 So Jennifer, Elizabeth, and Tina are all here. Tina's not here yet. Oh yeah, you are. I don't have the glasses on the way, do you? OK, so do have a preferred order to testify, but we'll just go down the list, otherwise. I think it makes sense for me to go and then Tina. OK, perfect. And then Elizabeth? OK. OK, I don't see her. I don't see her father from New York. No, no. So we're taking testimony on F2A April, and act relating to burning flavor tobacco banning flavor tobacco drugs. Yeah. Yeah. Tell you what. That's so funny. Tons, more than one. Burn them. Sorry. You're all home. Thank you. Thank you for having me. And I do have a PowerPoint that I believe is attached. So we've got four different things from you. So is it ending the sale of flavor tobacco that we're looking at? I'm not sure if it's the first you're saying that. Testimony? Yeah, that's your point. Any that sale flavor tobacco. So I did some recent written testimony as well, but I just need you to follow on with the PowerPoint. OK, perfect. So Jennifer Costa, government relations director for the American Cancer Society Cancer Action Network. I want to start by thanking the committee for allowing me to testify this morning. And also for taking the time, I know that you're considering a lot of issues, but for spending the time on this critical public health issue. So as the chair said, I'm here today to talk about ending the sale of flavor tobacco. The American Cancer Society Cancer Action Network, or ACS-CAN, which may be referred to the organization later as supports ending the sale of all flavored tobacco products with no exemptions. So that means all flavors, including menthol and all products. So that means the whole variety of e-cigarettes, whether they're clothes, pod, an open tank, and regardless of their nicotine content. Menthol cigarettes, which is the only legal cigarette flavor still allowed on the market, and other tobacco products. So you're talking your two snuff, roll your own, cigarillos, dip. You go to the next slide. Why are we talking about this now? We can see that flavored tobacco as a racing years of gains Vermont has made in tobacco prevention and cessation. I'll reference that later as I talk about the results of the most recent youth risk behavior survey that just came out last week. Smoking remains the number one cause of preventable death, both in the United States and in Vermont. This year alone, in Vermont, smoking will kill 1,000 Vermonters. And if smoking rates continue at their current rate, 10,000 Vermont kids alive today will die prematurely from smoking related illnesses. And also, I can underscore that smoking is expensive. I'll go specifically into the numbers in just a minute, but suffice it to say, smoking is costing Vermont hundreds of millions of dollars every year. And most importantly, flavors, hooks, kids. I wanted to see if this worked. I talked to Dory about how we could do this. I wanted you to hear in kids' own words, this is, there's a link. But I think if I play it, it's only one minute. If I play it, there'll only be one sound rather than everybody trying to do it. So this is from the counterbalance campaign. That's the health department's youth campaign. And it's, can everyone see if you think he can? Yeah. OK. And that's why I'm against the dog leash resolution. Next, we have Kali. Kali. Hello, Vermont decision makers. I'm here with my friends in the counterbalance campaign to tell you how kids like us, we, and cigarettes, they're still a bunch of two out of three kids say they use these products because they come in flavors their life. So are you going to take action against flavor tobacco or just let more kids like us? So that's from the health department's counterbalance campaign. We can switch back over. Onto the next slide is tobacco's price tag. When I saw these numbers, they were quite astounding. So smoking costs Vermont $348 million each year in medical related expenses. When you look at the Medicaid costs, those are almost $87 million a little bit more than $87 million Vermont Medicaid costs caused by smoking. When you look at productivity losses in Vermont, smoking costs $233 million a year. And so what does that mean for Vermont taxpayers? The state and federal tax burden for smoking costs government expenditures is more than $700, $750 per household. And I just wanted to point out that these numbers don't even take into account exposure to secondhand smoke, smoking caused fires, smoke with tobacco, cigar or pipe smoking. And then if you look at what big tobacco spends, nearly $17 million every year advertising their deadly products in Vermont. The next slide. This is critically important to the American Cancer Society Cancer Action Network because we know that flavors hook kids. Flavors are a marketing weapon that tobacco industry uses to lure kids into a lifetime of addiction. Tobacco flavors like cherry, grape, cotton candy, gummy bear are clearly not aimed at adult tobacco users. Years of tobacco industry documents confirm that the intended use of flavors is actually to target children. And altering tobacco products, ingredients, and designs like adding flavors can increase a product's appeal. And how is that done by masking the harsh effects of tobacco making the inhalation of nicotine that much easier? Consequently, and I guess it's no surprise, the youth say that flavors are the leading reason they use tobacco products. And they perceive flavor products as less harmful. The next slide. And flavors are a big business. Flavor-D cigarettes have flooded the market. More than 15,500 distinct flavors are now available to consumers to show the explosive growth in this industry. You only have to go back a few years. One of the studies shows that in just 2014, there were 7,700 flavors. I didn't even know that there were 7,700 flavors in general, let alone 15,500 flavors. But that's where we're at now in 2020. And if you look at some of the most popular flavors, they're clearly not aimed at adults. That's why I just put some of, so you can get a sense of what's out there, put some of the flavors on there. Gummy bear, mango, birthday cake, s'mores, crème brûlée, cotton candy, unicorn puke, which I didn't even know what that tastes like. Very, very slushy, apple pie, strawberry shortcake, Skittles, and buttered popcorn. Unicorn puke. Next slide. The American Cancer Society Cancer Action Network is an evidence-based organization, so we make all of our decisions rooted in evidence. And so if we look at the statistics, one of the most telling statistics is that more than 80% of teens who have ever tried a tobacco product started with a flavored product. More than 80%. And so if you look on the other side of the screen, if the CDC looks at current use, so the first statistic was ever use. Have I ever tried a tobacco product? So more than 80%. Some statistics studies even go up to 90%. But the CDC looks at current use. So seven out of 10 middle and high school students who currently use tobacco use a flavored product. And then there's a breakdown there. I know that I'm throwing a lot of numbers at you, that's why I thought it was easy in the PowerPoint, so you can go back and reference those. Yeah. Great, thanks. Next slide. So what is the impact here in Vermont? We see youth tobacco use rising. More than one in four Vermont kids now uses some form of tobacco. And just a minute we'll go deeper into the numbers, but that does show a market increase from just two