 We're going to get started, so there are two more folks who will be coming, and I think they're getting that call. Which is... Important. Well, it's sort of important. If you want a good listener. Yes. So we're continuing to take testimony on S288, an actor that used to ban flavored tobacco products and e-liquids. And we've taken some testimony on this, but what we haven't heard enough about, obviously, as you both appear, are the health facts of these chemicals that we're talking about. And what's been going on. So, we're here together. We'll go around and introduce ourselves, and then we'll ask you to introduce yourselves and offer your testimony. So, I'm Senator Jenny Lyons from Chittenden County. I'm Ed Covings from Washington County. Rich Westwood from Louisville. Debbie Ingram from Chittenden County. And Senator McCormick will be in on... Sure. Windsor District. Huh? Windsor District. Mount Holly and whatever. Yes. I don't know. Not the whole county. Oh, you got some add-ons. Oh, that's it. More than all of them. So, welcome. Why don't you state your name to the record and offer a little bit about your background, because it's an important phenomenon that has to be here, testimony. And we have stuff from you? Yes. So, we have... It's definitely... It won't email out. You made a handout with all our references that I should have emailed to you. So, I'm Rebecca Bellman, a pediatric ICU physician at EVM Medical Center. And also the president of the Vermont chapter of... Sorry. It's okay. And yesterday, was that hope in there? Who did you get stuffed, you know? That was a meow, actually. Let's be something more interesting than transportation. I mean, just wanted to say goodbye to you, Rich. Thank you. Goodbye. You got both. You got both. Yeah. Have a good trip on it. Thank you. Bye-bye. Bye-bye. That was our group leader. And so, I take care of infants, children and adolescents who are ill enough to be in the pediatric intensive care unit. And that includes both infants and children who are affected. The respiratory system is affected by smoke exposure from the home. And then also adolescents who have, you know, respiratory issues from their homes who are being vaping. My name is Dr. Lauren Ferresi. I'm a pediatric pulmonologist up at the University of Vermont. I see children in a number of different settings, in both outpatient clinics, emergency department, inpatient units, intensive care units, and then neonatal ICU and then pediatric ICU in the morning. And I take care of a lot of children who have chronic bowel diseases, either from being born early for chronic bowel diseases of prematurity, underlying asthma, cystic fibrosis, and I see children of all ages, so infants up through adolescence. And we'll also hear with our colleague, Dr. Sarah Kouser, who's a pediatric resident at the hospital as well. So we're here speaking on behalf of the Vermont Chapter of the American Academy of Pediatrics and Vermont Medical Society in support of this bill. We, you know, nationally, our national organization, American Academy of Pediatrics, was, of course, pleased that the administration is moving towards banning some flavors, but we're really quite disappointed that they didn't go ahead and really ban all access to flavors, including vape shops and leaving menthol on the market as well. And our concern is that we do have some evidence that we know both in Vermont and across the country the use of electronic cigarettes is going up. In Vermont, I know that you saw the Youth Risk Behavior Survey from 2019, which is quite concerning that youth use has more than doubled just in the two years. And that's despite some kind of small measures and restrictions on flavors. So, you know, Juul had started to cut back on their flavors, and that's the most common e-cigarette use. What we see then are the kids using the mint and menthol. And so we're concerned that if we just don't get rid of all the flavors that we're going to see, continue to see increased youth use. We have, in addition to Youth Risk Behavior Survey, we were able to have the opportunity to see a poster presentation by College of Medicine students at UVM, who did a little bit of a deeper dive into e-cigarette use in Vermont. So they surveyed just under 500 Vermont high school students just this year and asked them about their e-cigarette use. And when they surveyed those who use flavored e-cigarettes and they asked the question, what would you do if there was no flavor? You would think if the flavor wasn't a drive, or they would say, well, it wouldn't matter. I would just continue to use unflavored e-cigarettes. But only 23 percent said they would just continue to use unflavored e-cigarettes. 