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Testimony Before the Michigan House Oversight Committee regarding Gov. Whitmer's proposed flavored e-cigarette ban

September 12, 2019

Testimony before the Michigan House Oversight Committee regarding Gov. Whitmer's proposal to ban flavors in electronic cigarettes and vaping devices and how such bans are ineffective and likely to lead to black markets.

Testimony Before the Michigan House Oversight Committee
Lindsey Stroud, State Government Relations Manager
The Heartland Institute
September 12, 2019

 

 

Chairman Hall and Members of the Committee:

 

Thank you for taking the time today to discuss the issue of regulating electronic cigarettes and vaping devices, including proposing restrictions on flavors. My name is Lindsey Stroud. I’m a state government relations manager at The Heartland Institute, a 34-year-old independent, national, nonprofit organization whose mission is to discover, develop, and promote free-market solutions to social and economic problems. Heartland is headquartered in Illinois and focuses on providing national, state, and local elected officials with reliable and timely research and analyses on important policy issues. Heartland would like to submit the following testimony regarding the proposed flavor ban by Gov. Whitmer.

 

Electronic Cigarettes & Vaping Devices

Introduced to the U.S. market in 2007, there are different types of e-cigarettes and vapor products: “first generation or so-called cig-alikes, second-generation tank systems, and even larger third-generation or personal vaporizers.”[i] Cig-alikes are similar in size and shape to traditional cigarettes. They are typically composed of three parts: a cartridge that contains an e-liquid with or without nicotine, an atomizer used to heat the e-liquid to vapor, and a battery. The second and third-generation models, also known as “vaping” devices, are sub grouped into two categories: closed and open systems. Closed systems contain a disposable cartridge the user discards after consumption. Open systems contain a tank users can refill with e-liquid. Like cig-alikes, closed and open vaping systems contain an e-liquid, an atomizer with a heating element, and a battery, as well as other electronic components. Unlike the cig-alikes, however, the vaping systems are customizable, with users choosing their own modules, or “mods,” as well as flavorings and nicotine level.

E-cigarettes are regulated. The U.S. Food and Drug Administration (FDA) has had authority to regulate e-cigarettes since 2012.  In 2016, FDA issued deeming regulations that extended the agency’s regulatory authority to include electronic cigarettes and other THR products.[ii] All companies “engaged in the preparation, manufacture, compounding, repackaging, relabeling or processing of finished tobacco products” now must register with FDA.[iii] FDA’s regulations require e-cigarette manufacturers to comply with regulations governing tobacco, including completing a lengthy and expensive study process called the “premarket tobacco application” (PMTA). Beginning on August 8, 2016, no new e-cigarette product, including flavors and nicotine products, can be sold in the United States without first receiving premarket tobacco application approval from FDA. This one requirement alone will have a devastating effect on the industry. FDA estimates each PMTA will cost $330,000.[iv]

E-cigarettes have emerged as an effective smoking cessation tool, with a recent study in the New England Journal of Medicine finding their use to be “twice as effective” as nicotine replacement therapy (i.e. gums and lozenges), in helping smokers quit.[v] Since their introduction to the U.S. market, an estimated three million American adults have used these products to quit combustible cigarettes.[vi]

 

Health Effects of Electronic Cigarettes & Vaping Devices

Despite recent media reports, e-cigarettes are significantly less harmful than combustible cigarettes. Public health statements on the harms of e-cigarettes include:

  • Public Health England: In 2015, Public Health England, a leading health agency in the United Kingdom and similar to the FDA found “that using [e-cigarettes are] around 95% safer than smoking,” and that their use “could help reducing smoking related disease, death and health inequalities.”[vii] In 2018, the agency reiterated their findings, finding vaping to be “at least 95% less harmful than smoking.”[viii]
  • The Royal College of Physicians: In 2016, the Royal College of Physicians found the use of e-cigarettes and vaping devices “unlikely to exceed 5% of the risk of harm from smoking tobacco.”[ix] The Royal College of Physicians (RCP) is another United Kingdom-based public health organization, and the same public group the United States relied on for its 1964 Surgeon General’s report on smoking and health. 
  • The National Academies of Sciences, Engineering, and Medicine: In January 2018, the academy noted “using current generation e-cigarettes is less harmful than smoking.”[x]
  • The American Cancer Society: Most recently, the American Cancer Society noted that “e-cigarette use is likely to be significantly less harmful for adults than smoking regular cigarettes.”[xi] This is attributed to the fact that “e-cigarettes do not contain or burn tobacco.”

