Testimony to California Senate Health Committee
Senate Committee on Health
California State Senate
Re: S.B. 140 (Leno) Electronic Cigarettes
My name is Edward Anselm and I serve as medical director for Health Republic Insurance of New Jersey (HRINJ). I hold the title of assistant professor of medicine at the Mount Sinai School of Medicine. I have a 30-year history of tobacco-control advocacy and running smoking cessation programs. I recently joined the R Street Institute as a senior fellow. I am here today to share my thoughts about S.B. 140, and hope you will consider some modification to the proposed language.
HRINJ is the first health plan to implement a tobacco harm-reduction program. We have complemented a comprehensive program of smoking cessation with a recognition that the majority of smokers are not ready to change. Even if not ready to quit entirely, most smokers are concerned about their health. We provide counseling services to members who want to reduce their smoking level. This can be supported by several means, including FDA-approved medications and electronic cigarettes. While the science supporting the role of electronic cigarettes is far from complete, we have sufficient evidence to support patients and doctors having a dialogue about harm reduction.
Harm reduction as a public health strategy is inherently controversial. It is rooted in the concept that some degree of self-destructive behavior is inevitable. For example, medicalization and decriminalization of marijuana represent a set of compromises about people’s behavior and the consequences of intervention. The net effect includes increased ease of access to marijuana by young people. In every harm reduction strategy, there is a trade-off.
I want to talk about nicotine. Lots of young people try smoking, but only a fraction adopt it as a regular habit. Those individuals gain some benefit. A focus on the addictive nature of nicotine distorts our understanding of why people smoke. An important insight is gained from looking at the prevalence of smoking among people with mental illness, which is double that of the general population. Nicotine is an antidepressant, and when people stop smoking, they get depressed. People with schizophrenia and attention deficit disorder have better cognition on nicotine. My experience with smoking-cessation clinics shows that people quit smoking often, but relapse when overwhelmed by life stresses. People learn they can self-medicate with nicotine and they take the drug in order to avoid feeling bad. Here lies the harm-reduction opportunity: if people need nicotine, why do they have to smoke to obtain it?
Last year, we celebrated the 50th anniversary of the 1964 Surgeon General’s Report on Tobacco, and applauded the 50 percent reduction in the prevalence of smoking since its release. Notwithstanding this great progress, there are still more than 42 million smokers in the United States. Each year, we expect another 540,000 avoidable deaths attributed to smoking nationwide. The smoke of combusted cigarettes contains the well-recognized toxins that cause tobacco-related disease. Any reduction in the number of cigarettes smoked would translate into savings of life, health and health-care costs.
Electronic cigarettes represents an opportunity to provide nicotine to current smokers. There are now more than 600 brands of electronic cigarettes available in a market that remains largely unregulated. What these electronic nicotine delivery systems have in common is that they deliver nicotine to the lungs by heating liquid nicotine. By every comparison available, vapor produced by ENDS devices has far less harmful agents than cigarette smoke. No one is suggesting that electronic cigarettes are harmless, but it is not difficult to conclude that they are less harmful than cigarettes.
What about the harm to people who don’t smoke? The harm of cigarette smoke extends to household companions and co-workers who share the same environment. Legislation to protect individuals from other people’s smoking has been effective in transforming the culture of smoking and protecting many from exposure. If vapor is far less toxic than cigarette smoke, there may be settings in which electronic cigarettes could be considered to have minimal harm to others, such as the privacy of one’s home or in outdoor spaces.
In summary, I support the basic provisions of S.B. 140 with regard to restricting youth access to ENDS. I believe that appropriate distinctions need to be made between cigarette use and electronic cigarette use. An excessive restriction of electronic cigarette use by adults may limit their value in reducing harm from cigarette smoking.
Edward Anselm, MD
Senior Fellow, R Street Institute
Assistant Clinical Professor of Medicine, Icahn School of Medicine at Mount Sinai