Good morning, everyone. This is the Senate Health and Welfare Committee meeting. It is February 17th and today we're looking at S24, a bill that would eliminate flavors for tobacco and e-cigarette products in the state. And we have a long list of folks who are waiting to testify. So I just want to set some ground rules up front so we don't run into the time crunch. We do have a hard stop at a little before 1130, so I'm going to try and make it 1125, no later than. And we will, as much as possible, I'm going to ask the committee to hold questions until after each person has testified. If you have a real problem and need some understanding, then maybe we can stop folks in the middle, but just trying to keep things moving along. I think the testimony is pretty clear. So Senator Cummings may or may not be able to join us this morning, but so we'll, we'll wait and see if and when she shows up. And that's it. So this morning I would like to welcome you all who are here to testify. It's good to see you. And it is like deja vu all over again for me at least. And so we'll start out with Mike Rolo of the American Cancer Society and welcome. Please, each of you on the call. The members of the committee who are here are me, Senator Ginny Lyons, Senator Cheryl Hooker, Senator Joshua Taranzini, and Senator Ruth Hardy. And so that will I hope serve as introductions for us in the beginning. So welcome, Mike. And why don't you just go right ahead, introduce yourself for the record and offer us your testimony. Thank you, Senator Lyons. For the record, my name is Mike Rolo. I'm the director of government relations for the American Cancer Society Cancer Action Network here in Vermont. I've noticed I'm not Jennifer Costa used to represent the cancer society, who you probably are all familiar with, but Jennifer has left to go work for another very great cause to the Red Cross and so here I am. And I'm honored to be here this morning. Let me share my screen here I do. There we go. All right. So, thank you very much for having me this morning. My presentation isn't all that long and I do apologize if you see a child run by. We do not accept apologies for that. We're remote learning still here so we're entering almost the 12th month so it's no need to apologize. Well, thank you for that now. We're so as I said, ACS can is in full support of Senate bill 24 we thank the sponsor and co sponsors for bringing it forward again. And we support this legislation to ban all flavor tobacco products with no exemptions. All flavors include mint and mental, and we'll get into a bit as to why towards the end why mental in particular needs to be included. Although my colleague from the Heart Association, Tina's going to go into more detail about mental, and there's a few other experts towards the middle of the presentation that will go through that as well. But when we talk about all products we're talking about e cigarettes and all their different iterations, whether they're e cigars e hookahs, e cigarettes, if you name it there's an e in front of these days and so it includes those. As I said, menthol cigarettes, and then this very long list of things that are just known as other tobacco products that could be snooze it could be dip it could be chewing tobacco could be cigars it could be pipe tobacco. If you can imagine it the tobacco industry has pretty much created it and put a flavor on it so those products would be included as well. So why now. And the simple answer it well maybe not so simple for some folks but is that flavor tobacco is erasing years of games that you have all made here in Vermont. Over the years and tobacco prevention and cessation and towards the middle towards the end middle of the presentation will go through some of the youth risk behavior survey information. Which is self reported information by students in Vermont that will tell you whether or not they're using tobacco products or not. And why now smoking is still the number one cause of preventable death in the country. In every state in the country. It's approximate there will be approximately 1000 deaths to Vermont residents this year, caused by smoking, and if smoking rates continue at their current rates. There are approximately 10,000 Vermont kids that are alive right now that will die prematurely from smoking related illnesses, which ought to give us all pause. And that 28% of all cancer deaths in the state of Vermont are attributable to smoking. And again, most importantly, because flavors cook kids. I want to draw your attention if I could just for a moment to the picture on the screen to the left. Those are vaping delivery devices. Those are those are what kids would call vape, or you may hear the slang of vape product. It's a product called hide. I didn't embellish it with the name on it. That's what they look like. They're actually called hide. And I think they're called hide for a reason. I'm sure you could probably figure out why.  I don't know which one is on who's using it, I guess, or, but they're easily concealable. You could use them in school or at home and as a parent personally I don't know if I would even notice because I think my kids got so many lip balms. I wouldn't know which ones are which. And so I want to walk you through why, why this is important and why, why we are seeing what we're seeing. I want to tell you that when the tobacco industry comes before you to testify, or any of their many retailers they will tell you, they sell an age restricted product. It is only for adults, kids shouldn't be using it. And that's that. Well, senators, I want to draw your attention to just some of the electronic vape products that are available. These are what are commonly called as juice. That's the slang is eliquid. This is the little drops you put into, into refillable vaping products devices. And I think you'll you understand why this is concerning to many people on the left is of each group of picture is the vaping product and to the right is a food product. And food products that are mostly for children, although I do know some adults that eat sour patch kids, but the little picture on to you have your pink sticks is what the slang for the vaping product is. These are strawberry flavored chocolate dipped pretzel rods, I think or breadsticks that are sold that are attractive to kids to taste like strawberry chocolate photo next to it. Those are sour drops that kids put on their tongue. I find it repulsive but my eight year old enjoys it when her grandparents sneak them into our home. But the product next to it I think you'll notice looks remarkably similar. Same types of graphics same types of packaging to that next to that is, you have to look up and down at this point sorry but is candy King vape juice. Below it you'll notice it's the same coloring, same look and packaging as sour patch kids. Next to that, you'll see gummy worms crawlers I guess they're calling them. You'll notice that the packaging the color is remarkably similar to me as a parent of an eight year old the most egregious picture up here is the one that's called juice box because my eight year old loves her low sugar. Apple juice boxes. She just loves them. And what does that look like it looks exactly like a low sugar apple juice box that we buy at the supermarket. So, why don't we say flavors hook kids what do we mean flavors are a marketing weapon. Truly, there are a tool that the tobacco industry has used for a very long time to lure kids into a lifetime of addiction. Flavors like cherry grapecotton candy they pale in comparison to some of the ones we're going to go through in a few minutes, but they, they add them to to their products, not to entice established adult users. They put them into their products and their own documents bear this out. The internal documents show this that they do it to target children to get them at a certain by a certain age because they know then they'll have a lifetime customer. And so why do they alter these products why do they put these flavorings in because it masks the harsh effects of tobacco on your throat. Think of, I think a menthol personally, as a 16 year old kid, a friend of mine giving me a menthol cigarette, and I smoked it and it was harsh because it was the first time that I'd ever had a cigarette. But it wasn't all that bad because it was this cooling effect of my throat. The next time I saw this person. He gave me what I would call a normal regular cigarette and it was horrific and I gagged even more and, but I remembered in the back of my mind. Oh the ones with the green on the front of the box. They weren't that bad. You know they were they weren't that harsh. And so, consequently, you say these flavors are the leading reason why they use these products. And it's very alarming that they perceive these flavorful products as less harmful, especially the electronic cigarettes. For some reason there's this misconception that these vaping products are safe for them. They could be potentially less harmful, and some of the combustible products but I think we all recognize that less harmful doesn't mean safe. And so let's go through some of just a few of the flavors. There are more than 15,500. Now, I can't even comprehend this number to be honest with you 15,500 distinct flavors. I could ever think up that many flavors, but the industry certainly has and they doubled the amount of flavors that were available to people in just five years from 2014 to 2019. They went from 7700 flavors to 15,500 flavors. It's just mind boggling to me. And what are some of these and kid enticing flavors gummy bear mango adult might like mango birthday cake s'mores. I'm going to tell me what OMG tastes like. I don't know, but I can guarantee you it's not. It's not for someone like me. It's not my age demographic, a cotton candy, unicorn puke. Berry, very berry slushy stardust. Again, I who knows what stardust tastes like strawberry shortcake Skittles I know a Skittles tastes like because I've had candy, and then the ever popular boo boo berry. These names are created in a way to be attracted to children. I mean plain and simple. And so again, we say flavors hook kids more than 70% of kids nationwide, who have ever used a tobacco product started with a flavored product. And then you can see it to your left there. In the breakdown nationally from the CDC, 63% of students who currently using cigarettes have used a flavor you say correct 61% who currently use a hookah or currently have used have used a hookah that was flavored. And then 64% that currently use cigars. Use flavored cigars or have used flavored cigars. So the these products are there for a reason and they're there to entice our children. The impact is one in four kids in Vermont are now using some form of tobacco products. And that's very alarming. And so let's go through very quickly the youth risk behavior survey. So the most current data is from 2019 that the YRBS is commonly called comes out every two years. I believe there's going to be a delay due to covert. I think they're pushing back the 2021 survey until the fall. I mean, it's very dry this time of year at my house with the wood stove going. So from 2017 to 2019. The rate of whether or not a high school student in Vermont had ever used a flavor tobacco product went up 6% it's up to 27% now. And before age 13 middle school kids, it went up 5%. These are alarming trends. And these are all self reported these aren't. These are our anonymous surveys that are given to students. Have you ever tried and I should mention at the beginning to when you see the little bars down here. This is all obviously information that's provided by the Department of Health. And it will show the breakdown and I can go through that breakdown in just a moment but the different categories of folks that were surveyed the demographics rather. So let's try to vapor products in 2017 it was 34% of Vermont high schoolers in 2019 it was 50%. It went up 16%, which is very alarming if you look back at the bottom of the screen, you can see in 2015 it was 30%, then it ticked up to 34% over two years which is bad. I rocketed to 50%. Amongst the genders male and female, it's about even. But then you can see the breakdown by grade at least at the high school level, where it slowly slowly ticks up until you get up to seniors and they're at 58%. Then we have white non Hispanic and then students of color. It's about even and then heterosexual and LGBT there should be a queue there got cut off students as well and it's about even but it's slightly higher for the LGBTQ population. Current electronic vapor use these are kids that are currently using them in 2017 you're at 12% and 20 by 2019, we had more than double you're at 26%, you're above the national average, it went up 14% in just two years. I know you're going to hear from folks after me and I promise you I'm almost towards the end senator that they're seeing kids now using these products to self medicate because of what they're dealing with with the pandemic.  And so, to me, the scariest chart of all of these is this one right here and these two little circles. And I want to draw your attention to the slices that say every day. These are kids that are using electronic vapor products every day in 2017 you're at 15%, 2019 you're at 31% you're more than doubled in two years. These are that are you currently using daily daily they're using these products, and I can only imagine that the number is going to go up even higher, based on the stress levels of these kids are facing right now. And so, the current use of tobacco products. This is all tobacco products more than one in four kids in the state are using products. It went from pardon me from 19% in 2017 to 28% in 2019 up 9%. This is not a good trend. And there are ways that we can we can mitigate this. And one of them is to enact a ban on flavors, but there's all some good news. The current cigarette use in the state is down. And that's incredible that's great that's what we want to see it drop two points over two years. And on the downside, if you exclude mental from the list of products, which this bill does not and I thank you for that but if you do carve that out. Where are these kids going to go, they're going to go back to the only available flavor, and that is mental and I know that others are going to get into that but we would just caution you not to not to carve that out. I know there was some questions and discussion last week in your committee about what's happening with your neighbors. Massachusetts is that probably the, the, the leading example of what positive change can happen in the state. They have been the sale of all flavor tobacco products in their state. All tobacco products. They've increased retailer fines from to make sure that let them know that the Commonwealth is very serious they've increased their fines from 100 200 and 300 for the first second and third violations to 1000 2000 and $5,000. And to combat the black market because I'm sure you will hear all about that from the industry loves to talk about the black market that's going to happen. Massachusetts said okay well that's fine but we're going to combat them we're going to go out to the black market and 30% of all the revenue collected from fines. I will, we'll go to the Department of Public Health to their tobacco cessation and prevention prevention program to help combat tobacco addiction. There are more than 300 localities across the country that's cities towns and counties that have restricted the sale of flavored products. There is not a one size fits all application to this. They're all different there's 300 different localities and there seems to be three different approaches. Some of them ban just menthol cigarettes some of them ban just electronic cigarettes some of them carve out other products. But there are five states that have taken this on Massachusetts in