[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
EXAMINING JUUL'S ROLE IN THE YOUTH NICOTINE EPIDEMIC: PART I
=======================================================================
HEARING
before the
SUBCOMMITTEE ON ECONOMIC AND CONSUMER POLICY
of the
COMMITTEE ON OVERSIGHT
AND REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
__________
JULY 24, 2019
__________
Serial No. 116-51
__________
Printed for the use of the Committee on Oversight and Reform
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available on: http://www.govinfo.gov
http://www.oversight.house.gov or
http://www.docs.house.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
37-935 PDF WASHINGTON : 2019
COMMITTEE ON OVERSIGHT AND REFORM
ELIJAH E. CUMMINGS, Maryland, Chairman
Carolyn B. Maloney, New York Jim Jordan, Ohio, Ranking Minority
Eleanor Holmes Norton, District of Member
Columbia Paul A. Gosar, Arizona
Wm. Lacy Clay, Missouri Virginia Foxx, North Carolina
Stephen F. Lynch, Massachusetts Thomas Massie, Kentucky
Jim Cooper, Tennessee Mark Meadows, North Carolina
Gerald E. Connolly, Virginia Jody B. Hice, Georgia
Raja Krishnamoorthi, Illinois Glenn Grothman, Wisconsin
Jamie Raskin, Maryland James Comer, Kentucky
Harley Rouda, California Michael Cloud, Texas
Katie Hill, California Bob Gibbs, Ohio
Debbie Wasserman Schultz, Florida Ralph Norman, South Carolina
John P. Sarbanes, Maryland Clay Higgins, Louisiana
Peter Welch, Vermont Chip Roy, Texas
Jackie Speier, California Carol D. Miller, West Virginia
Robin L. Kelly, Illinois Mark E. Green, Tennessee
Mark DeSaulnier, California Kelly Armstrong, North Dakota
Brenda L. Lawrence, Michigan W. Gregory Steube, Florida
Stacey E. Plaskett, Virgin Islands Frank Keller, Pennsylvania
Ro Khanna, California
Jimmy Gomez, California
Alexandria Ocasio-Cortez, New York
Ayanna Pressley, Massachusetts
Rashida Tlaib, Michigan
David Rapallo, Staff Director
Richard Trumka, Subcommittee Staff Director
William Cunningham, Chief Counsel and Senior Policy Advisor
Joshua Zucker, Assistant Clerk
Christopher Hixon, Minority Staff Director
Contact Number: 202-225-5051
------
Subcommittee on Economic and Consumer Policy
Raja Krishnamoorthi, Illinois, Chairman
Mark DeSaulnier, California, Michael Cloud, Texas, Ranking
Katie Hill, California Minority Member
Ro Khanna, California Glenn Grothman, Wisconsin
Ayanna Pressley, Massachusetts James Comer, Kentucky
Rashida Tlaib, Michigan Chip Roy, Texas
Gerald E. Connolly, Virginia Carol D. Miller, West Virginia
C O N T E N T S
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Page
Hearing held on July 24, 2019.................................... 1
Witnesses
Panel I
Ms. Meredith Berkman, Co-founder, Parents Against Vaping E-
cigarettes
Oral Statement............................................... 4
Ms. Rae O'Leary, Public Health Analyst, Missouri Breaks
Industries Research
Oral Statement............................................... 6
Dr. Jonathan Winickoff, Member, American Academy of Pediatrics
Oral Statement............................................... 8
Dr. Robert Jackler, Professor, Stanford University
Oral Statement............................................... 9
Dr. Raymond Niaura, College of Global Public Health, New York
University
Oral Statement............................................... 11
Panel II
The Honorable Richard Durbin, United States Senator from Illinois
Oral Statement............................................... 30
Written opening statements and the witnesses' written statements
are available on the U.S. House of Representatives Repository
at: https://docs.house.gov.
INDEX OF DOCUMENTS
----------
The documents entered into the record are listed below, and are
available at: https://docs.house.gov.
* Statement from Dr. Bonnie Halpern-Felsher; submitted by Rep.
Krishnamoorthi.
* Statement from Dr. Brian Primack; submitted by Rep.
Krishnamoorthi.
* Statement from Kamal Mazhar, President, Teens Against Vaping;
submitted by Rep. Krishnamoorthi.
* Letter from Dr. Frances Leslie; submitted by Rep.
Krishnamoorthi.
EXAMINING JUUL'S ROLE IN THE YOUTH NICOTINE EPIDEMIC: PART I
----------
Wednesday, July 24, 2019
House of Representatives,
Committee on Oversight and Reform,
Subcommittee on Economic and Consumer Policy,
Washington, D.C.
