Testimony from:
Steven Greenhut, Western Region Director, R Street Institute

In OPPOSITION to Hawaii House Bill 1570, which “bans the sale of flavored tobacco and synthetic nicotine products; prohibits mislabeling of e-liquid products containing nicotine; and prohibits the marketing, advertising, or promoting of electronic smoking devices to appeal to individuals under twenty-one. Establishes fines and penalties for violations. Includes heated smoking products among the electronic smoking devices that are subject to restrictions under law.”

March 18, 2022

Senate Committee on Health

Dear Chairman and members of the committee,

I am writing on behalf of R Street Institute (R Street) in opposition to House Bill 1570, which includes a statewide ban on the sale of flavored tobacco products, including electronic nicotine delivery systems (ENDS). R Street is a nonprofit public policy organization focused on advancing limited, effective government in a variety of policy areas, including Integrated Harm Reduction. Because ENDS products give adult users a reduced-risk alternative to smoking combustible cigarettes, we are concerned about the negative implications such a ban would have on Hawaii’s public health, and we urge the Senate Health Committee to reject HB 1570.

E-cigarettes are a valuable harm reduction tool

The legislation includes a variety of provisions, but our main concern involves the ban on flavored nicotine products. Given that almost all vaping and lower-risk smokeless tobacco products include flavors, the legislation would essentially ban almost all reduced-harm alternatives to combustible cigarettes. In doing so, the Legislature would create the perverse consequence of outlawing most of the safer products that enable smokers to reduce their risk—while keeping the most dangerous products readily available.

That is a deadly proposition given that vaping products are far safer than combustible tobacco products. The U.S. Centers for Disease Control and Prevention (CDC) estimate that 480,000 Americans die each year because of smoking and second-hand smoke. [1] Yet over 34 million Americans a year continue to smoke cigarettes. [2] That is why R Street advocates public policies that encourage—rather than punish—people for making potentially life-saving behavioral changes.

Although we discourage the use of any tobacco or nicotine products, we advocate a harm reduction policy that encourages safer alternatives for adult consumers who are unable or unwilling to quit smoking. We prefer real-world health benefits over a utopian embrace of abstinence. We also question the wisdom of limiting adult-only products as a means to discourage their illegal access by teens. Instead, we should toughen enforcement of smoking age limits.

R Street’s principles of harm reduction recognize that abstinence-only approaches to public health are not effective and that prohibition comes with its own consequences. The Hawaii Legislature has recognized the validity of this approach when it comes to other risky behaviors, such as opioid use. For example, state law provides standing orders for the overdose reversal medication, naloxone, and provides protections for individuals who call for help when witnessing or experiencing an overdose. [3]

Harm reduction principles are grounded in the concept that if individuals engage in risky behavior, it is in the state’s interest to ensure there are options with which they can mitigate potential harm.

This same philosophy should be applied to tobacco use. Public health agencies including Public Health England; the Royal College of Physicians; the National Academies of Science, Engineering, and Medicine; and the U.S. Food and Drug Administration all recognize that tobacco products exist on a continuum of risk. [4] Because e-cigarettes do not burn tobacco, they do not release the 7,000 chemicals found in combustible cigarette smoke. [5] This places them at the lower end of the risk spectrum, near traditional nicotine-replacement therapies, whereas deadly combustible cigarettes are at the highest end.

The Royal College of Physicians concluded that the risk from vaping is unlikely to exceed 5 percent of the risk associated with smoking combustible cigarettes. [6] Even the American Cancer Society has noted potential health benefits for smokers who switch to e-cigarettes. [7]

Flavored e-cigarettes can be an effective smoking cessation device

Combustible cigarettes are exceptionally addictive and harmful, yet as with most substances, many people struggle to stop smoking. [8] Reduced-risk products such as ENDS not only provide a safer option for those who want to continue using nicotine, but they also can help people move closer to quitting completely. [9]

The United Kingdom’s National Health Service endorses e-cigarettes as a smoking cessation tool. [10] Indeed, randomized controlled trials indicate that e-cigarettes may be almost twice as effective as traditional nicotine replacement therapies at helping former smokers sustain abstinence from combustibles. [11] Public health models show that e-cigarettes have helped accelerate the decline in smoking. [12]

Flavors are an important part of this equation, enticing combustible cigarette users to switch to less harmful e-cigarettes and keeping them interested with a variety of options. One study of 4,515 former and current smokers—91 percent of whom had completely quit using combustible cigarettes—found that all participants viewed flavors as “very important” to their decision to cease or reduce their use of combustible cigarettes, and 40 percent said a lack of flavor variety would have hindered their ability or willingness to switch. [13] Another study found that e-cigarette users were more likely to switch completely from combustibles when they used non-tobacco flavors, including menthol as well as fruit, sweet or dessert flavors, likely because flavors assist smokers in disassociating a tobacco flavor with the pleasurable effects of combustible cigarettes. [14]

Flavors are not driving youth initiation

Many attempts to ban flavored tobacco products are rooted in the fear of encouraging youth uptake of e-cigarettes. However, research shows that flavors are not the main reason youth initiate use of these products. In 2019, the CDC found that 55.3 percent of minors using e-cigarettes cited curiosity as their primary motivator for trying them, whereas only 22.4 percent cited flavors as the primary factor. [15]

R Street shares the concern of this committee regarding youth uptake of e-cigarette products. We have not and do not promote any tobacco use among youth, and we were one of the first national think tanks to advocate for raising the age of purchase to 21. Notwithstanding, research shows that e-cigarette flavor bans not only risk undermining the harm-reducing effects of these reduced-risk products, they also may unintentionally create additional harm.