A 2017 study in BMJ’s peer-reviewed journal Tobacco Control examined health outcomes using “a strategy of switching cigarette smokers to e-cigarette use … in the USA to accelerate tobacco control progress.”[xii] The authors concluded that replacing e-cigarettes “for tobacco cigarettes would result in an estimated 6.6 million fewer deaths and more than 86 million fewer life-years lost.”

Role of Flavors in Electronic Cigarettes & Vaping Devices

E-cigarette flavors have a vital role in moving and keeping people away from combustible cigarettes. Restrictions on flavors could lead former smokers back to cigarettes. Evidence of flavor presence exists in use of smokeless tobacco, which is also considered a tobacco harm reduction tool.

A 2013 study examined data from five studies on smokeless tobacco use to gauge users’ “choice of brand flavor.”[xiii] Researchers noted that a majority of respondents’ “first and current choice of product was flavored, specifically mint or wintergreen.” The analysis also found a significant number of smokeless tobacco users moved to flavored smokeless tobacco after using non-flavored smokeless tobacco at initiation. Despite growing alarmism, the researchers noted that “flavored products did not appear to lead to greater dependence or increased exposure to nicotine or carcinogens.”

Additional research has been dedicated to the role of flavorings in e-cigarettes and vaping devices.

  • A 2013 study by the Onassis Cardiac Surgery Center concluded flavors in e-cigarettes “appear to contribute to both perceived pleasure and the effort to reduce cigarette consumption or quit smoking.”[xiv]
  • A 2015 online survey conducted by the Consumer Advocates for Smoke-Free Alternatives Association examined 27,343 Americans over the age of 18. Seventy-two percent of the respondents “credit[ed] interesting flavors with helping them quit.”[xv] Of the respondents that were still smoking, “53% say interesting flavors are helping move them toward quitting.”
  • A 2017 study discovered older adults’ “use of an e-cigarette flavored with something other than tobacco (69.3%) was … significantly higher than the same at initiation (44.1%).”[xvi]
  • A 2018 survey of nearly 70,000 American adult vapers “found flavors play a vital role in the use of electronic cigarettes and vaping devices.”[xvii] Moreover, 83.2 percent and 72.3 percent of survey respondents reported vaping fruit and dessert flavors, respectively, “at least some of the time.”[xviii]

Restrictions on flavors could driver former smokers back to combustible cigarettes. A 2017 study by the National Bureau of Economic Research examined the impact of a flavor ban in electronic cigarettes and vaping devices. The authors concluded banning flavors “would result in increased choice of combustible cigarettes,” and they said they expect e-cigarette use to decline by approximately 10 percent if flavors are banned.[xix] Additionally, a 2018 “systematic review of research examining consumer preference” for flavors concluded adults “in general also preferred sweet flavors.”[xx]

Flavor Bans (and other restrictions) Are Unlikely to Reduce Youth Use of E-Cigarettes

As flavor bans are relatively new policies, there is little data on the effects of such prohibitions. The Heartland Institute recently analyzed the California Youth Tobacco Survey (CYTS), finding that flavor bans have not reduced youth use of electronic cigarettes and vaping devices.[xxi]

Santa Clara County, California, banned flavored tobacco products to age-restricted stores in 2014. To purchase a flavored tobacco product in the county, the retail establishment must bar persons under 21 from entering. Despite this, data from the 2017-18 California Student Tobacco Survey for Santa Clara County found “the vast majority of high school students (82.3%) in Santa Clara County who were current tobacco users reported using a flavored tobacco product.”[xxii] Popular flavored products included “current hookah users (82.9%), e-cigarette users (82.6%), and [little cigars] users (82.3%).” Regarding combustible cigarettes, 62.9 percent of respondents “reported using menthol/mint cigarettes in the last 30 days.”

More pointedly, youth e-cigarette use in Santa Clara County has increased while the flavor ban has been in effect. For example, in the 2015-16 CYTS, 7.5 percent of Santa Clara high school students reported current use of e-cigarettes.[xxiii] In the 2017-18 CYTS, this increased to 10.7 percent.[xxiv]

Contra Costa County, another municipality in California that has restricted the sale of flavored e-cigarettes, has also experienced a recent increase in youth vaping rates. Although the 2015-16 CYTS survey included other localities including Marin, San Francisco, San Mateo, and Solana, the 2017-2018 CYTS survey reported only on Contra Costa. In 2015-16, 8.3 percent of high school students in the various localities reported current use of electronic cigarettes and vaping devices. In the 2017-18 CYST survey of solely Contra Costa County high school students, this number increased to 17.2 percent reporting current e-cigarette use.