years ago. Can you go to the next slide? The Vermont Youth Risk Behavior Survey, I think you all are familiar with it. Surveys thousands of Vermont students every two years. And so since I started with ACS-CAN, we've been referencing these 2017 numbers. We thought a lot of it was under reported and unfortunately our predictions are true. And so we can compare numbers from 2017 to 2019 now. And so the first slide is ever tried any flavored tobacco product. In 2017, 21% of high school students had ever tried any flavored tobacco product. Now we're at 27%. So that's an increase of 6% in just two years. If you look at even younger children, so under the age of 13, 10% in 2017 had tried a flavored tobacco product. Two years later, we're at 15%. So again, we're looking at increases of 6% and 5% in just two years, which is huge in the world of public health. In the next slide. So this is ever tried an electronic vapor product, fancy term for e-cigarette of all different varieties. So in 2017, 34% of our high school students had tried an e-cigarette. Now we're up to 15%. So not only does that represent a 16% increase in just two years, but what it's saying is one out of every two high school students has tried an e-cigarette. And if you look at the grade levels, as kids get older, the more likely they are to try it. So we have nearly 60% of our high school seniors trying an e-cigarette. And you can also see in the graph at the bottom from 2015 to 2019, every year there's a study and concerning increase. And in fact, in 2017 to 2015, you see how much it jumps. And the one thing that changed that I should point out in that time, when the survey was issued to students, it was right around the time that Juul hit the market, but it had not really come into popularity until a couple months after that. Except about 2017. Yeah, so what happened between 2017 and 2019 is Juul specifically hit the market. And then if you go to the next slide, it's current e-cigarette use. So this is not every use, this is children who currently use it. We have been referencing this number, you've probably heard myself and my other colleagues in the Coalition for Duwack of Fevermont talk about 12% of high school students are vaping. Well, unfortunately now that number is 26%. So in two years, we have more than doubled our amount of students who are vaping. And again, if you look at grade level, we have 34% of high school seniors. So more than one out of every three high school seniors is currently vaping. Is WNH and SOC that work in students of color? Yes, sorry, I should have said that. Yeah, so you have white, not Hispanic, and then SOC as students of color. And then heterosexual students who identify as heterosexual and then students who identify as LGBTQ, and you will see over and over again that students who identify as LGBTQ have higher rates of tobacco use, which is also concerning. And the next slide, this is the frequency of use. So not only are we concerned with if students are using, but how much are they using? And there's a startling difference here as well. If you look at 2017, the majority of kids were using their e-cigarette one to two days out of a whole month. Now the majority are every day. So it flip-flopped, one to two days was 37%. Now 31% is every day. And if you look at the pattern at the bottom, has a graph of 20 days or more. So not every day, but that's fairly consistent use is vaping 20 days or more. Down in 2015, we only had 13%. In 2019, we're up to 43% of kids in this age group. This is all Vermont-based data. This is all Vermont-based data. This is from the most recent Youth Risk Behavior Survey that was released last week. Right, so when we're talking students of color, we're looking at students of color in Vermont. Students of color in Vermont. And the same with the LGBTQ. Correct, these five slides are all Vermont-based data. That just came out. So we see now we have of the students who vape 43% of them are vaping on 20 or more days. And again, we have higher rates of use significantly for students of color and higher rates of use for students who identify as LGBTQ. 20 days a month? 20 days of a month. And so when you break it out, I guess you have got gender, you have males and females. For some of the other statistics, gender doesn't seem to matter here that you do start to see a difference with males that 47% are using on 20 days or more and females are at 38%. And if we're ready, we can go to the next slide. The next slide is current tobacco product use. So this is overall, this is looking at the number of high school students who use e-cigarettes, cigars, smokeless tobacco, e-cigarettes over the past 30 days. And again, we have been using this figure of 19% of all Vermont high school students use some form of tobacco. Well now we're at nearly three and 10. We have jumped 9% in two years to now we have 28% of kids in Vermont using some sort of tobacco. So you can really see how we are going backwards and our progress in youth prevention and cessation is being erased. And you can see it by, so here male and female is pretty much the same but if you look at grade level age matters and as the kids get older, you see a significant rise in how often they are using a tobacco product with 37%. So nearly 40% of our high school seniors are using some form of tobacco. White non-Hispanic and students of color about the same, they are the same here but you do see higher use for students who identify as LGBTQ. And moving on to the next slide has a glimmer of good news. So this is current cigarette use. In 2017, we had 9% of high school students smoking. Two years later, I'm happy to report that we're at 7%. This is the one place we've seen a decrease of 2%. And that chart there is nice because it shows a variety of substances. So you can see that that cigarette's use is going down whereas there's a sharp incline in EVP is the electronic cigarette's the electronic vapor product. So were they just trading? What's happening around the country? I thought this was important to talk about. Massachusetts last month, it may have been two months now because it's January, was the first state to ban the sale of all flavored tobacco products including e-cigarettes, menthol cigarettes, cigar pipe, another loose tobacco and chewing tobacco. That's the big highlight of their law. But other things that it did, it did a variety of things. It was a huge omnibus bill, but it increased retailer fines for sales to minors from 100, 200 and 300 to 1,205,000 respectively. So they're taking that really aggressively. It earmarks a percentage of the revenue collected on the civil penalties to their tobacco cessation program and it goes into effect on June 1st of this year. But I also wanted to point out that more than 230 localities restrict the sale of flavored tobacco products. The laws do differ by the application to specific products in stores, but at least 60 of these localities do restrict the sale of menthol cigarettes. And that link at the bottom will allow you to look to see exactly where this is happening. It links to Tobacco Free Kids, which tracks this very regularly and updates the site. So I'll just go to the next slide. Do you have a list of some of the localities that have restricted? Yep, so if you click on that link. Oh, okay, we can do that. Yep, it will take you. We're not gonna need to do it now. Thank you. So in conclusion, again, the American Cancer Society Cancer Action Network supports ending