Testimony from:
Chelsea Boyd, Research Fellow, Harm Reduction, R Street Institute

Informational Comments on House Bill 7869, “An Act Relating to Health and Safety – Department of Health,” House Bill 7870, “An Act Relating to Health and Safety – Department of Health,” House Bill 7871, “An Act Relating to Health and Safety – Department of Health” and House Bill 7881, “An Act Relating to Health and Safety – Department of Health – Tobacco Product Sales’ Restrictions”

March 29, 2021
House Committee on Health and Human Services

Chair Casey, Vice Chair McLaughlin, Vice Chair Donovan and honorable members of the Committee,

My name is Chelsea Boyd, and I am an Integrated Harm Reduction research fellow at the R Street Institute (RSI), which is a nonprofit, nonpartisan, public policy research organization. Our mission at RSI 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 House Bills 7869, 7870, 7871 and 7881 are of special interest to us.

Each of these bills would ban the sale of flavored electronic nicotine delivery systems (ENDS), commonly known as e-cigarettes or vapes, and establish these products as contraband. While the Rhode Island Department of Health has enforced this prohibition by emergency regulation since March 2020, H 7869, H 7870, H 7871 and H 7881 would make the ban permanent in statute.

E-cigarettes carry substantially fewer harms than combustible cigarettes for people addicted to nicotine, and flavors are an important element for smokers to dissociate the taste of tobacco from the effects of nicotine. For these reasons, RSI is concerned that enshrining the prohibitions on flavored ENDS will have a detrimental impact on Rhode Island public health.

E-cigarettes as a Smoking Cessation and Harm Reduction Tool

Studies have shown that e-cigarettes are a valuable tool to help smokers transition to less harmful nicotine delivery methods. Unlike combustible cigarettes, e-cigarettes operate by heating a nicotine-containing liquid, not by burning tobacco. This avoids the release of the more than 7,000 chemicals found in combustible cigarette smoke, some of which are highly carcinogenic. Removing combustion makes e-cigarettes substantially less harmful than their combustible counterparts. Public Health England; The Royal College of Physicians; The National Academies of Science, Engineering and Medicine; and the U.S. Food & Drug Administration have recognized that nicotine products exist on a continuum of risk, with e-cigarettes being at the lower end near traditional nicotine replacement therapies, and combustible cigarettes being at the highest end of the risk spectrum. Specifically, the Royal College of Physicians estimates that e-cigarettes are unlikely to exceed 5 percent of the risk associated with combustibles.

In many parts of the world, e-cigarettes have become the primary tool for smoking cessation, and they are endorsed as such by the National Health Service, the leading central health care agency in the United Kingdom. Models of global public health trends suggest that e-cigarettes are contributing to steeper declines in smoking rates than in previous years. In the United States and the United Kingdom, e-cigarettes are more popular smoking cessation tools than traditional quit methods (varenicline, nicotine replacement therapies and talk therapy) and have more successful outcomes. Additionally, in a randomized control trial, smokers who used e-cigarettes as a cessation device sustained abstinence from combustibles at roughly twice the rate of smokers who used traditional nicotine replacement. Even the U.S. Centers for Disease Control and Prevention (CDC) acknowledges that, while e-cigarettes are new and studies are therefore inconclusive, evidence suggests that smokers’ more frequent use of e-cigarettes is associated with less frequent use of combustible cigarettes.

The Role of Flavors in E-cigarettes as Smoking Cessation Devices

The non-tobacco flavors in e-cigarettes are a critical factor in their role as smoking cessation devices because they assist former smokers in dissociating a tobacco flavor with the effects of nicotine. One study of 4,515 current and former smokers who had transitioned to e-cigarettes found that 91 percent of e-cigarette users had switched from combustibles entirely, and, of those, 69 percent reported switching between flavors within a day. All study participants called the flavor variety “very important” in their decision to switch to e-cigarettes, and 40 percent reported that flavor invariability would have made it less likely for them to switch.

While much of the desire to prohibit flavored e-cigarettes stems from concerns over youth uptake of vaping—concerns that RSI shares, having been one of the first national think tanks to advocate for raising the age of tobacco purchase to 21 years old—prohibiting access to flavored e-cigarettes has not been shown to achieve this end. According to a CDC study, in 2021, 47.6 percent of e-cigarette users under age 18 cited “curiosity” as the primary factor for trying e-cigarettes, while only 13.5 percent cited flavors.

Conclusion

As this Committee considers H 7869, H 7870, H 7871 and H 7881, RSI strongly urges the consideration of the preponderance of evidence suggesting the value e-cigarettes can provide when used as originally intended: as reduced-risk nicotine products providing a harm reduction alternative for combustible cigarette users. There are effective ways to curb youth initiation and uptake, and they need not come at the expense of the 155,000 Rhode Islanders who smoke. Public health is better achieved when there are a range of products and alternatives that encourage, rather than discourage, smokers to transition away from combustible tobacco products.

Respectfully submitted,

Chelsea Boyd
Research Fellow, Harm Reduction
R Street Institute
202-525-5717
[email protected]

[1]  “Harms of Cigarette Smoking and Health Benefits of Quitting,” National Cancer Institute, Dec. 19, 2017. https://www.cancer.gov/about-cancer/causes-prevention/risk/tobacco/cessation-fact-sheet.

[2]  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; See, e.g., 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; See, e.g., Kathleen Stratton et al., eds., Public Health Consequences of E-cigarettes, (The National Academies Press, 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.

[3]  Tobacco Advisory Group. https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0.

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

[5]  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://www.ncbi.nlm.nih.gov/pubmed/30459182.

[6]  Health & Wellbeing Directorate. 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; Shu-Hong Zhu et al., “E-cigarette use and associated changes in population smoking cessation: evidence from US population surveys,” BMJ 358 (July 26, 2017). https://www.bmj.com/content/358/bmj.j3262.

[7]  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.

[8]  Centers for Disease Control and Prevention, “Adult Smoking Cessation—The Use of E-Cigarettes,” Department of Health and Human Services, Jan. 23, 2020. https://www.cdc.gov/tobacco/data_statistics/sgr/2020-smoking-cessation/fact-sheets/adult-smoking-cessation-e-cigarettes-use/index.html.

[9]  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.

[10] Ibid.

[11]  Andrea S. Gentzke et al., “Tobacco Product Use and Associated Factors Among Middle and High School Students — National Youth Tobacco Survey, United States, 2021,” Surveillance Summaries 71:5 (March 11, 2022), pp. 1-29. https://www.cdc.gov/mmwr/volumes/71/ss/ss7105a1.htm.

[12]  “Adult Cigarette Smoking,” Rhode Island Department of Health, 2018. https://health.ri.gov/data/tobacco/smoking.