 So this morning we are starting to look at S86, which is an increasingly legal age for buying and using tobacco from 18 to 21. And we welcome Senator Ingram from downstairs to tell us about the bill. Great, thank you very much. I appreciate you inviting me for the record. I'm Senator Nibbie Ingram from Chenin County. And I had the great pleasure of presenting S86 on the floor and was very glad that it passed this year. We've been looking at this issue for the last several years. And it's basically, it's just a tremendous opportunity for us to pass a public health initiative that is very important and that will save lives. I'm sure that we're all aware of the dangers of smoking, about all of the diseases that it causes. It contributes to many different kinds of cancers, heart disease, to Crohn's disease, to all kinds of different health problems. And there's ample evidence to show that the younger person starts, the more likely they are to get hooked and to continue to smoke throughout their lives, which increases their risk of having these chronic health problems. But if we can delay their starting until after age 21, they're much less likely to continue to smoke throughout their lives. And also I think it's, you know, it's kind of just a common sense sort of thing that if we, the lower we have the age limit, the more likely kids who are three or four years, even younger than that age, will have access to tobacco products. So, you know, it's likely that a 13 or 14-year-old would know an 18-year-old to be able to get cigarettes. But it's less likely that a 13 or 14-year-old would know a 21-year-old to be able to get access. So when I was telling Senator Lyons, you know, Chair of our Senate Health and Welfare Committee that I was coming up here to talk to you, she said, tell them to remember the children. And that really is, you know, what our thinking was, is what can we do for our young people to try to make sure that we protect them as much as possible. We're now raising the age for a lot of different things, and it also makes more sense to be consistent across these different substances. You know, our cannabis bill, you know, sets the minimum age of 21. This would cover not just cigarettes, but vaping and all kinds of other, you know, tobacco substitutes. So it would just be much easier also for our law enforcement and for our retail stores just to have the same age for everybody and just make it more, you know, much simpler. And, you know, basically the bottom line, the most important thing I think is, you know, is saving lives over the long term. So the Senate, we, as I said, we did have, in previous years we've had a little bit of trouble getting passed, but I guess the, you know, things change as new people come in, and we had no problem whatsoever this year, pasted on a voice vote. And we really hope that to you folks in this body will do the same kind of thing. Senator, thank you very much. We really appreciate it, and we'll dig into the bill. All right, great. Thank you so much. Jennifer Carby, Legislative Council. We are looking at S86, an act relating to increasing the legal age for buying and using cigarettes, electronic cigarettes, and other tobacco products from 18 to 21 years of age. You just heard a little bit about it from the original sponsor, I think, and one of the sponsors and reporter of the bill from the Senate. So it goes through first two findings. Do you want the findings? Yes, please. All right, so here are the findings. The General Assembly finds that an estimated 10,000 children under 18 years of age who are alive in Vermont today will die prematurely from smoking at late advances. Every day more than 1,200 persons in the United States die due to smoking. Third, cigarette smoking is responsible for more than 480,000 deaths per year in the United States, including more than 41,000 deaths resulting from exposure to secondhand smoke. Number four, the younger an individual is when he or she begins using tobacco, the more likely he or she will become addicted. Among youths who persist in smoking, one third will die prematurely due to smoking. Number five, compared with adults, adolescents appear to display evidence of addiction at much lower levels of cigarette consumption and their attempts to quit smoking thus may be less successful. Number six, among current electronic cigarette users under 18 years of age, approximately one-half borrow or acquire electronic cigarettes from someone over 18 years of age and nearly one in five purchase them either online or in a retail store. Number seven, prevention efforts must start on young adults 18 through 25 years of age. Almost no one starts smoking after 25 years of age. Nearly 9 out of 10 smokers began smoking by 18 years of age and 99% started by 26 years of age. Progression from occasional to daily smoking almost always occurs by 26 years of age. A 2015 National Academy of Medicine report found that increasing the minimum age of legal access to tobacco products from 18 to 21 years of age would reduce the rate of tobacco use by 12% and would decrease smoking related deaths by 10%. And finally, early indications suggest that high levels of awareness of and support for California's 2016 law disallowing tobacco and electronic cigarette sales to young adults under 21 years of age may have contributed to reducing illegal tobacco sales to youth under 18 years of age and to achieving widespread retailer compliance with the law. As far as the rest of the sections, they are pretty straightforward. They go through all of the statutes that relate to selling, purchasing, furnishing tobacco products, tobacco substitutes and tobacco paraphernalia. Terms you're probably familiar with from our work on age 26. And it changes the legal age from 18 to 21 years of age. So in the first case in Section 2 in 70SA, Section 1003, which relates to the sale of tobacco products, tobacco substitutes and paraphernalia, it prohibits a person from selling or providing these items to any person under and instead of 18 years of age, it would say 21 years of age. Then in subsection C where it talks about where retailers can display or store tobacco products or tobacco substitutes, and it has to be done. This is something this committee had actually worked on a couple of years ago. They have to be either behind a sales counter or in some other part of the establishment that is inaccessible to the public or in a locked container. And then there are some exceptions that say it doesn't apply to, and in this case, a display of tobacco products located in a commercial establishment in which by law no person under and this would change from 18 to 21 years of age is permitted to enter at any time. So they don't have to keep things locked away from the public if people under 21 would not go out to enter. In section three, which deals with people who are under, it would change it from 18 to 21 years of age, and they're possessing tobacco products or misrepresenting their age. I can actually say for purchasing tobacco products, but I should take a look at that. It would again change the age a person under now 21 years of age shall not possess, purchase, or attempt to purchase tobacco products, tobacco substitutes, or tobacco paraphernalia unless they work for someone who is a tobacco retailer with a license and has them in the course of their employment. In addition, a person under 21 years of age in this bill shall not misrepresent their age or attempt to purchase or attempt to purchase these items. And then this would be a good time, I think, to point out that there's actually another bill that you talked about on the House floor earlier this week that deals with increasing some fines and penalties for possession of and attempting to purchase tobacco products. Tobacco substitutes and tobacco paraphernalia by somebody who's under age. So while this bill lists the current law about what the penalties are, that bill that you passed, I think on third reading yesterday, would increase those fines and penalties. So we may want to look at those in the context of this if you continue to pursue this bill just so that you can understand what all the moving pieces would be. I think they would work fine from a codification standpoint if you were to enact them both, but we won't look at that. So then in subsection B, and this is current law, a person who possesses tobacco products, tobacco substitutes, or tobacco paraphernalia in violation of the prohibition is subject to having them confiscated and subject to a civil penalty of $25. And then this would increase the age to 21 for the increased penalty for someone who misrepresents their age by presuming false identification to purchase those items. And these are the sections that have the new fines? This is one of the sections that has the new fines. Section 4 deals with posting signs in retail establishments where tobacco products, tobacco substitutes, and tobacco paraphernalia are sold. So in this case under the bill, a person licensed under the chapter as a retailer would need to have a warning sign stating that sales to someone under 21 years of age rather than 18 years of age is prohibited. Section 5 increases the age for the provision on furnishing tobacco to persons under a certain age. Under current law that's 18 and this would increase the age of 21 years of age. And so this would say that someone who sells or furnishes tobacco products, tobacco substitutes, or tobacco paraphernalia to someone who is under, you know, would be 21 years of age would be subject to a civil penalty under current law of not more than $100 for first offense and not more than $500 for any subsequent offense. I think this is also part of the fee increases in that bill from the General Housing and Humanitarian Affairs Committee. And in subsection B it's talking about the division of liquor controlled compliance testing where they send people who were under, just under the legal age or a couple of years under the legal age in to see if they can purchase tobacco products, tobacco substitutes, and tobacco paraphernalia. And so this would change that age reference to talk about the provision on sales to persons under 21 years of age and have the people who are going in to do that compliance testing the age change from 17 to 20 rather than the current 16 and 17, which is under the legal age of 18. So this would be now 17 to 20 years of age. And somebody who was under 21 years of age under this bill who's participating in the compliance test is not violating the law of trying to purchase. Section 6 is just some conforming changes. So the penalties for attempting to purchase, possessing or attempting to purchase tobacco products and furnishing tobacco products to a person under the legal age are enforced through the Judicial Bureau in the same manner as a traffic violation. And so this is just a description to the legal age in those statutes as amended by this act. They would then be under 21 years of age rather than under 18 years of age. And similarly, Section 7 is an existing law provision that says the provisions of a particular case related to sale of alcoholic beverages doesn't apply to a violation of the tobacco law relating to the purchase of tobacco products. And I'm just adding in for conforming purposes, but not this isn't a change. Tobacco substitutes or tobacco paraphernalia, those are all currently addressed by the provisions of Subsection 1005A by a person under 21 years of age. So again, just a description, but because of the changes you're making and that you'll be making in the rest of the bill, it's important to update those references as well. And this would take effect on July 1st. Oh, that is Carl. Yeah, top of page 6. I'm trying to understand exactly what this, well, it's actually page 5, I guess, B1. Yep. Okay, this compliance test or whatever. I'm just trying to understand what it means that an individual under 21 years of age participating in a compliance test shall not be a violation of Section... What does that mean? Yes, so people who are, so under our existing law, in this case, we would just be changing the age ranges. Yeah. But it's against the law for somebody who's under the legal age to be in possession of, to try to buy or to be in possession of cigarettes and these other products. But people who are people just under the legal age who work with the department or the division of liquor control to help them with compliance testing by going into stores and trying to buy something. They have it for purposes. Exactly. So they're not violating the prohibition on trying to purchase by trying to purchase as part of a division of liquor control compliance test. Okay, but what about, like right now, if we put the law into effect, there are going to be some people that could possess cigarettes right now. Mm-hmm. All right. What happened to those people? They haven't had cigarettes that they purchased prior to the law going into effect. So what would happen to them under this scenario if they were found with tobacco products? Well, it would be illegal for them to continue to possess those products. And so they, if they were found to have them, they could be immediately confiscated as under the law and subject to fine, the civil penalty, which would be $25 under the current law or more than that under the proposed changes. So they would not be legally allowed to continue to possess those. So presumably they have between the time they pass this in the effective date, which is July 1st, to dispose of those products. Right, it's a good work for you. It's about smoking. Okay. Jessica, then about the topic. I am curious on page three, I believe it's two where it talks about tobacco, a person shall not sell or provide tobacco products, tobacco substitutes. Is this language meet the age 26, so it definitely will cover the electronic cigarettes? Because we changed some of the definition. So maybe I'm missing where we are. It's throughout the whole bill, but this was the first place I thought so I wrote it down. Okay. But it's just, we talk totally about tobacco products and tobacco substitutes. But I just wondered in the other bill, we talked about nicotine in a couple of places. So I just wanted to be sure that this bill covered e-cigarettes. This bill covers e-cigarette devices. It doesn't necessarily address the substances containing nicotine or otherwise intended for use with a tobacco substitute. Certainly something you could put into this bill. We could do throughout the tobacco chapter to be consistent. But in the context of that bill we were looking specifically at what people could buy over the internet. And so you put it in that piece. It is not in this bill as introduced, but it