the sale of all flavored tobacco. We do not want to erase the progress we've made so far. Vermont is a leader in tobacco cessation and prevention efforts. We want to keep that going. We see that cigarette use is the only area in terms of tobacco use that Vermont improved in 2019. So I can't trust enough that we cannot leave any flavors on the market and that includes menthol cigarettes because we know whatever flavor is left on the market is where kids will turn to mask the harsh tastes of tobacco. We want to place blame where it belongs and that's on the industry selling addiction. The evidence shows that penalizing a user is not effective. Purchased use and possession provisions or pop, you may hear them referred to, are disproportionately applied to communities of color. The very communities who have been targeted and marketed to by the tobacco industry. Holding kids responsible is a tactic that tobacco industry supports while at the same time continuing to market their deadly products to those kids. So we believe that ending the sale of all flavored tobacco will make it harder for the tobacco industry to target children into a lifetime of addiction. The American Cancer Society Cancer Action Network is part of the coalition for Tobacco Fever Month so you'll hear from, we just decided to split up the testimony so we weren't repetitive. You'll hear from my other colleagues today from I believe the Heart Association and the Lung Association and Tina will specifically talk about menthol and why we believe it's critically important to include it in the bill. I think that's a big question that folks have around menthol, the question is, suppose you eliminate all the other flavors and leave menthol, what's the consequence to doing that? So, I'll hold my question. I'll hold that question. But we'll get there. And then do you have any data, will anyone be presenting information on the health effects that we've seen as a result of an increased use of flavors of these things? We'll get data on that. I'm looking for people to come in and testify on that but I was wondering if you had any of you or if I have comments on that. Pratina, BMS may have. We have two physicians coming in on Friday. So they'll have some of that data. I think that's important to write. Dr. Gugu speaking at the press conference tomorrow, we'll mention some of that there. Good, all right, thank you. And I did include in my testimony, there's a couple of fact sheets, one pagers on both menthol and flavored tobacco in general. Right, you've got four different things for us. So, any questions from the committee on the data? Go ahead. First with disclaimer, I think we kind of addicted to something that gives you deadly diseases is not a privilege. But the people who use these products experience that as a privilege. They choose to do what they find a pleasurable and became. So I'm going to be treating it as a privilege. This is vaping, it's a fairly, fairly rude thing. Probably. We'll need to start with stripping vaping. What we'll be doing is taking something that's sort of getting started up and saying we don't like where we're going, we're gonna stop. Going back to Machiavelli, it's easier to take away newly achieved privilege than to take away the privilege to which people are accustomed. So aromatic piped tobacco. Would this include aromatic piped tobacco? Anything that is not tobacco flavor. So any sort of, any characterizing flavor. Apple cured tobacco. I'm not sure, I would have to double check on apple cured. I don't get a lot of asking kids, it's so nice. Well, you know what, this is a good question for Jen Carby. Yeah, but the second thing is that mental cigarettes, I don't ever have any history. They do. I mean, and I could spend the next 15 minutes, talking about that, but they don't wanna steal Tina's thunder, but we believe absolutely that one statistic that I know that she'll reiterate is more than half of kids who smoke choose mental cigarettes. 50 years ago, I made my living as a booze singer and booze singers work a wire to smoke mental cigarettes. That's part of the deal. And something I should have mentioned about e-cigarettes that I may have taken for granted because we've talked a lot in this committee about e-cigarettes and the Joule specifically. Some e-cigarettes, most e-cigarettes contain nicotine. So in terms of addiction, but Joule specifically has some of the highest nicotine content. We know that Joule is what is most popular with kids. One Joule pod is the nicotine equivalent to an entire pack of cigarettes. And anecdotally, we are hearing we've in preparation for this session, we've met with several students, many of which you'll hear from tomorrow, but students, teachers, youth organizations. And anecdotally, we're hearing that kids are now vaping one to two pods a day. So in middle and high school, we're having cases where we have one to two pack a day smokers, essentially, because it's the nicotine equivalent. And so that is, it's a hard addiction to break. So that's why we feel strongly the sooner that we can get these off the market because we know that the flavor is what is enticing these kids with 80 to 90% trying flavors as their, flavors as their reasoning for picking up the product in the first place, the better for public health. Any other questions? Okay. Thank you. Thank you. I heard also that there were some cartridges that contain equivalent of four packs of cigarette of nicotine. I mean, I guess it's possible. Yeah. Okay. Okay. There's a lot out there. There's a lot out there. I know. There's a lot of information. So, Tina's up. The link on your, any of your little fact sheets any input link to the youth risk and health survey? The not-behavior survey? I'm creating slides from it, but not the whole thing. Okay. We can find it on the Department of Health website. I can also email right now if that's easier. Yeah. Just a little bit. Yeah. I should have, yeah. We were going to start and have the Department of Health to talk about that survey. The last one I'm going to use, which would be our online group. Yeah. Perfect. Yeah. Yeah. No. No. The one that's labeled. Eliminating. Oh. That would be fine. So my, if you want to follow along, the PowerPoint is what I'm going to be referring to in my testimony. I did send you some background documents just so you would have the citations for a lot of the facts that I'm going to say in my piece instead of kind of gunking up the PowerPoint. Which one is the PowerPoint? It says, it starts with eliminating the sale. Yeah. Oh, oh, beautiful. So thank you for allowing me to speak today. Tina Zook, government relations director of the American Heart Association, as Jennifer said, we tried to break it up so you didn't hear the same thing twice and focus on specific areas. I am going to talk largely about menthol cigarettes. I am by no means the expert. You are going to hear from some of the experts. Dr. Phillip Gardner is actually with me today and you'll hear his testimony tomorrow and he'll give you so much more information but I wanted to just provide some background. Yes. Dr. Gardner, welcome. I didn't know it was you. I just did a radio show together this morning so you raised back here and right here. So our organization supports the elimination of all characterizing flavors other than tobacco from tobacco products and we feel this is essential to reduce the appeal to youth. We strongly support the provisions in this bill to end the sale of