34 percent said they would switch to cigarettes, which is sort of interesting. Again, signifying they didn't then go into, is it menthol cigarettes? But that's sort of the presumption, if you lose the flavor in the e-cigarette and then you move to a cigarette, why would you do that? And then 43 said they would just stop. That was 43 percent, which I thought was pretty interesting. So we do know that flavor is a big driver here. And we do know that the flavor does help the nicotine uptake. So young people are more apt to use the product more, they inhale more, and they're just exposed to more nicotine. And that's a problem because of nicotine dependency. And again, in that poster presentation when they asked these Vermont high school students who use e-cigarettes, how much time elapses between when you wake up and when you first start vaping? More than a third said within the first 15 minutes of waking up. And we do hear pediatricians telling us that young people are saying that they're sleeping with these products under their pillows, they wake up at night and use them, and then with more than a third saying they're using it within 15 minutes of waking up, that's a sign, a marker of dependency. So really concerning. And we know nicotine affects the brain. We know it increases dopamine. We know that developing brain, the adolescent's brain is very vulnerable to the effects of nicotine. It can actually, studies have shown that it can actually increase vulnerability to substance misuse of other substances. And it does actually change the neural pathways when they look at people who are heavy nicotine users and look at functional imaging that it does change the way your brain works. And then there's also the effect of the cardiovascular system too, which we know about with, we think about combustibles, but nicotine also by itself is changing the way blood flows, it changes the way our vascular system works, and can lead to heart disease and stroke. So for all those reasons we really are concerned about nicotine. And then I'm going to let Dr. Farrisie talk more about the, take a deeper dive into the health impacts. Yes, thanks. So I know that you've heard a lot about e-cigarettes in the last week or so. I wanted to talk about what we do and what we don't understand about the health effects on the body of e-cigarettes and how that relates to what we know about tobacco. And then I'll also talk a little bit about what I've seen as a pulmonologist up at the University of Vermont. So e-cigarettes generally contain three categories of listed components. The first one is something that helps aerosolize the vapors. So that's probably glycol or vegetable glycerin. And then flavors are a big component and often nicotine. So these products hit the market without any real health and safety data and no long-term data about their continued use over time. They were extensively marketed to youth population at that time. And we know that these are generally under FDA regulation, but they're not being regulated. So there's not a good understanding about what those contents are and what the health effects of them are. We do know that the vapor from e-cigarettes contains fewer toxins than tobacco smoke does. Burning an organic matter is just different from vaporizing what is made in this lab. And so that's led many people to kind of prematurely claim that there's fewer toxins and therefore this must be a safer alternative. When really the more appropriate response would be that these are different toxins and they likely contain a unique set of risk factors to the body that are just not well understood. These are a different category. So from a big picture level, when we talk about what tobacco risks are on the body over time, all you have to do is look at the top 10 leading causes of death on the CDC website and five of them are related to tobacco. Most people think about lung cancer. Cancer is number two. But we're also talking about a lot of other parts of the body. So chronic obstructive pulmonary disease or COPD and emphysema is a very, is a big source of health care utilization that's not cancer that causes a lot of problems. Heart disease, heart attacks and the effect on blood vessels. So that means high blood pressure, risk of stroke and difficulty in handling diabetes and the consequences of diabetes. So it's not just about cancer. There are a lot of other effects to keep in mind as we're discussing what the potentials are here. And when we think about the timeline of this, cigarette smoking became really popular in the U.S. around 1900. And lung cancer is going to rise after that. So in the 1930s, people said maybe there's a link between lung cancer and smoking, but it wasn't definitively proven with scientific evidence until 1950. And by that time, half of U.S. adults were smokers and it was very widely accepted that this is culturally accepted. So in 1964, the first Surgeon General warning came out that said smoking is related to early death. And at that point, there were many public health interventions and research that went into this to try to decrease the rate of adults who were using tobacco. And now we're almost 60 years later and we just in 2019 saw a drop in death related to cancer internationally speaking. So that's almost 60 years later. And the rate right now of adults who smoke is about 14%. So we have over 70 years of data more than that about what the long-term effects of tobacco are that convinced us that tobacco smoking is harmful. We don't have that data for e-cigarettes. It's just not there. These hit the market within the last 10 years. We're not going to have that long-term data for a while. And so what we do have is what people are seeing in the short term. And those effects that we're seeing are concerning in the emerging literature that's out there. So the trends that we're seeing nationally in Vermont and nationwide are very alarming because these substances that kids are using are appealing to them. They are accessible to them and they're very addictive. We don't have a good understanding of what the long-term repeated use of them is over time. So I do want to talk about what we do and don't know about