going to 
start supplying is going to be THC because that's what they can 
get their hands on.
    Mr. Bilirakis. OK. Well, thank you very much, and I look 
forward to working with you all.
    I yield back, Madam Chair.
    Ms. Eshoo. The gentleman yields back.
    Dr. Siegel, I would like to ask you a quick question. Are 
you representing the Public Health School at Boston University 
in your testimony today?
    Dr. Siegel. Well, I am a professor at Boston University.
    Ms. Eshoo. I know you are. But are you representing the 
Public Health School?
    Dr. Siegel. Well, when professors----
    Ms. Eshoo. Are you here as an individual?
    Dr. Siegel. No. I mean, when professors speak they're not 
representing the school they come from. They're representing 
their own opinions.
    Ms. Eshoo. Oh, OK. Well, that's important for Members to 
understand. Thank you.
    Now I would like to recognize Ms. Barragan from California 
for her 5 minutes of questioning.
    Ms. Barragan. Thank you. Thank you, Madam Chair.
    Dr. Siegel, you said something earlier that was to the 
effect that flavors are not the problem. Is that accurate? Is 
that accurate testimony?
    Dr. Siegel. Specifically what I said is flavors aren't 
causing the harm.
    Ms. Barragan. OK. So I just wanted to clarify----
    Dr. Siegel. It's not that they're not a problem. I mean, 
they're--you know, of course they're the problem.
    Ms. Barragan. OK. OK. I have a question that's going to 
follow. So I think the issue here is, do you believe that 
flavors are hooking children so that they then become dependent 
on nicotine? Do you believe the flavor hooks them?
    Dr. Siegel. No.
    Ms. Barragan. You don't?
    Dr. Siegel. I think it's the nicotine.
    Ms. Barragan. Do you think that the flavor attracts our 
young people to then vape?
    Dr. Siegel. Of course.
    Ms. Barragan. OK. So there--so at least you admit that 
there is some attraction, that the flavor is what gets them 
started?
    Dr. Siegel. The flavor--I mean, first of all, you have to 
understand there is no such thing as a nonflavored e-cigarette. 
There is no such thing.
    Ms. Barragan. OK. So it's--let's talk about the fruity 
flavors. Do you think that kids see the fruity flavors and, 
because of that they say, ``I am going to vape''?
    Dr. Siegel. Yes, I think that makes it attractive. 
Absolutely.
    Ms. Barragan. OK. So I just want to make sure we are on the 
same page because you kind of sounded like ``Well, the flavors 
aren't a problem, why are we going to get rid of them?''
    Yet, we know the Surgeon General in 2015 actually warned 
that tobacco companies were known to use fruity flavors to hook 
children.
    And there was a survey that was done by the FDA and the 
National Institutes of Health of young people and they asked 
them why they did it. More than 80 percent of the children 
marked the answer that says ``It comes in flavors I like.''
    So I think that, for me, at least, it's clarified because 
it was sounding to me like you didn't make a connection at all 
on why there would even be a discussion about why we wouldn't 
have the flavors anymore.
    I also was a little shocked when I was doing some of the 
research to see that the FDA actually warned about this problem 
and this issue in 2015, and they drafted a ban. So you had made 
some--you had provided some testimony that the FDA has to come 
up with regulations.
    Well, in 2015 the FDA actually came up with a draft ban on 
the flavors. What ensued after that draft ban was more than a 
hundred tobacco industry lobbyists and small business advocates 
met with the White House over the course of 46 days, and when 
you took a look at the number of health--public health 
advocates, it was, like, 7. And it's pretty remarkable then to 
see when the actual rule came out, the ban on flavors was gone.
    So this isn't the first time the FDA has looked at it, and 
then we have seen some result. Unfortunately, that it got 
stripped out and we know the power of advocates and lobbyists 
and the industry. You don't have to look too far than the 
tobacco industry.
    Mr. Gardiner, you--Dr. Gardiner--you brought up an issue 
that's very near and dear to me. I represent a district that 
includes Compton and Watts--it's a district that's almost 88 
percent Latino and African-American--and many of my colleagues 
have talked about it already, is the use of menthol cigarettes.
    And we've already spoken a lot about it. But do you have 
any idea what the impact on smoking rates for children of color 
might be if the menthol ban from this legislation goes into 
effect?
    Dr. Gardiner. We actually do. There's some great research 
done at the--in 2011 by Levi and Company that shows that, if 
just 30 percent of the people that are using these cigarettes--
just 30 percent, not many more--if 30 percent of the people 
stopped using these cigarettes, half a million lives would be 
saved, and as it relates to African Americans, over a quarter 
million of lives would be saved. I think that says it all. I 
can't say it any better.