The subcommittee met, pursuant to notice, at 9:06 a.m., in
room 2154, Rayburn Office Building, Hon. Raja Krishnamoorthi
(chairman of the subcommittee) presiding.
Present: Representatives Krishnamoorthi, DeSaulnier,
Pressley, Tlaib, Cloud, Grothman, Comer, and Miller.
Mr. Krishnamoorthi.[Presiding.] Good morning. This
subcommittee will come to order. Without objection, the chair
is authorized to declare a recess of the subcommittee at any
time. This hearing is entitled ``Examining JUUL's Role in the
Youth and Nicotine Epidemic: Part I.'' I recognize myself for
five minutes to give an opening statement.
After years of steady decline, youth nicotine use has
suddenly reversed course, seemingly overnight. Between 2017 and
2018, youth e-cigarette use, also known as vaping, rose 78
percent in one year to the point where over 20 percent of high
school students now vape. The lingering question is why? What
was the role of JUUL, the country's dominant maker of e-
cigarettes with almost 80 percent of e-cigarette market share,
in the dramatic rise in vaping? The panel assembled today will
help us address these questions and frame our discussion for
Part II of this hearing here tomorrow at 2 p.m. when JUUL
founder, James Monsees, will testify.
Today we will examine what exactly about JUUL's advertising
and marketing make it irresistible to kids. Dr. Robert Jackler,
the preeminent tobacco advertising scholar in the country, will
help us answer that question. After today we hope to understand
how JUUL appealed to youth while simultaneously avoiding
detection by adults. We will hear about JUUL's efforts to
market directly to kids, including how JUUL entered schools
under the guise of anti-vaping presentations. Then after all
school personnel left the assembly room in a lot of these
schools, unfortunately these JUUL presenters told kids that
their vaping tools were safe.
We will hear from the parents of kids who sat through one
such presentation. Two devoted mothers were so angry that they
founded a nationwide advocacy group. I suspect that of all the
schools JUUL entered, it regrets going into that one the most
because it incited the righteous anger that only comes from
parents who feel that their kids were being exploited.
We will also hear that JUUL's targeting of vulnerable
populations was not limited to kids. Rae O'Leary will describe
JUUL's attempts to test its market on Native Americans. JUUL
tried to pay her tribe to give free JUUL starter kits to tribal
members. JUUL told the tribe that its product is healthy and
proposed pushing it through the tribe's medical professionals.
JUUL appeared to think it could get away with this on tribal
land, and it tried to ensure no one else found out about it.
The JUUL product itself contains very high nicotine levels,
three to six times the amount of the e-cigarettes that came
before it. Its formulation eliminated the harsh taste that
would have previously accompanied that much nicotine, and
further masked it with flavors--flavors--which appeal to youth.
Kids do not grasp this. Sixty-three percent of users aged 15 to
24 do not know JUUL contains nicotine. They think that it is
only has flavorings and mistakenly believe that the product is
not harmful. Dr. Winickoff will help to explain the health
impact of youth JUUL use.
Perhaps we can better under what led to parents sending
JUUL letters, like one from June of last year, stating, ``My
daughter is highly addicted to the nicotine in JUULing. It is
very sad and occurred very quickly over the past several
months. She is 16 and now has addictive behaviors that she
never had before JUULing, such as stealing money and other
teens' JUUL's. She also lies and sneaks out at night to get a
nicotine fix.'' Perhaps we can understand why a therapist wrote
to JUUL in July of last year disheartened at how many of her
teen clients came to her about JUUL addiction, talking about
how ``desperately they need to vape.'' She expressed concern
about kids using JUUL to ``self-medicate from mental health
issues, like anxiety and depression.''
We will also examine what about the JUUL device makes it so
attractive to teens. It is discreet in a way that no cigarettes
or prior e-cigarettes were. It puts off a limited cloud of
aerosol and its smell doesn't linger. It is small. And before
JUUL was a household name, parents could have looked right past
it thinking it was a thumb drive. In fact, I have had one in my
hand during this entire statement.
JUUL hasn't provided satisfactory answers for these open
questions. It is my sincere hope that our hearings today and
tomorrow will help us better understand JUUL's role in this
terrible epidemic and point us toward solutions to prevent teen
vaping addiction.
The chair now recognizes the distinguished ranking member
from Texas, Mr. Cloud, for five minutes for an opening
statement.
Mr. Cloud. Thank you, Chairman, and thank you, witnesses,
for appearing this morning. For decades now, we have known that
smoking is dangerous and linked to cancer. Cigarettes result in
approximately 480,000 preventable deaths in America each year.
These deaths are only preventable, however, if individuals are
able to stop smoking.