California are the only two states that have banned outright. Although there is some there's litigation around the California ban is my understanding, and a referendum they govern by referendum a lot in California to reverse that. But in New York New Jersey and Rhode Island, they started out as executive orders from their governors, you'll remember a few years, it seems like a lifetime ago now, just before COVID. There was a rash of respiratory diseases caused by in kids especially caused by the use of e-cigarettes. And so the governor's in New York New Jersey and Rhode Island took it upon themselves to initiate a ban. They have gone into permanent effect. But each of those states carves out certain products like so for New York for instance your neighbor to the west. They only do electronic products they don't they don't do other products in New Jersey and Rhode Island carve out pipe tobacco and and others, but at least 60 of the localities of those 300 localities also restrict the sale of menthol cigarettes. So you would not be, you certainly wouldn't be the first, but it would, it would go a long way to curbing use in northern New England, your neighbors to the east of which I'm sitting in at the moment. Because I'm the government relations director for Vermont in New Hampshire now have a tobacco 21 policy in effect but no ban on any any types of flavors, but it would still be illegal to sell to anyone under the age of 21 in the state of New Hampshire. So in conclusion, why and why are we ending the sale of tobacco flavor tobacco products, because we really don't want you to erase the progress you've made cigarette use and like as I mentioned is the only area in Vermont where you've improved with tobacco youth tobacco use since 2019. And I pray that we keep continuing to see those trends in 2021 and into the future, but we cannot leave any flavor on the market, because as I said, if you leave menthol on the market, that will be where kids will return to And we're, and we're wanting to say thank you because in your bill, you're, you're working towards putting the place placing the blame on where it really belongs and that's on the industry selling these products not necessarily the kids that are addicted. And that's through the what so called pup provisions. Possession purchase and possession provisions the monthful. So that's why we say pup. And we've seen across the country that the evidence shows that penalizing the user is not effective. It's not an effective policy. These pup provisions were were a tactic that were were embraced by the tobacco industry many many years ago. Because it sort of took it took the onus off of them. And in many cases, there was a minor fine for those actually selling them at the retail level but the people that were actually responsible for these products. They get to walk away and they don't have to worry about anything. These these pup provisions across the country have been unfortunately disproportionately applied to communities of color. I think you'll hear quite a bit of presentation on that later on in the day. But really, at the end of the day, ending the sale of all flavored tobacco products will make it harder for the tobacco industry to target our kids. And at the end of the day, I mean, that's, I worry the most about, you know, look, we all worry about paying our mortgage or heating our homes or keeping the lights on. But at the end of the day, I worry more about my kids future than anything else and what kind of life are we going to leave for her, you know, what kind of planet and and don't worry though that tobacco industry has a kids menu and they're actively going after our kids. So I would implore you to to pass S 24 and help protect our kids. And with that senator I'm happy to take any questions. All right, thank you for that. You may want to take your screen sharing down. Okay. Committee, you know what I'm going to suggest is that unless you have some real burning question that was upon. I shouldn't have said that. Unless you have some questions of super clarification. We're just going to continue to move on. And I'll tell you we have at this point I think it's important for each speaker to be very careful about now stepping over the 10 or 15 minute timeline. Otherwise, we're going to be super behind. So I'm going to, I will try to moderate and facilitate the time a little bit so Tina's welcome. Go ahead, you can introduce yourself for the record and provide your testimony. So as you can see, I'm Tina zoo government relations director for the American Heart Association, we used to have a joke among our government relations people that we could do our job but not math and it's sort of the same with technology so it takes me a little bit to get going here but thank you very much for the opportunity. I wholeheartedly agree with everything Mike said we tried to divvy it up a little bit to shorten the message here because we do have some experts that have some great information on this subject and I'll start with you. But I'm going to talk largely about mental. Frankly, I think before a lot of us got involved in this issue we may not even have been aware of what mental was and why it was even a problem and that is frankly part of the problem here. I will say just to start off with though we wholeheartedly as an organization the American Heart Association supports this bill. It is great that you've included both flavored e-cigarettes and menthol we feel that both are absolutely necessary to ensure both health and racial equity. I also applaud the sponsors of the bill for including the removal of penalties as Mike was talking for pup provisions in this bill S24 they eliminate it eliminates rather the penalties for possession. I would encourage the committee I know there's a separate bill that you all talked about during your walkthrough of this one that it that goes a little bit further. I would encourage the committee to consider also eliminating the penalty and Vermont on possession and it is for the reason that Mike mentioned that we don't feel that those suffering from addiction should be penalized twice. Mike mentioned in Massachusetts that they have large fines for retailers we do feel that's where the owners should go the burden should be greater to those selling illegally to youth to to pay that penalty. In Massachusetts increase the theirs from one hundred two hundred and three dollars for penalties to one thousand two thousand and five thousand Vermont side believe and I believe Jennifer Harvey has this information are one hundred and five hundred so we could do more and make that penalty a significant deterrent to selling to our youth. So why menthol why is this even an issue there was a federal law that was passed in 2009 called the tobacco control act and it outlawed most flavored cigarettes unfortunately the one it left on the table was menthol. And it was probably the worst one they could have left because it makes cigarettes easier to smoke and harder to quit and therefore it makes a much more addicted smoker.  And we now know that mental makes up about 35% of the US cigarette market but as you'll see in the upcoming slides, there are certain populations that have been targeted aggressively by the industry, and are therefore paying the price and to reduce its rates but also in chronic diseases caused by those usage rates. As Mike mentioned earlier, one of the things that men fall does very well is it creates a cooling effect. It reduces the harshness that you feel when you smoke that burning cessation it suppresses a cough. That makes it super appealing to use. You might remember last year's press conference when I held up the cough drops, why do you take a cough drop. Because it helps your throat feel better and cool. This is what these cigarettes are doing they're incredibly appealing to you. And more than half that figures about 54% of youth between the ages of 12 and 17 use menthol cigarettes and for black youth who smoke it's seven out of 10. So, part of what I'm going to talk as well about is the FDA in action in relation to mental. The tobacco product scientific advisory committee is a mouthful it was required by the FDA and this federal legislation to review mental cigarettes impact on youth. The committee noted that mental cannot be considered merely a flavoring additive. It's a pharmacological action that reduces the harshness of smoke. It's, it's a drug. There's more than is tasting cool like gummy bears and bubble gum like the other flavors that Mike talked about this committee concluded that mental cigarettes do increase the number of kids who experiment with mental cigarettes, and therefore also become regular smokers. Here it shows as well some of what Mike had mentioned you'll see what is of interest to kids in terms of high school users in terms of flavors fruit is topping the list but look what second. So if you decide as a committee. Well let's just do the other flavor stuff and not touch menthol. Where do you think they're going to go if if you if you don't address mental as well. The other one is mental. As I just mentioned if mental isn't restricted in all tobacco products consumers who formally use flavor e-cigarettes will be pushed to other mentholated tobacco products and youth as we've seen will always gravitate to the available flavor it will become like a game of whack them all. They'll go from one to the other we need to get them all off the table. And as I think the one vaping device that most people are familiar with is jewel it really was one of the reasons this epidemic happened. When jewels started getting the heat. Getting some heat rather for for this increase use of flavors and kids using them, they pulled their kind of candy and other flavors off the market but they left meant in mental. When they did that, the use of mental went you'll see 42.3% in 2017 to 63.9%. So it shows kids will go to what's left on the table. Now we know that your action to restrict menthol and all tobacco products could steer youth in a more positive direction.  I'm sure in great detail I won't go into this a lot because we have some wonderful speakers who are coming after me that are really going to talk about the aggressive marketing of the industry to people of color. But as you'll see, there are certain demographics where the industry has really focused on their marketing, not just, you know, ads here and there, but price discounts sponsoring, you know, musical events and communities of color. As a result, 85% of black smokers who smoke menthol cigarettes and as I mentioned earlier, seven out of 10 black youth smokers use menthol. I want to jump back to that slide really quickly. It's not on my slide but to give an idea, we don't have a lot of data on who is using menthol in Vermont. I just think you plan to hear from Joint Fiscal in terms of menthol sales, etc. The sales of menthol in Vermont are around 18.8%. But in terms of people of color smoking versus white smokers, right now the adult smoking rate in general in Vermont is about 15%. In terms of color, it's 26%. And youth of color are 1.7 times more likely to smoke. That information is all from the Vermont Department of Health. And this is just, and you'll again hear more from Del Monte Jefferson and Dr. Gardner about this, but these are some of the types of ads that have targeted people of color from the 50s to currently to get them addicted to menthol. Well, as you'll see, permitting the sale of menthol is supporting disparities, inequality and cycles of poverty. We strongly, strongly urge you to address menthol as well. Especially now, I work for an organization who is absolutely committed to racial equality, racial equities, health equities, so much so that we release a presidential advisory this summer on structural racism, trying to get the society in general to address this issue and stop some of the inequities that have caused such disparities in health as well. As I just mentioned, tobacco industry documents highlight a long history of marketing and menthol products to vulnerable populations, including those of low socioeconomic status minorities, youth, women, LGBTQ and folks that are less educated.  We are not doing anyone any favors by keeping menthol on the market. Just to give some background as well as to why the state should act and not wait for the federal government. As I mentioned in 2009, the federal legislation that banned all other flavored cigarettes left menthol on the table, despite taking public comment in 2013 and again in 2018, and even though its own report in 2013 concluded that removal of menthol cigarettes from the market would improve public health, and also concluded that menthol cigarettes lead to increased smoking initiation among youth and young adults, greater addiction and decreased success including smoking. The FDA has failed repeatedly to take action. They did recently take some action. It does not go nearly far enough. So last January, believe it was even it might have been the day that we were all talking about this issue in committee with you folks. It released its new policy that did eliminate the sale of some flavored vaping devices. And I think it's important to kids. This has become such an issue with kids. They don't even say e-cigarettes anymore. It's not hip. It's not cool. Vaping probably isn't even cool, but with all the devices they've talked to what they've got. It's part of their culture now, frankly. But what the FDA did is it did eliminate the sale of flavored cartridge or pod-based e-cigarettes. That just means the jewel type ones that contain cartridges. But they left menthol and mint on the table for sale. So kids can still use those devices, jewels that are mint or menthol. And they excluded from that ban open tank e-cigarettes. Those that are typically sold in vape shops that you can refill with flavors. And the last one has really skyrocketed. These self-contained disposable e-cigarettes are allowed. And I'll show you pictures of those in the next slide. So allowing these flavored liquid nicotine and menthol flavors are still attractive to use. They will gravitate to those devices. So these are some of what kids can still get because of the FDA inaction. Devices sold with empty refillable pods are exempt. Soaring and smoke can be filled with e-liquids of varying nicotine strengths. And there's pictures of them right there. After jewel, these are the most popular e-cigarette devices among high school students. These are some of the disposable ones. Mike showed you some as well. The hide ones, the mojo ones look just like them. And on the left, the puff bars that look very much like jewel, only they're even cooler because they're colored.  