Further, banning certain types of e-cigarette products could increase youth use of other tobacco products, including combustible cigarettes. Existing data reveal regulations on e-cigarettes increase youth combustible cigarette use. After initiating a task force to combat youth e-cigarette sales, Lancaster County, Nebraska reported sales of vaping products to minors decreased “from 21.2 percent in 2017 to 5.3 percent in 2018.”[xxv] Meanwhile, sales of non-vaping tobacco products increased during the same period, from 5.9 to 8.7 percent. A 2015 study by the Yale School of Public Health reached similar conclusions, finding bans on the sales of e-cigarettes to youth increased smoking rates by “1.0 percentage point.”[xxvi]

Tobacco 21 (T-21) is another restrictive policy that has had little effect on youth e-cigarette use.[xxvii]

Hawaii was the first state to raise the tobacco purchasing age to 21, which went into effect January 1, 2016. In 2015, 22.2 and 5.0 percent of Hawaiian high school and middle school students, respectively, reported ever using an e-cigarette product, according to the 2015 Hawai’i Youth Tobacco Survey.[xxviii] Moreover, 12.9 percent of high school students and 7.6 percent of middle school students reported current e-cigarette use, or any use of an e-cigarette product within 30 days of the survey.

Despite T-21 taking effect in 2016, data from the 2017 Hawai’i Youth Tobacco Survey found e-cigarette use among high school and middle school students actually increased.[xxix] In 2017, 39.4 percent of high school students reported use of e-cigarettes—a 43 percent rise. Additionally, Hawaiian high school students reporting current use of e-cigarettes (within the past 30 days) also increased to 20.9 percent—a 38 percent surge.

What’s more, Hawaiian middle school students’ use of e-cigarettes also increased. In 2017, 21.9 percent of middle school students reported e-cigarette use—an increase of 77 percent from 2015. Current e-cigarette use among middle school students grew to 11.5 percent.

Benefits of Nicotine

Although nicotine in tobacco is the main reason individuals get hooked on smoking tobacco cigarettes, the nicotine itself is not considered a highly hazardous drug. Nicotine does not cause cancer, nor does it contribute to the development of pulmonary disease or cardiovascular disease.[xxx]

Nicotine is considered a mild stimulant and/or relaxant. It has many of the same properties as caffeine, a highly addicting substance that’s safely consumed by tens of millions of Americans every single day in a wide variety of products. Both nicotine and caffeine enhance concentration and mental performance, produce a sense of well-being, and elevate mood. Both raise heart rates and blood pressure levels temporarily during use. Additionally, abstinence after regular use of both these substances can be difficult and even “unachievable for many users.”[xxxi]

There is no significant scientific evidence connecting major health problems with the use of nicotine alone. However, because nicotine enters the body along with many harmful chemicals while smoking combustible cigarettes, many erroneously believe that it is the nicotine in cigarettes that causes hazardous health conditions such as cancer.

According to Raymond Niaura, Ph.D., professor of social and behavioral sciences at New York University’s College of Global Public Health, existing evidence “indicates that nicotine itself, while not completely benign, carries substantially lower risks than smoking.”[xxxii] This conclusion is shared by the U.S. surgeon general and the U.K. Royal College of Physicians, which agrees “nicotine, while addictive, is not the primary cause of smoking-related diseases.”[xxxiii]

In a comprehensive study of nicotine health effects, Niaura noted “that even very high doses of medicinal nicotine had little effect on cardiovascular function.” Emphasizing “a continuum of harm among combustible and noncombustible, nicotine containing products,” Niaura urged the use of alternative nicotine products, with “the goal of moving users away from the most addictive, appealing and toxic combustibles to less harmful alternatives — ideally FDA approved [modified-risk tobacco products.]”[xxxiv]

Latest Vaping-Related Hospitalizations Are Being Linked to Illicit Products

Recent media headlines have exaggerated claims of vaping-related hospitalizations. To date, no single product has been identified as the cause of such health issues. Further, these hospitalizations are increasingly being linked to the use of vaping products containing tetrahydrocannabinol (THC).