certainly could be added. Okay. Because it does seem like it's moving along. And so maybe as a community we can talk about that a little more. And that was my other question, which is does this language mirror the language in H26 just to be consistent? So generally this idea of tobacco products, tobacco substitutes, and tobacco paraphernalia is consistent. But that, except for that, that additional piece that was added in the context of H26. So that might be something that you will look at. Okay. So there's another section that talks about, oh, in the findings. If you look back at the findings, there's, it makes it sound like you can buy things online. One of the findings says early indications where, which one was it? Oh, because right now you can. Right. Right now you can. I thought that tobacco was what we did was just make it so. You do have, so you're right. So under current law you're not supposed to be able to. You're not supposed to be able to purchase cigarettes or to, for somebody to sell ever month cigarettes online. I think anecdotally for members of the committee you were hearing that perhaps that was possible. Yeah, no, it is not. Okay. Okay. Because it says half in the findings. Yes. And I think some of these make national statistics as well. Okay. Just a little bit. This makes harder to find for month specific, especially with the e-commerce being fairly borderless. Okay. Okay. All right. Thank you. Carl. Oh, wait. No, I got my questions. It was buying one. At the moment, at the moment it's silent on marijuana. Is that right? Marijuana is outside of the context of this bill as it doesn't appear in this chapter. So the tobacco statutes are all in one chapter in title seven, and I think the marijuana statutes are... Oh, this bill doesn't touch on it right now. It's not in this chapter that I work on. No. But we could add that. You could certainly add things. I think the legal age for... Don't work in this area, but I think it is already 21. And I just wanted to know before we move on, we're down to 6% on the iPad. Yeah. I don't know. I'm sorry. It's like... No, it's okay. Maybe we could lens up. I have 15% though. We just can't. We can't have both of them plugged in. We can't project and charge. No, you can't. Yes, we can. Oh, we should be able to. You can't. Right on the whiteboard. Yeah. You know what I'm saying? Blow on my mind. This is great. So we're keeping this on the tobacco bill. Okay. So in this bill there's no provision for grandfathering, so in other words? Not in the bill as introduced. No. I think there may have been in versions in past years that I've drafted. Yes. But in this, in the bill as it has come to you from the Senate, there's not. In fact, I think the bill on your wall from the House proposal may have grandfathering. Maybe that's not a question for you. Do you know if there was any discussion in the Senate about including that? There was not that I was in the room before, so I'm not aware of any discussion about that. If the committee is interested in knowing more about what the discussion was in the Senate, we can, and that was my error in not having a reporter. She did. She did. She did. She just gave her the gift. Oh, okay. How similar is this bill to I think H-27 as the House bill? So you're going mostly on my memory of drafting both of them, but I think they are basically the same with the exception potentially of a binding and the grandfathering. In other words, the House bill will have some grandfathering language on it. Do you want me to pull up the House bill? Would that be helpful just to look at that last piece? So it's H-26? H-27. H-26. H-26 is the E-26. Oh. There's seats if you want. Are you scared? I know. Yeah. So it is basically the same except, here we go. There's a section 8 in H-27 that says notwithstanding any provision of this act, the contrary, the prohibition on the sale or furnishing of tobacco products, tobacco substitutes for tobacco paraphernalia to a person under 21 years of age shall not apply to any person who attained 18 years of age to honor before July 1st, 2019. Similarly, the prohibition on the possession of purchase of or attempt to purchase tobacco products, tobacco substitutes, or tobacco paraphernalia by a person under 21 years of age shall not apply to any person who attained 18 years of age to honor before July 1st, 2019. So that's the grandfathering provision in the House bill. Madam Chair, we're going to have either the presenter on the bill on Sunday so we can ask questions about the witnesses that they talked to. I'm interested in, I'll tell you what I'm interested in. Did they contact anybody in the National Guard? We have the witness list and Julie is pulling it out and house this. Whether or not they heard from someone from the National Guard, we would like to hear from them right now. In this first list, it does not look like they did. But what they did and what we do, if that's someone that you would like to hear from, we will, this is not the only day that we're going to take this out. I just want to make sure that they're on board with this and they can actually comply with it. Okay. Well, that's a great question. Julie, could you add that? I believe that last year or two years ago, we had, I mean, and whether or not that's the same person, but we had someone testify. We had a couple of people testify if I recall on that. So that's a good question. I remember that and I remember the language. I'm just wondering if they've changed. You know, they talked about how hard it would be to do it, but they would, you know, do their very best to comply. And they supported it. They supported the change, but said, what you said, but in the end, they supported it. Are there other questions for, let's say, a council? Sure. Or before you leave, are there things you want to tell us? No, thanks. Okay. I'll be right over here. Back to me. Oh, yeah. Okay. So I want to thank the committee for giving me some time to speak about tobacco 21. A little bit about me. Hi. My name is Prosper Ogogo. I'm the director of the Cardiac Health Lab and UVM Medical Center. And so part of that job is understanding our statistics. So I can actually give you real statistics of our monitors who suffered consequences of tobacco. And Dr. Eif, I so apologize. It's probably much more healthy to have you standing, but we sit. I can sit. And it's one of those, you know, roles that we don't talk about. So, and I'm here for two. So as you can imagine, I'm a physician that takes care of the late consequences of smoking-related illness. I'm more like a fireman who's already running to a fire, rather than someone who's trying to purify from having a first place. But there's two motivations for me for this. One is, I'm trying to put myself out of business. And the other thing that should be the motivation of most physicians is to make sure that the health of the population is good and that your services are less needed for them. Secondly, my son is 12 years old. And so he's going to be, as we may have heard from Mother Testimony and other parts of this legislature, the principles of this rule are talking about how prevalent the problem of avatars is and how on our middle school students. So I want to share some of those things, not only the statistics about our hospital, but about some brand new statistics that just came out at the College of Cardiology in New Orleans just last week, about the risks of avatars. I'm sort of like the ghost of smoking past, present, and future. That's the whole thing. So presently, I just want to share you some statistics at UVM Medical Center. So to talk about stem procedures, that's what I do on a day-to-day basis. I perform stents in patients who have blockages of their arteries because of atherosclerosis. So if you look at all the stem procedures that we do each year at UVM Medical Center, about one in four patients who require a stent are current or recent smokers. You should know because nationwide and in Vermont, that population of people in Vermont are smoking is less than 15%. So there is an association here of higher risk. And when I say this in terms of stem procedures, these are patients not coming in with heart attack, but for any reason that might need a stent. That's how many we do. 1,300. So the cost of these things, you can imagine, is quite exorbitant. We're talking about how many people need a stent per year not including Dartmouth or Albany, which may be the other places where the moderators get their stents. So one fourth of... Yeah, one fourth of 1,300 are current or former smokers. So 280 is the number of patients who come to UVM Medical Center each 12 months who have a large heart attack and require a stent. So this is the most acute situation. This is the person at home who starts clutching their chest when they're getting a stent. A lot of people actually drive themselves to the hospital which is not what you guys see. But calling the ambulance, the ambulance gets the EKG and right on the EKG at the patient's home, they see big profound changes that have a large heart attack. And then they get in the hospital two in the morning, we roll, run in there for cath lab staff and get the patient's artery open. 280 times per year. Unfortunately for us, 65% of that maybe that's another motion which is why I'm talking today. Smokers, so 48%. So remember, I'm talking about the large heart attacks run into the hospital two in the morning type thing. About half of the patients who have a large heart attack are current or former smokers. So smoking actually is fairly toxic to the arteries and there's a lot of inflammation in the arteries associated with cigarette smoking and other arteries on stage. So one out of every two patients who gets treated at the hospital with a large heart attack are current or former smokers. And here's the cost. So I know that you're going to hear about the costs of this bill. Well, you're not going to recoup these in the first year. But this is the cost right now for treating these heart attacks. $13,000 is the average reimbursement. Not necessarily the cost of the care. But the average reimbursement that Medicare pays the hospital every day. So the bottom number, 3.4 to 4.5 million that's how much the payers, Blue Cross Blue Shield Medicare, Medicaid, SIGNA and all the other payers pay the hospital per year for the treatment of these patients each year. And so that's only at UDM and we're not talking about Dartmouth or all of them. All right, so a little bit about the past. Now here's where we were and this is great. So this is the statistics from the American Heart Association. From top to bottom, the blue numbers are the smoking rates amongst men between 1965 and 2015. Big drop. The pinks are the smoking rates amongst women between 1965 and 2015. Another big drop. More recently, we're looking at smoking amongst American youth aged 12 to 17 in the yellow. And that's from 2002 to 2016. Again, a big drop. And finally, American high school students from 2011 to 2016, 16 to 18 to 8%. Okay, so we've made some progress in terms of preventing smoking amongst the youth and amongst all Americans. But there is a concern and let's talk about the potential future of this whole thing. So I'm not, I put a question right there because this is, I think that this bill can change us into a different future if we pass it, but let me talk about the future. So this is sort of a rhetorical flourish that I've made into this presentation. The reason why you see these kind of goofy colors, I mean, kind of funny colors that you see here is because this color palette is what Joule uses to advertise to you. $38 billion. Now that's an important number because that's the market capitalization of Joule. Altria, which is the largest corporation of smoking-related products, that's the use of ERJ, Reynolds, and Nabisco, bought one-third of Joule last year for $12 billion. So, and the reason why they are such a high-value company is because their growth has been voracious. They've gotten so much take into the American high schools and amongst the American colleges that their growth has been astounding. That's why they're such a high-value company and they're a Silicon Valley company. So we can imagine maybe with some of the private concerns with Silicon Valley companies, this is also one of those things where maybe this is what we need to do and that's what we have to face. Our kids are facing a billion-dollar company and we have to do everything we can to defend them from this. Okay, so up to nine times. This is from a study last year looking at kids who have smoked within the last year and kids who have evaved within the last year and kids who have never done either. When they looked at this survey, kids who have evaved in the past 12 months in this survey were nine times more likely to move on to combustible cigarettes so this head study has some controversy about it but again, this is one of those studies out there that shows that there may be a gateway product from being able to conduct combustible cigarettes. So I'll move on to the data that was just released this past weekend. This is by the Center for Disease Control. It's by the National Health Interview Survey and this was released at the American College of Cardiology Scientific Sessions in New York. This was released this past Monday. So this survey looked at three years because they didn't have any smoking or vaping related questions in 2015 like 2014 and 2016 and 2017. They surveyed 96,467 Americans over the age of 18 regarding their habits with smoking and vaping. And also, they asked them questions about their health. So this study was looking at the association between vaping and cigarette smoking and things that we care about such as car attacking. What was interesting in this study was also looking at the demographics of who is vaping. So this is a pie chart of who is vaping based on their attainment of education. I think what's really interesting here is at least divided up to high school diploma or less or college or more. So college or more is 73% of people who answer this question have had some college or more. And if you think about that, that makes this an aspirational product. This is what people with education are doing and you can see it on college campuses UVM, downtown you just see this big cloud of smoke coming out of cars not smoke but vape. And you can tell it's vape because it's out there it's profound and then it disappears into the atmosphere within a couple of seconds. So this is no longer cigarettes. This is vaping and it's everywhere in Burlington so we can look. So here's the data that's really interesting. This is from that survey. This is the association between cigarette smoking vaping or e-cigarettes and heart attack. So the blue is the non-users and you can see that vaping and e-cigarettes are associated with a 56% increase of heart attack. Not as much as smokers. You can see that's 165% increased risk and there's a signal that there is risk even with these vaping products. So these have been proposed as the safe products at least that's some of the marketing earlier that they're not allowed to use anymore as a safe products. They may not necessarily be there. This is still a controversy but certainly I've never seen this study that shows absolute safety either. So there's an association of heart attack this is the association with stroke again much more profound with cigarette smoking but there is still a signal of risk with vaping products. And finally this is interesting depression and anxiety syndrome a diagnosis or at least dealing with depression and anxiety. Actually this is where vaping and e-cigarettes are actually there's a stronger signal for risk with depression. 