these. So purple and black hole and flavors are in this FDA category that is referred to as generally recognized as safe. And that is a category for food additives, which is something that if you put it as a food flavoring, your GI tract can handle that. It does not cover inhalation. Things that are inhaled is a very different route to the body. And so when we think about things that are toxins that harm the body, we think about how much is exposed? What's the dose? And how is it getting into the body? And what's the body going to respond to that based on how it's getting in? So the GI tract evolved over time to handle all of the wild stuff that people were trying to eat and get good nutrition out of. And it's designed to take what it can use, get rid of the rest. And the function of the lung is very different. So the job of the lung is to breathe in air and use the oxygen in it and get rid of gas that the body doesn't need anymore so that the body can just do its job. This process, it happens that a very structurally delicate part of the lung is deep in the lung. And the design of the lung is to protect that. So all the tubes that lead to that part of the lung are lined with defense systems. The main one is these hair cells that start at your nose and they go all the way down to the tiny tubes. And with the help of mucus, they sweep out things that are invading them. So that might be dust particles, smoke, bacteria. It's a defense mechanism to protect that very important and fragile part that's deeper down. And we know that with repeated tobacco smoke exposure, that constant and repetitive, noxious assault is very damaging to those defense systems. It creates a lot of inflammation that then essentially destroys the walls of those air tubes. The hair cells don't work right. They make too much mucus. And then they're not able to protect the body anymore. The body is unable to get out, the gas that it needs to get out. And then the lungs are not able to inhale and exhale as easily as they should be. And that's what COPD looks like. COPD and emphysema is that kind of a process. One of the more alarming things that's recently come up in the research literature is from a study published last month where researchers took fluid samples from the lungs that have three categories of people. They looked at non-smokers, cigarette smokers, and people who vape. And then they compared what those different profiles of the fluid look like. And the fluid from the smokers and the vapors looked very similar in that they contained a lot of these destructive proteins that are known to cause COPD. And this is really alarming to the research community that the chronic use of e-cigarettes will set off a very similar process for COPD risk that is seen in tobacco smoke. So going back to the question of what is generally recognized as safe, I'd like to talk a little bit about flavors specifically because these are chemicals. They're not foods. They're chemicals that are used to flavor foods. And there are data to say that when food flavoring is inhaled, it causes lung damage. That has been documented. The population that it has been most noted in are workers who work in food flavoring manufacturing. In the early 2000s, it's garnered a lot of attention because there were a series of workers who developed a severe obstructive lung disease, but they weren't smokers. And they tied it back to all of these workers who worked in a microwave popcorn manufacturing plant. And they were all exposed to the same chemical called diacetyl. And diacetyl is what gives the buttery flavor to popcorn. And generally, recognize as safe? That we all love. That we all love. And if you eat it, that's fine. But when you're breathing it in, it's causing these really serious lung problems. So that's documented. In the media, that was called popcorn lung. And that's known, that that's related. And then there's a lot of studies now where people come and start looking at what's in these e-liquids. And when looking at the sweeter flavors, there was one study that looked at 160 of those flavors and looked for diacetyl. And it's in over 70% of those. So this substance that resulted in popcorn lung and these workers who are accidentally exposed to it is deliberately placed into e-liquids that people are smoking on a regular basis. That's just one example. Many others are different aldehydes or esters or alcohols that are known in industrial workplaces to be toxic. And a lot of them have recommended exposure limits. So for people who are working with these chemicals, there are limits for what the maximum recommended exposure is to keep the workers safe. And when researchers look at what's in the chemical from an e-cigarette that's exposing the person who's using them this way, they are exceeding those recommended limits that are set by industrial standards. So it is known that these flavor-specific additives result in lung disease. And it's something that's regulated in a workplace and it's not regulated in e-cigarettes. So right now there are over 7,500 flavors available on the market. The flavor contents, the concentrations and the combinations of these are not regulated. And we know that a single flavor might have 6 or 7 different chemicals that makes that. And each of those combinations has a unique toxicity profile. It's not clear exactly which ones are more or less harmful. And we also don't know what they do once they're