Officials in six states (California, Illinois, Indiana, Kansas, Minnesota, and Oregon) have confirmed recent deaths to lung disease in individuals that had reported recent e-cigarette use.[xxxv] [xxxvi] [xxxvii] [xxxviii] [xxxix] [xl]

The Oregon Health Authority reported an individual who died in July “had recently used an e-cigarette or vaping device containing cannabis.”[xli] The Minnesota Department of Health reported an individual died from a “lung injury [that] was associated with vaping illicit THC products.”[xlii]

These are similar to findings from the Wisconsin Department of Health Services (WDHS), which first reported vaping-related hospitalizations on July 25, noting the “names and types of products used remain unknown.”[xliii] On August 29, WDHS reported 89 percent of patients interviewed had “reported using e-cigarettes or other vaping devices to inhale THC products, such as waxes and oils.”[xliv] WDHS urged residents to stop using products that “may include chemicals or additives that are unknown, unregulated, and unsafe.”

A September 6 report in The New England Journal of Medicine examined hospitalizations in Illinois and Wisconsin. Of the 53 case patients the authors examined, 84 percent “reported having used [THC] products in e-cigarette devices.”[xlv] Although patients reported “a wide variety of products and devices,” 21 of the 41 patients interviewed stated using a “THC product … marketed under the ‘Dank Vape’ label.” This is alarming because empty packaging for that and other known brands is available for purchase by many online retailers, as well as empty devices, or “cartridges.” Instructions on how to infuse THC in vaping devices is easy to find on YouTube.

Moreover, the FDA, is urging consumers “to avoid buying vaping products on the street, and to refrain from using THC oil or modifying/adding any substances to products purchased in stores.”[xlvi]

Myth: Formaldehyde in E-Cigarettes Poses Health Risks

Opponents of e-cigarettes often assert these products contain harmful levels of formaldehyde. They base this assertion on a New England Journal of Medicine article titled “Hidden Formaldehyde in E-Cigarette Aerosols.”[xlvii] However, there are strong reasons to believe formaldehyde does not pose a risk to e-cigarette users.

The experiment described in the New England Journal of Medicine article produced formaldehyde by overheating e-cigarettes, a process called “dry puffing.” Although this process can result in harmful levels of formaldehyde, the resulting vapor tastes so bad that users do not inhale it. Thus, the formaldehyde produced under these conditions is not “hidden” at all and not dangerous, because it is contained in vapor that users find intolerable.

This finding was verified by a careful examination of the New England Journal of Medicine report.[xlviii] In that study, researchers replicated the overheating technique and compared its results to heating at “lower, normal vaping power.” Under “normal vaping power” conditions, the researchers found levels of formaldehyde were minimal, “only 20 micrograms,” which is about two-thirds the amount of formaldehyde in combustible tobacco cigarettes.[xlix]

In a separate study, the Centers for Disease Control and Prevention sampled air quality in a vape shop in which users had vaped. CDC tested formaldehyde levels in the shop and found they were “well below” various health agencies’ recommended levels of exposure, including the Occupational Safety and Health Administration’s personal exposure limit and action level.

Although e-cigarettes can contain formaldehyde, when used properly, vaping devices produce significantly lower levels of the substance than those reported in the New England Journal of Medicine study and lower than the levels of formaldehyde found in traditional combustible cigarettes.[l]

Myth: E-Cigarettes Cause ‘Popcorn Lung’

One false claim made by opponents of e-cigarettes is that using these THR products causes the health condition bronchiolitis obliterans, commonly called “popcorn lung.”

In 2015, a study was published in the journal Environmental Health Perspectives that found e-cigarettes contain chemicals linked to popcorn lung, such as diacetyl, acetyl propionyl, and acetoin.[li] These chemical agents are used to provide the “buttery” flavors in e-cigarettes. Of the 51 flavored e-cigarettes tested in the study, flavoring chemicals linked to popcorn lung were found in 47 samples. Diacetyl was determined to be present in 39 samples.

The researchers associated their findings with similar exposures experienced by workers in microwave popcorn factories. These workers have been determined to be susceptible to popcorn lung by established medical research.[lii]

The 2015 Environmental Health Perspectives study alarmed public health officials and the media, many of whom claimed e-cigarettes can cause popcorn lung, despite substantial flaws in the research. For example, to analyze the chemicals, the researchers in the Environmental Health Perspectives study “used an aggressive procedure that vaped the samples dry.”[liii] The “puffs” analyzed lasted eight seconds, considerably longer than normal “puffing.” This longer period likely produced “higher-than-normal temperatures, combustion, and smoke.”[liv]

Further, the authors of the Environmental Health Perspectives study failed to mention in their report that cigarette smoke contains the same chemical agents causing concerns about potential links between popcorn lung and e-cigarettes. In fact, combustible cigarette smokers are exposed to 750 times more diacetyl in tobacco cigarettes.[lv] And yet, to date, there has been no association between smoking tobacco cigarettes and popcorn lung.