122% increased risk of having problems with depression and anxiety. Now a lot of you might be asking well a lot of people might be using e-cigarettes to get out of smoking. So are these vaping people that you see in these last two to three slides are those the people that are trying to get out of cigarettes and now their risks are all related to cigarette smoking and now they moved on to e-cigarettes. Well this study actually tried to take that out of the factor so they control statistically for people who said they have a previous smoking history. So the assumption would be that this day that I'm showing right now are people who have never smoked that have moved on to vaping but have never smoked before. So again even when you take out those risk factors and this also takes out cholesterol and hypertension and there's still a clear signal that there's an association between vaping and heart attack and depression and anxiety. So I just want to finish with this again this data is profound and it's striking and it's beautifully colored but this is an association and not causation in science the only way we can really prove that this is a problem is to take give them vaping and then 500 other kids and say no let's just follow you out for 15 years and see what you got. That is the data that we would consider causal and not really associative but we're never going to do that. This is some of the best ideas you're going to get and I think it's something that's actionable for my opinion especially since my kid's going to be 13 soon and he's going to be experiencing some of these 18 year olds that are selling dual products and we have questions first Carl and then Mary down. Yeah just I've gotten some comments from constituents about the fact that they use a vaping product to stop smoking and that's why they don't want me to do this or whatever they think vaping is good so what would you say about that I mean I think I'm in your camp but I want to be able to answer those questions. So I think the good news is this bill is not necessarily for people who have been smoking for a long time and need to quit this bill is about preventing kids from starting or developing life. The jury is still out on whether these are effective smoking cessation devices some medical societies other parts of the world have already recommended these devices to help smokers quit and if you look at those slides there is a harm reduction as you can see by moving out of vaping from cigarettes so it's still controversial but again I think that's a little bit out of the purview of what we're talking about here in terms of preventing these. Thank you. So I am concerned about people who are smoking now we're between that 18 and 21 and they're not so much from the standpoint of they can't do it anymore but from the standpoint of we were addicted and what happens and what will be the influx of the medical community received from people who were I mean that whole public health issue of people who are smoking yeah so I think again that's controversial these devices have not been approved by the FDA for smoking cessation devices so in this country we still don't have an official decision that these are effective devices I would say that there's a lot of other effective smoking strategies out there including patches I saw one other presentation of the American College of Cardiology for prevention and looking at how to get people quit and it's not necessarily device or a patch or a piece of gum or cold turkey it's actually making sure that you get in a supportive group of people who help you quit and that's really what we miss a lot of times is that people, a lot of my patients say I'm just going to go cold turkey like no don't do that a failure rate of cold turkey is like 95% so really it's about calling them on a quicksline getting some help with counseling and making sure you get in a support group including your family that's supporting you that's very difficult but that's that's the most effective way just as a follow up on that one of the difficulties is that kids who are showing up that are underage so they shouldn't have been smoking so now we would be adding another group to that in schools they're really starting to figure it out and they're really putting the cap on it the problem is that they're finding withdrawal symptoms in the schools and yet because they're not supposed to, it's not legal for them to have been smoking they're not doing much in the area of okay so how do we help these kids get over the hump of now I'm addicted or you know what's your thoughts on that the age of the patient that I deal with is 62 so I will be able to answer that question and actually I will defer to my colleague coming up after me I mean this is more of her age group and in terms of I think we actually wouldn't be all I mean look at that with any kind of scientific data so it may be an under underserved population and we've actually maybe we're two years or three years late on this bill to prevent this from happening in the first place but yeah I think there's going to be little size defining how you treat these kids and that's really the importance of the group of concern is that aggressive behaviors in school right I have other questions thank you thank you very much Dr. Bell thanks Becca Bell on pediatric clinical care positions at the Medical Center in the pediatric ICU and thank you for having me back to talk about this issue I'm also here representing the American Academy of Pediatrics Vermont chapter and like Dr. Go with the Vermont Medical Society both of which are wholeheartedly supportive of this measure and I'm going to talk about a little bit of a different perspective so I talk a lot about smoking when I work and it's not so much to my patients but to my patients' parents and you probably know that Vermont has a very high maternal smoking rate so our rate is actually twice the natural average, natural average is about 8% of pregnant women smoke in Vermont it's like 16 to 17% so what does that mean so infants born to mothers who smoke are at risk of being born early, they're at risk of being born when they're small and then once they're born and they go home they go home to smoke exposure and I see that in the pediatric ICU because for instance right now it's winter time there are lots of respiratory viruses going around when an infant gets a respiratory virus the difference between sort of getting through it at home maybe seeing the pediatrician and actually needing to be in the ICU modulated by smoke exposure so infants that are small that are born early and are exposed to smoke at home when they get a respiratory virus breathe that normally and they actually stop breathing this is what they call apnea and those exposed to smoke are at much higher risk of apnea when that happens we have to actually put breathing tubes in these babies in Vermont then only they're going to come to the ICU and so in that moment the parents are always saying what can we do to prevent this and this is a conversation I have and we have smoking cessation counselors in the hospital this is not a good time for people to try to quit smoking when their child is critically ill and these parents are just desperate to stop this habit but can't, they're usually young parents and they're already addicted and have trouble the other patient population is the very very sick kids, the kids with asthma who come to the ICU over and over and over again and one of the major exacerbating factors is the smoking exposure at home to the point where we have to sometimes separate kids from parents because they get better in the hospital they go home and they come back a week later because the smoke in the home has exacerbated their asthma so this is a big deal and these parents, every single one of these parents wants to quit but they can't so often times when you talk about quitting they say I can't but if you ask them they never started so most smokers don't want to be smoking, it's very costly it's really inconvenient and they have poor health outcomes and they know their families have poor health outcomes and when you ask smokers nationally, the CDC did a survey about this question should we raise the minimum age from 18 to 21 70% of current smokers said yes please do that and that's because the earlier you start smoking the harder it is to quit smoking as you've heard okay so how does this actually work Senator Ingham actually went through this a little bit so I won't spend a lot of time on it but when the Institute of Medicine actually did a study predicting how this would change our smoking population they found the biggest decrease in smoking initiation among ages 15 to 17 and that makes sense right so you have 14 to 15 year old freshmen you have an 18 year old who can legally purchase these products and that social circle is completely overlapping they're in the same building every single day this is really easy you take this from 18 and you move it up to 21 and that social circle still might overlap a little bit but not as much anymore and certainly the overlap between the 21 year olds and the middle schoolers have really increased and we know that young people are really susceptible to changes in opportunity so if things become a little bit more expensive if things become a little bit harder to get that actually does really change the behavior because they don't have unlimited resources to then pay extra or to drive similar and get these products so they're really susceptible to these small changes so the Institute of Medicine predicts that if we made this change you would have 12% reduction in adult smokers later on in life and this measure just like every measure is a small part in what we need to do to reduce smoking but that's pretty significant when you look at Vermont our smoking rate prevalence rate among adults is about the 2016 numbers is about 18% so if we reduce that by 12% and sort of extrapolate looking at the Vermont census that's about 11,000 fewer Vermont smokers when the current teen population becomes adult so that's pretty significant and then I would also just as a caveat say that because of this e-cigarette problem and because more and different kids are starting e-cigarettes I think that number is going to get higher before it gets lower and so that number that 11,000 I think will actually even be greater if we're able to do this so if we you know of 6th graders 67% of 6th graders who start smoking become regular adult smokers once you get to even 11th grade it's 46% which is still a lot and as you've heard 90% of people start smoking by the time they're 18 so everyone's using this product before they're even able to buy it everyone can get their hands on it so if we can even get older teens people to start not in middle school but later in high school or even later it's easier for them to quit they become adults that don't smoke as much so those who start in middle school for instance smoke more packs per day as an adult they have worse health outcomes so that difference really matters because as a brain ages that reward center the susceptibility to nicotine improves when we look at Dr. Gogo mentioned the very obvious and not at all controversial cost effectiveness of long term if we reduce our smoking population I think that's something that everybody agrees on when there have been now seven states that have done this that have increased them from 18 to 21 when California did it one of the concerns was well it's going to be great that we have fewer adult smokers long term that's going to be great like millions and millions of dollars saved live saved but what about the lost tax revenue we don't have as many smokers so they actually looked at the short term fiscal response and found that just by looking at going back to the maternal smokers we have 15's today that don't pick up the habit of smoking we have lots of young parents in Vermont they're going to be parents very soon the savings you get from reduction and premature births and all the stuff that's so soon when that actually recruits the cost 5 years of that lost tax revenue just looking at that so of course we always think about the long term like reduction in heart disease, reduction of lung cancer reduction of COPD in the adult population but we're talking now about families and people who are going to have families soon and infants and the reduction of costs there can be seen really quickly actually and when you read the numbers about lives that will be saved by reducing the or increasing the minimum age it really is talking about those patients the COPD the cancer, the heart disease the stroke but there's no way to really capture how much it will put in the lives of young people who are experiencing second hand smoke so the infants that I'm talking about that come to the ICU and they're intubated that can't be captured in the data the infants that have a higher risk of sudden infant death because of smoking at home that's a real number and that's again an exacerbating factor that we can't really capture really quantitatively and then my asthmatic patient who comes to the ICU every month they're on steroids constantly they miss school I have patients that just have missed grades because they missed school for their illness and that again is something that's hard to quantify and that's because of a parent smoking at them so we have these really impressive numbers that we think are going to be direct causes of increasing this but I think we also have these secondary gains that we don't even we can't even measure so I think just between the obvious cost effectiveness the improvement of health and then you know there's a lot of health outcome