heated, inhaled, and then they land on a wet surface in the lungs. That's not well elucidated. We don't have a great understanding of what the byproducts of e-cigarette vapor do either to the user or people who are not using but are standing near this vapor and inhaling that. It is not just water vapor. The contents of this are known irritants such as formaldehyde or there's concern about the metal coil. That's another unique aspect of e-cigarettes is that there's a metal coil in it that's part of the heating process. And with this repeated heating and cooling, some of that metal leaks into the e-cigarette liquid. And so this is generally nickel or chromium alloy and maybe some other metals that are used in there. And we don't know what the risk of that is for inhalation over time. I would assume it is not good based on what we've talked about with COPD. The things that we see in welders who inhale metal tubes from welding. But we don't really know with how much the exposure that is what the net effect is going to be over time. There's not a reason to believe that it is benign. So another area that we need to address is that it is unknown what e-cigarette exposure does to the fetus of a pregnant woman who is using these. We know that tobacco smoke during pregnancy is directly linked to premature birth under developed lungs and neurodevelopmental problems of the brain. And some of these effects are related to nicotine. So we don't have studies to say what happens when pregnant women use e-cigarettes and then what happens to their offspring. But that is a population that is uniquely at risk, especially as we have a youth population with women of childbirth and age coming up who are using these. So I'd like to make a comment about the use of e-cigarettes for smoking cessation as well, because I'm sure you'll hear about that. We have been getting emails about that so it's very good. Yeah, so right now the current state of the evidence does not support using e-cigarettes as a safe or effective alternative way to quit smoking. So quit smoking is a very complicated and difficult process. And right now the recommended medical recommendations for that are to use nicotine replacement therapy with counseling or the pharmacologic therapies with counseling. And in some of the very small randomized controlled trials of people using e-cigarettes or those recommended modalities, it looks like maybe they're similar. But when we look at the whole, like all the studies that are out there and in real world examples, it actually looks like it might make it harder for people to quit smoking cigarettes. That they're 27% less likely to have a successful quit attempt with using e-cigarettes. There are some specific problems with using e-cigarettes as a form of smoking cessation and it's by design. The way that e-cigarettes are designed is to allow the user to get a lot of nicotine at once that goes to the brain and there's a buzz that is with that. And most of the FDA approved nicotine replacement methods that are supported by the medical societies, they don't do that. There's not a peak and valley or reward pathway that's set. The goal is to have kind of a lower or steady state kind of nicotine level in the blood without these peaks. Because that feeds into factors that promote addiction and so that in itself makes it difficult to think of e-cigarettes as a potential for quitting smoking. Many people continue to use both cigarettes and e-cigarettes. It is possible that for an individual user that using e-cigarettes might be a harm reduction method and that's something that still deserves some study. There probably are some users that that is helpful for harm reduction. That needs to really be weighed against the public health impact of the availability of those for that population of people. So we've seen as Dr. Bell was saying a really dramatic rise nationally and in Vermont where now 28% of high school students are saying that there are regular users of e-cigarettes. This is a huge and alarming increase and the adult use of e-cigarettes has really remained constant at 3% in the last 10 years. That has not changed and so when you think about what's the risk of having these youth have access to e-cigarettes and then potentially go on to smoke combustible cigarettes which is also being shown. Does that really outweigh the benefit for having those available for people who are for a harm reduction standpoint? I'm sorry I'm running out of time. You're alright. There are people who have kind of speculated that at the rates that youth are using and adults are using to use this for smoking cessation that the net effect is just that it will create more combustible cigarette smokers in their 30s than it does for people to quit. So that has yet to be really seen but I think that's an important thing to balance for an individual versus the public health effect. We won't know for a few years. What's that? We won't know for a few years. Yes. It's difficult. Not an experiment. Maybe we're going to try. And it wasn't marketed in the U.S. in that way. That's the other thing to think about. It wasn't started that way. It was with a youth market in mind of non-smokers. So I would like to kind of wrap up by commenting on what I've seen in my clinical practice where the use of flavors as a hook to get kids started on these cigarettes is absolutely a pattern that I have seen play out in my office. And I can think of one particular