Perhaps most importantly, there have been no known cases of an e-cigarette user being diagnosed with popcorn lung as a result of his or her e-cigarette use. In 2017, researchers published a three and-half-year observational study that found no indications e-liquids cause popcorn lung in users. According to the study’s authors, “no features consistent with early signs of bronchiolitis obliterans were described in any of the [e-cigarette users observed].”[lvi]

It’s also important to note that to ensure the safety of their products, many vaping e-liquid manufacturers have since 2015 chosen to not include the ingredients associated with popcorn lung in their e-liquids.

Fact: Michigan Spends Little Tobacco Moneys on Education and Prevention

It’s disingenuous that policymakers in Michigan would restrict access to tobacco harm reduction products while the state spends little of its existing tobacco settlement payments and taxes on helping smokers quit.

In 2018, Michigan received an estimated $1.2 billion in tobacco taxes and settlement payments, yet spent only $1.6 million, or 0.001 percent, on education and prevention programs.

For years, Michigan has used tobacco settlement money on issues other than “tobacco control and public health.” In 1999, Gov. John Engler “proposed using [tobacco settlement] funds to finance a merit scholarship program”[lvii] with officials arguing “that the state had spent enough on tobacco control and the public was sufficiently aware of smoking’s harms.” In 2000, none of the settlement funds were diverted to tobacco control programs.

Worse, Michigan needs future smokers because the state has “sold” its tobacco settlement moneys by issuing capital appreciation bonds. In 2006 the state sold future tobacco settlement moneys to secure upfront cash.[lviii] Though payments will reach maturity in 2034, in 2014 it was estimated that Michigan owed more than $7 billion on tobacco bonds.[lix] Another analysis finds Michigan will “pay back more than 1,800 times the amount it borrowed.”[lx] In essence, Michigan needs future smokers in order to pay off these existing bonds.

Rather than punishing former smokers, Michigan should invest more of existing moneys into tobacco control programs to address youth use of electronic cigarettes and vaping devices.

It is disingenuous that lawmakers would purport to protect public health yet restrict access to safer products. Rather than restricting access to tobacco harm reduction products and flavored tobacco products, lawmakers should encourage the use of e-cigarettes and earmark adequate funding for smoking education and prevention programs.

Thank you for your time today.

For more information about The Heartland Institute’s work, please visit our website at www.heartland.org, or contact Lindsey Stroud by phone at 757/354-8170 or by email at lstroud@heartland.org.

 

[i] WHO Framework Convention on Tobacco Control, “Electronic Nicotine Delivery Systems and Electronic Non-Nicotine Delivery Systems (ANDS/ENNDS),” August 2016, http://www.who.int/fctc/cop/cop7/FCTC_ COP_7_11_EN.pdf.

[ii] U.S. Food and Drug Administration, “Deeming Tobacco Products To Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Restrictions on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products,” Federal Register, May 10, 2016, http://bit.ly/2x90ef.

[iii] Keller and Heckman LLP, “FDA’s Establishment Registration and Product Listing Deadline is Fast Approaching – Are You Prepared?” December 15, 2016, https://www.khlaw.com/FDAs-Establishment-Registration-and-Product-Listing-Deadline-is-Fast-Approaching---Are-You-Prepared.

[iv] Susan Adams, “E-Cigarette Manufacturers Say New Regulations Will Devastate The Industry,” Forbes, May 5, 2016, https://www.forbes.com/sites/ susanadams/2016/05/05/e-cigarette-manufacturers-say-new-regulations-will-devastate-the-industry/#6aa5124a66d4.

[v] Lindsey Stroud, “Randomized Trial Finds E-Cigarettes are More Effective Smoking Cessation Tool Than Nicotine Replacement Therapy,” Research & Commentary, The Heartland Institute, February 11, 2019, https://www.heartland.org/publications-resources/publications/research--commentary-randomized-trial-finds-e-cigarettes-are-more-effective-smoking-cessation-tool-than-nicotine-replacement-therapy.

[vi] M. Mirbolouk et al., “Prevalence and Distribution of E-Cigarette Use Among U.S. Adults: Behavioral Risk Factor Surveillance System,” Annals of Internal Medicine, August 28, 2016, https://annals.org/aim/article-abstract/2698112/prevalence-distribution-e-cigarette-use-among-u-s-adults-behavioral.

[vii] A. McNeill et al., “E-cigarettes: an evidence update,” Public Health England, August, 2015, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data

[viii] A. McNeill et al., “Evidence review of e-cigarettes and heated tobacco products 2018,” Public Health England, February 2018, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/684963/Evidence_review_of_e-cigarettes_and_heated_tobacco_products_2018.pdf.