disparity that occurs because of smoking in this state I mean the folks that are most affected by it are the lowest socioeconomic status folks and they're already at higher risk for other things and then you add these poor health outcomes on top of it and you have this disparity if we could improve and decrease the rates of smoking in this state that those health outcome disparities should improve so that's all I have I'm happy to answer questions too about what you have but this is something supported by AP Vermont and Vermont just following up on the previous question they asked about you know people that are either younger than 18 and shouldn't be using tobacco or you know cigarettes and then those that are smoking now in that 18 to 21 range and it's illegal and kind of like what's in place to kind of help them you know many of whom are addicted now so I think first of all we just want to reduce that population exactly what you're talking about we want to just have fewer kids smoking so we don't end up in that situation I think Shaila Livingston will talk a little bit more about what's in place from a public health perspective and how we address that it's something I don't know as much about but certainly we have as Dr. Gogo mentioned other ways to help people through smoking cessation and certainly something that's recognized by pediatricians and always working with patients to try to reduce that but that's going to get worse what you're talking about is going to get worse because of these e-cigarettes and so we really want to reduce that and again when we have 13 or 14 year olds starting to smoke and they get to 17 and they're like I don't want to do this anymore it's really hard for them to quit so if we can reduce that well we're going to be in a better place Shaila, in your testimony you made mention of a bunch of studies or you said things like NIH has done something that returned on me that if we could have links to some of those that would be very helpful to I have all of the stuff I mentioned up Thank you Are you ready? Good morning everyone Good morning everyone Shaila Livingston from the Health Department I'm so glad you asked that question because now I have a reason to be here I first want to start by saying that the commissioner would have love to be here and if you take further testimony would like to hear from him directly he is happy to come in in the future I will stand in as a force of duty today for him as a commissioner and as a provider so I did provide you with the handout here this is just a simple one pager as you've heard there are lots of risks to smoking it is the number one problem cause of death in Vermont and in the United States and people start young and that's what we're trying to prevent with this bill so I have to go through it but I don't want to repeat everything that was just said I can talk a little bit about the public health approach to this so the public health department has worked long and hard in Vermont and in the U.S. to address smoking among youth and among adults we've made great progress as the doctor pointed out but in Vermont we have plateaued a little bit with adults and it takes sort of greater bigger efforts in this case to reach those populations I do also want to stress in Vermont we have big disparities among who is a smoker and who is a non-smoker and that could change with electronic cigarettes but right now the tobacco users in Vermont are higher risk populations already and those who are already vulnerable and so it's another reason to take a next step in addressing this issue in this state do you want to address the question of what's in place so we fund the 802 quits online and that has specific guided quick information for teens and young adults so it's not just the one side it's all the same program and they have two-week checking calls we also now have a texting method since younger people and including myself sometimes prefer texting while we're talking on the phone so that is available what was that? I could be another person and and then there's a program called Become a Smoke-Free Teen which is an online program for teenagers and young adults you can also always go to a pediatrician smoke quick devices like the patch or other types of devices are approved for young adults and teens those can be obtained through a pediatrician as well just like for an adult so those resources are all available to both those young adults but also to teens there are also ever been schools to start to provide counseling and it actually came up in the senate economic development committee the other day this question of what are schools doing around helping these kids who are now addicted primarily to probably the electron cigarette use and how do we help them manage them and there are new school policies coming out for school nurses and school counselors around treating it as it is substance dependence and how to support those students and children so I'm happy to take additional questions have you heard much about whether or not one of the things that I read somewhere and I think we talked a tiny bit about it yesterday is that the e-cigarette folks who are addicted to the e-cigarettes are having a harder time the cessation isn't working as well because of the way that it's delivered and the impact of a full pack of cigarettes in that one little pod is making it the cessation, the patch is not working as well I don't know the answer to that I don't know either of my there's a lot of nicotine in it I can look into it and see if our program knows anything more about that so Shayla I was very surprised I'm watching television two nights ago on channel 3 I saw an ad for jewel as a smoking cessation and I think that I know that Dr. Goh-Goh mentioned that but I think it would be important for us to hear the multiple perspectives on whether or not jewel and vaping is an effective way for 18 to 21 year olds to stop smoking because I know that vaping folks we want to get the full so there's a couple of things to think about there one is that in terms of tobacco 21 in the context of this bill specifically we absolutely need it to apply to both electronic cigarettes and combustible tobacco the reason for that is that we know a lot of students are starting with electronic cigarettes they're not starting with they are then at much higher risk as the doctor mentioned for picking up combustible tobacco and all the negative consequences that we know are associated with that so in the context of this bill that is not relevant if and when electronic cigarettes are approved by the FDA as a quick device they could then be prescribed by a doctor or pediatrician as a putting tool for a teen or a young adult so in that context eventually they could then be prescribed like any other prescription in that context so if again in that context I'm thinking about this bill that's what I would respond to if you're thinking about it for adults as a quick tool it's a similar response which is that once it is approved as a quick device and becomes a prescription then it can be prescribed through a provider and if the legislature decides to tax electronic cigarettes et cetera et cetera et cetera there would be other ways for those individuals to access that as a medical method for cleaning I just wanted somebody I forget whose testimony it was but there was a statistic used that 70% of current smokers would say we should raise the age to 21 is that pretty well established I mean there's literature yes there's both that's a great question so there is both popular support as well as support among smokers there are also this is anecdotal but there are now many college students who are very dependent on electronic cigarettes who are really upset because they did not know and they feel very dupe constricted into what's happened to them and they can't quit chapter you just brought up a very important point about the people who are upset that didn't know my question is in terms of the health department what are you doing with the schools to educate young people everything humanly possible so our tobacco program works closely with AOE and AOE actually has a tobacco program as well and they are working with the OVX and VCAT student groups they are putting out model policies and that's something that actually promises on the economic development committee that I can get for this committee as well for schools there are informational campaigns and ad campaigns to students like Instagram and Facebook and where students go Snapchat etc basically in every possible way including parents and so having said that it's not working so we are behind they got out ahead of the public health community and the provider community so Juul and electronic cigarettes and vaping have a few years head start that said we have done this with tobacco and we will try our best to do it again with electronic cigarettes and I think the bill in front of you is a good example to prevent so she can't do it can't do what this one here in front of us it talks about combustible I mean combustible tobacco products we need to put the Juul thing in it's in here mine is in here it's in here is the statutory term for electronic cigarettes and vaping devices so we don't have to do it well so it's in your bill it's in the bill that's my point we don't have to do it you don't have to add it because it's already in there but you would have to ask the bill is this in my bill? I'm not going to say anything lawyer it isn't in there but it is no I forgot what I was saying oh yeah do you think we should have the Attorney General come in do you think we should have the Attorney General come in to this committee and talk about enforcement as teachers they are first reporters on certain things should they become first reporters on this it's happening all over the schools so you report them so schools have their independent policies on how they address this they're not working they are so schools are implementing these policies like I said I think that the industry got out in front of everyone however they are catching up and they are implementing them I do think that the Attorney General's office could be an interesting witness I have a question before electronic cigarettes became really popular kids were smoking in schools and you guys did stuff maybe was that effective did the number of kids who were smoking when you did when the health department and schools saw smoking combustibles in schools as a problem did those efforts work in decreasing the number of kids who smoked so that is an excellent point yes so that worked one of my favorite stories I'm just trying to let you know this strategy worked for cigarettes so when you are saying the industry got ahead of us you are talking about the e-cigarette industry and you are you are testifying the fact that the strategy worked with combustibles so a similar strategy would be effective absolutely yes you tell it very well just that in the old if you look 10 years ago the big remember the song Smokin in the boys room well that all was because they were monitoring bathrooms now in Seth Berlington the doors off of the bathrooms because you can't smell it anymore in the same way is it Burlington? I think it's Burlington too you mentioned it they were not taking them but be careful they are not taking the doors off of the bathrooms inside the bathrooms when you first said that I thought like really in other words they haven't had to monitor the bathrooms in 10 years the public health has done such a great job of reducing the amount of smoking in schools the problem is now with e-cigarettes we have seen in one year a total switch back to that again to removing doors on bathrooms another little anecdotal piece my son is 16 on instagram and snapchat and I looked at his instagram the other night and that's one after the next it's really amazing what are we going to do on a federal level to combat the advertising? I don't know I would have thought I was seeing things except and we were not watching it in the same room but Logan also saw the ad right? yeah I saw it on like a google oh yours was on google mine was on channel 3 oh wow okay we have to go ahead so I know that you don't actually do enforcement but let's say for example that the ad that the chair saw was just wrong but it was fraudulent would you refer that to the attorney general and say I believe that that's true but you should check with them they could be a good witness to come in and talk about enforcement and then the other group that does a lot of enforcement for tobacco and tobacco products is the department of law so in terms of what would we like to hear back from the department about what other information would we like to hear from the 70% of current smokers would be supportive of increasing the age if you have a study it would be great to see that okay so we'd like that what else would we like right now we'd like having you when you keep calling back but I wanted to give you a heads up I would just say like you mentioned all of these different programs for youth some little yeah that would be great just to have super tenants in school districts I'm sure they all know about it but parents too thank you very much Nolan I don't know morning for the record Nolan and I, well we're talking fiscal office I'm sad to say this is the first time that I've been in this committee to testify this year well we're happy to see you yes question so you see in the iPad there is a fiscal note for S86 you know the first thing I'll say is that the public health benefits on the long term for this policy are undeniable you know in terms of the law this will impact this public health benefit they're undeniable and if your policy is successful less people will buy cigarettes and therefore you'll have less tobacco tax revenues so we worked with the marijuana tax will make up for it yeah we're focusing on tobacco 21 but is it fair to say that while our tobacco tax will receipts will go down yes our Medicaid costs might also go down and I think the one you know I I've talked to Dr. Till a lot over the years on this bill and one of the things we've talked about is one of the shorter term impacts of things you might see Dr. Bell could probably confirm this is the prenatal care that's the kind of thing that you could see in the short term immediately but you can't count those reductions in your what in terms of like the Medicaid budget but those are the kind of things you could see pretty quickly in the sooner out years rather later out years so we worked with Tom and his estimates are that it would reduce the tobacco tax revenues by $450,000 we raised about $60 million a year in tobacco taxes so this is