flavored e-cigarettes as well as menthol tobacco products and we consider this legislation very strong in that regard. However, we know the tobacco industry has aggressively targeted certain populations with its market and including youth, African-Americans and we wanna ensure that those suffering from addiction aren't penalized twice by possession and purchase penalties so we would ask that the possession language be stripped from this bill and we ask you to consider including penalties on retailers that owners, operators, not the clerks who may violate tobacco laws as a much stronger enforcement measure. So some background on menthol. This is all full, thank you. I think some of us have talked about the possession piece and the clerk piece so and we have our ledge council here listening. Yeah, I think what we were leaning to is with the tobacco 21 legislation that you just passed last year, there's some penalties to retailers in there that seem like they would make sense. So Jennifer alluded to this, menthol I think sometimes gets forgotten. People think that flavored cigarettes don't exist anymore. It is the only legal cigarette flavor on the market. In 2009, the Federal Tobacco Control Act outlawed flavored cigarettes but it exempted menthol due to tobacco industry lobbying and it's troubling because menthol makes cigarettes and you'll hear more about this from Dr. Gardner, makes cigarettes easier to smoke and much harder to quit. Industry documents consistently show that companies manipulate the amounts of menthol to reinforce smoking behavior and increase the ease of smoking. A nationwide study showed that a young adults over 18 who smoked the most started with a menthol cigarette and menthol now makes up 35% of the marketplace. So I brought these with me because I'm the heart association I'm not gonna push menthol cigarettes but if you want to try one of these you're welcome to. They're cough drops but if you turn on the back and you look at the active ingredient it's menthol and what it says next to it for the purpose it's a cough suppressant and an oral anesthetic and that's one of the problems with menthol cigarettes. So on the slide, menthol creates a cooling effect. It reduces the harshness of cigarette smoke, it numbs your throat and it suppresses your cough. Those effects make it very appealing to youth and it leads to nicotine addiction. You don't get that sensation. More than half as Jennifer said earlier 54% of youth ages 12 to 17 who smoke use menthol cigarettes and for black youth who smoke it's much higher at seven out of 10. This is one of the biggest reasons we are talking about menthol today, menthol hooks kids. The Tobacco Product Scientific Advisory Committee was required by this federal tobacco control at to review menthol cigarettes especially on youth. They noted quote that menthol cannot be considered merely a flavoring additive to tobacco, it's pharmacological actions reduce the harshness of smoke and the irritation for nicotine much in the same way. I said with the cough drops. Their conclusions were menthol cigarettes increase the number of kids who experiment with cigarettes and the number of kids who become regular smokers increasing overall youth smoking and young people who initiate using menthol cigarettes are more likely to become addicted and become long-term daily smokers. Can you go back to slide four please? Which is the menthol hooks kids slide. And then this is the US data. Yes, this isn't Vermont specific, this is not. But do we have anything Vermont specific we can ask the Department of Health if they have anything as discreet as this but this is pretty interesting. Yeah, I don't know that we've been able to find specific Vermont data on kids. We've been trying. Does the other Vermont data that we have reflect what is happening at the national level? Well what Jennifer just said with the e-cigarettes youth I actually think our numbers passed the national right because it was one out of four high school students used e-cigarettes and I think our numbers 28% now so I don't know if they all changed but that's what the number was before. So I have a slide here that does show the preferences of flavors currently among high school students and this is of e-cigarettes but our concern here is as you'll see from 2017 to 2019 some of the fruit flavors are dropping in favor and menthol has increased every year with the youth use of menthol e-cigarettes increasing. I ask the committee to think about if menthol is left on the table where we think youth are going to turn to. And that's what this next slide says basically if menthol isn't restricted in all tobacco products consumers who formally use flavored e-cigarettes will be pushed towards other mentholated tobacco products and we've already seen some of this happening Juul voluntarily pulled its flavored products off the market and we saw that the youths gravitated to menthol so from 2017 it was 42.3% use of menthol with kids and it went to 63.9%. So just to clarify, when Juul pulled the flavors off they did not pull menthol? They did not pull menthol and so that's where the kids moved to, right? I don't know what they considered it but they left it to be available, yes. And however, I would like to note the last bullet point here because I think it's important your action to restrict menthol in all tobacco products could steer youth in the other direction as nearly 65% of young menthol smokers as well as 39% of overall menthol smokers and 45% of black smokers said they would quit smoking if menthol cigarettes were banned. We'd also like to make the case that eliminating the sale of menthol helps to ensure health equity. You will hear much more about this from Dr. Gardner tomorrow but evidence from tobacco industry documents show a concerted effort to really target blacks through specific advertising. As far back as the 1950s the tobacco industry has targeted African-Americans with marketing for menthol cigarettes through either sponsorship of community and music events, targeted magazine advertising, youthful imagery, I can never say that word, price discounting, so offer them cheaper to get people hooked and marketing in the retail environment. And as a result, 85% of black adult smokers smoke menthol, it's higher than any other racial or ethnic group they're listed on the side there. And a higher percentage of black adults who smoke started by using menthol cigarettes, 93% of them, than white adults who smoke which is 44%. And the next slide shows you some of the marketing that we have seen. Oh, that's good to ask. And that targets it again, you'll see more of this over the next couple of days with Dr. Gardner but also the students from Burlington High School you're going to have a great treat to talk to these ladies, they're fantastic and they have some of these ads as well. I want to see their lungs. Right. You were going to bring your lung in. I'm just looking at the pictures. Yeah, they're old. Some of them, but some of them are the middle one is, I think Dr. Gardner may have some as well. Yeah, I could use some of those. Yeah, but as I mentioned, it isn't just in the ads, it's marketing in certain venues, music festivals and events and the price discounting which we see on the top as well. Permitting the sale of menthol is also supporting disparities in equality and cycles of poverty. Tobacco industry documents highlight a long history of intentionally marketing mint and menthol products