And these are more of the disposable products that are available. Then the mojo looks just like the hide that Mike was talking about. And these are the e-liquids that are still available to refill the larger pod systems. These are clearly look at the pictures marketed to kids, not adults. Mike mentioned some of this earlier, but I know the committee had some questions as well during the walkthrough. Ontario Canada also banned menthol cigarettes in January 2017 and the Canadian government also banned menthol cigarettes in October 2017. I believe Dr. Valenti has some information about what happened there after the fact. Massachusetts was the first state to end the sale of menthol along with all flavored tobacco products. The ban on flavored e-cigarettes was immediate. That happened in November 2019. And then the menthol cigarettes part of it was last June 2020. California became the second state to ban most flavored tobacco products. They did include menthol. They were a couple of carbouts for some other products. We would encourage you not to carve out anything. As I mentioned, Mike mentioned, the kids will move to what's left on the table, so we need to make sure it's nothing that's left on the table. We would love very much for Vermont to be the third state to have a comprehensive ban on all flavored products. I think during the walkthrough of the bill, there was a question as to impact of that. California's was passed much later. And as I mentioned here, Massachusetts, the menthol part of it didn't start happening until June. So they don't really have a lot of data they can show you about impact because there hasn't been enough time. They will get that data likely from the youth risk behavior survey, especially they show the impact on kids. One thing I will point out is that when these bills come up, there's always the question of impact on sales and revenue, etc. What is happening in terms of sales is in line with what the tax department in Massachusetts and the public health community predicted. They thought there would be a decrease in revenue, maybe 120, 130 million. The industry was much higher said it would be around 300 million in that state. After six months, the impact has been about $69 million. So for a year, they feel it will be right in line with what the tax forecast was and the public health community had suggested. I will stress though, it is not about the money. It really should not be about the money at all. It should be about the kids. And I will tell you one of the reasons it should be about the kids is if it's not about the kids, it will even further be about the money. We're spending $348 million right now treating tobacco cause illnesses, and we need to start now to prevent that later is very important. Another call to action I believe is we all heard from the state's economists about a month ago about revenue impact of various things. During this COVID pandemic, one of the things that has happened with this pandemic is according to Tom Kovett, e-cigarette and cigarette sales have surged. Those are his words. So between those and alcohol sales, I think the extra revenue is $8 million. That's not revenue we want. I don't think anybody wants to make sure that kids and adults keep smoking and vaping so we have more money in the state coffers. And I will suggest as well a fact to keep in mind when you're making this decision is what you can save when people quit. Now, a long time ago, the tobacco program in Vermont was evaluated to see if it was working. If we get people to quit smoking, what happens? And between 2001 and 2014, the state saved $1.43 billion. That's billion. That's huge. That should be reason enough right there and $586 million of that was Medicaid savings. And more recently even between the years of 2017 and 2018, the health department worked on a concerted effort with Diva on trying to get providers more aware of the cessation services available for Medicaid folks and then also for Medicaid recipients to know what's available. There was a decrease in smoking that resulted in $12.2 million in savings in just that one year. So it makes sense for so many reasons and I will let you get to your other great witnesses and thank you again for your time. Tina, thank you. You have a lot of data included in your report and it would be helpful maybe to get some of the financial data that you indicated at the end. If you don't mind, maybe send that in to Nellie and we can put that up on our webpage as well. Of course. Thank you. Senator Cummings has a question. I'm, I had the same concern last year. You've, I've got some cognitive dissidents going here. We tried prohibiting alcohol. It didn't work. We tried prohibiting cannabis and just, you know, made that legal because kids said it's easier to get marijuana than it is to get alcohol. Bands didn't work. I'm interested in when we ban all this. And you also said, kids will gravitate to what's left on the table. So if bands haven't worked in anything else, why do we think banning flavored tobacco will stop them, especially if it's only on a state by state. And if we do succeed in stopping it, where will kids gravitate. And I'm also, I have to, in this time of heightened sensitivity, somewhat uncomfortable with picking out basically anyone that isn't white heterosexual and middle class and saying, for some reason, we seem to have been able to withstand advertising and these other groups haven't I do remember Virginia slims and you've come a long way baby ban. I'm just, I'm looking for why, why is this going to be any different than all the other prohibitions. Do we care where kids go. I mean will we just say well yeah they'll go somewhere else maybe it'll be cannabis. Maybe they'll just drink more hard lemonade or hard cider or Boone's farm if that's even still on the market I mean. Why do we think this will work. Senator Cummings, that is such an excellent question and I think it underlies a lot of what we're hearing today. That absolutely needs some clarification. What I'm going to suggest is that that that question be fundamental to the, what the information we're trying to get today. And that as we go through and hear from folks that if you can help us understand the answer to that question. That would be really very helpful and I know Dr Volante may actually offer some comments on that as we go forward. But it's a you know it's a it's a super question and we hear it from people, our constituents and others so let's put that one out for everyone to help help answer and help help us understand so it's excellent. And so I'm going to move right on to Dr Volante Volante and she's going to answer all of our questions. Sure. Yeah. And I do you need to share a screen. Yes, I will share my. All right, that would be terrific and then go ahead and introduce yourself for the record and we look forward to your testimony. Good morning. My name is Andrea Volante. I am an associate professor in the department of psychiatry at the UVM College of Medicine. I've also been doing work on flavored tobacco for about a decade now, starting at the time that FDA gained regulatory authority over tobacco products through the family smoking prevention and tobacco control act that Tina mentioned in 2009. To address specifically your question, Senator Cummings, I think that this is, this is different because it is not an entire product ban when we banned alcohol there was, it was the entire category was banned similar with cannabis we're talking about banning particular flavors. And I don't mean that as a pun but we're talking about banning a portion of access to a product in a product class part of a product class that we know has greater appeal for young people. And that makes it harder for adult users to quit. So we're not talking about a widespread ban on the entire class of tobacco products we're talking about identifying which of those products cause greater harm to the population and how we can reduce use of those products. And I'm happy to talk more and answer any additional questions. This is my information and my disclosures I received funding from the National Institutes of Health, Food and Drug Agency and the health health resources services administration. I don't have any industry funding or any other disclosures to share. So the key points that I want to discuss today are related to the science on menthol and flavored tobacco product use. First that menthol cigarettes and flavored tobacco products facilitate youth initiation and beyond initiation actually facilitate progression from trying a product to become a regular user of the product. Menthol cigarettes impede adult smoking cessation and that's particularly true for non-white cigarette smokers. And that banning menthol and flavors in tobacco and e-cigarette products would reduce the number of tobacco users and thereby benefit public health. And I think Tina made some really excellent connections between those reductions in tobacco use actually leading to reductions in medical costs and morbidity and mortality down the road. So there are four points that I want to share with respect to initiation and progression. First that we see that the highest prevalence of current flavored tobacco and e-cigarette use is in youth, followed by young adults and then adults over the age of 25. Among new users, the highest prevalence of trying of first flavored product use. So among a group of people who have tried within the past year, for example, the highest proportion of flavored product use at the first time of use is in youth, followed by young adults. So we see again that flavors and initiation are really tied to trial in young people. Third, that the first use of a flavored tobacco product is associated with use a year later in all age groups. So first trial of a tobacco product leads to subsequent use when we follow them up over time. And then finally, most recent data that I've been working on is related to menthol and mint cigarette or in cigar use where we see a similar pattern again, where first use of a menthol or mint cigarette or cigar is associated with later use in youth and young adults. So this is some of the data supporting those statements. You can see here, if you kind of blur your eyes, a very clear trend down. What you see is this is age across this X axis. So the prevalence of flavored tobacco use decreases fairly sharply as people get older with the highest percentage being in youth age 12 to 17, about 80% of current of current tobacco users using a flavored product. You can see the same type of pattern, you can see this gradient across age groups again with the youngest at the far left and the oldest group at the far right for all tobacco products for e cigarettes for hookah and smokeless, where among new users, the highest use of the first use of flavored product is higher in youth than in young adults and adults. So again, we're seeing this really strong pattern with young people being the most likely to be current users of flavored products and also new users, most likely to use a flavored product if they're young. We look forward and we follow people over a year or more. What we see is that their first use of a flavored product is associated with their continued use of that product at the subsequent time point so this is using a large national asset called the population assessment of tobacco and health. And when we look across all products we see a very similar relationship, whether it's a flavored or menthol cigarette, a flavored cigar a flavored e cigarette flavored hookah flavored smokeless tobacco. We see the this strong relationship where first trial of that flavored product leading to subsequent use of that product a year later. We also see that this first flavored product use is associated with daily use of menthol e cigarettes and flavored e cigarettes. And that's really important when we're thinking about well if they try a product it's not such a big deal. They maybe don't try again and we're not going to see the long term health effects. What we're seeing here is that this first flavored product use is associated with daily use, which likely reflects dependence on on nicotine and likely continued use. I want to highlight here that we have this strong significant relationship, you know, 61% higher odds of being a daily user if your first cigarette was flavored. We do not see that same relationship for e cigarettes for youth. And I think the reason is because of the smaller sample size in this study, because we do see this really consistent pattern across all the flavored products. And then specifically on mint and menthol cigarettes and cigars. We see that new use of menthol cigarettes is associated with greater use in the past year among young adults that new use of menthol or mint flavored cigars is associated with past 30 day use or what we call current new use a year later in youth and young adults. So again, just a very consistent picture across all the products where we're seeing influences on both initiation and progression to becoming a regular user. Interestingly, another hat that I aware is one of the leaders of the pace Vermont study which is a cohort study of Vermont youth and young adults that I run in collaboration with the Vermont Department of Health. And in data collection that we completed in December of 2020, we asked about policy support and we saw that about half of youth did think it should be illegal for flavored tobacco products to be sold in Vermont. Now looking at how other where other flavored policies have ended up in terms of impacts on tobacco use. In TS Tina mentioned in 2009 FDA enacted a ban on flavored cigarettes so that included cherry flavored cigarettes, you know fruit flavored cigarettes, etc. It exempted menthol cigarettes. Data from studies on evaluating the impact of that ban found that it reduced youth cigarette use overall which was great. But there were increases in youth menthol cigarette use in cigar use and in pipe use all of those being available in flavors. And the conclusion of that study was that the results suggest that the ban, the flavored cigarette ban did achieve its objective of reducing adolescent tobacco use, but the effects were likely diminished by the continued availability of menthol cigarettes and other flavored tobacco products on the market. In Ontario, the Ontario enacted a menthol cigarette ban ahead of other provinces in Canada. And one of the interesting things that they did as part of the lead up to evaluating this effort was to ask menthol cigarette smokers, what they would do and that's the blue bars here what they planned to do ahead of the actual ban and then they followed up with them. A month after the ban was enacted to find out what they actually did so the blue bars represent what what adult menthol smokers thought that they would do. And the red bars are what they actually did. So interestingly here if we look at how their behavior changed. Many thought that they would switch to non menthol cigarette, and that was much lower in actuality at a month follow up then was expected. They, a smaller proportion thought that they would use alternative flavored tobacco products in response to a ban, and it was actually a larger proportion than expected on nearly 30% reporting that they had used alternative flavored tobacco products in response to the menthol cigarette ban. There are some other categories here and I will come back to them a little bit later. So some of the work that's been done recently is sort of synthesizing across all of these hypothetical ban research that has done this sort of hypothetical research, what would you what would you do in the face of a ban, compared to what actually happened. So what we can see here is that in, in these actual mental mental cigarette ban, meant a flavor ban that was only a cigarette flavor ban and then a flavor ban of all tobacco products, that there's some movement to other tobacco products. The menthol cigarettes alone were banned. That was a fairly high percentage moving to other tobacco products. When there was a flavor ban on all tobacco products. There, there was a much lower percentage of people switching to other products. So again, I think the whack-a-mole analogy is a really helpful one here. And to which we leave flavors on the marketplace, we will likely see some shifting across to different products. We did not see as much movement to the non-menthol products as we expected in the face of a menthol cigarette ban. We can see here that a flavored cigarette ban that does not include menthol cigarettes that does not include other flavored products led to greater use of menthol cigarettes and other flavored products. A menthol cigarette ban that did not include other flavored products led to greater use of flavored tobacco products. And I think what you have proposed in this bill is right on in terms of keeping all of those flavors under the umbrella and trying to minimize this type of substitution. So again, just to highlight the importance of including menthol and a flavored