For years now, smoking has been on the decline, but we are
far from eradicating it. It is clear that the methods for
cessation that existed just a few years ago--quitting cold
turkey, using nicotine gum or patches--sometimes simply are not
enough. Recent studies suggest that electronic cigarettes could
be part of a broader tobacco control strategy and could be
considered viable components to cessation.
There is a growing consensus in the scientific community
that electronic cigarettes are significantly less harmful than
traditional tobacco products. In fact, a study commissioned by
the Public Health Service of England found that e-cigarettes
were 95 percent less harmful than tobacco cigarettes. And for
this reason, some smokers wanting to quit have turned to e-
cigarettes as a cessation aide. Though the FDA has yet to
determine that e-cigarettes are effective for this purpose,
other studies have found the e-cigarette use was associated
with nearly twice the rate of successful smoking cessation than
other nicotine replacement therapies.
We do need to be clear about one thing. No one wants kids
to use tobacco. No one wants kids vaping, and no one wants
vaping companies to target children with advertisements. It is
illegal for anyone under 18 to purchase and to consume these
products. The Tobacco Control Act of 2009 also applies to e-
cigarettes. Members of Congress draft and pass legislation that
legislation. That process should always begin with strict
fidelity to facts and research, and in order to obtain these
facts and hear the research, the questions I hope to have
answers to today are: what are, if any, the public health
benefits to e-cigarettes, can electronic cigarettes be part of
an overall tobacco control strategy, and, if so, how do so in a
way that ensures that kids are protected, and many more
questions that I hope we will hear answers to today.
As Dr. Scott Gottlieb, I believe, said, ``Two-thirds of
adult smokers have stated they want to quit. They know it is
hard, and they probably have tried many times to quit. We must
recognize the potential for innovation to lead to less harmful
products.'' If two-thirds of smokers in this country want to
quit, which is a great thing, Members of Congress could be
cautious in moving forward with making transitions more
difficult than it already is. Like anything else, whether it is
use, access to marijuana, or alcohol, the first line of defense
is engagement by parents, schools, and local communities to
educate children about the risk and ensure healthy lifestyles.
I hope we have a productive discussion today. Thank you
very much for being here.
Mr. Krishnamoorthi. Thank you, Mr. Cloud. Now, I would like
to turn to our witnesses. First of all, thank you all for
joining us today. We very much appreciate you taking time out
of your very busy schedules. And thank you to all of you in the
audience for coming here on an otherwise slow, fake news day.
[Laughter.]
Mr. Krishnamoorthi. Today we are joined by Ms. Meredith
Berkman, who is the co-founder of Parents Against Vaping E-
cigarettes. Also, Ms. Rae O'Leary, a member of the Turtle
Mountain Band of the Chippewa and a public health analyst and
researcher with Missouri Breaks Industries Research in South
Dakota. Dr. Jonathan Winickoff, a member of the American
Academy of Pediatrics. Dr. Robert Jackler, who is the Sewall
Professor and departmental chair at Stanford University Medical
School and a practicing surgeon. And finally, Dr. Raymond
Niaura of the Department of Social and Behavioral Sciences of
the College of Global Public Health at New York University.
Thank you all for coming. If you would all please rise and
raise your right hand, I will begin by swearing you in.
Do you swear or affirm that the testimony you are about to
give is the truth, the whole truth, and nothing but the truth,
so help you God?
[A chorus ayes.]
Mr. Krishnamoorthi. Thank you. Let the record show that the
witnesses answered in the affirmative. Thank you and please be
seated.
Without objection, your written statements will be made
part of the record. With that, Ms. Berkman, you are now
recognized for five minutes. And let me just quickly explain
the lighting system here. So you have five minutes, and there
is a countdown on the clock. Green means you are in good shape.
Unlike with stoplights, yellow means speed up and red mean
stop. So with that, please begin, Ms. Berkman.
STATEMENT OF MEREDITH BERKMAN, CO-FOUNDER, PARENTS AGAINST
VAPING E-CIGARETTES
Ms. Berkman. Not stressful at all. Thank you very much.
Good morning, Chairman Krishnamoorthi and Congressman Cloud--
thank you for your words--and distinguished members of the
House Oversight Committee on Economics and Consumer Policy. I
am Meredith Berkman, and I represent Parents Against Vaping E-
cigarettes--we call it PAVe--a grassroots group founded over a
year ago by three concerned moms. We already have groups of
activated parents across the country from California to New
York and places in between. We have people with us here today
from Texas, from Georgia, from Virginia, New York, New Jersey,
et cetera.