    Ms. Barragan. Great. Thank you, Doctor.
    Dr. Gardiner. Can I say something about the----
    Ms. Barragan. Sure. Please do.
    Dr. Gardiner [continuing]. The menthol--the flavor? In 
2016, it was the deeming regulations were put forward by the 
FDA, bringing all the products under their roof. There were 19 
pages on flavors and why flavors should be restricted, and 
menthol was part of that.
    Those--maybe it was 16 pages, or 19 pages--they were all 
redlined by the Office on Management and Budget. That's why the 
deeming regulations--so they tried.
    Ms. Barragan. Right.
    Dr. Gardiner. So there's been some tries. So we have--this 
is another shot at--another bite at the apple, as we----
    Ms. Barragan. Great. Thank you.
    Mr. Myers, with about 10 seconds left, I was pretty 
outraged to hear about the advertising on our youth. What 
impact would this legislation have on advertising for vaping 
products and e-cigarettes?
    Mr. Myers. It would have a dramatic impact, and it would 
curtail much of the kind of advertising that the industry has 
used to make these products so appealing and so attractive to 
youth and made them undo the denormalization we did with 
cigarette smoking.
    Ms. Barragan. Great. Thank you. I yield back.
    Ms. Eshoo. The gentlewoman yields back.
    Mr. Rush of Illinois is now recognized for his 5 minutes of 
questions.
    Mr. Rush. I want to thank you, Madam Chairman, and to all 
the witnesses it's been a very informative hearing that we've 
had today.
    Dr. Gardiner, I am just kind of astounded by some of your 
conclusions. I think that you're right on point, and there is a 
familiar saying--you might have heard it--that when the White 
community gets a cold, the Black community gets pneumonia, and 
I've found that to be relatively true.
    And I understand the whole issue about menthol-flavored 
cigarettes and how they have adversely affected the African-
American community.
    Now, the marketing has been predatory in relation to the 
African-American community. But maybe I am old school. I just 
have not seen the issue of vaping to be as widespread or to be 
one of the alarm factors as it relates to the African-American 
youth.
    That's not to say that it doesn't exist. I just have not 
seen it rise up in my district, which is minority African-
American.
    When you consider that most of the issues in my district 
center around gun violence, that vaping is not really--it is 
not really moved to the forefront.
    But because I am ignorant of it, I ask will you to kind of 
explain to me what is the state of the preponderance of 
incidence of vaping that's occurring in my district and other 
districts?
    Dr. Gardiner. It's a great question. It's right on--it's 
right on point. I like to look at it this way. In the Black 
community, folks are doing marijuana. Folks are doing little 
cigars and cigarillos, and smokers are smoking menthol 
cigarettes.
    But just like what happened with the skateboarding--
remember, 40 years ago Black folks weren't doing no 
skateboards. Today, they skateboard. OK. So this is happening 
as we speak here.
    This comes up all the time, because I travel around the 
country, and you ask--you go to the high school, kids are doing 
it and kids are then doing it with their little cigars, too.
    So it's happening. The data right now shows that it's less 
than in White communities. Like the cold and pneumonia thing, 
that's correct.
    But that is changing. I love the skateboard analogy. We 
have--unfortunately, we have anecdotal evidence from Arkansas, 
from Georgia, and parts of Florida where there are 
concentrations of Blacks, particularly in Georgia around some 
of the HBCUs, where there's some disproportionately high rates 
of e-cigarette use.
    Things are changing. I think this bill would help to maybe 
nip that in the bud. Excellent question. Excellent.
    Mr. Rush. [Inaudible.]
    Ms. Eshoo. The gentleman yields back.
    Mr. Rush. All my questions have been asked and answered 
already. So I do yield back.
    Ms. Eshoo. I now recognize the gentlewoman from Illinois, 
Ms. Schakowsky, for 5 minutes of questioning.
    Ms. Schakowsky. As always, I thank the chairwoman for 
allowing me to participate in this hearing. Though I am not a 
member of this subcommittee, I am very concerned about this.
    It appears that at least the first reported death was from 
my State of Illinois, and subsequently we are talking about 
1,300 people hospitalized and 26 deaths because of e-
cigarettes, and sometimes cause not exactly known.
    And we know that last year almost 5 million middle and high 
school students indicated that they were using some form of 
cigarettes, including e-cigarettes, and I think that number is 
on the rise. I think Dr. Gardiner could talk to us about that.
    But I wanted to focus right at this moment on Ms. Fuhrman, 
and I want to thank you for your very personal testimony and 
your personal experience and the willingness that you have to 
share it.