less than 1% drop that $450,000 though is used to match for commitment so we're losing about $550,000 I forget what the number is $525,000 in federal dollars so the total reduction to the Medicaid program of $975,000 one of the things that he talked about though is one of the reasons why the revenue is actually loss is relatively small because he felt that the compliance wasn't a very strong compliance piece so he was feeling that compliance wouldn't be very high to give him away the languages right now so that's one of the reasons the revenue is on the smaller side he said if you were if you created a tighter compliance piece the reductions could be as much as $2 million so we've attached his whole memo about his piece it's attached to the fiscal note so it should be following after that of course none of these are ever an exact science and these are all based on what we think the behavioral impact would be for people in this age group and then also as discussed the ESIG piece would also reduce the revenues ESIGs by about $45,000 based on what the estimated ESIGs revenues were going to be to reduce those revenues Any questions? I'm curious I don't totally understand how we match dollars I understand the Medicaid program when we spend money on certain things we can match but the revenues coming in from cigarette sales we can match that as well the revenues from the cigarette sales are money we use to match so we have many sources we have provider tax, we have cigarette taxes but this is the state share that we use along with other journals these are the dollars we use to spend to then match and we'll have to still come up with those dollars to spend so we'll still be matching them they'll just be from different sources so we book how much I think we're going to raise each year and with this legislation we would assume that we're going to have $975,000 to spend unless we find the money elsewhere there's no bill, there's no offset so it would be but do you see my question is that if you have the expenses for Medicaid you're going to have those no matter what so don't we have to fund the funds to match it? I get the first one yes and you're correct and that's the whole moving piece of the budget so if we think we're going to have that spent in Medicaid and we have this less revenue we have to find it elsewhere in the budget offset so you have to find it twice or you increase the tobacco tax but the flip side is the governor puts forth their priorities and if this is a priority you work with appropriations to find that offset within the budget to match your priorities it's less than 1% it's less than 1% of the total tobacco tax and if we can find a way to really match that to reduction in costs inside of the Medicaid program it's less people are sick well that was the point it's a long term cost I can't offset it in year one but I think in the long term I think it's undeniable I think there's some things like the asthma in the homes and kids who are in homes smoking if we reduce we'll see that as a quicker turn around than our the person who won't have a heart attack in 30 years okay thank you are there other questions for now thank you very much I appreciate it sorry I wasn't as funny as Jen works out for you so committee before we take a break before we take a break because we have people coming in at 10.30 we will be taking this issue up again who on the sidelines have not testified that they want to be testifying because they represent groups we already have Andrew playing Dana, Aaron, Rebecca, Ryan Nick Sherman for my friend okay you would like to okay who else I think I'm on that one yes you are is there anyone else I'm looking um Andrew to you and to Nick because I don't know who what other and we have Aaron the Grocers what other part of the industry might need to testify Heather Sheldon is the only person I would think that might but I'm not sure who she is that's the only one I can think of okay thank you committee who are the we want to hear from a national guard or a military person what are you and why are you from the AG's office well whoever I just want to make sure I just want to make sure that if there's a way to get at it at the core of the school so okay do you have a quick question do you have something that you want to hear from someone else or do you want someone to come back I have some concerns about being able to go I don't know what the law is in New Hampshire as an example on New York on Massachusetts if somebody feels like I know we have ready access to a whole car all around us so you want information about what the states are and what our neighboring states are what information do you want I'd like to know the e-cigarette tax that we just that could pass if that could make up for some of this I believe it's commented a little bit but we can ask Joint Fiscal to speak more to that later okay what about the retailers Aaron Seagress is president of Vermont Retailers and we have our own retailer right here yes we have a filled in any other groups or questions so that we know okay so we've got seven minutes so for the record my name is Jeffrey Wallen I'm the director of the Vermont Crime Information Center with the Department of Public Safety and one of the areas within my area of responsibility is our therapeutic use program depending on the particular terminology we want to use it today really what I hope to do is answer any questions that the committee has that's my primary goal here today to answer information I'm also happy to give a brief from my perspective overview of the report that you have in front of you and is up on the screen I wouldn't begin perhaps my comments simply by saying they are a number of individuals who are appointed to that committee the department provides administrative support organizing meetings, phone calls, etc circulating around drafts but it is an independent committee that is not overseen per se or directed by DPS what is its purpose the purpose actually begins and essentially it's to evaluate and make recommendations on the program to the assembly they are required to submit that every year for the authorizing statutes that set up the medical marijuana program before you go over this given the fact that we have people who are against medical marijuana what is our current law what's the current landscape if you could start there certainly happy to do that from a programmatic perspective essentially the medical marijuana program I'll use that term just to discuss the program there are members of the body who everyone uses medical marijuana but find that counter-indicate they use the term marijuana for syndrome relief therapeutic use is another term you will see occasionally but I will try not to fall over the acronym SUP as we discussed the program today as we go through essentially the role of the program is to provide registration to individuals that work for marijuana residents that qualify for inclusion and there's basically a list of conditions or symptoms in the statute a spelled out in statute that qualifies someone to receive a card an identification card and those are issued by the registry and those provide the individuals with certain protections in Vermont law and also allow the individual to either grow or purchase marijuana from one of the registered dispensaries which segues into the second other significant responsibility of the program which is to provide oversight and support of the now five different marijuana dispensaries in the state so the doctor is right at prescription? so that's a great question doctors do not write a prescription for marijuana rather they verify that someone has a qualifying condition and in their professional opinion would be of some benefit in the individual in question the second is a little bit more that's how doctor-patient relationships work it's not necessarily written into the statute per se they simply are verifying a condition however from our interactions with both patients and healthcare providers is not going to fill out the form if I think it's not at the pace of the best interest or going to be of some potential benefit generally speaking I just moved into the state can I get a card? so we do require residency for that that concept as the committee may know is a little bit challenging per se exactly what a resident is it's not always made clear however we do require an individual to have a Vermont driver's license or a Vermont driver ID and in certain instances they have to have a particular length of patient and provider relationships we just can't go to a doctor that they've never seen before and say hey I've got chronic pain fill out form forming there are some instances based on their condition where that can be waived depending on where they're coming from do they have a marijuana card in their prior state and their particular condition and that gets into some of the twists and turns that can be a little bit head scratching we've got to work through the patients on that on that piece but it does require residency in Vermont and sometimes that length of residency may vary depending on the individual service now committee you'll have opportunity of course again are there other questions about what the program is in Vermont right now is there an age? there is no age limit I don't have this exact number but we do have a small number of individuals under 18 who are on the registry at any given time and typically their parents are the ones who are signing off on the forms that we have so is there a limit? is there a limit? so if you're approved through your physician do you have a limit on how much? there is a limit on the amount product that you can receive or equivalent in a 30 day period and that is two ounces that the individual can receive and that is tracked by the dispensaries if they are selling products to the individual or by the individuals themselves and I have cancer and I'm not able to drive so if someone is in a situation where they are unable to drive themselves to get product there's a couple of options they have dispensaries to offer delivery that is authorized and they are able to do delivery it's fairly restrictive you can't meet it in public space you can't meet it in a parking lot it has to be to the individual's home most of the dispensaries have security requirements where they verify ID they won't come in the home they'll simply knock on the front door and hand it over but that is something that is available also patients may have someone called a caregiver that is a term that can be a tad confusing just to many of us that sound like your doctor or healthcare provider would be your caregiver it's not in this particular case it's an individual but a patient has elected or selected to procure or grow product on their behalf so for example if I was a patient and I selected a friend or family member to be a caregiver I couldn't drive to a dispensary to pick up my product they could go pick it up on my behalf they receive an ID card it's the same as a patient but they're able to transfer that information back or to potentially grow or manage any of my cultivation on behalf of them are there any limitations as to who can be a caregiver if they've been there are a few restrictions on caregivers primarily it's based on a criminal history background check so we do run we want to see that the individual doesn't have a violent history and criminal history there are other certain conditions that may initially prohibit them but depending upon the individual's circumstances they can appeal that if they have a drug possession or a charge within an X number of years they may be initially denied but then they can appeal that based on rehabilitation etc on there so there is no similar prohibition on patients sometimes there is a thought that a patient that has a criminal history cannot have or receive a card there is no prohibition there is no prohibition on that but there is a prohibition on caregivers with certain criminal backgrounds I have a green thumb and I would and I'm very particular I would like to do it myself may I if a patient or their caregiver would like to grow or cultivate on their own they are able to do that one of the most common follow up questions is well how do they get started we do have occasionally folks that call us one word are you putting my seeds in the mail we don't do that there is a reason why I have one of my staff who keeps the plants in my office alive which are not covered under this particular statute regular house plants because I would kill them if I looked at them the wrong way but they certainly can be grown if the patient or their caregiver has a green thumb is very particular etc they do have to be in a secure location away from others secured from an infirmary address etc they can be cultivated the dispensaries are authorized to sell essentially clones of the small water bound plants that you may have seen just in any number of scenarios why they are called clones I am not a botanist nor a biologist so I can comment on why they are called that as opposed to seedlings or some other such thing but they can be sold from the dispensaries so if you wanted to do that and you wanted to get a couple of quote-unquote starter plants for lack of a more delicate term you can offer to us from the dispensary is there a limitation to how many plants I can have? there is a limitation to the number of plants you can have but it depends on their growth stage as they mature you can have fewer because they turn larger for those I had never yes I can say with confidence I had never seen a marijuana plant in person until I took this job I had always seen them on television I had never seen one in person I also did not know what it smelled like until I walked by the evidence room one day she got a score I went to the University of Tennessee Martin in a very small regional campus apparently the 60s involved one streaking incident back in the 60s and that was all that ever happened the very rural conservative campus there but I did not know for example that these plants when they reach maturity can become substantial in size the most common analogy is think a not a small but modest size Christmas tree they can be fairly substantial when they reach their maturity so having a limit of a small number of mature plants does not particularly restrict the amount of material someone can have when they are processing the repair you can receive a fair amount of product on so are there for folks who have minds like this like mine just don't remember or for folks from who this is at first run through but you have other questions around what the program is right now okay now you can go ahead with what you were prepared to do