through vulnerable populations including those of low socioeconomic status, minorities, youth, women, LGBTQ and the less educated as we've heard earlier, more than 50% of these smokers use menthol tobacco products as a result of marketing. Individuals of lower levels of income and education are more likely to smoke menthol tobacco products and smokers with mental illness are more likely to use menthol cigarettes than those who do not have mental health conditions and 25% of those with mental illness live below the poverty line. I mean, I've heard people say, well, you know, if you take away menthol, then you take away their crotch. Well, so we're taking away menthol. This legislation would leave tobacco flavored, like tobacco products, not flavored, but it would leave today. So it isn't eliminating all tobacco products, it's just eliminating menthol. So it leaves, it leaves, it would leave cigarettes. It would leave e-cigarettes. They just wouldn't be flavored. Okay. So we would also like to make the case to take action, to take action now instead of waiting for the FDA because it will be a long wait. The same legislation in 2009, that banned all other flavored cigarettes allowed the FDA to regulate or ban menthol and despite taking public comment 2013 and again in 2018, and its own report in 2013 that concluded removal of menthol cigarettes from the market would improve public health and menthol cigarettes lead to increased smoking initiation among youth and young adults, greater addiction and decreased success including smoking, the FDA has repeatedly failed to act. Menthol is still out there on the marketplace. You have probably heard about recent FDA action. It doesn't go far enough. Just in this past month, January 1st, FDA released a new policy. It is only on e-cigarettes, not menthol cigarettes and it falls far short in addressing flavored e-cigarette and menthol. Under the new policy, flavored cartridge or pod-based e-cigarettes so like jewel, that's the pod-based, other than menthol or tobacco flavored must be removed from the market within 30 days. However, open tank those bigger devices such as those typically sold in vape shops and the flavored e-liquids that are used to fill these can continue to be sold. You'll see some examples in just a minute. Also, flavored self-contained disposable e-cigarettes would still be allowed in the marketplace. By allowing these menthol flavors and flavored liquid nicotine using open tank systems to remain on the market, we feel the administration will leave a wide pathway for continued e-cigarette use among kids. So here's sort of the fun part to see some of these devices. The first example here, devices sold with empty refillable pods, these would be exempt. So, soren and smoke can be filled with e-liquids and varying nicotine strengths and thousands of flavors. Smoke is that purple, long-skinned one and soren is the kind of teardrop looking thing. After jewel, soren and smoke are the most popular e-cigarette devices among high school students. Disposable products. The next slide, as I mentioned, are also exempt. An example of products that would not be captured by this definition include completely self-containing disposable products. Can I ask you, I'm looking at the smoke and the soren and the e-cigarettes. Those were all different brand names. Are they brand names? I believe so, yes. But they're refillable, so they wouldn't be touched by the new FDA policy. And the disposables, again, would not. And their flavor, look at the mojo mango, still would be available for whoever wants to use them, including kids. The next slide is another example of disposable products that are exempt that wouldn't be captured by the FDA new regulation. This is all the FDA stuff, all the stuff that escapes the FDA. Correct, yeah. But would be captured by this legislation that you're considering today. And then the last slide just shows some of the horrible juices that you can put into these devices. I don't know who would want popcorn flavored e-juice, but donut juice and fruit pop and ice cream cake you can vape if you're so inclined. That's right there. What are these disposable things that you're for landfills? If the disposable products are exempt, then that and the other products won't that just sort of drive users to be exempt? Yeah, yes, they would, yeah, exactly. Clarify that the disposables are not banned by the FDA, but they would be banned this by now. The exemption you're referring to is the FDA. Yeah, the FDA, that's why my point is really you need to pass your legislation now, because there are some who want the FDA to just act because they can, but they haven't and the action they just took really doesn't do a whole lot. It would stop like jewel, kids from using jewel, but as you saw, there's all these other products that they could easily turn to. And so lastly, again Jennifer mentioned some of this, but our neighbors are starting to end menthol sales. She mentioned Massachusetts, which banned all flavored tobacco and it was done in stages, so immediately the flavored e-cigarettes went into effect and the menthol will be effective this June. But Ontario, Canada banned menthol cigarettes of January 1st, 2017, and initial evaluation results suggest that the law led to increased quit attempts in smoking cessation among adult menthol smokers and then the Canadian government subsequently banned menthol cigarettes nationwide in October 2017. As of now, there have been localities across the country that have banned a flavored and menthol. Massachusetts is the only state that just did it in November. We love her Vermont to be number two. So thank you. I'm happy to answer any questions that you have. Again, you're welcome to try a cough drop. I thought it was kind of cool to remind myself what it felt like to have you have that feeling, but that's what you get when you smoke menthol. And you will hear, we'll have some experts on menthol later. Go ahead, Senator McFarland. Speaking of neighbors, I'm the only member of this committee from the eastern part of the state. The answer that I'm going to hear from people is, well, people will just go to New Hampshire by then. Well, lots of states are looking at that. I can't promise New Hampshire's going to do it this year. Well, we've seen that with other tobacco issues too. And quite frankly, the science has shown that people don't go across to stock up. What happens is people who shop there continue to shop there, but with cigarettes, we know that they don't. After, like, well, when a tax goes into effect, there may be early action where people go and stock up, and then it stops. So I'm not an economist, so I can't predict that. But that's what we've seen with tobacco tax. And it's good news that one of our neighbors is at least. And so maybe that will make New Hampshire move in the right direction. You do too. Questions? So the experience that has happened in Ontario and then with Canada overall, has it pushed people into smoking regular tobacco products? I don't have that detailed information. What I found is that it talked about it could attempt. I don't know. I think in general, the fact from the CDC is that about a third of people would quit mental and then move to traditional CDC subsequent or after they've been mental if the rate of smoking went down. Yes, it has. What's for the record? Dr. Gartner, say your name, please. I'm Dr. Phil Berger. Good. Where were you born? So there's some published data