tobacco ban, we have had such tremendous declines in adult cigarette smoking and youth cigarette smoking. And one of the really important things to note is that that is largely related to declines in non-menthol cigarette consumption. You can see here this line. This is the number of cigarettes consumed in the U.S. over about a 20-year period. And you see that the non-menthol line mirrors what we see in smoking prevalence, that really strong decline. This has really held steady over this time period and now represents something like 36% of the market share of cigarettes in our country because of that tremendous decline in non-menthol cigarette consumption. Now, at the same time, we have seen these tremendous increases in youth e-cigarette use. This is data from 2016 to 2020 from the National Youth Tobacco Survey. The green line here is e-cigarettes. The blue line is any tobacco or e-cigarette use. And the red line is any combusted tobacco product. Combusted tobacco being anything that burns, like cigarettes, cigars or hookah. And I want to just highlight that while this e-cigarette piece is really of concern and certainly has gotten a lot of attention in terms of flavors and flavor bands, cigarette smoking is still the dominant reason for the burden of death and disease from tobacco use in our country. Smoking accounts for 480,000 deaths annually in the US. That's 1,300 smoking-related deaths per day. You know, we have a tremendous number of youth that are expected to die prematurely from smoking. And if we think about smoking-related deaths compared to other epidemics that we are addressing like opioid overdose, you know, that this number dwarfs opioid overdose. Unfortunately, as I'm looking at this and thinking about this, we're not, you know, we're sort of on par with where we are for COVID deaths in this past year, which is pretty sobering. Another piece of this is that cigarettes have actually become more lethal over time. We have more death and disease as a result from smoking despite having lower per capita consumption and lower smoking prevalence. The products are highly engineered and the way they have been engineered to facilitate continued smoking has likely produced more harms to individuals and quitting smoking benefits smokers at any age. One of the arguments frequently about leaving menthol cigarettes on the market is that it's an adult choice, that it is an argument about, you know, that their freedom to choose the product. But I think it's really important to note here that people who smoke cigarettes don't necessarily want to be doing so. More than half of adult cigarette smokers want to quit, fewer than one in 10 succeed in quitting each year. And what we know from a number of studies is that menthol cigarette smokers are more likely to try to quit and less likely to succeed in quitting. And this is particularly true for non white menthol smokers. So again, this idea that we could have an impact on cessation and improve cessation for adult users in addition to protecting kids is really powerful. And if we look at this again expected reaction versus actual reaction in Ontario. In terms of smoking, we saw that there is actually a really high proportion of people who quit as a result of the menthol cigarette ban, nearly 30%. And so that's a really important thing for us to think about, you know, we frequently frame this argue this argument about flavors in terms of youth but there are potential strong benefits for adults as well. Senator Cummings. Just said how difficult it is to quit smoking. It's a very heavy addiction. We've got a whole industry selling quit smoking patches. Did you say these were done a month after the survey. So in the life of trying to quit smoking. It's interesting to see how the results held a year later. So, yeah, I apologize I don't have those data in this presentation but I'm happy to share them with the committee after this because yeah absolutely the effects on quitting as far as I recall. They did have sustained impacts on quitting over time not just a month following the implementation. So and this is just to highlight again that quit attempts and successful quits were increased as a result of the actual menthol cigarette ban. This is really promising. So the last thing I want to share and I apologize this is not in your slides I'll send them to I'll send this to Nelly is just the fact that we are in a place where tobacco sales have actually increased in the past year. The sales have increased significantly. And what we can see here is there is this category of spitless tobacco products that has changed tremendously in the past year. So I just wanted to highlight that these are other products nicotine pouches that are available now. This is a new product that has essentially come on to the market really taken off in the market about a year ago over the past year. There are other flavored tobacco products that should be covered under under S24. And just just a reminder that there is just tremendous innovation in in in tobacco companies and the extent to which we can protect against that whack-a-mole problem relies on what is baked into the bill the bill itself. I also again from my pace for month work data from the fall of 2020. We asked young people who had used substances in the past 30 days, whether they had changed their substance use during the COVID pandemic and the red bars here represent increases in use self recorded increased use in young people who are using different substances. What we see here is that about a quarter of our young people reported increased vaping and increased cigarette use since the start of COVID. One consideration I would like to raise is that we are conducting research ongoing on flavors in in tobacco products at UVM we are one of nine centers across the country funded to do work to inform national regulatory policy in tobacco. And so I'd like to request that the consent that the committee consider including language in the bill to allow that scientific research to move forward even in the face of a ban on flavored products. So thank you all for having me I'm happy to answer any more questions and share additional data. Thank you very much Dr. Volanti. So, I noticed that your your slide on the COVID question increase use isn't in our little slide deck and I'm wondering if you can share it with us as well the other that you indicated that would be terrific thank you.  Correct. Okay. All right. So, I'm going to ask my vice chair to keep me on track with that one. Senator Hardy. All right. All right, thank you so much. Is any additional questions this is pretty powerful that your, your work into behavior is so, so important to us and meaningful. So, thank you for that I know how it's just not an easy area for anyone looking at a cell on a slide, maybe is a little bit easier, but looking at the whole kid. That becomes problematic. Thank you. All right, so I think that will move on. All right, next. Yes. Oh, Senator Hooker, go ahead. Sorry. I just ask Dr. Volante, if there's any indication that the FDA will be doing anything under the new administration. I wish I had a crystal ball. What I have seen is that this has been, you know, this has been on the list for the past 11 years and nothing has moved on it. So I don't think that we can wait for FDA to act. I think the best thing that we can do is act as a state, and then have FDA see the evaluation data coming out of our states and have a stronger case to move forward at the national level. Thank you. That's a good question. A good answer. Dr. gogo is here. Thank you for taking the time to be with us this morning. Dr. gogo, why don't you introduce yourself for the record and we look forward to your testimony. Thank you. And I will need to share my screen here so I'll go ahead and do that. All right. So my name is Prospero gogo. I'm the director of the cardiac catheterization lab at the university of medical center. I'm also a professor of medicine at the liner college of medicine. And the data you're going to see before you is reflective of local data. So my kind of role in this whole process is more of a consequences kind of guy, instead of the other side. So, and this will be in fair detail at least on the local impact of continued cigarette use as well as the fears that a lot of us have. If this really public health success story and decreasing the rates of tobacco smoking in the United States over the last 4550 years takes a turn and goes back the other way. And, you know, I think from my role in this whole thing. I'm generally a fireman that puts out the fire. And I spend 90% of my professional life in that but this is my one part of my professional life where I can actually do something to prevent the fire in the first place. Let's go into historically what we're talking about here. So this is the past success and you seem slide similar to this from the other speakers, but just want to reiterate. The numbers you see before you are comparisons and certain subgroups of Americans in terms of their decreased use of combustible tobacco products. These in some cases for men and women appear to use smoking in the in the 21st century. This is a public health success and so to answer a little bit about Senator Cummings concerns about whether restrictions or bands are are helpful. What you see before you is a result of restrictions and certain bands and being more regulatory on a harmful product without a complete ban. The numbers you see before you have also resulted in a public health success in terms of the consequences.  Part of it is better treatments in terms of what I do every day. But that's not it. The majority of this is related to better preventive measures for developing the problem the first place. This includes, for example, pharmaceuticals to lower cholesterol, but a large percentage of that benefit has been related to the smoking restrictions that have been implemented in this country, including a ban on advertising and youth and that kind of thing in the last 40 years. So here's what we're really worried about. This is what we're really worried about. And you saw a slide from Dr. Bermonti earlier showing an increase in the use of so this is all those slides I just showed you a progressive decrease in the amount of combustible cigarette smoking amongst most users. But this electronic cigarette rise in the last in the last four years amongst us teens. Okay. So this is now, I'm going to show you what this little population might become in 30 to 40 years of accumulated use. Okay, so why I want to show you are the data we have at UVM Medical Center in terms of the burden of tobacco use today. As you saw in the earlier slide, the prevalence of tobacco smoking amongst adults is around the mid teens are low teens now. However, if you look at all the procedures that we do where we insert a stent in a patient's arteries to relieve a blockage. The smokers are disproportionately represented in this population. This is 22% of all of our stent procedures. We are the only hospital in the state that does stent procedures in the coronary. So this is this will represent a large swath of Vermonters. We did 1055 stent procedures and for those of you who are on the committee last year I presented something similar but these slides are updated with the latest numbers. 1055 stent procedures and at UVM last year, which is a slight decrease. So this is related to the pandemic and unfortunately, this is also reflective of that large heart attacks to UVMC physical year 2019 which ended last September 210. The pandemic affected this, the number of large heart attacks coming in for treatment decrease so this is actually treated heart attacks. Unfortunately, we because of the pandemic there was this increase in mortality from heart disease because, for example, possibly fear of patients, a fear of patients had of coming into a medical center in the early part of the pandemic. But here's a big number. So those large heart attacks. It's this number has been has remained steady almost half of higher tax that we treat where it's a high risk, highest risk, high attack, highest risk of mortality in the short term. And there's there's a disproportionate representation representation of of combustible to cigarette smokers in this population. And this is what it costs. And so what you're seeing before you are the Medicare numbers so this doesn't explain the payments for all Vermonters. And this doesn't reflect what private insurers pay for the same diagnosis or Medicaid, but generally they all take a tag off of Medicare so this is Medicare payment for the DRG 280, which is heart attack with complications, $13,314 and 20 cents per admission. In the last year that this was measured in 2018 where there's publicly available data from the Centers for Medicaid Services for Vermont, we had 418 Vermonters in 2018 present for heart attack and all of the Vermont hospitals to and the cost for the reimbursement for care of these Vermonters is $4.2 million. So heart failure itself heart failure there is an association of cigarette smoking and heart failure so this is a big contributor to the development of heart failure. And again, an expensive admission so a single admission for heart failure of Medicare will reimburse a hospital 11,412 dollars and 12 cents per admission. And so there were 886 Vermonters in 2018 who presented with heart failure diagnoses and the total cost for carrying of these Vermonters was $9 million through Medicare alone. This again does not include private insurance reimbursement or Medicaid. I showed you two facets of the consequences of cigarette smoking tobacco cigarette smoking and heart attack and heart failure and there's actually a larger portion of these things I didn't show you that incur costs, including other cardiac diagnosis like angina unstable angina and also cardiac arrhythmias. But of course this is a larger health problem. All of these things that you see before you are diagnoses or entities or disease processes that are strongly associated with the continued abuse of tobacco. And the numbers are also not reflective of actually patient experience, I mean we can look at the numbers all day and be very objective about it but this is true human suffering. And I can't, I don't want to belabor that too much but true human suffering related to all these diagnoses. I see it every day in terms of coming into the procedure room for large heart attacks. A lot of these patients are left with problems that continue to play them from their chronic cardiac disease. And a lot of these patients unfortunately continue to smoke in the midst of having these diagnoses. A colleague of mine has a mother who has been who started smoking menthol cigarettes 40 years ago. And her mother is unable to quit menthol cigarettes despite two years ago coming in, having severe coronary artery disease that needed to be fixed but unfortunately she was not eligible for coronary artery bypass graft surgery because she has COPD also related to continued cigarette smoking. So she received a high risk step procedure two years ago has been left with some disability related to that include and the comorbidity of her cigarette of her COPD and guess what, she continues to smoke menthol cigarettes, even today. So it is really hard to get over this, this problem and it starts way back when starts way back when we're talking about the kids. Again, these numbers have been talked about in previous presentations. Tina also talked about this as well 1000 estimate number of modern desk by smoking each year with $348 million spent a direct health care cost from smoking related illnesses. And each household pays a state and federal tax burden of $866 per year to take care of the smoking related illnesses. And here at the tobacco industry, which may be talking to you later today is spending a lot on marketing spending $15 million to make sure that the youth and our adults continue to use their products. So, what you've seen and I've talked about this in last year's presentations may not be so much of a surprise, but the colorways this is sort of a rhetorical flourish I like to use. But this is how the tobacco industry works. And this is kind of a variation of Joe camel if you think about it, right. So, what do you see for you are was the jewel advertising before they are really where they had to give us up because of public scrutiny and public criticism, but very healthy appearing very young people with a lot of bright bright colors and the lettering the text that you see on this presentation are based on the college from the jewel advertisement. Here's what I and I, our first speaker today actually talked about this more specifically but again this is what your our youth are represented. And part of my role here is not just as the cardiologist who treats for monitors who are sick with tobacco disease but I'm also a father of a 14 year old. And I'm doing my best to make sure that this isn't something that he picks up as well and hopefully that's going to extend to a lot of our monitors if we are able to pass this legislation. But this is the advertisement from unicorn vomit, which is one of the best one, still one of the most commonly purchased flavors from the baby mall.com. And I won't. I'll just say, some of the things are very interesting in terms of how they have market this so you can see.  