My co-founders, Dina Alessi and Dorian Fuhrman, are behind
me with members of our families. Between us we have nine kids
between the ages of seven to 19. Along with our friend, Mimi
Boblich, also here, we created PAVe in response to the JUULing
epidemic that, as you said, seemed to come out of nowhere, yet
experts consider one of the most serious adolescent public
health crises our country has faced for decades.
Our goal today is to give voice to the 3.6 million teens
who are vaping, most of them JUULing. This most recent figure
from the CDC is already outdated. As you said, between 2017 and
2018, there was a 78 percent rise in the use of these products
by high school students and a 48 percent rise in use by middle
school students. Experts believe that the new figures due this
fall will likely be much higher because nothing has happened to
have them go down.
We hear from desperate parents every day who contact us
seeking resources, information, and help for their JUUL-
dependent, nicotine-addicted kids, but there is not yet any
FDA-approved treatment for this kind of teen nicotine
addiction. I will share very briefly just one or two stories
because they are heartbreaking, and they come from every state
represented here on the panel and probably every state of
people in this room.
From Massachusetts, our PAVe advocate, Kristin Beauparlant,
speaking about her son, Cade, a hockey player, described how he
developed a cough and complained he was not able to breathe
while skating. He became distant, moody, irritable, and had
extreme bouts of anger, a very common thing that people report.
``Our home environment was toxic, and it turns that Cade has
restrictive lung disease. He needs inhalers and oral steroids.
He had smoking a pod a day, the equivalent of more than a pack
of cigarettes a day, for years, for three years.''
Kelly Kinard from North Carolina is with her son, Luca,
whose addiction was so severe, he spent 39 days as an inpatient
at rehab in California. Kelly said, ``We began living with a
stranger. Our straight A student's grades dropped to F. It was
the extreme anger. It turned out our 14-year-old had a
substance abuse problem, and that substance was JUUL.''
Now I want to share a personal story, the story of how JUUL
went after our kids and their friends by coming into their
school. Without the knowledge of the school or of us concerned
parents, JUUL sent a representative to talk to our kids about
its product under the guide of education. On April 3, 2017, my
then 15-year-old son, Caleb, who is here, told us there had
been an anti-addiction talk at school for the 9th grade. The
teachers left the room, and the man named Ali gave a confusing
talk about JUUL, telling them it was not for kids, but for
adults. It was much safer than cigarettes. The FDA would
approve it any day.
When Ali was done, Caleb and his friend, Phillip, Dorian's
son, went up to talk to him. Ali repeated that JUUL was for
adults, not kids, then he took out this sleek-looking JUUL,
showed the boys how it worked, and called it the iPhone of
vapes. That's when we moms decided to fight back. We had
discovered a few months before that our kids were JUULing at
home right under our noses, which is also very common. It
doesn't mean you're a bad parent if your kids are JUULing. It
is stealth by design.
We knew that nicotine was harmful to our kids' brains, and
as we researched and put pieces together, we learned that
JUUL's deceptive behavior seemed to be part of its marketing
strategy. In California, a retired school superintendent was
offering schools in his state and in Massachusetts money if
they would implement the anti-JUUL curriculum that a man named
Bruce Harder was offering on JUUL's behalf. We came across the
Stanford Medical School's Tobacco Prevention Tool Kit with an
odd disclaimer, that we immediately realized was reference to
JUUL taking information it shouldn't have.
None of this is surprising. As I said, JUUL is stealth by
design. JUUL says it no longer restocks retail orders of the
flavors that research has proven are hooking the kids. Yet just
the other day in a 1-block radius in two different stores, I
was able to buy these mango pods that JUUL says are no longer
on the market, but they are still online.
And that is the problem. If JUUL really wants to slow the
youth vaping epidemic and keep younger kids from starting, they
will immediately remove all flavors from the market, including
menthol and mint, one of the most popular kid flavors, and they
will stop spending millions of dollars on lobbyists to oppose
sensible legislation that PAVe's parents and our many coalition
partners are fighting for all over this country to restrict
youth access to JUUL and other products.
We hope today's hearing motivates Members of Congress on
both sides--we all care about kids--to hold JUUL accountable
not only for the epidemic, but for its predatory practices and
for causing harm to so many kids in this country. It is not a
political issue, but a moral one. If we don't take action now,
we face an entire generation of kids addicted to nicotine, who
are human guinea pigs for the JUUL experiment overall. Thank
you.
Mr. Krishnamoorthi. Thank you. Thank you, Ms. Berkman. Now
Ms. O'Leary, you are on the clock.