thank you ma'am happy to and I would say as a button to that and then to briefly review from my perspective and I know we have some other folks who can speak to the report as well who are on the committee that the way the program operates is we want to process patient applications as quickly and efficiently as we can we try to be as responsive as possible recognizing that these folks often are dealing with health challenges we want to provide appropriate but as minimally invasive as possible oversight of the dispensaries for lack of a better term these are small businesses running in Vermont that employ Vermonters and sell to you Vermonters so while we are required to provide oversight to them we want to do that in a way that is the least intrusive as possible given the requirements that we're tasked with and the type of product which leads into my third comment which is we also want to minimize the media version we don't want to see product going on the back door we don't want to see a product being stolen by employees without it being known we don't want to see individuals purchasing and then turning around and reselling on the black market even though they have a car so that is the three different prongs or pillars of how we kind of manage the program on the day to day perspective in reviewing the report from my perspective from the department's perspective a couple of things popped out in reading through it and the first is and it comes through this several times that there is a concept of testing product is really hammered home several times and this is not unlike any other product particularly for those individuals that may have compromised immune systems etc. the current testing paradigm in Vermont is essentially self-testing the dispensaries are the only entities that are currently able to really do testing of their product a number of them test each other's products which have brought some level of assurance and oversight but at the end of the day the dispensaries are the ones who are responsible for their product and testing their product and several times through the report you will see a note about enhancing or improving the testing paradigm I thought we would put something in about the ag department some periodic testing the department of agriculture is setting up a lab to do that kind of work currently they are not doing that work and that is something I think that comes through here but then we set up something that they were supposed to do I'm not aware of anything where they are required to do anything but they may do something in that regard and I don't want to speak for the dispensaries completely out of term but I think generally speaking they would welcome based on my interactions with them additional testing it would be like an independent test correct yes sir absolutely absolutely so the first item again that runs through the report is the desire for testing both from a product safety but also from a policy perspective one of the things that I learned right off the bat with this as I got involved a little over nine years ago now when I first came to DPS and to service with the state was this isn't a single thing if you or I have a headache we can go buy ibuprofen and it doesn't matter which brand we buy it's the same product at whatever labeled strength 200 milligrams per tablet marijuana is not a product like that it is a very broad category and individual plants or strains may have different chemical makeups there are some broad similarities but different chemical makeups that can affect individuals very different it is not a single ground or single developed product and some of the testing not only for purity but also for potency is one of the issues that comes up and comes through there as well another item is noted in the report is the desire to make sure any fees collected by the dispensary or excuse me by the program are used specifically for the management maintenance of the program as the committee may be aware a few years ago the program did have surplus funds they came from some of it was one time funds we were never going to receive them again others were others were a slight overage every year building a balance and we had earmarked that for an updated information or IT computer system we were using a bear we still are using an antiquated one we are in the process now of updating that but some of those funds were taken to deal with the budget deficit a couple of years ago and understandably that upset some individuals within the program and the community so they're restating their concern with that here an example that I provided of a paradigm from some of my federal partners not with this particular area but others for any fingerprint checks that are done the vast majority of those are ultimately evaluated by the FBI and every two years they go through an analysis of how much it costs them to do fingerprint checks and then they modify what they charge the states and then we turn around and charge the individuals being fingerprinted or their home agencies so every two years that rate changes slightly based on new technology whether it's volume et cetera or staffing costs et cetera so something of that nature maybe food for discussion down the road Carl it might be useful to review for us approximately how many people participate in this program on a statewide basis maybe what the growth has been over the last two or three years currently the number of registered patients currently 5300 it varies literally from day to day but that's the approximate number of patients we also have a small number of caregivers several hundred it's not that many when I first started we had I won't say it was a one to one ratio but it might have been two to one of patients to caregivers and that has not changed the number of caregivers has remained fairly low while the number of patients has increased if I can do this correctly I will attempt to there is unfortunately it's sideways my apologies but you can see there that for the vast history of the program the growth has been no pun intended growth it has grown and grown and grown it's kind of hard not to wait into kind of a bad pun about growth and marijuana in this discussion I'll try not to do that but as the committee can see over the last just recent period last few months we have seen the first actual decrease in number of patients while I will not formally speculate on what that is there are other factors in the broader society around marijuana that may be affecting maybe affecting that number we don't know if this is going to be a one-time correction where we may see a slight decrease and then level off or if we're going to continue to see a decrease we simply don't know I can tell you in the past and I tried for budgetary reasons to predict the growth I was always wrong it was going to be way low so we kind of got out of that business and simply just assumed the number was going to remain pat knowing that it wouldn't and then deal with that going forward so does that speak to your questions sir about the volume what's green line the green line represents the number of caregivers so you can see where that number while it has grown has remained predictable shall we say a predictable slow growth as to where the number of patients has has significantly increased some of the jumps during the time of the patient growth relate to when dispensaries were open so you saw an increase because the plant from what I understand again I have no first-hand knowledge but from those that I certainly believe in respect that these plants are difficult and best to grow so that was a barrier for some individuals getting access to them and once they purchase them in a commercial capacity to drive growth in the program so a couple of the key points that were noted by the committee one was to remove the current two ounce per 30 day purchase limit for medical car holders and the department has no position on that per se and the program doesn't need that's a recommendation from the committee the availability of marijuana for medical patients should be prioritized I believe that was a concern that if some of the dispensaries get involved with non-medical commercial sales that would their products be potentially sidelined or de-prioritized and then medical marijuana maintaining a tax exempt status currently sales of medical marijuana are not subject to any sales tax the primary way that the program is funded is through two mechanisms one the annual fee that patients pay but also the dispensaries are charged a flat fee per year and they do then of course have to pass that along to the patients who are funding the business but there is no actual tax per se there is no 10, 20%, 5% whatever sales or other tax on the program program itself there are a few recommendations that the committee made that s117 come over from the senate for the committee's review that the oversight committee mentioned one was removal of the psychotherapy or counseling requirement for mental health providers based upon language and the current drafting of 117 any condition would be eligible for inclusion or recipient of a card so why would you potentially require someone with PTSD to have an enhanced verification when someone with anxiety depression is there wouldn t require that given the way that 117 is currently drafted are we supposed to respond to some of these now no this is what obviously I have a comment to make on that no I mean sometime when we actually discuss the bill yes I mean we don t have the bill and I would want to provide us with an opportunity to one set the stage like what is current and you know and these recommendations are the recommendations from the committee that s correct yes we have part of my question before I mean this is hard the bill hasn t come over yet hasn t been voted out if I don t think of the senate yet I don t believe so it s in finance so I don t know if it will move anywhere is there a way you could start with what are the recommendations for legislation that this committee has can happen well the recommendations that the committee has are listed right in the report and I can just be from my perspective some not but I would defer again from my perspective just a quits boom boom and would defer that the first is that that modification of the PTSD requirements particularly assuming that the bill has drafted comes over the second would be modifying some language to clarify individuals with chronic or persistent issues or symptoms the second bullet the third one would be from the committee's perspective would be to require individuals with chronic diseases to well let me rephrase that there is currently language in the bill of S117 that would allow individuals with chronic diseases to not have to renew their card that would be a financial challenge for the program to remain viable given that over 70 percent of the funding comes from patient registration fees a couple of other recommendations as well that the committee makes including increasing the dispensing limit to 3 ounces and again concern about the staffing and management of the program if the funds come in I should say and perhaps this is a way to wrap up and then I'll of course answer any questions that remain available is the program is completely self-funded there are no general fund dollars that are provided to this program is completely self-funded nor do any funds from this program support any house except the marijuana registry it is not used to support any other VCIC functions nor any other DPS functions it is strictly a self-contained program that has been I have not been around for the entire history of the therapeutic use or medical program but certainly for almost nine years now and it has always meant to be a self-sustaining program and not require general fund or any general tax revenues to support the program any other questions I can answer maybe I misunderstood the chair's question but I would like to know if the senate bill never leaves the wall are there any changes that your committee would like to see us make now and what I would like to say is that he's not going to answer that someone else is certainly if there were any if 117 does or does not come through and the committee wants the department's perspective on any potential we have absolutely this is we are not talking about s1 17 we are talking about what is this report and what coming out of irrespective of what the senate is doing what are the recommendations and maybe this is a time to have someone absolutely thank you hi thank you very much thank you if you could give your name for the record I'm Amy Klingler A-L-I-M-G L-M-E-R everybody gets it wrong I am a patient and I am a member of the oversight committee I live in Manchester, Vermont and I have used both grass roots for monitoring dispensary and I've used the phyto care that's now in the benefit I am what a marijuana patient looks like does this shock anybody I prefer the term medicinal cannabis because I get benefit from the whole plant not just THC in fact I seek more of the CBD therapeutic anti-inflammatory I seek more antibacterial properties I seek sleep assistance properties and I microdose anybody want to know what microdosing is? so we people who and I'm speaking I'm no expert I'm just speaking from the patient community and very much a patient advocate because I have the ability to be here I have the luxury and privilege that I have a vehicle and can drive a vehicle and have a good day and can talk to you previously my neurological condition was so bad I couldn't talk and use the side of my face I couldn't eat I couldn't brush my teeth all of the medications that neurologist had me on I was shaking like this terrible tremors screaming nightmares upsetting my son upsetting my family so I am not someone that the pharmaceutical world can help I'm very sensitive so I microdose what does that mean? that means I seek out particular strains of cannabis for their unique properties or terpene which is sort of plant juice compounds to produce the symptom relief for the symptom I am having that day I do not roll a joint and smoke it I guess would be kind of the stereotype that does not help me I take a particular type for my particular struggle I use a very small amount of that see how I am doing potentially later reinforce that dose or move to something else and I am doing this in conjunction with a whole bunch of eating organic and other holistic and herbal practices and integrative whole body care I cannot work anymore I was a attorney I was a bankruptcy attorney I was a prosecutor for five years mostly I was a litigator so I make jokes that I am a recovering litigator because if you were a courtroom