[ix] Royal College of Physicians, Nicotine without Smoke: Tobacco Harm Reduction, April, 2016, https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0.

[x] Committee on the Review of the Health Effects of Electronic Nicotine Delivery Systems, “Public Health Consequences of E-Cigarettes,” The National Academies of Science, Engineering, and Medicine, 2018, https://www.nap.edu/catalog/24952/public-health-consequences-of-e-cigarettes.

[xi] The American Cancer Society, “What Do We Know About E-cigarettes? June 19, 2019, https://www.cancer.org/cancer/cancer-causes/tobacco-and-cancer/e-cigarettes.html.

[xii] David T. Levy et al., “Potential deaths averted in USA by replacing cigarettes with e-cigarettes,” Tobacco Control, October 2, 2017, http://tobaccocontrol.bmj.com/content/early/2017/08/30/tobaccocontrol-2017-053759.info.   

[xiii] Andrew J. Oliver et al., “Flavored and Nonflavored Smokeless Tobacco Products: Rate, Pattern of Use, and Effects,” Nicotine & Tobacco Research, January 2013, 15(1): 88-92, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3524058/.

[xiv] Konstantinos E. Farsalinos et al., “Impact of Flavour Variability on Electronic Cigarette Use Experience: An Internet Survey,” International Journal of Environmental Research and Public Health 10 (December 2013): 7,272–82, http://www.mdpi.com/1660-4601/10/12/7272.

[xv] Carl V. Phillips, “CASAA ecig survey results,” Consumer Advocates for Smoke-free Alternatives Association, January 4, 2016, https://casaa.org/wp-content/uploads/CASAA-Vaping-Survey-Results-CVP-post-4-January-2016.pdf.

[xvi] M.B. Harrell et al., “Flavored e-cigarette use: Characterizing youth, young adult, and adult users,” Preventative Medicine Reports, Vol. 5, March 2017, pp. 33–40, https://www.sciencedirect.com/science/article/pii/S2211335516301346

[xvii] Lindsey Stroud, “Research & Commentary: Largest Vaping Survey Finds Flavors Play Important Role in Tobacco Harm Reduction,” Research & Commentary, The Heartland Institute, October 2, 2018, https://www.heartland.org/publications-resources/publications/research--commentary-largest-vaping-survey-finds-flavors-play-important-role-in-tobacco-harm-reduction.

[xviii] Ali Anderson, “Ex Smokers Prefer Fruity E-Liquids Says Doctor’s FDA Survey,” Vaping, August 14, 2018, https://vaping.com/blog/news/ex-smokers-prefer-fruity-e-liquids-says-doctors-fda-survey/.

[xix] John Buckell, Joachim Marti, and Jody L. Sindelar, “Should Flavors Be Banned in E-Cigarettes? Evidence on Adult Smokers and Recent Quitters from a Discrete Choice Experiment,” National Bureau of Economic Research, September 2017, http://www.nber.org/papers/w23865.pdf.

[xx] Samane Zare et al., “A systematic review of consumer preference for e-cigarette attributes: Flavor, nicotine strength, and type,” PLoS ONE 13(3): e0194145. https://doi.org/10.1371/journal.pone.0194145.

[xxi] Lindsey Stroud, “Flavor Bans Do Not Reduce Youth E-Cigarette Use,” Research & Commentary, The Heartland Institute, August 29, 2019, https://www.heartland.org/publications-resources/publications/research--commentary-flavor-bans-do-not-reduce-youth-e-cigarette-use.

[xxii] Shu-Hong Zhu, Ph.D., et al., “Tobacco Use among High School Students in Santa Clara County: Findings from the 2017-18 California Student Tobacco Survey,” Center for Research and Intervention in Tobacco Control, University of California, San Diego, 2019, https://www.sccgov.org/sites/phd/hi/tf/Documents/castudent-survey-2019.pdf

[xxiii] Shu-Hon Zhu, Ph.D., et al., “California Youth Tobacco Survey 2015-16: Results of the Statewide Student Survey, Grades 8, 10, and 12,” Center for Research Intervention in Tobacco Control, University of California, San Diego, https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/CTCB/CDPH%20Document%20Library/ResearchandEvaluation/Reports/CSTS%2015-16%20Report%20FINAL.pdf

[xxiv] Shu-Hong Zhu, Ph.D., et al., “Results of the Statewide 2017-18 California Student Tobacco Survey,” Center for Research Intervention in Tobacco Control, University of California, San Diego, https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/CTCB/CDPH%20Document%20Library/ResearchandEvaluation/Reports/2017-18CaliforniaStudentTobaccoSurveyBiennialReport.pdf.

