R Street Testimony In Opposition to an E-Cigarette Flavor Ban in Connecticut
Sarah Wall, Government Affairs Region Manager, Northeast Region, R Street Institute
In OPPOSITION to Senate Bill 367 – “An Act Concerning Electronic Delivery Systems and Vapor Products”
March 14, 2022
Joint Public Health Committee
Chair Daugherty Abrams, Chair Steinberg and Honorable Members of the Committee,
My name is Sarah Wall and I am the government affairs manager for the Northeast region at the R Street Institute (RSI), a nonprofit public policy organization focused on advancing limited, effective government in a variety of policy areas, including integrated harm reduction. I am also a resident of Hamden.
I am writing on behalf of RSI in opposition to Senate Bill 367, which establishes a statewide ban on the sale of flavored nicotine products used in electronic nicotine delivery systems (ENDS), also known as vapes or e-cigarettes. Because these tools are effective in reducing the negative consequences associated with smoking combustible cigarettes, we are concerned about the negative implications such a ban would have on Connecticut public health, and we urge the Joint Public Health Committee to reject SB 367.
E-cigarettes are a valuable harm reduction tool
RSI’s principles of harm reduction recognize that abstinence-only approaches to public health are not effective at the population level.  The Connecticut legislature has recognized the validity of this approach in terms of other risky behaviors, such as sex education; for instance, state law requires students to receive instruction on acquired immune deficiency syndrome (AIDS).  Harm reduction principles are grounded in the concept that if individuals engage in risky behavior, it is in the state’s interest that they do so with the least subsequent harm.
This same philosophy can and should be applied to nicotine use as well. 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 (FDA) all recognize that nicotine products exist on a continuum of risk, with e-cigarettes at the lower end of the spectrum near traditional nicotine-replacement therapies, and with combustible cigarettes at the highest end.  These devices do not burn tobacco and thus do not release the more than 7,000 chemicals—some of which are carcinogenic—released by combustible cigarettes. The Royal College of Physicians also concluded e-cigarettes are unlikely to exceed 5 percent of the risk associated with combustibles. 
Accordingly, Public Health England, which is the leading public health agency in the United Kingdom, specifically endorses electronic cigarettes as a smoking cessation tool.  Indeed, e-cigarettes have become the number one quit tool in many parts of the world, acting as a highly effective nicotine replacement device for countless smokers.  Public health modeling suggests e-cigarettes are contributing to a more rapid decline in smoking than in previous years, and randomized controlled trials indicate that smokers who switched to e-cigarettes were able to sustain abstinence from combustible cigarettes at nearly twice the rate of those who used traditional nicotine replacement therapies. 
Flavored e-cigarettes can be an effective smoking cessation tool
Flavors are an important incentive for combustible cigarette users to switch to the less harmful alternative of e-cigarettes. In one study of 4,515 former and current smokers who used e-cigarettes, 91 percent had switched entirely, and 69 percent reported using two or more flavors daily.  All participants listed flavors as “very important” to their decision to switch or reduce their use of combustibles, and 40 percent reported flavor invariability would have made it less likely for them to switch.  Another study found e-cigarette users were more likely to switch completely from combustibles when they used non-tobacco flavors, including menthol and non-menthol (fruit, sweet, dessert) flavors, likely because flavors assist smokers in disassociating the taste of tobacco with the pleasurable effects of combustible cigarettes. 
While much focus has been on flavors attracting youth uptake of e-cigarettes, research shows flavors are not the primary factor driving youth to initiate use of these products. In 2019, the U.S. Centers for Disease Control and Prevention (CDC) found 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. 
RSI 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 years old. However, studies have consistently shown that e-cigarette flavor bans are not only ineffective in reducing harms associated with smoking combustible cigarettes, but they also have the opposite effect, with a recent flavor ban in San Francisco being associated with an increase in smoking.  With nearly 12 percent of the Connecticut population using combustible cigarettes, R Street asks this committee not to disregard the health of over 420,000 constituents by removing the less harmful alternative of flavored e-cigarettes. We urge the committee to oppose SB 367, which would eliminate a harm reduction tool for Connecticut smokers.
Government Affairs Region Manager
R Street Institute
 Office of the Surgeon General, “Smoking Cessation: A Report of the Surgeon General – Key Findings,” Department of Health and Human Services, Jan. 23, 2020. https://www.hhs.gov/surgeongeneral/reports-and-publications/tobacco/2020-c
 Ch. 164 “Educational Opportunities,” Sec. 10-19, part (b), Connecticut General Statute. Effective July 1, 1989. https://www.cga.ct.gov/current/pub/chap_164.htm#sec_10-19.
 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; “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;
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.
 “Nicotine without smoke,” Tobacco Advisory Group, 2016. https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0.
 Public Health England, “Using e-cigarettes to stop smoking,” National Health Service, last accessed March 7, 2022. https://www.nhs.uk/oneyou/for-your-body/quit-smoking/using-e-cigarettes-vapes-to-quit-smoking.
 “E-cigarettes,” Health & Wellbeing Directorate, 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; Shu-Hong Zhu et al., “E-cigarette use and associated changes in population smoking cessation: evidence from US current population surveys,” The BMJ 358:j3262 (July 26, 2017). https://www.bmj.com/content/358/bmj.j3262; K. Michael Cummings, et al. “What Is Accounting for the Rapid Decline in Cigarette Sales in Japan?” International Journal of Environmental Research and Public Health 17(10):3570 (May 20, 2020). https://www.mdpi.com/1660-4601/17/10/3570.
 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; 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. 629-37. https://www.nejm.org/doi/full/10.1056/nejmoa1808779.
 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. 7272-82. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3881166.
 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.
 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.
 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 Pediatrics175:8 (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.