    If you could talk to JUUL's CEO right now or the CEO of any 
of the other e-cigarettes brands, what would you tell them 
about the impact of their product on your family and so many 
others?
    Ms. Fuhrman. I would--you know, the impact is devastating. 
It was difficult on our family. However, there are so many 
families across America who are experiencing so much worse.
    Not even mentioning the lung illness, which is a cause and, 
you know, comes out of this, there are families who are dealing 
with kids who are so severely addicted they have explosive 
anger issues.
    They're breaking things. They're throwing things. They're 
getting kicked out of school. They're losing scholarships. 
They're being kicked off the sports team. I mean, it's a huge 
issue, and there is no--as Dr. Tanski said, there is no FDA-
approved cessation method.
    So, even if you take these flavors away--and I do want to 
add that we are leaving tobacco flavor, the bill leaves tobacco 
flavor on the market. So as Dr. Siegel said, smokers who are 
using flavors don't have to go to the black market. They can 
use their tobacco vape.
    It's not like we are banning these vapes. But something 
really has to be done, and the flavors--taking those off the 
market is the first step.
    Ms. Schakowsky. Thank you.
    Mr. Myers, as chair of the Subcommittee on Consumer 
Protection and Commerce, I am very focused on leveraging the 
Federal Trade Commission's authority to protect consumers from 
deceptive business practices.
    How do you believe the FTC could better investigate Big 
Vape and Big Tobacco?
    Mr. Myers. I think the FTC's Division of Advertising 
Practices could do much more. There is no question that the 
manner in which these products are being marketed is misleading 
kids into believing that these products are much safer than 
they are and, in many cases, safe.
    They're also misleading kids into believing that they don't 
have nicotine, with regard to that. So that if the FTC uses its 
authority over false and deceptive advertising, I think it 
could do--be much more aggressive in preventing these companies 
from misleading our youth. It's what they did with tobacco 30 
years ago. They need to be at least as vigilant, if not more 
so.
    Ms. Schakowsky. Thank you.
    Dr. Gardiner, the e-cigarettes initially were ``quit 
smoking tobacco, and this will--this will be a help.'' But I 
what I want to know, are we actually developing more smokers by 
creating a nicotine addiction and making it all right?
    I mean, I worry that these young people who may be vaping 
now for the rest of their lives may be smoking tobacco 
cigarettes.
    Dr. Gardiner. That's an excellent question. I think it goes 
something like this: There are more people getting on the on 
ramp than are getting off the off ramp, and that is a problem 
that we are facing with the electronic cigarette situation 
here.
    Let me just say something about the cessation thing. It's 
true the New England Journal of Medicine published a great 
article that showed that using e-cigarettes allows people to 
quit. That's true.
    There's been somewhere in the neighborhood of about 35 of 
these type of studies done. Somewhere in the neighborhood of 27 
have shown that they don't really work that well.
    There's some that work, and think of it this way. If you 
regulated the nicotine in it, if you got rid of the flavors, if 
you decreased the dose, if you couldn't buy it over the line, 
if there weren't 15,000 flavors available, too, then maybe it 
could actually serve as a cessation device.
    Right now it's like--it's like a candy bar, OK, and you can 
buy it in any number of different flavors. So, as it's 
currently done, I think we have a problem. More people are 
getting on than they are getting off.
    Dr. Siegel. Can I--can I just say, I think since you 
mentioned the 37 other studies, I think it's only fair if you 
tell the congresswoman how many of those 37 studies were 
clinical trials.
    Ms. Schakowsky. My time has expired, and so I yield back. 
Thank you.
    Ms. Eshoo. Thank you, and thank you for joining us. Ms. 
Schakowsky, thank you for joining us, and the excellent 
questions.
    What I would like to do now is to thank each one of the 
witnesses on behalf of all of the members of the subcommittee.
    We've been, let's see, 3 hours--3 hours. So thank you for 
your patience. Thank you for the substance and the content of 
your testimony.
    This is a real challenge for our country, and these are 
issues that really an individual can't address all by 
themselves. This really calls out--I think it cries out for 
strong public Federal policy, and that's what the American 
people deserve.
    We know how we made progress relative to tobacco and 
addiction, and now we are right back to addiction again. So I 
think that we have a roadmap that we can follow.
    And I look forward to working with all the members of the 
subcommittee and, again, I thank you for--you know, for being 
with us today, and the work that brought you to the table. It 
is--it's nothing short of extraordinary.