STATEMENT OF RAE O'LEARY
Ms. O'Leary. Good morning, committee members, and thank you
for the opportunity to explain JUUL's marketing to minority
populations is relevant to this hearing. My name is Rae
O'Leary, and I'm serving as a fact witness representing the
Cheyenne River Sioux Tribe, which I will refer to CRST.
I am the founder of the Canli Tobacco Coalition, which is a
grassroots anti-tobacco coalition on the reservation. The Canli
Coalition opposes the use of all commercial tobacco products
because of the tobacco industry's historical targeting of
American Indians which has contributed to the health
disparities and death on the Cheyenne River Reservation.
In January and February 2019, three representatives from
JUUL used the historic tactic of the tobacco industry by
handing out free product to tribal decisionmakers and offering
a switching program to the CRST Health Committee. JUUL proposed
that healthcare professionals from the CRST Health Department
refer smokers that are 21 years or older to their switching
program. Using their referral, American Indian patients would
enroll in JUUL's online portal by entering personal data and
health behaviors.
JUUL proposed to sell starter kits valued at $50 to the
tribe for $5 apiece. The tribe would then turn around and
provide free JUUL starter kits to patients who enroll in the
switching program. Throughout JUUL's presentation, they made
multiple claims that their product is effective for smoking
cessation and less harmful than tobacco products. These claims
as well as JUUL's actions to hand out free product are all
clear violations of the Family Smoking Prevention and Tobacco
Control Act.
JUUL indicated that their investment in the tribe switching
program was worth over $600,000 to the tribe. Initially, some
tribal council members were convinced that JUUL's switching
program could help members of the Cheyenne River Sioux Tribe
quit smoking, improving their quality of life for smokers, and
eventually resulting in fewer healthcare costs to the tribe.
Despite initial interest in JUUL's switching program, the CRST
Health Committee members wisely requested written documentation
of JUUL's switching program proposal.
JUUL did not provide written documentation detailing the
program as requested. Instead, they sent a mutual nondisclosure
agreement to the tribe's attorney general with untrue
information that the nondisclosure agreement had already been
discuss by the CRST Health Committee. The nondisclosure
agreement was not signed. As a result, JUUL has not returned to
the Cheyenne River Sioux Tribe.
Earlier this month, the CRST Health Committee unanimously
approved a resolution that declares ``CRST shall neither
solicit nor accept any tobacco, electronic smoking device, or
nicotine-related funding or sponsorship.'' This resolution is
currently being considered by the CRST Tribal Council as well
as several other sovereign tribal nations and the National
Indian Health Board.
The Canli Coalition emphatically opposes the offer JUUL
made to the CRST Health Committee for many reasons, including
grave safety concerns regarding exploding e-cigarette batteries
and nicotine poisoning of children, and unknown, but probable,
long-term health risks, such as cardiovascular disease and
cancer. Even though the switching program is intended for adult
smokers, the Canli Coalition has great concern that our
American Indian youth will begin using JUUL due to increased
access and a highly concealed and flavorable product. This
concern is supported by the data that American Indian middle
school students in South Dakota are using e-cigarettes three
times more than their white counterparts.
Another concern is that JUUL has not been proven to be safe
or effective for smoking cessation. In fact, there is a growing
body of evidence that e-cigarette users smoke more and quit
less. It is true that some smokers have successfully quit
smoking using e-cigarettes like JUUL, but it has also been
found that for every 1 adult smoker who quits using an e-
cigarette, 81 adolescents will initiate e-cigarette use.
Clearly JUUL and other e-cigarettes are being used for more
than an alternative to smokers.
The CRST may have looked like an easy target for JUUL
because of the FDA's inability to enforce tobacco regulations
or publish reports of our 51 percent adult smoking prevalence,
coupled with our genetic propensity to addiction, or maybe they
were drawn to the CRST because of our young population base or
a recent status as the poorest county in the Nation. JUUL did
not provide an acceptable justification for their choice to
offer the switching program to sovereign tribal nations. I
would challenge the members of the subcommittee to uncover why
JUUL is interested in partnering with tribes and exactly how
this partnership will improve lives of CRST members as JUUL
claims it will.
As an American Indian woman educated in public health and
knowledgeable about the tobacco disparities that exist among
indigenous populations, I am putting my words on the record
that the scenario of the tobacco industry targeting American
Indians and exploiting tribal sovereignty has played out for
far too long. I put a great deal of thought into my decision to
testify at this hearing today. In the end, it was the Lakota
Seventh Generation Belief that helped me reach my decision to
testify. What happened on CRST and other tribes is simply too
important not to be shared. It is time to take action to
prevent JUUL and all tobacco companies from preying on at-risk
populations.