[xxvi] Lindsey Stroud, “How Do Electronic Cigarettes Affect Adolescent Smoking,” Research & Commentary, The Heartland Institute, March 28, 2016, https://www.heartland.org/publications-resources/publications/research--commentary-how-do-electronic-cigarettes-affect-adolescent-smoking?fbclid=IwAR3MXDoO2v8rmSyez8yhSxLDNe_pTQJAPzbKRlWx8AIMTZeBMsMg88o7xnw.

[xxvii] Lindsey Stroud, “Tobacco 21 Laws Do Not Reduce Youth E-Cigarette Use,” Research & Commentary, May 1, 2019, https://www.heartland.org/publications-resources/publications/research--commentary-tobacco-21-laws-do-not-reduce-youth-e-cigarette-use.

[xxviii] Lance Ching, Ph.D., et al., “Data Highlights from the 2015 Hawai’i Youth Tobacco Survey,” Hawai’i State Department of Health, April 15, 2016, http://www.hawaiihealthmatters.org/content/sites/hawaii/2015_HYTS_FINAL_June2016.pdf.

[xxix] Lance Ching, Ph.D., et al., “Data Highlights from the 2017 Hawai’i Youth Tobacco Survey,” Hawai’i State Department of Health, June 29, 2018, http://www.hawaiihealthmatters.org/content/sites/hawaii/YTS_2017_Report.pdf.

[xxx] 7 Brad Rodu, “The True Consequences of E-Cig and Vape Use,” Presentation at the National Association of Tobacco Outlets’ Annual Meeting, April 22, 2015. Full presentation available from author upon request.

[xxxi] Ibid.

[xxxii] Raymond Niaura, “Re-thinking nicotine and its effects,”  Truth Initiative,  accessed June 5, 2019, http://vapit.it/wp-content/uploads/2016/12/ReThinking-Nicotine.pdf

[xxxiii] Peter N. Lee, “Summary of the Epidemiological Evidence Relating SNUS to Health,” Regulatory Toxicology and Pharmacology, March 2011, https:// www.sciencedirect.com/science/article/pii/S0273230010002229?via%3Dihub.

[xxxiv] Raymond Niaura, supra note 32.

[xxxv] County of Los Angeles Public Health, “Press Release: Public Health Investigates First Death Associated with E-Cigarettes in LA County,” September 6, 2019, http://publichealth.lacounty.gov/phcommon/public/media/mediapubhpdetail.cfm?prid=2137.

[xxxvi] Illinois Department of Public Health, “Illinois Resident Experiencing Respiratory Illness After Vaping Dies,” August 23, 2019, http://www.dph.illinois.gov/news/illinois-resident-experiencing-respiratory-illness-after-vaping-dies.

[xxxvii] ,” Indiana State Department of Health, “Indiana Health Officials Report First Vaping-Related Death,” September 6, 2019, https://calendar.in.gov/site/isdh/event/indiana-health-officials-report-first-vaping-related-death/.

[xxxviii] Kansas Department of Health and Environment, “Health Officials Report Death in Vaping Related Lung Disease,” September 10, 2019, https://khap2.kdhe.state.ks.us/NewsRelease/PDFs/9-10-19%20vaping.pdf.

[xxxix]Minnesota Department of Health, “Health officials report death in a patient hospitalized for vaping-related lung injury,” September 6, 2019, https://www.health.state.mn.us/news/pressrel/2019/lunginjury090619.html.

[xl] Oregon Health Authority, “State investigating death from severe lung illness linked to vaping,” September 3, 2019, https://www.oregon.gov/oha/ERD/Pages/State-Investigating-Death-Severe-Lung-Illness-Link-Vaping.aspx.

[xli] Ibid.

[xlii] Minnesota Department of Health, supra note 32.

[xliii] Wisconsin Department of Health Services, “Severe Pulmonary Disease Among Adolescent who Reported Vaping,” July 25, 2019, https://www.dhs.wisconsin.gov/dph/memos/beoh/2019-02.pdf.

[xliv] Wisconsin Department of Heath Services, “Majority of Wisconsin Lung Disease Patients Who Reported Vaping Cite THC Products,” August 29, 2019, https://www.dhs.wisconsin.gov/news/releases/082919.htm.