that I actually looked at a year after the Ontario mental plan that smoking has gone down, mental use has gone down. The question then is are people coming across the border into the United States? It's the same question. Yeah. We do this city by city, and then why don't we just go to the next city? The real question is why doesn't the FDA do something and we don't have to do all of this until the FDA does something? But yeah, there has been anything. Okay. Toward the other point that's leading them all of this, well, when the black market rise, and the punchline is this has been done in 200 and so cities across the country, and again, 36 of them, men fall completely no black market. So, being a tobacco historian myself, the black market has generally been driven by the tobacco industry historically in the United States. And let's not drive into that level, but there's been a question that you asked, and I think there's some data to support it. Terrific. I'll be great. I want to talk about that at the border. Good. Yes, great. Thank you. Anything else? Any questions? We're getting the information, maybe. And so you've given us other handouts. Yes. If you want to say anything about them just briefly. One of them is testimony, a letter to Dr. Garner, and he's going to talk about that in detail. One is from the Truth Initiative that talks in detail about some of the information I presented on menthol in terms of marketing, youth use, the characteristics of it, and also the CDC documentation that also confirms that it's, you know, harmful to kids and starts youth initiation and disproportionately targeted to various demographics. Okay. Thank you. Is Elizabeth Hanlon here? There you are. Hi. Thank you. Do we have anything online from you? You don't. And I need to apologize for that. I was with my mom in Connecticut. Okay. And we did not have internet for three days. We had a snowstorm. Yeah. There was a snowstorm in Connecticut and in New York, so I've been storm chasing. So why don't you explain yourself for the record and then if we could get some written testimony and you could send it in the door, that would be true. Definitely. I have some notes written down. So my name is Elizabeth Hanlon. I am the Director of Advocacy for the American Law Association in Vermont and I also cover New York and Massachusetts. So I want to thank you for this invitation to come and speak today. And the Long Association, as you may already know, we work on behalf of 33 million Americans living with lung diseases that are including lung cancer and COPD, which are primarily caused by tobacco use and exposure to secondhand smoke. And so the Long Association has been raising the alarm about cigarettes, e-cigarettes, for the past decade. And we've been warning about the use of these flavors as the inhalation of the harmful chemicals can cause irreversible lung damage. And we know that due to this FDA lack of really strong response that it is the state's responsibility to do something about it and we really appreciate and respect that you are moving forward with this and hope that you continue to keep the menthol and all of the flavors within the flavor tobacco bill. And so let's see. Well, we know that flavors have been consistently cited as one of the main reasons that kids use e-cigarettes and flavor tobacco products. And from 2019, 71.7% of high school students who currently use e-cigarettes reported using flavored e-cigarettes in the past month. In November this year, a study in the Journal of American Medicaid Association using data from 2019 NYTS, 66% of high school students who currently use e-cigarettes reported using fruit flavors and 57.7% reported using menthol flavors in the last month. Overall, close to 73% of high school students who use tobacco products report using a flavored product. And so continued progress on reducing both cigarette smoking and other tobacco products use required bold and swift action. And we cannot sit here and wait for the potential action of the FDA. We recognize, let's see. Without a doubt that flavored tobacco products are attracted to kids and flavors are one of the main reasons youth use e-cigarettes in epidemic proportions. And you've probably heard a lot of this, so I'll skip over to some of the things we know about the aerosol in e-cigarettes that by heating this liquid that typically contains nicotine, flavoring and other chemicals. The e-cigarettes currently being sold have not been reviewed by the Food and Drug Administration. That means the company has not had to disclose the ingredients in the products to the FDA. We do know that e-cigarettes contain nicotine as well as chemicals and toxins that are unsafe to inhale. Since 2016, we have had evidence that flavor additives in e-cigarettes, especially those that are based in natural plant extracts, are menthol-based and food-related additives, such as syndomycin, I believe it's how you pronounce it. These are particularly toxic to the lungs and when they are inhaled. And one study found that these additives significantly affect the lung cell viability and the respiratory barrier integrity. Another study found that lower concentrations of these flavor additives in e-cigarettes cause inflammation and create symptoms consistent with endothelial dysfunction. I won't give you a long anatomy presentation right now, but needless to say that these are all linked to some type of respiratory disease. And we feel that the FDA must use this authority to clear the market of these products that have not gone through the pre-market review and absent of the FDA enforcing the Tobacco Control Act, that we must use every tool at our disposal to end this public health emergency. And one of the most effective ways is to clear the market of all the flavored products. And Vermont has done a great job last year doing the Tobacco 21 bill and addressing the internet and sales on the internet. And these are all prevention efforts. So this is another prevention effort to keep kids from having access to any kind of flavored tobacco product. And when considering this legislation, it's important to remember that it needs to be a comprehensive bill and to address all the flavors and all the products. And in April of 2013, the Long Association, along with our partners, such as Kids Society and Heart Association, we submitted a formal proposal to the FDA and to prohibit the menthol as a characterizing flavor. And the FDA, this study came out called the Tobacco Product Scientific Advisory Committee, concluded that menthol cigarettes have an adverse impact on public health in the United States. And menthol cigarettes have no public health benefit. And menthol cigarettes increase the likelihood of addiction and the degree of addiction in youth smokers. Menthol is not only a flavoring, it's a chemical with complex drug-like properties that can impact smoking, initiation, addiction, and cessation. Menthol has a cooling, as Tina so well put it, you know, you have that cooling cessation when you have a cough drop in your mouth. And these properties reduces the airway pain and irritation and can also suppress coughing. So when someone inhales a cigarette, they are not gonna cough the same way as when they first try a different cigarette. And that's one of the reasons why kids are so likely to pick up menthol and keep using it. And the use of menthol cigarettes by youth is also more likely that the youth will go on to become regular smokers. And while