    I would like to place in the record the following 
documents: a letter of support from the American Dental 
Association, coalition letter from the Campaign for Tobacco-
Free Kids, et al., a letter of support from the National 
Medical Association, letter of support from the National 
Association of County and City Health Officials, statement of 
support from the American Cancer Society and Cancer Action 
Network, statement of support from CVS Health, and a statement 
of support from the American Osteopathic Association.
    So I would like to ask for unanimous consent.
    Mr. Burgess. Without objection.
    Ms. Eshoo. I thank the ranking member.
    [The information appears at the conclusion of the hearing.]
    Ms. Eshoo. And with that----
    Mr. Burgess. Madam, may I be recognized for a unanimous 
consent request?
    Ms. Eshoo. Certainly.
    Mr. Burgess. So I have unanimous consent to put into the 
record a letter from the Texas Food and Fuel Association, and I 
would also like to submit for the record the data I had on the 
taxes collected by the Center for Tobacco.
    Ms. Eshoo. So ordered.
    [The information appears at the conclusion of the hearing.]
    Ms. Eshoo. I want to remind Members that, pursuant to the 
committee rules, they have 10 business days to submit 
additional questions for the record to be answered by the 
witnesses who have appeared today, and I ask each witness to 
respond promptly to any such questions that you may receive.
    So, at this time, with gratitude again to the witnesses, 
the audience that stayed for the duration of this important 
lengthy hearing, this subcommittee is now adjourned.
    [Whereupon, at 1:37 p.m., the committee was adjourned.]
    [Material submitted for inclusion in the record follows:]

                 Prepared Statement of Hon. Greg Walden

    Chairwoman Eshoo, thank you for holding today's legislative 
hearing on the Reversing the Youth Tobacco Epidemic Act. As I 
have stated previously, the use of e-cigarettes by minors is an 
epidemic that is impacting thousands of families across the 
United States. I am glad that this committee and the Trump 
administration are working to find solutions that will curtail 
youth access to these products.
    The upward trend in adolescent use of e-cigarettes in just 
the past 3 years is alarming. The 2018 National Youth Tobacco 
Survey showed that about 20.8 percent of youth reported using 
e-cigarettes. This is a big jump from 11.3 percent reporting 
use just 3 years ago. This trend is playing out in States 
across the country. In my home State of Oregon, a recent county 
health survey of 11th graders in Deschutes County found that 
the number of students vaping increased from 19 percent in 2016 
to 29 percent in 2018.
    The use of these products by children is particularly 
troubling since we know that most e-cigarettes contain 
nicotine--an addictive substance that the CDC has warned may 
harm brain development and increase risk for future addiction 
to other drugs. Some recent studies have also found that those 
adolescents who use e-cigarettes are more likely to try regular 
cigarettes than children who have not used e-cigarettes 
previously.
    While I look forward to working together in a bipartisan 
manner to address the issue of youth access to e-cigarettes, I 
want to express my disappointment that representatives from the 
Food and Drug Administration (FDA) are not here to testify 
today. I understand that the Majority feels that the Agency's 
participation in today's hearing is not necessary given their 
testimony last month at the Oversight Subcommittee hearing. 
That hearing, however, was not intended to address and receive 
feedback on the various provisions in the legislation before us 
today. Very few, if any, questions were directed to the FDA 
about the legislation before us today. Moreover, much of the 
testimony at last month's hearing was related to the ongoing 
epidemic of vaping-related illnesses. It doesn't appear that 
anything in the legislation we are considering today will help 
prevent vaping-related illnesses like those that have been 
reported.
    I appreciate that staff was able to verbally receive FDA's 
comments on the bill last night. The Agency is actively working 
to provide thorough feedback on this legislation and stated 
that additional written technical assistance would be 
forthcoming to address some of the more complex aspects of the 
bill. It is important that we receive this written feedback 
before moving forward to ensure the committee is taking actions 
that will curb youth access and use, promote the continued 
cessation of smoking by adults, and will not lead to unintended 
consequences.
    I also want to make sure in our conversations about the 
youth vaping epidemic, we draw distinctions between the factors 
that may be contributing to youth access and use of e-
cigarettes and those factors that have been causing the recent 
outbreak in vaping-associated lung illnesses. While no 
definitive cause has been established at this time, most of the 
reported illnesses appear to be linked to counterfeit products, 
containing THC, and purchased on the black market. Some of 
these black-market products have been found to contain 
contaminants including pesticides and others that, when heated, 
produce gases that can directly injure the lungs. For this 
reason, I want to echo my earlier request for a full 
investigation into counterfeit THC cartridges, as well as the 
vaping and cannabis black markets.
    Again, I thank the chairwoman for holding a hearing on this 
important topic and I yield back.

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]


                                 [all]