September 24, 2019
The Honorable Diana DeGette The Honorable Brett Guthrie
Chairperson Ranking Member
The Oversight and Investigations Subcommittee The Oversight and Investigations Subcommittee
U.S. House of Representatives U.S. House of Representatives
2111 Rayburn House Office Building 2434 Rayburn House Office Building
Washington, D.C. 20515 Washington, D.C. 20515
Chairperson DeGette, Ranking Member Guthrie and Members of the Committee:
We appreciate the opportunity to submit our testimony regarding the upcoming hearing on e-cigarettes and public health. However, rather than investigate only the public health threats of e-cigarettes, we suggest the committee also consider the public health opportunities of e-cigarettes. Smoking is the leading cause of preventable death in the United States, and it is vital that we continually evaluate our strategies for decreasing tobacco-related morbidity and mortality. E-cigarettes provide such a strategy.
Undoubtedly, the trends of youth use and the recent outbreak of lung illnesses are causes for concern and continued investigation. However, they cannot be the only measures of the effect of e-cigarettes on population health. Based on the body of research as a whole, we urge the committee to consider pursuing policies that reflect the short- and long-term population health impact of e-cigarettes relative to the known harms of combustible cigarettes.
The best available science indicates e-cigarettes are not likely to exceed 5 percent of the harm associated with combustible cigarettes, a conclusion supported by both Public Health England  and recently the National Academies of Sciences, Engineering and Medicine.  Also, like traditional nicotine replacement therapies, e-cigarettes do not produce the environmental tobacco smoke that harms bystanders. It is estimated that e-cigarettes have potential to save up to 6 million lives by 2100 if only 10 percent of current smokers switch to e-cigarettes over the next 10 years.
Although there are a number of pharmaceutical products that can help smokers quit, it is important to remember that it is not only nicotine dependence that makes quitting combustible cigarettes difficult. For some, smoking offers stress relief, comradery or other psycho-social pleasure, and some may even consider it a component of their identity. This often makes the physical act of smoking just as difficult to quit as the nicotine. Unlike the FDA-approved methods of smoking cessation, e-cigarettes do not force a smoker to forgo the secondary pleasure they get from the act of smoking at the same time that they are adjusting to the physiological effects of decreased nicotine. This may be one reason why in a randomized trial smokers who used e-cigarettes as a cessation device achieved sustained abstinence at roughly twice the rate of smokers who used nicotine replacement therapy. 
Similarly, the availability of non-tobacco flavors also assists smokers with the transition from combustible cigarettes. The International Journal of Environmental Research and Public Health reports that limitations in flavor choices negatively impact user experience. About 40 percent of former and current adult smokers predict that removing their ability to choose flavors would make them less likely to remain abstinent or attempt to quit.  In fact, data suggests that current smokers are partial to the flavor of traditional tobacco, while fruit and sweet flavors are preferred by former smokers.
Moreover, it has recently been demonstrated that e-cigarette users who use non-tobacco flavors, including menthol and non-menthol (fruit, sweet, dessert) flavors are more likely to completely switch from combustible cigarettes than those who choose tobacco flavors.  Flavored e-liquids are yet another way that e-cigarettes can help smokers disassociate combustible cigarettes—and the characteristic flavor—from their pleasurable effects; this is essentially classical conditioning.
Of course, smokers are not the only population impacted by e-cigarettes. Preventing non-smoking young people from establishing both e-cigarette and combustible cigarette use is vital to the future health of the population. Although the rate of past-30-day e-cigarette use among young people has been increasing, the smoking rate has continued to decline since e-cigarettes were introduced.  This suggests that young people who try e-cigarettes are not transitioning to combustible cigarettes in large numbers. This is supported by Levy et al.’s study that analyzed data from the major national surveys of youth tobacco use and found evidence that the rate of combustible cigarette use began declining more quickly after the introduction of e-cigarettes. These findings suggest that e-cigarettes may be diverting young people from using combustible cigarettes. Without question, youth use of any tobacco product is not desirable, and policies intended to deter youth use must be carefully crafted so they do not unintentionally encourage more harmful behaviors such as increased combustible use or purchase of unregulated products from black markets.
The outbreak of lung illnesses is cause for concern and continued investigation. However, it is important to look at any disease outbreak in context and refrain from overcorrection that may carry dangerous unintended consequences. This may include exacerbating the proliferation of black-market products that may contain dangerous chemicals. Although the experiences of individuals affected by the recent lung illness outbreak should not be minimized, these cases offer a sobering warning of the risks associated with purchasing substances from unregulated sources.
Fortunately, there are a range of regulatory options that minimize harm to both smokers and non-smokers of all ages. First, the R Street Institute supports increasing the minimum age of purchase for tobacco products to 21 years of age. Given that 75 percent of high school seniors are of legal age, this will help prevent youth access in high school. In combination with more stringent point-of-sale age verification and meaningful penalties for merchants who violate minimum age to purchase laws, this change will have a significant positive effect on limiting youth access.
Finally, it is important to recognize that the FDA has developed a regulatory pathway to evaluate the safety and public health impact of all new tobacco products, including considerations of flavors. This is a process that has been carefully designed over several years to ensure new tobacco products, like e-cigarettes, will not have a negative impact on the health of the population as a whole. Allowing the safety and regulatory experts at the FDA to lead the way in authorizing sale of these products is the most appropriate way forward.
Policies that treat e-cigarettes the same as combustible cigarettes encourage current smokers to continue doing enormous harm to their health by discouraging a switch from combustible products. Conversely, policies that reflect the reduced harm of e-cigarettes can significantly reduce the enormous burden of disease that combustible cigarettes impose on society.
One thing is for certain: We are all striving to improve and protect the nation’s health. To do so, we must recognize the potential of e-cigarettes to mitigate risks associated with combustible cigarettes if we wish to encourage a healthful populace. We encourage you to consider policies that reflect the reduced risk of e-cigarettes compared to combustible cigarettes as we work towards creating a healthier population.
Thank you for your time and consideration.
Carrie Wade, Ph.D., M.P.H.
Director of Harm Reduction Policy
R Street Institute
Chelsea Boyd, M.S.
Research Associate in Harm Reduction Policy
R Street Institute
 “Nicotine without smoke: tobacco harm reduction,” Royal College of Physicians Tobacco Advisory Group, 2016. https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0 .
  “The Public Health Consequences of E-cigarettes,” National Academies of Science, Engineering and Medicine, January 2018. http://nationalacademies.org/hmd/reports/2018/public-health-consequences-of-e-cigarettes.aspx .
  Peter Hajek et al., “A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy,” The New England Journal of Medicine 380 (2019), pp. 629-37.
  Konstantinos E Farsalinos, et al., Impact of flavour variability on electronic cigarette use experience: an internet survey. Int J Environ Res Public Health, 2013. 10(12): p. 7272-82.
  Christopher Russell et al. “Changing patterns of first e-cigarette flavor used and current flavors used by 20,836 adult frequent e-cigarette users in the USA” Harm Reduction Journal 15: 33 (2018)
  David T. Levy et al., “Examining the relationship of vaping to smoking initiation among US youth and young adults: a reality check,” Tobacco Control (2018). https://www.ncbi.nlm.nih.gov/pubmed/30459182 .
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- “https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0”: https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0
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- “https://www.ncbi.nlm.nih.gov/pubmed/30459182”: https://www.ncbi.nlm.nih.gov/pubmed/30459182