child who I saw for poorly controlled asthma who's a 17-year-old. The day that I first met him he told me how much he loved baking. And he really liked that he could do tricks with the vapor. He'd do it inside. He could do it with playing video games with his friends. And he loved that there was this strawberry QE flavor. That was his favorite flavor. And he assured me that this only contains glycerin and flavors and there's no nicotine in it and it's fine. And then the next time I saw him he was using nicotine-containing products. And his use has escalated since I've seen it, since I've been following him for about the last year and a half. So now that he's waking up and he uses right when he wakes up and then he's vaping throughout the day while he's awake. And every time I see him I am, he's wheezing and he feels poorly and I'm putting him on systemic steroid medicine to treat an asthma exacerbation. Despite him being on the highest dose of inhaled asthma medications that I can prescribe for him. So that piece I've seen play out. He was not using nicotine initially and now he is. What's interesting about this kid is that he, the first day I met him I said, oh, do you smoke cigarettes? And he scoffed at me and he said, oh, that's disgusting. I would never smoke cigarettes. And that response, that attitude about cigarette smoking, that is the result of like six decades of public health intervention to work towards de-glamorizing and de-normalizing the use of cigarettes. And that is something that is at risk that we're losing here with these alarming trends that we're seeing. And I don't know if this kid is going to go on to smoke tobacco cigarettes. I'm not sure if he will or not because the studies that we see that have consistently borne out that youth who are using e-cigarettes do go on to smoke combustible tobacco at higher rates anywhere from four to eight times the risk. And these are kids who aren't otherwise at risk for starting to smoke cigarettes. So that's this kid, this kid who said, I would never smoke cigarettes. In five years I don't know if that's going to be true for him. He wouldn't use nicotine. What's that? He wouldn't use nicotine. Right, he said he wouldn't use nicotine. So I think the addiction is a big driver of that, the dependence. And that's one, this very alarming trend in that use is one of the main reasons that the broad chapter of the AP and the Vermont Medical Society are supporting this ban on flavors in e-cigarettes and tobacco. And we think it will be an effective way to reduce youth access and demand for these products. So I thank you for your time and I'll take any questions you have. We put a lot into a short period. We'll take some time for questions. I know we have another group waiting to testify but it's important that we are able to ask any of the questions. That was very helpful actually. Thank you for this fascinating thing to get all the science there. So I actually have two questions. The nicotine portion of the e-liquid, when it exists. So it's synthetic nicotine, right? So it's not actually from tobacco? I believe it is extracting it from tobacco. I don't think it's all synthetic. Okay, so what would it taste like, would it taste like tobacco then without the flavors? Nicotine is a bitter product. So it would likely, that's a great question. I believe it would need a tobacco flavoring but I don't have the answer for you about that. But nicotine itself, when inhaled, is a bitter substance. Okay, so it would probably taste really awful but it didn't have the flavors in it. And then the other thing, so it sounded like what you were saying is the flavors, because of the way the lungs are and the way the inhalation process works, flavors themselves are actually harmful. Regardless of nicotine. Because they're chemicals, just chemicals that aren't supposed to be in the lungs. Yeah, I didn't actually realize that. So thank you very much. Other questions? So the pseudo stratophyciliad pulnarabithelium. I hate that. So good. So we will get your testimony. So we'll have it, because the data that you have there, we did not pack that all the way. I understand. We have references on the handout that's on the email. Okay. And we're happy to respond to any further follow-up questions by email. Or if there are more specific questions. So I know Santa performing had a very good question yesterday, which was the peer pressure, or that it's kind of the cultural influences that we see with kids. So in the past it was tobacco, and now is there some of the cultural thing that's going on, so now it's more accepted to be a vapor? I think it's a widely accepted cultural thing. I'm not sure about the pressure piece in particular as opposed to the normalization, and that it's just everywhere. And I know you've heard from youth in high school settings and it's everywhere. It's everywhere in their schools. It's everywhere on their Instagram feeds. It's inundating their lives. So it's not necessarily a pressure. It's a successful marketing campaign of normalization. Maybe there's pressure too, but I think that instead of this, it's normalized. I think that's what the kids said. It was just, that's what the cool kids did. Everybody did it if you didn't do it, you were different. You don't want to be different. Thank you. I think we may well be in touch. Either collectively or individually, so this is very helpful. Thank you so much for having us. Thank you.