[xlv] Jennifer E. Layden, M.D., Ph.D., et al., “Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin – Preliminary Report,” The New England Journal of Medicine, September 6, 2019, https://www.nejm.org/doi/full/10.1056/NEJMoa1911614?fbclid=IwAR0kTs_r_tf_FmGLzEWRoaLk7-yS1URk9xe1euOoKQuwpZwx0CN79edr5Do.

[xlvi] U.S. Food and Drug Administration, “Vaping Illnesses: Consumers can Help Protect Themselves by Avoiding Tetrahydrocannabinol (THC)-Containing Vaping Products,” September 6, 2019, https://www.fda.gov/consumers/consumer-updates/vaping-illnesses-consumers-can-help-protect-themselves-avoiding-tetrahydrocannabinol-thc-containing.

[xlvii] R. Paul Jensen et al., “Hidden Formaldehyde in E-Cigarette Aerosols,” The New England Journal of Medicine, Volume 394, January 2015, pp. 392– 394, http://www.nejm.org/doi/full/10.1056/NEJMc1413069.

[xlviii] K.E. Faralinos et al., “E-cigarettes emit very high formaldehyde levels only in conditions that are aversive to users: A republican study under verified realistic use conditions.,” Food and Chemical Toxicology, August 31, 2017, https://www.ncbi.nlm.nih.gov/pubmed/28864295.

[xlix] Brad Rodu, “Antidote to NEJM ‘formaldehype’ arrives at last,” R Street Institute, September 19, 2017, https://www.rstreet.org/2017/09/19/antidoteto-nejm-formaldehype-arrives-at-last.

[l] Leonard M. Zwack, et al., “Evaluation of Chemical Exposures at a Vape Shop,” Health Hazard Evaluation Report, U.S. Department of Health and Human Services, Centers for disease Control and Prevention, National Institute for Occupational Safety and Health, 2015, https://www.cdc.gov/niosh/hhe/reports/pdfs/2015-0107-3279.pdf.

[li] Joseph G. Allen et al., “Flavoring Chemicals in E-Cigarettes: Diacetyl, 2,3-Pentanedione, and Acetoin in a Sample of 51 Products, Including Fruit-, Candy-, and Cocktail-Flavored E-Cigarettes,” Environmental Health Perspectives, Volume 124, June 2016, pp. 733–739, http://ehp.niehs.nih.gov/15-10185.

[lii] Brent D. Kerger and M. Joseph Fedoruk, “Pathology, Toxicology, and Latency of Irritant Gases Known to Cause Bronchiolitis Obliterans Disease: Does Diacetyl Fit the Pattern?” Toxicology Reports, Volume 2, 2015, pp. 1463–1472, http://www.sciencedirect.com/science/article/pii/S2214750015300767; Brad Rodu, “Red Flag for Vapers: Avoid Some Flavoring Agents,” Tobacco Truths, November 10, 2015, http://rodutobaccotruth.blogspot.com/2015/11/red-flagfor-vapors-avoid-some.html 

[liii] Brad Rodu, “Is the Harvard E-Cigarette Buttery Flavor Study Credible?” Tobacco Truth, December 10, 2015, https://rodutobaccotruth.blogspot.com/2015/12/is-harvard-e-cigarette-buttery-flavor.html

[liv] Ibid.

[lv] Michael Siegel, “New Study Finds that Average Diacetyl Exposure from Vaping is 750 Times Lower than from Smoking,” The Rest of the Store: Tobacco and Alcohol News Analysis and Commentary, December 10, 2015, http://tobaccoanalysis.blogspot.com/2015/12/new-study-finds-thataverage-diacetyl.html

[lvi] Riccardo Polosa et al., “Health impacts of E-cigarettes: a prospective 3.5-year study of regular daily users who have never smoked,” Scientific Reports, November 17, 2017, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5693960.

[lvii] Frank A. Sloan et al., “States’ Allocation Of Funds From The Tobacco Master Settlement Agreement,” Health Affairs, January/February 2005, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.24.1.220.

[lviii] Attorney General of the State of Michigan, “Taxable Tobacco Settlement Asset-Backed Bonds,” May 12, 2006, https://emma.msrb.org/MS247053-MS222361-MD432888.pdf.

[lix] Cezary Podkul and Yue Qiu, “Tobacco Bonds May Be Dangerous to Your State’s Financial Health,” ProPublica, August 7, 2014, https://projects.propublica.org/graphics/tbcbonds-statemap.

[lx] Gavin Haynes, “The Dirty Story of How Tobacco Was Brought Down to Size,” Vice, November 5, 2018, https://www.vice.com/en_us/article/vba4zm/the-dirty-story-of-how-big-tobacco-was-brought-down-to-size.