lawyer you would get it so I microdose so I am luckily not someone who gets anywhere near my allotment but there I want to be here to speak for the people who have to drive two hours to get to their dispensary and have to wait till their particular strain is available and have to wait till they either have some money or for some reason their strain goes on sale there are more of those people than there are of me and I see that and it is heart breaking it is hard because I know sometimes how hard I struggle and at least I know I can go to the bathroom on my own so we are talking about people with significant challenges and we are talking about people when you hear the word caregiver please know that these are moms and spouses and adult children who are administering however the form of cannabis they choose to some a child who has seizures or severe autism or whatever is happening or to an adult with dementia to calm down or to a spouse of a military veteran who has had a head trauma PTSD and needs someone else to monitor this so when we say caregivers that's who we are talking about really mostly family and they have asked me to let you know they have particular challenges with getting to the dispensaries dealing with the allotments they only get to the dispensary once every three months and they need to be able to buy everything they need in that period of time the other thing I think it's important that you guys understand is the pricing of the dispensaries is not going to fuel the backs of the black market the price of the dispensary is it's high it's a lot of money and it's there is no there would be no ability to buy the dispensary to sell it because especially now with the legal home grow people are not even selling it they're scraping it they're I grew this and you grew that so if people are concerned still about dispensaries that they're going to fuel you know re-fer madness they're not you could not afford to do that it's just impossible so as you continue your story if you could circle back to the report you are a member of the report what is the purpose of your committee so the purpose of our committee is for our patients different patients from all the representatives from the different dispensaries to get together with you know the group that runs it the oversight and to talk about the issues how the law is working for us for accessibility the problems with it needs to be changed how this works on the ground I mean to help you with that Logan or could you go up to the beginning of this report up for the introduction there so that folks see the context the ability of patients and registered caregivers in all areas to obtain timely access to marijuana the effectiveness of the dispensaries etc and the Carl this goes to like one of your questions and someone else's the sufficiency of the regulatory and security safeguards so what we've been talking about in the context of the current law the current bill we have discussed the proposed new but for these purposes the ability of the qualifying patients to obtain time we needed access we've talked about that a bit about waiting periods and establishing whether someone's in current therapeutic relationship we as the patient oversight committee recommend again not putting the burden on it's in particular right now it's just on PTSD it's not on anybody else and so those patients have to prove that they are in ongoing counseling therapy and that may not be appropriate for them and they may not be in counseling or therapy with you know they may cross the border into New Hampshire or Massachusetts or New York so that's a problem that the patients are having with the access so that this I don't see that as a s 117 bill recommendation I do not see that as a recommendation of removal by the committee by the oversight committee so was that a recommendation of the oversight committee just as a fair warning it was this committee who put that limitation on it because of the testimony that we received from mental health professionals who said that there are documented issues with concerns around PTSD that is not if the person is not monitored that's basically contraindicated in many cases so and that's why fair warning the concern was from our committee perspective a lot of people are receiving counseling from people who don't technically qualify because they're over the border or they're that type of counselor so the PTSD folks were saying they were not complaining about the component of attending treatment it was please allow my and I'm just trying to look at what this report is yes and perhaps the date the date was I don't know when the date was submitted but that's alright so I was looking at analysis and perhaps this is erroneous in my part in terms of what the committee particularly recommended was irrespective of what else has happened irrespective of whether or not we legalize we do tax and regulate irrespective of whether or not there are bills other where in the thing if we were if you were in what was the recommendation that you would have for this committee to act and so I'm not sure where that is here in terms of this in the document I mean that's I guess that's we addressed it as the bill recommendation okay and again these are patient recommendations I'm trying to provide the representative so as is the marijuana symptom relief oversight committee is that made up only of patients okay so what I'm so you are speaking not for the oversight committee but for the patients on the oversight is that correct that is correct so who and what we are I mean I can't really speak you know I'm here just patient advocate okay and that was thank you for that Clara I thought you were here just as a member of the marijuana which is fine I'm on the oversight committee as the patient representative for Bennington particularly the patients asked me to be here to represent patients concerns because we were getting an overview from the department so our concerns aren't always the same okay so if we can go to the beginning analysis under that part as you are a member of the committee so it sounds like testing is something that the committee thought was important absolutely is testing something that you as a patient advocate absolutely okay and we would specifically what we've mentioned is we would like testing there are not just of the THC levels but to know various token combinations if possible and also there are other cannabinoids other than THC that are desirable that I've mentioned like antibacterial antiviral we would like the most common eight or nine for the dispensaries to show us those qualities in a hopes that we'll encourage them to produce more medically effective strains so we can go hey this isn't good enough you can do that that's the purpose of that also obviously we want mold contaminants and metals we want to know that that's not in there because that could kill some of us okay and also get the mold in all of those things and then in terms of the testing is to be the recommendation is to be independent is that party testing and is that also the patient representative okay yes now it says here and Jeffrey maybe you can help the number of registered dispensaries is currently limited to five so we have seven so can you explain that to us certainly I think for the record Jeff Wallen Department of Public Safety the current number of dispensaries is capped at five however they're able to have multiple dispensing locations or sites or a term that I would use maybe mildly unperfected I think it comes across the retail points of sale where they can sell to individuals so they can have multiple of those we have five dispensaries or small businesses but currently a couple of them have multiple dispensing sites and a few more and have approached us with doing the same thing I'm an entrepreneur I live in Chittenden County it's the biggest area of the state there are more people in our lots of colleges graduate schools and it's where the hospital is we're people who progress it so I would like to open a dispenser can I currently we're not able to accept any application for dispensary licenses we have our maximum of five that we're authorized to have I I only wanted the five but I want to open up one in a community in Chittenden County so if one of the dispensaries were to be interested in that then we would ask them to provide essentially an application documenting where there are a number of requirements to dispensary applications absolutely so any number of them including they can't be a dispensing location has to be so far from any day care schools for example we also want to see that it's going to be financially viable they're going to be able to have product available to patients they're also security requirements we're on cameras facilities being secure etc etc appointments also have to be meetings with patients also have to be by immediate patients in a secure confidential location often times it involves looking at building schematics etc or the upgrades to a facility and once we receive that information we will review that and respond back to the dispensary requesting that it's like any permitting for lack of a better term concept usually have a few additional questions we'll have or we'll make a few requests for modification assuming that they meet those then we'll go ahead and move forward with that I think Chittenden County already or the Burlington area already has one and Franklin County doesn't you will allow another one if it met all those other requirements and we would certainly consider that geographic distribution is something that we do look at part of it is one of the requirements it's not a there's no requirement that we must have one in each county before we have two in each county for example there's nothing quite to that level we do look at that but also recognizing where patients are patient growth is and the fact that dispensaries now can have these for lack of a better word satellite and delivery is also an option as well that has just changed the metrics slightly is there a limit to how many satellites I can have there is I believe it's two per entity thank you two satellites two total centers I have to double check on that I can't recall if it's two or three total the question okay so we need to do that testing what's this last registration fees that was where we just echoes that we don't want the money we pay in we want it to stay in the program and not be taken away and used for other purposes because we have some patients who are living solely on social security and that $50 represents a large chunk of their income for a particular month is a burden and so it's just this one to see that cost of the program fly up the window until we click our money in our program is the money now in a big bank account or is it or have we like we do for some other things have the oil we have we directed it elsewhere and say government currently the program is a special funded program so that those monies remain in the program and in the account to support the program for the monies that were pulled approximately two years ago I'm not entirely sure pulled by the administration I don't exactly know if those went into the big account to just pay the general deficit that year I'm not exactly sure where those monies were allocated more they just were a drop in the overall budget do you know if this year in the governor's budget there was a way of budgeting it took some of the excess from this program and used it elsewhere not to my knowledge I don't know if there was now request to cycle additional funds from this year has extended so the final bullet point there at the bottom of page two the way that it currently stands we have to select a dispensary and that's our home dispensary and that's the dispensary we can go to and we can change our dispensaries once every 30 days that's a paperwork process and then we have to wait to get a new card sent and so and then if you wanted to change back to your old place there's another waiting period what we as the patients are asking for is the ability to be able to go to any dispensary of our choosing because I'll use an example before Fido Care opened with a patient of grassroots grassroots has a strain called sherbet cooking that is amazing for nausea and if you suffer from migraines or Crohn's or any stomach issues like nausea relief is one of the big things you look for in your medicinal relief I when Fido Care opened it's much closer for me a much shorter drive I switch to that dispensary they do not have a nausea assisting strain they just don't have one that addresses that so now for a reason I'm not sure I understand the needs of administrative accounting I can't get the best possible medicine for me I have to make do and I frankly go without because you know nothing is going to help like that and there are people who have that for migraines are people who have that for seizures I mean I just think about nausea and I consider myself lucky there are people who have this need a particular strain sour diesel is a very well known migraine preventative it's discussed in the online migraine community having access to something like that that's your daily preventative is key so when your dispensary runs out of sour diesel it would be great to be able to get it from the other dispensary it would also be great to have them competing price-wise and quality-wise for us as patients right now we're hostage to the dispensary we're signed up with I don't know if you can answer this or not if you're on the board maybe you can my understanding is that dispensaries could move the product from one to the other they can through what their business structure is but that's not the same I don't think grassroots is going to sell its product to phytopair and some of them are cooperative and some of them grow their own strains and do not like some of them grow their own blend and will not participate like that so well well phytopair brings in product from at least two other dispensaries grassroots does not they are solely that's what you get they've invented the green mountain strain I don't know if they invented the right word but horticulture they've created it so they're very proprietary about that if they're moving product that's a business decision right now and it's not a patient-centered decision and so patients are not having access it seems to be more driven by money than need I'm going to ask a question maybe you're going to have to answer this can the dispensary sell a product to another dispensary that's in the trading that is now authorized for them to do that so they can sell any barter which was problematic from a keeping perspective so they can sell products if