Chair and members of the committee,

My name is Mazen Saleh and I am the interim director of integrated harm reduction policy for the R Street Institute (R Street), which is a nonprofit, nonpartisan, public policy research organization. Our mission is to engage in policy research and outreach to promote free markets and limited, effective government in many areas, including tobacco harm reduction. That is why SB 938 is of special interest to us.

It has been proven time and again that abstinence-based approaches to public health concerns do not work at the population level—whether for sex[1], substance abuse[2], or alcohol[3] use. At R Street, we believe in helping individuals reduce the harms associated with the use of tobacco if they cannot or will not abstain altogether; that is our definition of harm reduction.

Over the past several decades, public health has made great strides to decrease smoking initiation and promote smoking cessation interventions.[4] However, no cessation or prevention program is 100 percent successful. R Street’s ultimate goal is to bring harm reduction approaches into equal standing as a third pillar of tobacco control alongside demand reduction (increased cessation and prevention measures) and supply reduction (shifting to economies that do not rely on tobacco production). It is for this reason that I write to you out of concern over SB 938, which seeks to prohibit the sale of flavored electronic nicotine delivery systems (ENDS). It is important to acknowledge that HB 6396 is being heard by the House Committee on Health and Human Services on the same day as this hearing. While R Street does not advocate for the use of combustible tobacco products, the proposed legislation of HB 6396 shares similar implications for ENDS products as those proposed in SB 938. From a public health perspective, it is important to incentivize people to use less harmful products; allowing their availability alongside combustible cigarettes will encourage adults to choose safer alternatives.

E-Cigarettes are a harm reduction and smoking cessation tool

R Street has long been concerned with the impacts of smoking combustible cigarettes and our work on tobacco harm reduction is focused squarely on adult smokers. We have not and do not support any form of tobacco use by youth. Years before it became law, we supported efforts to raise the age to purchase tobacco products to 21 years old, and urge officials to enforce such measures to keep tobacco products out of the hands of young people.

Although there are a number of pharmaceutical products that can help smokers quit, their low success rates necessitate that the public health community consider expanding the cessation toolbox to include ENDS. The simple truth is that e-cigarettes are fast becoming one of the most effective tools smokers use to quit and are a far better alternative to combustible cigarettes.[5] In fact, according to Public Health England, e-cigarettes are 95 percent less harmful than combustible cigarettes.[6] Further, a recent study claims e-cigarettes are a more effective cessation tool than nicotine replacement therapies, such as the patch or gum.[7] Given this, the Rhode Island Legislature should be pleased when more smokers consider switching to less harmful e-cigarettes. However, e-cigarettes’ reduced harm profile alone may not be enough to encourage smokers to quit for good, but that is where flavored vapor products prove useful.

Flavors help smokers transition away from combustible cigarettes

The availability of non-tobacco flavors 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.[8]  About 40 percent of e-cigarette-using, 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.[9] 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.[10]

Moreover, it has recently been demonstrated that e-cigarette users who use non-tobacco flavors, including menthol and non-menthol (fruit, sweet or dessert) flavors are more likely to completely switch from combustible cigarettes than those who choose tobacco flavors.[11] Flavored e-liquids are yet another way that e-cigarettes can help smokers disassociate combustible cigarettes—and their characteristic flavor—from the pleasurable effects of nicotine.[12]

Studies show that adults greatly prefer non-tobacco flavors.[13] However, if all flavored vapor products are banned—as is proposed in this bill—it is less likely that current smokers will make the switch to less harmful products. This is something that Rhode Island cannot afford to risk. As it stands, around 480,000 Americans die from tobacco usage a year—many in Rhode Island—and roughly 14.6 percent of those in the state smoke combustible cigarettes.[14]

As you consider SB 938, I strongly urge you to examine the utility of flavored vapor products as harm reduction tools that compliment traditional prevention measures to reduce cigarette consumption among adults in Rhode Island. It is imperative that a range of products remain accessible at a level that encourages, rather than discourages, smokers to choose these less harmful alternatives. The health of Rhode Islanders depends on it.

Respectfully submitted,

Mazen Saleh, MSc
Interim Director, Integrated Harm Reduction Policy
R Street Institute
[email protected]

[1] John S. Santelli, et al., “Abstinence-Only-Until-Marriage: An Updated Review of U.S. Policies and Programs and Their Impact,” Journal of Adolescent Health 61:3 (2017), pp. 273-280. https://www.sciencedirect.com/science/article/pii/S1054139X17302604.

[2] Diane E. Logan and G. Alan Marlatt, “Harm reduction therapy: a practice-friendly review of research,” Journal of Clinical Psychology 66:2 (2010), pp. 201-214.

[3] Ibid.

[4] See, e.g., Office of the Surgeon General, Smoking Cessation: A Report of the Surgeon General, U.S. Dept. of Health and Human Services, (2020). https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf.

[5] Shu-Hong Zhu, et al., “E-cigarette use and associated changes in population smoking cessation: evidence from US current population surveys,” BMJ 358 (2017). https://www.bmj.com/content/358/bmj.j3262.

[6] Ann McNeill et al., “Evidence review of e-cigarettes and heated tobacco products 2018: executive summary,” Public Health England (2018). https://www.gov.uk/government/publications/e-cigarettes-and-heated-tobacco-products-evidence-review/evidence-review-of-e-cigarettes-and-heated-tobacco-products-2018-executive-summary.

[7] J Hartmann-Boyce, et al., “Can electronic cigarettes help people stop smoking, and do they have any unwanted effects when used for this purpose?”, Cochrane, Oct. 14, 2020. https://www.cochrane.org/CD010216/TOBACCO_can-electronic-cigarettes-help-people-stop-smoking-and-do-they-have-any-unwanted-effects-when-used.

[8] 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 10:12 (December 2013), pp. 7272-82. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3881166.

[9] Ibid.

[10] Ibid.

[11] 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). https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-018-0238-6#Abs1.

[12] Ibid.

[13] Ibid.

[14] Centers for Disease Control and Prevention, “Tobacco-Related Mortality,” Department of Health and Human Services, April 28, 2020. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/tobacco_related_mortality/index.htm; Centers for Disease Control and Prevention, “Map of Current Cigarette Use Among Adults,” Centers for Disease Control and Prevention,” Department of Health and Human Services, Sept. 14, 2020. https://www.cdc.gov/statesystem/cigaretteuseadult.html.