As you consider possible actions and policy following this
hearing, I challenge you to learn from the Lakota people's
Seventh Generation Belief that in every decision, leaders must
consider how it will affect our descendants seven generations
into the future. Thank you.
Mr. Krishnamoorthi. Thank you, Ms. O'Leary. Dr. Winickoff,
you have five minutes.
STATEMENT OF JONATHAN WINICKOFF, M.D., M.P.H., M.D., M.P.H.,
MEMBER, AMERICAN ACADEMY OF PEDIATRICS
Dr. Winickoff. Good morning, Chairman Krishnamoorthi,
Ranking Member Cloud, members of the subcommittee. My name is
Dr. Jonathan Winickoff. I'm a practicing pediatrician at
Massachusetts General Hospital, and I have over 20 years of
experience caring for children and adolescents. I'm here today
representing the American Academy of Pediatrics, a professional
medical organization representing over 67,000 pediatricians
across the United s.
JUUL use among adolescents has reached epidemic
proportions, and I see the impact of this every day in my own
practice. Every one of my teenage patients, and even many of my
pre-teen patients, either uses e-cigarettes or has friends who
use them. Many of my patients have wildly incorrect beliefs
about e-cigarettes. They know that cigarettes are dangerous,
but believe that JUUL is harmless.
I have to explain that e-cigarettes do not have the same
positive health benefits as the fruit flavors that they copy.
Rather e-cigarette liquid contains, in addition to nicotine, a
number of toxins and carcinogens. E-cigarettes are also not
good for growing lungs. They're particularly bad for children
with asthma. They can cause serious lung conditions, including
hypersensitivity pneumonitis.
The FDA has publicly warned now about increasing reports of
seizures in children who use e-cigarettes. My patients are
often not aware of JUUL's massive nicotine content and that one
JUUL pod contains as much nicotine as 20 cigarettes. They also
don't understand that nicotine dependence impacts areas of the
brain that control executive function, memory, and mood.
Nicotine addiction can take hold in only a few days, especially
in the developing adolescent brain that is particularly
vulnerable to addiction.
E-cigarette addiction concerns us because use of e-
cigarettes can lead to combustible tobacco use. Compared to
adolescents who do not use e-cigarettes, those who use e-
cigarettes are 3.5 times more likely to begin smoking
traditional cigarettes. Many of my patients use JUUL daily and
find it impossible to stop. Nicotine withdrawal can cause
headaches, insomnia, irritability, anxiety, and depression, yet
doctors lack effective tools to help adolescents stop using
JUUL. The only surefire way to eliminate e-cigarette use in
adolescents is to stop it before it starts. Luckily, we already
know what needs to be done. We need to make e-cigarettes less
appealing to children, we need to make them harder for children
to access, and we need to make them regulated appropriately by
the FDA.
First and foremost, we must discuss JUUL's flavors. JUUL
pods come in a number of sweet flavors, including mint, mango,
and creme. Youth surveys show that e-cigarette flavors are one
of the primary reasons teens try e-cigarettes, yet flavors also
help mask the harsh taste of nicotine, making repeated use more
likely an increasing addiction. JUUL has chosen to keep mint
and menthol flavored pods available for sale everywhere. It is
completely false to suggest that mint is not attractive to
children. From candy canes to toothpaste, children are
introduced to mint from a young age. In tobacco products,
menthol's anesthetic properties cool the throat and make it
easier for children to inhale the poison.
When JUUL removed some of its other flavors from stores, I
saw the majority of my JUUL-using patients switch to mint.
Nevertheless, children are still gaining access to other
flavored JUUL pods, even though they are now sold online. If
the products are available for sale somewhere, children will
get their hands on them. We must eliminate child-friendly
flavors from all tobacco products. We urge Congress to pass
legislation immediately to prohibit flavors, including mint and
menthol, from tobacco products.
Mr. Chairman, members of the subcommittee, JUUL is a
fatally flawed product. A recent study showed that 15-to 17-
year-olds are 16 times more likely to report JUUL use than 25-
to 34-year-olds, even though JUUL claims its product are only
intended for adults. When so much of the product ends up in the
hands of children, it is time we declare it a failed product.
The American Academy of Pediatrics believe that JUUL is a
public health threat that must be removed from the market as
soon as possible. JUUL and products like it are eroding the
progress we've made in reducing teen tobacco use. Teenagers
today are using e-cigarettes when many of them would otherwise
never have used a tobacco product. JUUL must be held to account
for the epidemic it has created, and Congress and the
Administration take action to end it. Thank you.
Mr. Krishnamoorthi. Thank you, Dr. Winickoff. Dr. Jackler,
you have five minutes.