With hints of fruit and candy notes, it'll bring out your inner child. So again, the text is is somewhat really trying to get at adult users of this, but I would say that the majority of that phrase is very attractive to my son specifically because he loves our patch kids. And here are the top 10s are top eights for each website for flavors from the big mom the flavor was I will mention that menthol is in the top five of each one of these lists in terms of frequency of purchase from online flavor shops. And I'm not. I'm definitely not a youth tobacco expert like Dr. Valenti but I will rehash some of the data she's suggested previously studies suggest that there's a 300 to 800% more like increased likelihood of a child who picks up an electronic cigarette or a vaping product moving on to combustible cigarette smoking. So another slide, the last set of slides I have for you for the rest of my presentation are other slides in terms of the consequences. Now I'm going to focus. All the consequences I talked about before in terms of step procedures and heart attacks are mostly driven by combustible cigarettes. However, I'm going to share some of the data that suggests that these products in and of themselves may cause health effects that we don't yet understand because they're so new, and they got out there so quick with minimal regulatory scrutiny that they may actually be causing some kind of health effects, an epidemic of health effects that are delayed by met by several decades that may accumulate over time. So this is the abuse I think by the CDC, they took 96,000 people who use tobacco and vaping products over the age of 18 on the years that you see down there. A couple of things about this, in terms of where people are using vaping and electronic cigarettes you saw earlier data showing that a substantial proportion of these of the electronic cigarette and vaping use are the highest percentage of youth using these using any kind of electronic cigarettes. But if we're looking at the age greater than 18. This study suggested that you can see where this is coming from this is actually an aspirational product. Okay, this is the majority of the people who enter the survey are highly educated. More than high school, some college but the majority of people actually have at least grad college degrees or even some advanced degrees. And so this is an aspirational product that's gotten out there and this is part of the reason why it isn't attractive to others because it's an aspirational from when you're looking at the people who use these things. And then it also because they're using things and they're successful, then it doesn't seem to be as harmful as it otherwise should be. It could be, excuse me. So, but here's the thing. If you look at the odds ratio for developing a cardiac related illness in this survey. You can see that there seem to be a 34% chance of increased risk of developing a cardiac diagnosis. We control for all the other risk factors, compared to non users. Okay, so this isn't this doesn't go down with a granularity of how long someone's been vaping, or whatever this is a current user of the product only who who has reported cardiac illness so this doesn't get into whether these people, these these survey respondents moved over combustible cigarettes to cigarette to vaping products thinking it's a little safer. Because they've had a previous cardiac diagnosis, but again there is an association with with vaping and cardiac use. And the thing about it is this is association and not causation. So again, we are the very beginning of population based use of these devices. As we know from cigarette smoking it may take two, three, four decades for the manifestations of continued exposure to those toxic and intoxicants to your body to develop to make to cause chronic disease processes that become very expensive. So this is association not causation from the survey I just showed you, however, the data is starting to accumulate. Okay, so the, the quotes I'm showing you are from, from well respected journals peer reviewed respective journals so these are just data looking preliminary findings in terms of how what what is the potential harm of even just vaping products. Okay, decreased heart rate in increase in fact own similar to smoking cigarettes it's jama cardiology in 2017 LDL is the bad cholesterol in your body. And if it becomes oxidized it tends to be more toxic to your vascular chair. And so what jama cardiology this article showed that there's increased LDL oxidized ability compared to non smokers and people who are using vaping products only. Vaping nicotine free products causes vascular dysfunction on MRI and otherwise healthy volunteers as radiology 2019 vaping nicotine free products causes increased markers of inflammation and healthy volunteers American general physiology. E cigarette use produce an adverse lipid profile and glucose alterations and pattern similar to smoking. In circulation that's one of our most highly respected cardiac journals, a chronic e cigarette users demonstrate more persistent corner endothelial dysfunction the chronic combustible cigarette users again in circulation 2019. And I'll finish up with these last three. Last three studies that are that have been published since the last time I testified in front of the committee. And so these are all done, all published within the last 10 months, E six cause alteration in cardiac structure and function in diet induced obese mice. E six cause elevated cellular oxidative stress and circulating immune cells and otherwise healthy young people. Vapors of a users of a products have impaired endothelial dysfunction similar to use users of combustible tobacco products. So again, we're very early in this. I can't say that this is going to be as as harmful as cigarette smoking most of the day suggests it's not as harmful. In fact, other countries have suggested that electronic non flavored electronic cigarette products could be a harm reduction tech option for some people. But, but again, there is also in those patients there are people who moved over to main products there's still a signal of harm. And so it's maybe a harm reduction thing but there's nothing better for your risk than complete cessation of any tobacco based product. So, I will stop there and take any questions and again I want to thank the Senate Committee for having me testify.  There's so much here and it, it's a lot of it is new so thank you. I have a quick question and Senator Hardy has a quick question. My quick question is, as you're reviewing some of the literature related to cardiovascular other risks. And maybe we'll hear this from other people so I'll just put it out as a question don't have to answer it. The relationship between COVID and smoking and vaping. I mean we've seen some issues there so but I'll just, I'll leave that for now. Yeah, I think there was there was some data that came out and I was reading the literature last night and there was one paper that suggested there was an association of worsened coronavirus disease in someone who's vaping or smoking. But I think that paper had some trouble with it so I can't hold that out as as yes this is a definitive finding for an association so I'll pull back on that a bit. All right good thank you. Senator Hardy and then Senator Cummings. Thank you Senator Chair and thank you Dr go go for your testimony and everyone for their testimony. I think you answered the question that was that I had, but I just wanted to make sure I'm understanding. In the earlier part of your presentation as you were presenting data on heart catheterizations and heart attacks at UVM and learner, learner School of Medicine. And then later in your pre yes okay and later in your presentation you presented data that that is starting to show that vaping and the use of non smoking tobacco products could be leading to similar or even different but similar health risks is that general summers. And just of it is yes right now we have a pen, we have an epidemic of smoking still in this country, which is still leading to bad cardiovascular outcome as well as other disease processes. But and this is based on having a population experience of cigarette smoking for, for, you know, hundreds of years but also heavy smoking experience among adults who started in the 60s and 70s. So the problems we're seeing with disease processes today were established by a smoking habits in the 1980s. For the most part 1990s, or even 1970s. My worry is, and I will, the data is lacking because vaping is so new, but there are preliminary data suggesting that vaping may have adverse health effects that we have yet to quantify. So I can only say that it's if there's preliminary data, we're looking at a biochemical process that are adversely affected by the by vaping and electronic cigarettes. But in terms of whether this is going to produce a cardiovascular effect causing high attacks 30 years from now for continue vaping as bad as cigarette smoking, half as bad as cigarette smoking, 20% as bad as cigarette smoking, we don't have that data. Yeah, that's helpful. Thank you. Senator coming. You're muted Senator there. All right. One of the concerns that came up when this bill was passed last year was that I think the most recent number I heard was like 2019 and in 2019. We raised the smoking age to 21. And I'm just wondering, has there any recent statistics has that had any impact. Personally, I don't think I can answer that question. That's not where my focus of research is but Dr Valenti actually may have that kind of data. Dr Valenti, can you give us a yes, we so we haven't seen impacts on use at this point, because the not the state surveillance systems haven't been in place since, you know, before and after. And I can say is in our pace Vermont data, we are seeing that has had an impact on ease of access to tobacco products and young people so right before they tobacco 21 went into effect and right after we surveyed. The survey waves in the field and what we saw was a tremendous increase in young people reporting that it was harder for them to access tobacco, tobacco products after tobacco 21 was was in place. Nothing that indicates that they stopped. So I think we'll probably get that data from the wire BS as it gets collected this year, and we'll be able to look at the difference between 2019 and 2021. The data that I have are not representative of the entire state so I can't make a statement about the, the true evaluation of the effective tobacco 21. Thank you. Are you good Senator Cummings. Yes. Okay, great. Thank you very much. We're going to move right along to Dr Pharisee. And thank you for being here. And I'll try not to bring up pseudo stratified saliated columnar epithelium but you never know. This is part of our last discussion. Good morning and thank you for the opportunity to come back and speak to this committee about a very important child health issue. My name is Dr le Pharisee and I am a practicing pediatrician at the University of Vermont Children's Hospital. I specialize in caring for children with lung and breathing problems. And I'm here today to speak on behalf of the Vermont Medical Society and the Vermont State chapter of the American Academy of Pediatrics and support of legislation that eliminates flavors into tobacco products and eliquids including mentin menthol. You may remember last year when we talked to everyone was talking about vaping as an epidemic and then an infectious epidemic came and captured our full attention rightfully so. But it would be naive of us to think that this isn't continuing to be a big problem as Dr Vellante showed you youth use of e cigarettes in Vermont is not going away. I see a lot of teenagers in my office and I talked to them a lot about vaping because once I started asking people started telling me what they were doing and what their friends were doing. And I can attest that it is an incredibly common product to use and if kids aren't using themselves they know a lot of people who are. It is everywhere around them. One, I can tell you that the scenario that you've heard about with flavors hooking kids is absolutely something that I've seen play out in my clinical practice.  