Studies show that, when faced with a potential flavor ban, many ENDS users report a willingness to add their own flavors, find their desired products on uncontrolled markets or simply return to combustible cigarettes. [16] Indeed, a recent flavor ban in San Francisco was associated with an increase in youth smoking combustible cigarettes. [17]

Thus, R Street strongly urges the examination of the potential of flavored tobacco products as harm reduction tools that complement other tobacco cessation strategies and the opposition of HB 1570, which would cut off a valuable harm reduction tool for Hawaii’s smokers.

Thank you for your consideration.

Best regards,

Steven Greenhut
Western Region Director
R Street Institute
(909) 260-9836
[email protected]

[1] Centers for Disease Control and Prevention, “Smoking & Tobacco Use: Fast Facts,” Department of Health and Human Services, June 2, 2021. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm.

[2] Centers for Disease Control and Prevention, “State Tobacco Activities Tracking and Evaluation (STATE) System: Map of Current Cigarette Use Among Adults,” Department of Health and Human Services, Oct. 22, 2021. https://www.cdc.gov/statesystem/cigaretteuseadult.html.

[3] U.S. Government Accountability Office, Drug Misuse: Most States Have Good Samaritan Laws and Research Indicates They May Have Positive Effects, U.S. Congress, March 2021. https://www.gao.gov/assets/gao-21-248.pdf.

[4]  See, e.g., Health & Wellbeing Directorate, “E-cigarettes: a new foundation for evidence-based policy and practice,” Public Health England, August 2015. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/454517/Ecigarettes_a_firm_foundation_for_evidence_based_policy_and_practice.pdf; Tobacco Advisory Group, “Nicotine without smoke: Tobacco harm reduction,” Royal College of Physicians, April 28, 2016. https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0; “Public Health Consequences of E-Cigarettes,” National Academies of Science, Engineering, and Medicine, 2018. http://nationalacademies.org/hmd/reports/2018/public-health-consequences-of-e-cigarettes.aspx; U.S. Food and Drug Administration, “FDA announces comprehensive regulatory plan to shift trajectory of tobacco-related disease, death,” Department of Health and Human Services, July 27, 2017. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm568923.htm.

[5] Tobacco Advisory Group. https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction.

[6] Ibid.

[7] Steven Greenhut and Carrie Wade, “Cancer society’s evolving position on vaping refreshing,” The Mercury News, March 9, 2018. https://www.mercurynews.com/2018/03/09/opinion-cancer-societys-evolving-position-on-vaping-refreshing.

[8] Sharon Cox and Lynne Dawkins, “Global and local perspectives on tobacco harm reduction: what are the issues and where do we go from here?,” Harm Reduction Journal 15:32 (2018). https://link.springer.com/article/10.1186/s12954-018-0239-5.

[9] Centers for Disease Control and Prevention, “Smoking & Tobacco Use: About Electronic Cigarettes (E-Cigarettes),” Department of Health and Human Services, Sept. 30, 2021. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html#e-cigarettes-less-harmful; Jamie Brown et al., “Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study,” Addiction 109:9 (September 2014), pp. 1531-1540. https://onlinelibrary.wiley.com/doi/full/10.1111/add.12623.

[10]  National Health Service, “Using e-cigarettes to stop smoking,” Department of Health and Social Care, March 29, 2019. https://www.nhs.uk/live-well/quit-smoking/using-e-cigarettes-to-stop-smoking.

[11]  Peter Hajek et al., “A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy,” The New England Journal of Medicine 380 (Feb. 14, 2019), pp. 629-637. https://www.nejm.org/doi/full/10.1056/nejmoa1808779.

[12]  David T. Levy et al., “Examining the relationship of vaping to smoking initiation among US youth and young adults: a reality check,” Tobacco Control 28:6 (November 2019), pp. 629-635. https://pubmed.ncbi.nlm.nih.gov/30459182.

[13]  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 (Dec. 17, 2013), pp. 7272-7282. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3881166.

[14]  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 (June 28, 2018). https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-018-0238-6#Abs1.

[15]  Teresa W. Wang et al., “Tobacco Product Use and Associated Factors Among Middle and High School Students — United States, 2019,” Surveillance Summaries 68:12 (Dec. 6, 2019), pp. 1-22. https://www.cdc.gov/mmwr/volumes/68/ss/ss6812a1.htm.

[16]  Ping Du et al., “Changes in Flavor Preference in a Cohort of Long-Term Electronic Cigarette Users,” Annals of the American Thoracic Society, 17:5 (May 2020), pp. 573-581. https://pubmed.ncbi.nlm.nih.gov/31978316.

[17]  Abigail S. Friedman, “A Difference-in-Differences Analysis of Youth Smoking and a Ban on Sales of Flavored Tobacco Products in San Francisco, California,” JAMA Pediatrics 175:8 (May 24, 2021), pp. 863-865. https://jamanetwork.com/journals/jamapediatrics/fullarticle/2780248?guestAccessKey=227700a4-e3cb-4ccf-8ad5-ae5133e0009c&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamapediatrics&utm_content=olf&utm_term=052421.