STATEMENT OF ROBERT JACKLER, M.D., PROFESSOR, STANFORD
UNIVERSITY
Dr. Jackler. Chairman Krishnamoorthi and Ranking Member
Cloud, thank you for the opportunity to testify before your
subcommittee today.
Almost all smoking begins during adolescence. It is part of
teen rebellion, typically commencing between the ages of 12 and
19. It would indeed be a very rare 40-year-old who woke up and
said, hey, I think I'll start smoking today. Once a teen
becomes hooked on nicotine, it is exceedingly difficult to
quit. Many are stuck with a lifelong addiction. From the
beginning, JUUL professed a noble mission of improving the
lives of a billion smokers. Instead they have spurred an
epidemic of nicotine addiction amongst youth. So how did JUUL
stray so far from its stated mission?
As a majority of smokers in America are ages 30 to 60, JUUL
should have designed their advertising to connect to a middle-
age audience. Over the first year--could we have the slides,
please, Garrett? Okay. Over the first year after JUUL launched
in June 2015, it held at least a series of 50 highly stylized
parties with youth-oriented entertainment in cities across
America. Thousands of young people were given free JUULs, often
by attractive young girls. JUUL's initial campaign called,
Vaporized, was designed by an advertising agency whose goal was
to create a cult-like following, and they succeeded beyond
their wildest dreams. Vaporized featured models in their 20's
in trendy-appearing poses and exhibiting behaviors more typical
of underage teens than mature adults. The tobacco advertisers
have long known that these imageries are exactly how to target
underage kids.
Just last week in a televised documentary on CNBC, JUUL co-
founder, Adam Bowen, claimed that the 2015 Vaporized campaign
only lasted less than six months, it was lifestyle oriented,
and ``had no impact upon sales.'' Lifestyle oriented? It was
obviously, if we could see the images, it is obviously youth
oriented in that way.
Now, contradicting Mr. Bowen, JUUL's co-founder, James
Monsees, a mere seven months after JUUL launched, bragged,
``Now we're actually the fastest-growing e-cigarette company in
the world.'' So today they say their early advertising, which
was patently youth oriented, made no difference. But, in fact,
at the time, they were bragging they were the most rapid
growing in the world. This is either revisionist history or
intentional deception. I'll let you be the judge.
From its inception, JUUL mostly advertised on social media,
especially Instagram, which skews heavily toward youth. JUUL
paid influencers, who are social media stars with a large
number of online followers, to praise JUUL. JUUL multiplied its
reach by the use of hashtags, which became online gathering
places for teenagers. Under intense regulatory pressure, JUUL
halted its own social media postings in November 2018. However,
this was a hollow gesture. It didn't matter much, and the
reason was that viral peer-to-peer promotion amongst teens
assured a massive visibility of their products on an ongoing
basis.
For example, after JUUL quit its own postings last
November, community posts and #JUUL by kids surged, tripled.
Now there are 540,000 posts and millions of views of that
youthful material. JUUL leadership claims, ``We were completely
surprised by the youth usage of the product.'' Co-founder James
Monsees brags, ``We are the most educated company, the most
diligent, the most well-researched.'' They are indeed a data-
driven company. They know their market, to whom their products
are distributed, and the identity of their customers. The New
York Times interviewed a former JUUL manager who disclosed that
JUUL knew that their products were becoming popular amongst
underage users within the first months on the market.
So JUUL professes to be a technology which disrupts big
tobacco. Like many tech startups, as the money starts rolling
in, JUUL made many compromises to their grand vision. What
should have become an offramp for adult smokers instead has
become a heavily traveled onramp to nicotine addiction amongst
teens, many of whom graduate to traditional combustible
cigarettes. From a policy point of view, the best way to
eliminate adult smoking is to keep teens from starting in the
first place. So JUUL's recent partnership with Altria combines
the leading youth initiation cigarette, Marlboro, with a
leading youth initiation e-cigarette, JUUL. Their agreement
specifies joint JUUL/Marlboro marketing is of great concern. So
JUUL has been unmasked for its hypocrisy.
Rather than obsoleting big tobacco, JUUL is very much part
of it. It is as though they lit the kindling, stood by making
no effort to contain the resulting fire, even stoked it, and
when the fire department came, expressed shock and dismay about
the resulting major conflagration, while loudly protesting that
their actions had absolutely nothing to do with it. Thank you.
Mr. Krishnamoorthi. Thank you, Dr. Jackler. Dr. Niaura, you
are on the clock.
STATEMENT OF RAYMOND NIAURA, PH.D., PROFESSOR, COLLEGE OF
GLOBAL PUBLIC HEALTH, NEW YORK UNIVERSITY
Mr. Niaura. Thank you. Mr. Chairman and members of the
committee. Thank you for holding this important hearing on a
topic of great concern to the Nation's public health. I'm
privileged to appear before you this morning to testify about
the challenges we face regarding youth use of e-cigarettes and
other tobacco products.