And the first day that I met him he told me about how much he loved that he loved, and he assured me that this was not a big deal because it didn't contain nicotine. And he liked doing tricks with the paper and doing it inside with his friends while they were gaming. And then the next time I saw him he was using nicotine containing products. And after that, every time that I saw him, he would describe vaping almost as soon as he woke up in the morning and continuing to use throughout the day. And every time that I see him, he is having an asthma flare that has needed systemic steroids to treat that. And at the same time, he is still unwilling to talk about cutting down on his use of nicotine. So this teenager like many youth didn't think that the contents of e-cigarettes were harmful. These products reached the market without any extensive preclinical toxicology testing or long term safety trials and then they were heavily marketed to target a youth population as a product that's perfectly safe to use. They're generally under FDA regulation, but the contents of them are not well regulated and the listed ingredients may or may not reflect what's actually in the e-liquid. And that includes what the nicotine content is. Some products that are listed as not containing nicotine are found to contain nicotine when researchers look at them in a lab. And they do know that e-cigarettes contain fewer toxins than combustible cigarettes. And that's more about how organic versus synthetic matter burns. And that's led people to believe that these must be inherently safer and that's just not a safe assumption to make. In reality, we know that e-cigarettes probably just have a different risk profile, given what we know about the potential toxins in there. And I would also encourage us to frame the conversation not about is it safer to smoke tobacco or e-cigarettes because that's not the group of people we're talking about. We're talking about youth who are not smokers. These are non-smoking youth. And so the question is, is it safer to not smoke anything or to use e-cigarettes? That's the framing. It's not, is it better than smoking cigarettes? Because that's a different question and a different population. The ingredients in e-cigarettes are generally recognized as safe when they are food additives. That's the category that the FDA uses, but this label does not apply to inhalational safety. The lung is an organ that's evolved over time to breathe in oxygen and breathe out carbon dioxide. And it does have some defense mechanisms against irritants, but it can't make it through repetitive noxious insults over time like irritant chemicals without getting damaged. And in fact, significant lung disease has been reported when people accidentally inhale food flavorings over time, for example, in factory workers. And even more worrisome is that the concentrations of the flavors in e-liquids often exceed the occupational exposure limits recommended for the protection of workers who encounter these chemicals on their job. And the inflation of these chemicals is regulated in the workplace, but it's not regulated in e-cigarettes. And as Dr. Gogo was saying, we obviously don't have long term data about e-cigarette use over time the way we have about combustible cigarettes. The serious dangers of cigarette smoking were established much too late. And it was at a time when half of Americans were regular smokers. Pediatricians are worried that our nation will follow the same pattern with e-cigarettes. And based on what I know about other lung damage from inhaled irritants and what the early research shows with biomarkers in the lung, I have every reason to believe that people who regularly vape are at risk of developing chronic lung disease similar to COPD. The negative short-term effects in youth like repeated asthma flares, ongoing cough and wheeze are things that I've seen and that's concerning enough. You'll also remember in the summer and fall of 2019 that there were thousands of cases nationwide of a vaping related lung injury that was severe enough that people needed to be hospitalized, some needed to be on ventilators, some died. And a young athlete who was 17 or 18 years old had to get a double lung transplant. We also know that youth can have reactions that are similar to allergic reactions, which is something that I saw in my practice up here in an otherwise healthy 18-year-old who had been vaping for three years and had previously been a competitive athlete, but had to quit his sport because he couldn't exercise without coughing or wheezing. And his symptoms worsened over the course of three months. And during that time he wasn't able to stop vaping even though he was having difficulty breathing. He had to be admitted to the hospital for low oxygen levels and then he had to be treated with steroids for 10 weeks to calm down the inflammatory response in his lungs, the response that they had to e-cigarettes. And this young man's inability to stop vaping despite feeling sick and so short of breath that he had to go to the hospital speaks to how dependent his body was on nicotine. Nicotine withdrawal can cause headaches and poor sleep and irritability, anxiety, depression, and these symptoms make it really hard to stop using. Both teenagers and adults that I talked to talk to me about how hard it is to overcome a nicotine addiction. And so I want to talk a little bit about the way nicotine works in the adolescent brain because it's different from how it works in adults. Nicotine hits the brain while it's at this developing stage where the signals that are strengthening are those that are used on a recurrent basis. And so vaping delivers this rush of nicotine to the brain and in the brain it imitates a chemical that releases dopamine, which is kind of a pleasure and reward pathway. And then when these pathways are used over and over again, those behaviors are reinforced. So once the brain becomes dependent on nicotine, it will continue to seek other quick and easy forms of reward and pleasure. And this leads to increased risk for addiction to other substances. It might be other forms of nicotine like combustible cigarettes, and it might be another drug of abuse. The other long term impacts of nicotine on the adolescent brain include having a hard time paying attention impacts on memory and the risk of mood disorders and poor impulse control. So understanding these patterns can help explain why 90% of adult smokers started when they were teenagers. And it also helps us understand the pattern. But really concerning that show that youth who use e-cigarettes are more likely to go on to smoke combustible cigarettes, including those who especially said that they had no intention to become smokers. And that's really key because these are youth who start smoking combustible cigarettes eventually who weren't at risk for doing before. So we're not talking about youth who we can say, oh, they were going to start smoking anyway. This is a population of kids who weren't going to do that. Being epidemic is creating gender risk. It's going to take a long time. Policies like this one before you that will help prevent or delay the use of nicotine containing products should be a priority. Nutrition's parents and schools are struggling to support a large number of youth with nicotine dependence. The degree of widespread use that we're seeing is not harmless experimentation. And it's also not inevitable. Many youth show signs of serious nicotine addiction. And I've spoken with school nurses who have seen so much use in their high schools that they've considered one potential solution would be to have a blanket prescription for nicotine gum the way that they have for an EpiPen to just be able to give it out from their office as needed. If they have youth who are so irritable and distracted that they can't focus in class because of their nicotine withdrawal. The issue, though, is that we don't have a lot of research about how to support youth who are struggling with nicotine dependence. We can do our best to extrapolate from what we know from adults. So using things like nicotine replacement patches or nicotine gum. But this use is off label for kids under 18. As pediatricians we try to adapt and support youth however we can. And in fact I'm giving a presentation next month to try to teach people how to go about using off label nicotine replacement for youth when it's necessary. And I have to do that because of the scale of this problem of what pediatricians in our state are encountering. But then even if we prescribe nicotine replacement there's no guarantee that it's going to be effective and studies on nicotine replacement for youth with nicotine dependence from e-cigarettes has not been studied. The patient I described earlier who was hospitalized for a vaping related illness was still struggling to quit tobacco products three months after his hospitalization. And that was despite trying to use nicotine replacement. He didn't like the way the the lozenges made his throat feel and the patch was really uncomfortable on his skin so he wasn't able to tolerate wearing a nicotine patch for any duration of time. As pediatricians and other healthcare providers, parents and schools are scrambling for solutions to help nicotine dependent youth, but the most effective thing to do would be to prevent nicotine dependence in youth from ever occurring. We know that the tobacco industry has a long history of using flavored tobacco products to attract youth flavors are used to increase the appeal of tobacco and e-cigarettes by improving the flavor and making it less harsh. Particularly true for menthol. There is no public health reason to exempt menthol from a ban on flavors and the public public health data on menthol strongly support the need to remove this from the market. And as you have heard from others today, and we'll hear after me. This including mental and this band is really key for working towards eliminating health disparities. So in order to protect children from initiating tobacco use the Vermont Medical Society and the Vermont State chapter of the American Academy of Pediatrics advocates for complete removal of all flavored tobacco products, including menthol and menthol from the market. And this legislation can be a key part of that prevention work we make as we work to make harmful and addictive substances less appealing to youth to use. Thank you. Thank you. And we have, we have two separate sets of testimony from you on our webpage and so I followed along the, the longer written piece and I know you also have an outline of information and that's extremely helpful. Appreciate that very much. Welcome. I do want to just address quickly. Senator Cummings question about how this is different than other substances and I think the piece about the nicotine dependence is a real major part of this. And, you know, to marijuana cannabis and alcohol have their own issues with that but the way that nicotine works in the brain is really priming it for a lifetime of dependence and so the goal with any of this legislation with tobacco 21 is about delaying. As much as we can the start of using these are preventing use entirely during that really critical period of brain signaling development and I think that's unique to nicotine containing products. Thank you for that. That's helpful. And part of my concern is New Hampshire is right next door, and there is no penalty so I can go to New Hampshire.  I come back here and I can walk down the street smoking them without compunction. I mean, no one can tell me not to. It might, you know, the forbidden fruit it might. I could be really cool and if you were my friend I could give you some vapes. I have a problem with outlawing things and then feeling really good about we ban them and then walk away and not make sure that they did what we wanted them to do. That's, I'm concerned about Dr. Gogo's. I think it was your person, somebody's the grandmother I know people who are on oxygen and they take off their oxygen tank to smoke. They're highly addicted. We're just going to make their lives more, you know, how do we have a little compassion for those folks and it's trying to stop youth without having them go to something worse. And at the same time, I know last year the example of the guys and gals that come out of the AA meeting, and they're all standing on the step, and they're all smoking. You know the dual addiction issue and how do we balance those. You know, I asked about 20 different questions. No, for you, Senator. But they are important. I get for hearing this last year I can ruminate on it some more. So I, you know, I, every single one of our folks who has testified turned their screen on when you started bringing these issues up. We've got a few minutes where a little bit ahead of schedule, which is a good thing. And so I'm going to turn to Dr. Volante Volante first and if others would like to just really briefly comment. That would be helpful. You know, I think the thing that we have to realize and put in place is that this is not the solution. This is not the only thing. And this has to be done in connection with boosting our cessation resources, building out our efforts. This is a piece of the puzzle. This is a really important piece of the puzzle, but we have to create those supports and make sure those supports are in place to help people quit to keep kids from starting. You know, and I think that we are in a great place in Vermont, where we have a great quit line. We have support for tobacco treatment through Medicaid. We just need to get more people to those services and figure out how to how to support them in a more sustained and bigger way with greater reach. This is Dr. Phillip Gardner. Hi everybody. I emphasize what Dr. Volante said, when we work around the country on these different bills trying to get mental out of cities and other locales. Senator Cummings, we make it that you also have to include cessation services that are culturally appropriate. If you don't do that, then you're setting yourself up. I appreciate that this is only one step forward. But people need to have that ability to do that. And I think that should be, I don't know if that's part of this bill to increase cessation services or to make them available, then they need to be made available. Before the thing of walking down the street and smoking your. There should be the complete decriminalization of tobacco products we we've gotten down the road where we're arresting people for possession and use and purchase of things when they shouldn't be arrested at all for this stuff. We should prevent retailers from selling them. I would suggest. But let's not. It's not a risk kids for doing that. So, while I think it's a difficult step. And this come your point is well taken. Senator Cummings. We're doing this work in Maryland and then Delaware and in California and everybody say well I can just go here and I can just go there.  You're right the people are going to just do that but we started with the city we will do it at the county level we're doing it at the state level. We sued the FDA somebody at some point it's going to break. And this is just a step in the process. Thanks for that. And before we get to your testimony at other any other answers to the question Zoe. You're here we haven't heard from you yet but please if you can give a quick response to the question you heard that would be helpful. Hi, I'm Zoe become a youth advocate. And I think I can kind of connect to this question on a more youth level and why it would be effective on kind of preventing the youth use because right now the flavors are very they're very in and they're very cool they're part of the youth culture. And so taking away these flavors that make it appealing and enticing and more easy to use will kind of will take it out of the culture because they no longer have access to those flavors. So yes they can go out of the state but I think progress also has to start somewhere and it is always has to start small and has to start somewhere. So I think that the span will definitely be different because if we take it out of the out of their culture now and out of youth culture now they will set them up for more success in the future. Thanks for that when we look forward to your testimony and just a little bit so any other comments from those folks who have testified already. I think we, we, we hear the question. It's one of those it's fairly difficult to answer, but we do have we did get some data from from each of you that helps us clarify, and we appreciate that. Okay. Well, we're making terrific progress and we're actually right on time. A little bit before, before time and Dr. Philip Gardner is here with us and Dr Gardner Thank you so much I know it's early in California. Feel free to have your coffee or tea or what you need. I would like very much for you to introduce yourself for the record and then who you are who you represent and then your testimony and we thank you again for being here. Well, thank you Senator lines for having me. Good morning all again. I'm Dr Philip Gardner I'm the co chairperson of the African American Tobacco Control Leadership Council. I'm recently retired I retired last year from the University of California. I've been in tobacco related disease research program off to the president. I've been in tobacco control for nearly 25 years now and been fighting mental to get mental on the restricted list since the FDA and since the Senate passed the bill that excluded tobacco products over the last 10 years we've gotten to states over 65 cities to get rid of mental and while there's another hundred not excuse me another 200 or so that have gotten rid of flavors they have all kept mental. Anyway, so that's that's who I am. I have some slides I'm not sure how this works. I have you share screen. And put the Nelly can you give Dr Gardner. The share screen. You should have that ability already. Okay good. So you can, you can put your slides up and then we'll see them as you're scrolling through. Can you see my slides. Yes we can.  