I've just lost my place, basically, overall cigarette sales have been declining, but the proportion of smokers using menthol cigarettes has been increasing. And over half of the kids who smoke cigarettes use menthol cigarettes. The health disparities, and that might be a different number than what has recently come out, I think it may be more now. And the health disparities of these that are correlated with the use of menthol cigarettes has been very troubling for us. The sale and marketing of menthol cigarettes disproportionately burdened African-Americans. And that's a result of the decades of marketing, as Gina was pointing out. And the use of menthol cigarettes is the most common among female smokers, LGBT smokers, and those with mental illness, and racial and ethnic minorities. Nearly nine in 10 African-Americans smokers, age 12 and older, use menthol cigarettes. So I can ask her any questions you'd like about anything that I might know, or give back to you if I don't know. So thank you. And it would be very helpful if you would just submit your testimony and writing. Definitely be very good with some of the data that you have there. I was wondering what New York is doing? Right now there's the governor is talking about, well first he did an emergency action when all of the lung illnesses came out and that was primarily just electronic cigarette flavors. And at first he left out menthol and had the commissioner of health research menthol to decide whether or not it was something that should be in there, so he subsequently added menthol to the ban, the emergency ban. That was in regulation, so the emergency act was going to be in regulation. Unfortunately the big association came in the day before it was supposed to take effect, brought the case to court and basically Cuomo was told that while it was needed to have this emergency action it should have been done through legislation instead of regulation. And so he should, now we're looking at today actually he's going to be doing the budget address and he's going to be discussing flavors. New York has a little bit different demographics and we're really pushing to keep menthol in the forefront of everybody's minds. So hopefully we'll have a comprehensive flavor restriction as well. There's other counties that have been doing it. There's one I believe in Herkimer County, there's Albany County that's trying to pass a bill in Westchester County and Long Island that all have bills that are addressing flavors. So if our legislators in New York can't pass this bill, then it's going to be like the tobacco 21 laws where it just keeps growing through county level. Thank you. It's very helpful. Thanks. I'm going to ask a general question. You don't need to answer it right now. But you know in the United States there has been no pre-market review. Now that holds for a lot of different things, chemicals as well as baking products. But the European Union is slightly different. I don't know if anyone has a testimony on that. Okay. I don't know if anyone talked about the pre-market review that. We're going to get some of that information. The European Union was scheduled in June to restrict the sale of netball and all of the flavor products. So they passed that in 2016 and gave it four years to review. Right. Cool. So we still have one here. Thank you. Thanks. All right. The other thing is the general question, at least don't answer it now, of course there's a lot of data out there about vape being THC, I'm just going to state that as a fact. So that's something else that we may be questioned about. Oh, it's a brave one. You can't do anything today. I think that's my question. Part of why youth smoke or try things is the youthful rebellion. That's not going away. So if we take away this, where is it going? Is it going back to alcohol? Is it going to marijuana? Is it... I think it's going to marijuana regardless. I don't know. We'll have to look at the data. I don't know. I'm sitting here saying... There are alternatives like the Icelandic model is to try to give kids other things to do, you know, rather than trying to mind all the reasons. But youthful rebellion and stretching is not going to go away. No, never will. But we don't want to enhance it. No, promote it. No, both. And really enough money to turn this state into Iceland today it is Icelandic. No. So, I mean, I'm just... Well, we're processing it. Yeah, we're processing it. So, you know what, Jen, would you like coming up? We have a few more minutes. I don't think we need to hold ourselves here all morning, but we've heard a lot of information that is going to take time to go through it all and process it. And looking at the Youth Health Risk Behavior Survey, Department of Health would be good for us to do it individually, but we will get the Department of Health in here on this topic. So they'll also be able to help us. Welcome. Thank you. And so there was some comments by, I think it was Tina to change some of the legislation to amend it. And I'm wondering if we might look at that together. We have, what's the bill number? 288. Jennifer Kirby, Legislative Council for the Record. Yes. So I think the two things that you heard from Tina as suggestions or recommendations, one of them is on page four. The other one is not in the bill. It was required adding something to the bill. So I'll give you a minute to get to it. I'm going to go get to 288 as introduced. Just a little infant bill. All right, so on page, if you look at page four, the rest of the bills were leading up to the band and we have the band on page four. So subsection V says a person shall not sell, offer to sale, et cetera, any of these products. And then subsection C is the one that I think would be acting to come out of the bill, which is the ban on possession. Possession purchase or attempt to purchase flavored tobacco products, flavored eliquids or flavored tobacco substitutes. I was actually thinking about this over the weekend and trying to figure out how our departments of public safety would deal with this. Well, I know that when the band would put a thing on possession of cigarettes under the age of 18, I did hear from my then police chief and I think we had some testimony that police departments are working very hard to develop a friendly, trusting relationship with youth and to have them put in the position of having to cite them or arrest them, buy them for possession of a cigarette which most kids don't see as a... It's like a parking ticket. They don't see it as evil. It counteracts that effort and they really didn't want to be put in that position. So if we took this out or remain silent on the possession piece, then there wouldn't be a ticket? So then you get into the... Not for possession. You would not have banned possession, so however somebody procured the items just possessing them or purchasing them if the store were to sell it to them would not be... So the person who had purchased or was in possession would not be breaking the law or violation of the law. But if that shop happened to be in a jurisdiction where it was legal to sell it, then it would be okay to possess it and I'm using it to care. But this doesn't specify any consequences? Because it doesn't specify any, there is a default provision in this title that would apply. But I think the other piece of what you're being asked to do is to put in some specific penalty provisions that would go in here. That's the other piece of this. Tina was recommending. So it would be... Not that there's no penalty currently, but it would fall under the default in 7 BSA Section 6. Where are we? Section 5 is our presumption. 