they so choose to they may so in this particular case the dispensary that has it could sell it to the dispensary where you are if they won't I'm still stopped yeah if they won't but if I'm in business I'm going to sell it to whoever wants to buy it I'm not a grower but they are they are very particular when we were talking about clones versus seedlings clones are pieces cut off a plant and have the genetics of that plant versus the seed produces whatever comes out you can't be sure it's female in most cases yes I would hope that that happens but we haven't seen that level of cooperation and as patients that's what we're you know and you have deliberations on the board did you bring it up and say why don't you sell this stuff to them absolutely we did and that was a whole discussion of that's the dispensary's business method all we can do is say hey you know as patients we want this and that's why we're hoping we're allowed to go to any of the dispensaries we can sort of say here are our expectations as patients here's the consistency we're expecting across the board because right now the the patient service at each dispensary seems to vary with some people having a very big problem and others having great access okay the oversight committee that they have oversight yes so I would think that since you just brought that problem up the recommendations if they're not doing it we should tell them to do it I just I don't know how you do that on the business end have you televised a business they've got to sell I'm going to leave that with you I'm just going to let you know our request is it to empower us as patients and as customers if we can actually not be locked into one place who makes the decision that you're locked into one place it's legislative business we didn't want people going from one to the other next day tracking it's what we we did that in a different way for certain kinds of over the counter medications in terms of we put in requirements and structures so that people would not be doctor shopping and getting there two ounces or whatever it is from multiple places from multiple places that doesn't mean it's not something that couldn't be looked at but there were I mean right now we are hearing what they are we are not debating we don't have a bill but this is something that is under the jurisdiction and policy area of this committee and we may or may not be getting bills from the senate related to this that and in addition every regular it's every year every two years there is a report and so we were purpose of this was to go through the report just as a little aside I understand that was the concern but again if you are going to buy one ounce you are talking about almost $400 so if you are going to buy two ounces you are talking about close to $800 or more monitors like nobody has $800 to go to dispensary dispensary to dispensary and if we got Vermont licenses and Vermont cards I mean yes there are bad actors that we always have to think about but on the other side we've got people who can't who can't function who have MS who have Parkinson's who need what they need and they can't just roll into the dispensary go oh well you don't have what I need so I'll take whatever we are not those people we are not trying to get high we are trying to live so it doesn't mean no good my place doesn't have it and I know a place down the road does but it's too hard for somebody else to figure out how I can do that so that's where I guess the patients veered a bit from the oversight committee and said we understand that you've got to do the record keeping and so forth but we need some we need some ability to get what we need and we need to take a little bit of power back to as consumers with that recommendation yes we can choose to go to any dispensary if we want and we can choose to change every 30 days but in reality with your waiting for your card and your applying that can get much bigger than 30 days and again we have people that can only make it to their dispensary every 3 months and are buying their full allotment at that time so we are trying to make sure they are not required to deliver so sometimes there aren't delivery one patient in particular has a problem because the dispensary's own internal program about delivery is you can only have a delivery within so many days and the way the allotment works it's not like on the first of the month you get your full allotment back it rolls it's a rolling allotment so if her rolling allotment doesn't match up with their delivery day she can miss out a whole delivery and she was saying I'm stuck and that's what we're saying well if we could shop at other dispensaries we get some power back so maybe the dispensary's are going to hear that but we think that's just going to result in better product better pricing better everything so those were our recommendations like what can you do now to help us that's what you can do now I won't talk about the looking ahead we really don't want to get lost into some other program we want to make sure everybody remembers we're here and we actually do have meetings we're having them about every three months in talking so we are you know when we send you this stuff we've spent time on it and we care and if we can answer any questions have a talk it would seem from the report that you favor keeping this program in place even if we create sales and marketing especially because it would seem that if there was a legal market the availability of products would even be greater as far as the needs you've described because people would want to sell those products it would seem that if it was opened up that the need for this program may go away but you're saying you would want it to stay and be really picking up on what you're saying Carl you were speaking about patients being in charge and being able to shop around and being able to go where you want to and so going to you from your question wouldn't that that would take care of some of your problems because you can go anywhere to buy a particular strain or product and presumably the incentive for those private enterprises would be to provide the products that people want but there's a different consumer for there's a THC consumer out there who's looking to alter their state and that's their goal and there are plenty of reasons for doing that and I'm not judging but so I'm not looking to roll into a retail store and buy a 30% THC that's not going to help me that's going to make me sick I want to go to a place that has what I need that says yes people need antibacterial and so we're going to promote and grow this I don't want to be relegated to the flavor of the month that probably won't help me that isn't grown with medicinal in mind the potency of the turkeys and the recreational growers are concerned is there's a big difference when you walk into a head shop or a smoke shop where they sell glass pipes and paraphernalia and when you walk into a holistic store and they have e-products and that's us we're the people going into the CVD store we're the people saying I don't feel good what's going to make me better and then there's that retail group of people who is seeking life with alcohol what's the highest content I can get and what has the coolest name books the best we don't want to be left with only that market that will not serve us that will not help us so what makes you think that you would be able to continue to get those products because I'm a business person and I know there's a market out there how many people 5,000 there's a 5,000 Vermonters right now who access marijuana percent of relief and so that is a market that I want so I'm going to have a full service store and I'm going to sell everything from the product that is going to make Carl High to I hate to see that yeah to the product that Carl, they like gummy bears to the product that will deal with your migraines and that it is all there and that I might be a 23-year-old hippy-dippy I guess we don't call them that just another 23-year-old hippies and I really just I want to feel good and I like to drink and so I might not go to the Neiman Marcus of head shops but I might go to so if you're talking about patients if you're talking about competition and the market don't you think there would be a market for if you are afraid that if we were to go to a tax and regulate my guess is there has to be stores and stores will have to be licensed or whatever if you're afraid that stores won't meet your need why on earth would dispensaries stay in business I mean they're not what would be their current dispensaries if you're afraid that your needs won't be addressed first of all I'm not competing with the general population to get access to something I legitimately need a blood level medication and a consistent strain that I know so I have that concern but I don't quite but I'm having trouble but I think it's important for you and for patient advocates to clarify your fear that your medicinal needs will not be met and I might say well what about the fear that they won't be met because dispensaries will be limited to medical and maybe it's not cost benefit for them to continue doing that so I think your risk might be greater as a consumer of the product I have experienced levels in quality and medicinal I have no use for a capuco goal it's all the rage if it was retail places would be loaded with it everybody wants it there's no medical use for me and I do not want to roll into somewhere where I can only have an 8 or a quarter because of the store being limited in their supplies and they have the right to say that to retail customers and I'm worried that I'm not there is a difference I'm not arguing so that's just our concern I just don't know how in the business decision how you can be secure in the fact that your medical needs are going to be met I have a state law that says you're allowed to but there's no state law that says there has to be a medical dispenser so they might disappear if they were I mean it would lower the cost presumably if you went to a regular cost I'm not advocating for it I'm on the other hand I don't want to tax them regulated frankly so I'm arguing a point on the opposite direction again I can I will admit I am coming from a place of my life is so much better and I have fear of losing a very holistic solution that is impairing me and all the points of these questions are how do we insure and what is the best way to insure it and is the best way to have a separate standalone program or to let them market James I was just kind of picking back on you not whether or not there's merit in having a dispensary I guess the concern or fear could be that once tax regularly comes that the other side would be lucrative so to speak it's better for me to be a retail they don't leave you behind that's what I think you're trying to get at it's a question if there's any dispensaries out here when and if we get a bill they would we understand that we understand that Jessica and then Topper can I have a question I just want to clarify I'm kind of curious if you right now were to go to a state that's already doing tax and regulation like Colorado for example and you went into one of those shops would you feel that you could find the things that would make you feel better do you think or is that I do already see that as an issue I would be very cautious I would be very cautious because I'm cautious with my product anyway I mean I inspect it like it's produce essentially it's produce I just I would have a concern because I feel like I and again this could be naive but I'm interfacing with people and I'm developing a relationship of the dispensary and I'm trusting them not to give me a product you also a lot of these people in the dispensary they're serving as like de facto social worker they're these people are getting just a place to say what all their trouble is so that function is happening too but I would be cautious I'm not someone who's going to run to Colorado and chop it up and that's not my reason I asked the question I'm mostly curious about the future but and I think that we all struggle with you know there are pediatricians who we totally trust to take care of our children in a certain way and then they retire and you freak out you know how we do your kids are all in their thirties my point is that I start thinking about that before it happens so that's why I wonder if you've sort of I've started to explore immune compromised people we worry about this with everything so this is just part of a lot of our already and our concern is we realize that local smaller batches produce healthier and better quality things and we don't want Monsanto coming in here because there's I mean do you guys know there's GMO weed that's neon colors I don't want that stuff please don't let that come here please don't let them come in and aggregate do this where they chemical wash the plants and they don't change their soil and they flush their soil please don't let that happen I can't believe what I'm saying so maybe it's all struck at city market and healthy living as opposed to and they sell produce and they sell all the things as opposed to when they want the big chain store I won't use any names because they're smaller and I trust them and they have the same people I mean so we're not saying to the big chain stores you can't come in I'm just saying I'm not going to shock them I'm just saying that you know Vermont and we like our stuff I like to know which farm the cheese came from and there's a group of us who are like that who are very much you know we do not want any genetically modified stuff coming in that's neon purple because it looks cool to the party kids that's what we're scared of in the stores that's what we're scared of and what there's a debate you know what gets to be called organic and what actually is organic so they're going to comment and label stuff what does that mean to you in the soil did you use chemical so we've got all these issues of definitions that overlap without agriculture that overlap a lot of areas of the medical community I don't know how we solve all of it but we're just we within ourselves are trying to get better access and stereotypes so thank you thank you very much it's been interesting and we walked through the report and we will if S117 comes over we will have the not just with all due respect not just the patient advocate but someone who actually can speak for the board and speak for the board to go over the recommendations and then get your comments and then anyone else who's interested in this but this was to set the stage thank you very much and I hope I conveyed all the other patients information it was a big responsibility thank you