I've just told you who I was and I want to again thank folks for inviting me. I'm kind of sitting at an angle if I step back like that the sun is coming up and it's kind of just is great it's beautiful but it's quite interesting. Having said that, I'm going to start it with some factual information about what mental is and what it does I think sometimes this gets lost in the sauce and we talk about this. Oh it's a flavor over flavor I would suggest to you that it's the ultimate candy flavor. And I would suggest to you that it helps the poison to go down easier. And many of you already have probably pointed out at mass the harsh harshness taste of smoking, but also has cooling sensation and it activates taste buds and cold receptors in your mouth and in your throat. It increases throat grab. It's interesting it activates the same taste buds that capsaicin does which is the active ingredient and hot sauce. So there's a little bite to it a little grab to it. And so by definition is an anesthetic. That's what it is that's that's its chemical. That's what what it is. When we use the term mimics bronchial dilation because of the anesthetic effect you feel like you can inhale deeper and you do it more. The deeper you inhale the more nicotine you take in. When you smoke inhibits nicotine metabolism we have studies that show that when you smoke menthol cigarettes. Coating is what is metabolized in the liver. It takes longer for it to metabolize because of the menthol so people who smoke menthol have nicotine that stays in their body much longer. It's a group of big words independent sensory activation of neurotransmitters punchline is menthol cigarettes attract more nicotine receptors in the brain. The study done by Brody at all 2013 in fact we we the TRDRP where I used to work funded this study to find out that so why are menthol smokers why is it so hard to quit well they they have so many neurotransmitters in their brain they're flooded by menthol that they do. It increases salivary flow and trans butyl drug absorption another group of big words the punchline being if there's menthol in chewing tobacco. It crosses the gum barrier much more effectively. Greater cell permeability. That means when you smoke cigarettes and they penetrate the cells in your lung if there's menthol in the in the smoke it gets through the cell membrane much more effectively. This is why it makes it go down easier this this is not let's not kid ourselves this is a this is an anesthetic that is being put in cigarettes to help the nicotine get into the system, much more effectively. There's already we know of racial differences in the coat mean clearance. A lot of this we think has to do with that black folks disproportionate use menthol cigarettes. I published my colleague for as a stop late LL sale. The coat mean stays in the body longer in blacks, it has a longer half light. And even though this goes back and forth the last little one the amount of nicotine and cigarettes. This is varied over the years but generally speaking, most menthol cigarettes have more nicotine in the cigarette. People don't obviously know sometimes the punchline here mean the darker your skin means the more nicotine you store in your body, the darker your skin the more nicotine you store in your body. So even, you know, it's obviously true for African Americans, but for any other people that for any other color people that stays in your body longer. The tobacco industry has known this for years, and it's only now in the last decade that we've come to know this. menthol is harder to quit. I love this study there's actually a number of studies that show this that mental folks try to quit more often. That's my little thing try to quit more often. You're less successful at it. The word on the street, you know, to be a little non scientific is that you're trying to get off two things you're trying to get off the nicotine and you're trying to get off the menthol. Menthol the new cigarette choice, Dr valentes great study of 2016 punchline although overall smoking prevalence has declined the prevalence of mental cigarette use in the past 30 days has increased. We're going down pretty significantly but mental use was going up 35% between 2008 2010 and 39% between 2012 and 2014 from the same study that mental cigarettes and used among adults it's increased in all ages. All ages of people who smoke are using mental cigarette. Again, my colleague, Dr valentes study and the third thing from her study. And while African American prevalence has remained constant and high whites have increased at Asian Americans and Hispanics. All smokers are choosing menthols these days, people are choosing flavors flavors help the poisons go down easier and that's why we should get them out of cigarettes and I appreciate someone to put. Dr Andrea put it best. This is just one step but it's a very important step. What we have today with the electronic cigarettes whether it's the cigarettes, the tanks or the pods is that they're all, they're all about flavors. 15,000 flavors involved. And while I will talk a little bit in a moment about what the FDA is done or not done in terms of this be aware that flavors are us. That's what's going on. Flavors generally recognize this safe that's what grass is not for inhalation. If you take anything away from what I have to say today it's this slide. Aldehydes toxicologically or primary irritants of the mucosa of the respiratory tract. That's what flavors are there. They're an irritant. The lungs have a different spectrum of toxicity than the intestinal tract substances known to be safe when swallowed and still be dangerous when inhaled. This is an extremely important distinction. Think of think of it this way.  And it ends up in your liver. When you smoke something doesn't go through any of that. It goes to the bottom of your lungs and to the top of your brain. Within seven to 10 seconds. So, yeah, they're not generally recognized it's safe. Aldehydes cause respiratory inflammatory inflammation and pairs immune cell functions deregulates anti toxin responses increases susceptibility of infection and contributes to emphysema and COPD. These are what flavors are there aldehydes they're irritants. And cinnamon maldehyde in E cigarettes. We are at this is that this is a recent study of suppresses bronchial epithelial cells cellulomotility deregulation of mitochondrial function with essential respiratory defenses down inhalation of cinnamon maldehyde made increased the risk of respiratory infections and cigarette users. Just straight up. Some flavors more dangerous than others. So here we have, and to make a long story short, the combination of viscosity V liquids in some classes of chemicals and sweet flavors may increase the risk of karyogenic potential and of course, when I read this study the first time and I was oh they're talking about cardi they're not talking about cardi they're talking about gum disease they're talking about cavities in your teeth. And I have to look up because I just immediately thought it was a party cardio but it was a carry out. These are these are sweet flavors this is what they do. As you all heard about popcorn lung. This is the diacetyl what is put into microwave popcorn gives it, you know, butterscotch taste buttery cheesy taste. We know that this flavoring induces lung disease, the tiny bronchial passages located near the air exchange of the alveoli become gradually scarred and shut. One can become progressively shorter breath due to this absorption. The diacetyl has been found in many cigarette vapors especially sweet flavors. We all know the case in 2012 for the folks at the microwave popcorn plant I believe it is in Missouri. Actually we're exposed to excessive amounts of diacetyl one person died of it for people were permanently injured from it. Let me put the not too sharp of a point this is also a health disparity issue and a social justice issue. Many people that sell eliquids actually know this about diacetyl and take it out. But the cheaper you go, the more you're going to find diacetyl in it that means your poor people your people of color, your, your disenfranchise are going to be exposed to this flavors in the heart and I know Stan glance wants me to do 14 slides on this I'm going to just do one. Flavoring so popular with kids and young adults are cardio bad and they disrupt the heart's normal look electrical activity. This is study was just done last year. We know that these are flavors, all the stuff is about flavors. My favorite slide of all time. This was a sacrificial lamb. I would suggest to you that the, the family smoking prevention and tobacco control act that was enacted in 2009 may have been a deal with the devil. This was a deal cut by Philip Morris Southern Senators, and yes some representatives of the tobacco control movement. It eliminated 13 flavors and cigarettes, but excluded mental. It essentially tossed African Americans women youth native Hawaiians Filipino LGBTQ folks Puerto Rican behavioral health folks with issues under the bus. Why did they keep mental think think about that for a minute. Why was mental kept. Why is this whole discussion going on to answer that at the end that somebody should think about it. First we fought back against that New York Times ran an article in 2008 saying menthol was getting a pass. Joseph Califano and Louis Sullivan sent a letter these are past HHS heads sent a letter to every member of Congress saying it was discriminatory to do this. John A Christensen got an amendment passed in 2008 that the first order of business would be to issue a report on the impact of the use of menthol cigarettes on the public cells including such use among African American Hispanics and other racial and ethnic minority. That tobacco products scientific advisory committee report came to the conclusion that the removal of mental products from the marketplace would be beneficial to the public cell. This report was sat on until 2013. They did they meeting the FDA did an internal report that came to the same conclusion in 2014. The tobacco industry suit to prevent the use of the tips that report. And then we all kind of stood up and took notice that in 2017 FDA Center for Tobacco Products took the bold step of including restrictions on the selling of menthol and all flavors in the newly deeming regulations that brought cigarettes, cigars, cigarettes, and the like all under their purview. And even though it didn't, didn't include cigarettes, they all they had a, they had a 16 pages appendices talking about flavors should be removed from all of these products that they just brought in. In order to add insult to seven years of inaction and injury see the 16 pages of the new deeming regulations were redlined and deleted by the office on management and budget that pertain to flavors and mental, thus again exempting mental. We found out that Andrew Pruitt, who worked in the White House Office on Information Regulatory Affairs at the Office on Management and Budget from 2008 to 2014. He oversaw the FDA and USDA policy relating among others to things to tobacco. He quit in 2014. He was hired by the Cigar Association and enjoy in 2014. He quit them in 2015 and was rehired by the White House to serve on the OMB in 2015. The punchline here being this is the person who redlined the 16 pages we, we've got a smoking gun, no pun intended. I mean pun intended. Where are we today, I would suggest to you that it's a hot mess. The agency does not allow any prefilled flavored vape pods that snap into vapes like jewel they're trying to deal with jewel jewel jewel. But what they went on to say and it's still allowed. All refillable flavor vapes like surron and smoke are still available. All single use disclose of flavored vapes like puff bar are still available why have an asterisk there. The FDA is cited puff bar, not for using all 15,000 flavors but excited them for not making their product wasn't on the market before 2016 therefore they're out of compliance. So it's a technicality but at least they're being sued but they're not being sued for the 15,000 flavors. So they prefilled mental and tobacco flavored pods. Other thing to keep in mind the FDA could rule later on that some of these pods are flavors are fine, and they can be back on the market. So I, it's, it's, and then this is what's going on nationally each locality and state has varying degrees of things going on. It's in the fight against mental. Of course we just mentioned the family prevention tobacco control act 2013 Chicago passed the first mental regulations to prohibit selling mental within 500 feet of schools. I've mentioned to you the deeming regulations of 2016. In 2018 San Francisco passed the first citywide prohibition on all flavored tobacco products period in the discussion, of course the tobacco industry suit and etc, etc, etc. Now there are people there over 65 cities around the country that have adopted the San Francisco model. In 2019 we went and testified on the HR 233 the Pologne bill, it passed the US House of Representatives and of course set on the floor of the Senate. And Mitch McConnell's desk for it's still there on the floor and there's still a discussion, what we have to revive it to bring it up. As you are acutely aware in 2020 Massachusetts passed the first state to pass mental restrictions. In June of last year my organization the African American Tobacco Control Leadership Council and action on smoking and health suit the FDA for failure to take steps on mental. We have subsequently been joined as plaintiffs by the American Medical Association and the National Medical Association. And just as past August California passed SB 793 that we get rid of all flavor and mental products of course the asterisk is there as you all know that we are being sued by the tobacco industry, or said another way they've taken a referendum to the ballot. That's supposed to go on the ballot in 2022. If you're into the details it might come up in 2021. Where we are today. 207 jurisdictions have flavor restrictions. 