650... 661, there we go. It's just violations of title and it goes through certain things and then it says a person that willfully violates a provision of this title for which no other penalty is prescribed or that willfully violates a rule of the board of liquor and lottery should be in prison not more than three months nor less than one month or find not more than $500 nor less than $100 or both. So sort of put it under the default but you can go more specific with it. What section is that? It's 7 BSA. 7 BSA, 661. And I put it in there in part. I mean, I relied on that in part so that you could have the conversation about what you would want a penalty provision to look like. Okay. So instead of creating a new one before you had really looked at the bill. Okay. So and under current law the penalty for sale to somebody under age now 21 as of what you did last year makes a person that sells or furnishes tobacco products, tobacco substitutes or tobacco paraphernalia to someone under 21 is subject to a civil penalty of not more than $100 for the first offense and not more than $500 for any subsequent offense and that goes through the judicial bureau like a traffic ticket. So if we didn't have possession here that I in my youthful entrepreneurship took the family car, went to New Hampshire and bought some of the banned product and brought it back and sold it to my friends. We'd be violating a few provisions. It would be a big problem. You would also be selling without a license Right. Yeah. Okay. So you're the robbers of Ferris Bueller. Well, yeah. And we haven't stopped it. But there would be there would be a penalty for that. Right. Yes. For selling. Yes. There would probably be a few controls. Can we look at one other thing? I know we're going to come back to this Friday or whatever day we had for a discussion with you but the section on advertising I would just ask that when we do come back to that to look specifically at why it's a study and why we can't do something sort of the interstate commerce clause issue if there's one. There's interstate commerce. There's first amendment. First amendment. Right. But yes, first amendment in commerce clause issues. And then what about can the state do anything about labeling or providing information? I have to look specifically most of that if not all of that is in the federal Yeah. sphere. But I'm not sure if it's a legal or a ceiling. Okay. Generally we have more control over sort of what would be posted near a product than what would actually be on the label itself. Okay. That's good for now. I think we'll come back and we'll walk through carefully and talk about things that are important to us after we've had some more testimony. And I did want to correct one thing that I said on Friday and that is I indicated that none of the tobacco companies were going to come in to testify. That's not true. At least one tobacco company has indicated through its representative in the building that they will testify but the other one, the global one will not, which is unfortunate. Thank you. They might if it goes to finance they might testify there. It's all about money. It's not about health anyway. Sorry. I might say that tomorrow. Just a quick comment from the record. I didn't want it to look like just Tina is asking for those changes in the American Kansas State. I understand. It's a whole coalition. Yeah, we got it. We understood it. Tina did it. But it is not one in their testimony. I understand. We understand. All right. Thank you, Gals. Now, if there are people in the room who would like to testify on this bill we'd very much like to hear you. So just let Dory know and we'll continue to take testimony this week and next week. I think this week is probably pretty full and then next week we'll add in some other folks. Make sure she can get your name down. And then I did want to say welcome to Dr. Gardner. We're very happy that you're here and we'll go around the table. Tomorrow we'll do the same thing but I thought they would be helpful to introduce ourselves and maybe by tomorrow we might recognize one or more of us. So do introduce yourself briefly, please. Well, thank you for having me. I'm Dr. Philip Gardner. I work at the University of California Office of the President tobacco-related disease research program. I've worked there for the last, I was admitted this tomorrow. I've worked there for the last 23 years. Next week is my last week of work. I retired five years ago and I'm dragged with it. And that was a good hang-on for me. I'm also the coach here in the African-American tobacco-controlled leadership council. We're based in California and we work, obviously, nationwide. And we've been the pusher of the mental issue since the FDA, I think, filled this job in 2009. I must admit this last discussion, the question of the possession was really important. I really don't think you want to bring it to the criminalization of kids for possessing something that's being sold to them that they shouldn't be being sold to. And I don't have it in my slides. I sent slides to Doris. And please take a look at them. I can also talk about these cigarette stuff all day, too. I used to oversee the new products that were teased at the tobacco-related disease research program. There's a lot to talk about. There's a lot of science behind a lot of this, too. There's been an interesting deal with tobacco scientists. All these questions come up. Send them down the high that people are talking about. Stuff is not good for them. And then there's a question on the baking of marijuana. Unfortunately, this free article written on the same thing that's in marijuana is in cigarettes. All dried, it's what we call a bio-massage. If you're burning leaves in the ground, your driveway, forest fires, cigarette, a joint, they all produce the same chemical. Some have active, some have active T and C. But when you burn it, that's what happens. I mean, I think the difference is people smoking 20 cigarettes a day, one person smoking a joint a day. That's part of the problem. There's some data on that, too. Anyway, I think that wraps it up. Good day, Gretchen. Thank you very much. We appreciate you being here. I'm going to go around our table and introduce, and then tomorrow we'll do the same thing again. Anne Cummings from Washington County, right here. I'm Rich Weston, and I'm the senator from Ohio, right here. Still. That's your bottom. I would say there's a lot more towns than just... I'm Senator Ginny Lyons. I represent Chittenden County, which is the Burlington area where the kids will be coming from tomorrow. I'm Debbie Ingram, I'm also from Chittenden County. I'm Dick McCormack. I represent the towns of London, Darien, and Mount Holly, and all of Windsor County. And Jessica, why don't you introduce yourself because you'll be here again in a while. Jessica Brunston. I'm a representative from Shelford and St. George, and I'm introducing the same bill in the House. Thank you again. Okay. We're good. We're going to call it a wrap for today and then we'll be back tomorrow at 9 o'clock in room 11. We'll be a little more clean air. It's good. Okay, thank you. 11 or 12 minutes early. Did you not walk there? We will be getting the synchronization for all this. We'll be having some people that are going back to school.