65 jurisdictions have mental restrictions to states have flavor and mental restricts of Massachusetts in California. We would love for Vermont to be the third. Take home messages, mental is the social justice issue and even though I haven't talked a lot about African Americans. Which I normally do I figured out, given the small percentage African Americans in Vermont may not seem like appropriate but the punchline is that the disproportionate marketing and targeting of candy flavored poison the African Americans and other people especially oppressed sectors of our society is outright discriminatory genocidal. The poorest, the folks that are the least informed with the fewest resources, indeed the definition of train on the most vulnerable section of our society is what the tobacco industry. If mental were banned hundreds of thousands of lives would be saved I think this is in response to some of the questions raised by Senator Cummings. If only 30% of the people who smoke menthol cigarettes only 30% that's meant to be 80% but just 30% half a million lives would be saved. Quarter of a million of them would be African American. So what's at stake. It's our future and our children's future classic picture young man surrounded by surround literally surrounded by tobacco industry advertising. With that I want to thank you. I know many of you have heard this before I've kind of come in a little bit different. Let me just go back to and say I'm going to stop sharing my screen. There's no left out. Why are we having this discussion of, I would love to hear what people think about that. Dr Gardner Thank you so much. Your testimony is always enriching and very welcome. And I think your approach this time was equally effective as it has been in the past. So thank you for that. So you've asked everyone a question about thoughts on menthol but I think before we get to that stage of discussion I'd like to see if the committee has any questions of you. Any questions. Senator Hardy. I don't have a question this is the first time I've heard this testimony and all of this testimony because I'm new to the committee so this is really helpful for context for me. I just want to thank you especially for your connections to the sort of, for lack of a better term I'm not I'm not a doctor so the biological connections between menthol and smoking and how it impacts the body and the the connection between menthol and melanin was and nicotine was really fascinating so I just appreciate that information it's not something I'd heard before and I find it incredibly fascinating so thank you for that. Thank you. Other other comments or questions from the committee. The question that you have raised Dr Gardner is. What do we think about menthol can you maybe a little bit. Yeah, let me restate it. Thank you. Please. Yeah. Why was mental left out of the deal. What, what, what, what's the reasoning there. Let's let's ask the committee that question I think they're probably the folks who have testified. I have answers but let's, let's see, does anyone from the committee wish to address the answer. If not I certainly will. So we're going to go with Senator Hooker and then Senator Hardy. It's pretty obvious Dr Gardner when you talked about Andrew Perot, and you know the politics that was involved there so you know, that's always top on the list and the fact that the legislation still things haven't moved. I know that in the last session I wasn't on this committee either, but I had people talking to me about the fact that we were being discriminatory against African Americans because they tended to use this, this product more. And so if we did away with menthol then they'd be left without essentially without anything except maybe just regular tobacco. So I think politics has a lot to do with it and I'd like to hear your comments on that. I actually appreciate that I didn't bring that up in my talk. There are three points that are being made by the tobacco industry that if you get rid of menthol cigarettes you're being discriminatory or racist toward black people. Nothing could be further from the truth. It was menthol that was pushed down the throat of our community over the last 60 years. My general slide that I use with this that in 1953 only 5% of African Americans use menthol cigarettes. By 1968 it had almost tripled to 14%. By 1976, yeah by 1976 it had tripled again to 40, 42%. By 2005 it had doubled to over 80%. Today over 85% of African American adults use menthol cigarettes. Where did that come from? They were cheaper in our community. There's more advertising in our community. There's greater promotion in our community. We get sport figures that talk about it. They took, they got jazz going on. Look at it this way in the midst of the civil rights movement when people are being hosed and dogs attacking them. We're putting in place in North Carolina black executives at Philip Morris and RJ Reynolds and Brown and Williamson to put to run this forward. Where did this come from? The short story is they found a market when folks after the Second World War moved to the North in this segregated society. There were different products for these segregated folks. There were different hair dressings. There was different foods. There were different clothing. And again, after they did focus groups in the 50s, they found out that there were different smokes for different folks. They found that the messaging on television was being more readily accepted by African Americans and they began to pour money into television. When the March on Washington is going down in 1963, we have black people in commercials selling cigarettes.  The tobacco industry is clear what they're doing, so that's their first point that we're being racist. Their second point, well, what about the unintended consequences? They essentially mean that there'll be more interaction with the police. And as you heard in my presentation, we need to decriminalize all of this tobacco use in terms of that. And I like to say that in terms of unintended consequences, look at what the intended consequences of smoking. Half the people who smoke, 50% of the people who smoke regularly die from it. There's a period. They have to replace those people. That's the intended consequence. Whoa, thank you. Terrific. And you want to ask or make a short comment to answer that question on men fall. Yeah, thank you. I'll be quick because I know we have other witnesses I want to hear from here. I think the conversation from my recollection from last year just specific to our conversation about this bill last year was one of the things that I heard was menthol is an adult flavor. And the other ones are kid flavors. And so it's, it's, you know, easy for us to say we want to protect kids from the kid flavors and the kid marketing but menthol is really an adult flavor and that was a distinction that I heard when we when this bill came up last year. So, just in short, what we know today is that kids disproportionately use other flavored products, but we have even more recent data and Del Monte might be able to correct me on this or Andrea. So somewhere in the neighborhood of 40 to 50% of youth who are using tobacco products are using mental in their vapes and and and and the like so that doesn't play that way and the last thing I'm going to say about this, even if it's an adult flavor, it's adult people are dying, particularly African Americans it's not like oh let let them die. I answered my question that I'm going to shut up and we can get on with the other testimony. Look, the punchline is this, the tobacco industry in the United States, it was calculated in 2018 somewhere to be in the neighborhood of $220 billion industry. The FTC and yet you can look it up and I can send you the link the FTC shows that 36% of all cigarettes sold are mental. So you're talking somewhere in the neighborhood of a $70 billion. That's what this is about it's not about human lives don't care about black folks or white folks are that better. If you've got if you took 10 years ago if you took mental off the market the tobacco industry would be severely injured. So let's keep that let's keep it on there and even though it disproportionately kills black folks and other folks. So what. That's a deal that was made with the devil. They did it because it was profitable to them. That's why they keep mental on the mark that's where we can have a discussion. Thank you very much. My answer was going to be it's all about money, among other things so we'll I, you know, we probably all could have a really terrific conversation and maybe at some point, we should regroup our witnesses and not just you folks who are here but the other witnesses who will be hearing from in the future to to have a discussion. So today it's important for us to keep moving along and we do have the Monte Jefferson who is here with us and thank you for being here. Mr Jefferson. We look forward to your testimony and would be happy to have you introduce yourself for the record, and then go from there I don't think I see anything from you on our web page, though you may have sent something into Nellie I'm not sure. Yes, I did. Yes, I did. Thank you. All right. Well, it's all yours. Thank you so much. Thank you so much. I'm Del Monte Jefferson. I'm the executive director of the Center for Black Health and Equity. Our organization used to be called the National African American Tobacco Prevention Network. I've known Dr. Phil for over a decade since this whole fight to to reverse, you know, when the Senate left out menthol from that legislation we've been working to overturn that so that's, that's over a decade and then it's, it is funny when you say it that way Dr. Phil over a decade, you know, 10 years that we've been working to overturn that. It's very interesting. It's very interesting. I'm speaking right now I've got the liberty to answer Dr. Phil's question. He said, why, hey, why was men thought the left what's this all about. And you know we do a presentation. We say that mental banning men thought could be an end game solution to tobacco use. If you banned men thought you can end tobacco use and that epidemic in general. And so no, no one, no one on that money side wants to do that as Dr. Phil said, yeah, it's a $70 billion industry just for the men thought sales, but men thought if it's a starter product that you do through those other tobacco products as well. Men thought is accountable for that whole $220 billion industry so yeah money money Senator Lyons is a huge factor as to why than any men thought doesn't happen and it's not happen. Each year, you know, we have about 45,000 African Americans dying from a preventable smoking disease. And this is what we've been working our organization was founded back in 2000. And that's what we were doing we were trying to what wait a minute how can we address this because that 45,000 number of African Americans dying is not a good deal how can we say these black lives and so we wanted to build communities of capacity, the capacity of communities of color to be able to advocate for policies that are going to promote optimal health. And when we talk about promoting optimal health. We really talk about something and I heard earlier, you know, how do we look at the intersection of health, social justice and economic empowerment they're all tied in together. And I and I and I've got to do this other commentary since I have the floor right now. I'm encouraged. I'm encouraged at what I've heard this morning. I'm really encouraged because 10 years ago, 10 plus years ago. When we were saying, hey, wait a minute, you've got a bad man thought our group nappin was saying it at that time we were caught nappin and the African American Tobacco Control Leadership Council was saying it at that point in time. Nobody else would listen to us. Nobody else was saying it nobody else was echoing it. And so you know I we get funding with CDC and so we do a lot of programs and with the states, and we were saying wait a minute guys you got to address mental. We went to the FDA time and time again and said FDA, you've got to do something about mental. And there was crickets. There was silence. No one did anything. And so this morning when I'm sitting here and I'm listening you know I have my screen with it on the I was listening, and I'm hearing speaker after speaker, doing great presentations using the same data the same information, you know, and I was encouraged I was really encouraged by what I've heard today and that that Vermont is trying to go into this next, this next effort of banning statewide mental and other tobacco products. I always have to say this. Why does our organization why do we focus on mental I mean, yes there's other health issues there's all kinds of health issues that African Americans and other people of color face all kinds of disparities out there.  And we've heard this we've heard about the advertising. We've heard about the cigarette sampling vans and and Dr Phil was just talking about silver rights is happening. And they're saying go ahead and smoke, go ahead and smoke. And then you know even in our reports, not just us the surgeon general they came out with all these reports that talking about how the mentalated flavoring increases the addictive potential and then how the fruit flavors and the seeds, they use this marketing tools. This is the federal government saying this this isn't us the federal government is saying, yes, menthol is used to addict people to smoking. So we focus on mental they focused on us, we're going to focus on them. And then you know, there's this national movement. So what you guys are doing here in Vermont is outstanding because there's a national movement to restrict the sale of mental and other flavors. It wasn't like this 10 years ago, 10 years ago, we were making plans that Dr Phil and Carol Gruder and Dr Yerger, we're going to sit down have a sit in at the White House in front of the White House and possibly get arrested and then my group was going to go and bail them out. That was the movement then, you know, we were going to get arrested and get bailed out before Chicago happened before Chicago, you know which banned the sale of menthol around the buffer zone and Chicago, we are going to get arrested. But since then, over 300 different localities across the US have put on some type of restrictions on the sale of menthol and other flavored tobacco products, at least 100 of these communities restrict the sale of menthol. In addition to other flavored tobacco products this is huge. And we already talked about of course the two states Massachusetts in California and Vermont will be the third. Now, this is also an answer to Senator Cummings question we just I just added this in what we were talking here. The FDA is the only entity that has the authority to ban menthol. A state of locality can't ban menthol you guys can't do that, that only sits within the FDA so you can't ban menthol now you can ban the sale of menthol. You can ban it you can restrict it to certain places to certain locations and so you're not banning menthol. So to get that out because you can't do that you can't ban menthol. Only the FDA can ban menthol but you can have it sold in certain places and you can have it if you want it to have it sold in certain places adult only stores or whatever it is in Vermont so that people don't have to cross a border and go to another state to get it. So if you know just in case you know that comes up. Remember, you have the authority to ban the sale, but not menthol. And you know, I think Dr Phil covered this but don't forget menthol is in every single tobacco product you have out there some traces are smaller a lot smaller than others. So for it's a characterizing flavor, but there's some level of mental because of the same science that Dr Phil talked about how it makes it easier for that poison to go down. It's in chew it's in snuff it's in liquid it's everywhere menthol is everywhere.  Now, you know and I'm just going to talk a little bit about the equitable enforcement because we got to make sure. You know, if we're trying to have an equitable policy like Bandy menthol and we've already talked about Dr they talked about the cessation which you know, great. The banning the sale of menthol is great that's that's almost like the COVID vaccine. That's the cure.  All right, but you still have to wear a mask right now. And so you still got to have cessation efforts. You can still got to have all these other pieces that are part of the puzzle. The ban of the sale is not the end all and beyond you got to have all those other pieces now and again why did we need equitable enforcement. And I'm just going to throw out three names we can talk about more but we're going to say Eric Connor we're going to say Sandra Bland we're going to say George Floyd, and we know what they all have in common cigarettes, cigarettes. First of all, there's several things they've been in common actually.   Secondly, secondly, they're all dead. They all died at the hands of law enforcement. And thirdly, all of them and their encounter with law enforcement has something to do with cigarettes that's amazing that's amazing. All black, all died, and their encounters had something to do with cigarettes so we have to got to make sure that we're addressing equitable enforcement so that we don't have this because we know we saw we witness. In the summer we witness what happened, you know, when that unequivocal enforcement happened over cigarettes over menthol cigarettes we saw what happened we saw the protests we saw the rise we've seen our country turned upside