My name is Dr. Ray Niaura. I'm a clinical psychologist,
professor of social and behavioral sciences and epidemiology at
the College of Global Public Health at New York University, and
I have spent my entire professional career engaged in research
on understanding and treating tobacco dependence and finding
and testing ways to help smokers quit smoking.
As a public health and tobacco use scientist, I, too, share
concerns about youth tobacco use, including vaping. For the
record, I believe no youth should be using any tobacco or
nicotine-containing product or any drug for that matter. We
should do all we can to discourage youth use by providing
appropriate education and counseling, and by making it
difficult to purchase such products. I also believe that
companies that manufacture and sell vaping products should do
all they can to make sure that products are marketed only to
adult smokers. I take some comfort in the fact that marketing
strategies and health claims will eventually be subject to the
U.S. Food and Drug Administration review and approval.
During the fall of 2018, the FDA and the U.S. Centers for
Disease Control and Prevention expressed acute concern about
youth vaping when they looked at data from national surveys,
and this prompted Dr. Scott Gottlieb, who was the FDA
commissioner at the time, to declare that youth vaping is an
epidemic. This concern was reinforced by data coming from the
National Youth Tobacco Survey in 2018.
When the data were eventually released to the public, we
looked at it ourselves, and we indeed confirmed that past 30-
day vaping had increased from the prior year. And while an
increase in uses are of concern, our analysis showed that most
adolescent vaping was occasional, and that most regular use was
concentrated in adolescents who had already been smokers. I
think this is an important point. Yes, we need to be concerned
about vaping, but we also need to be concerned about use of
other tobacco products. We also looked at youth who had never
used tobacco products, and thankfully vaping rates were quite
low. Again, this is not to minimize the importance of concern
about youth vaping.
Cigarette smoking remains a major concern here in the
United s of America, and I would like to also emphasize another
point, which is that e-cigarettes have the potential to help
adult smokers stop smoking, and we've seen evidence
accumulating showing that adult smokers who use e-cigarettes
can quit smoking. Regular cigarette studies have come out, for
example, in the New England Journal of Medicine, indicating the
same. Just last week, a survey reported that smokers who
switched to e-cigarettes and used them every day were
significantly more likely to quit smoking compared to those who
did not use e-cigarettes.
These results are important because we know that despite
their effectiveness, smokers don't often use quitting methods,
such as nicotine replacement therapy or other medications. So
as they stand now, e-cigarettes are a consumer product that is
proving to be very popular with smokers, and helping them to
actually quit smoking cigarettes. Quitting smoking is the
number one health priority for cigarette smokers, and we need
to use all the tools available to help reduce this burden,
which prematurely claims the lives of over half a million
Americans every year. So currently about 38 million adults in
the U.S. smoke cigarettes, and clearly this is and ought to be
a huge public health priority.
I would like to close by saying I think that this set of
issues, both youth tobacco and nicotine use and adult smoking
have been portrayed as at odds with one another, and they
really should not be. We in the public health community and
Congress ought to find ways where we can do both. I think we're
smart enough to figure out how, but I don't think we have all
the answers yet. Thank you very much.
Mr. Krishnamoorthi. Thank you, Dr. Niaura. I now recognize
myself for five minutes of questioning.
First of all, Mrs. Berkman and Mrs. Fuhrman, after you
discovered that a presenter representing JUUL gave a closed
assembly at your children's school, you researched the issue
and formed an advocacy group to inform parents around the
country about the dangers of adolescent e-cigarette use. Thank
you for your continued advocacy. As a parent of three young
children myself, including a teenager, I was shocked to hear
JUUL had access to children without the presence of teachers or
administrators, and without parental permission. JUUL continues
to partner with youth organizations across the country, so it
is important to understand what outreach looks like on their
part.
Mrs. Berkman and Mrs. Fuhrman, I would like to ask a couple
questions of your sons, if that is okay.
Ms. Berkman. Yes.
Mr. Krishnamoorthi. Phillip and Caleb, can you please come
to the table for a couple minutes? I would like to first
address Caleb. Caleb, what grades were you and Phillip in the
year of the JUUL presentation?
Mr. Berkman. Ninth grade.
Mr. Krishnamoorthi. Can you just speak directly into the
microphone?
Mr. Berkman. Ninth grade.
Mr. Krishnamoorthi. Thank you. What were students told
about the presentation before it began?
Mr. Berkman. We were told that we were having a mental
health/addiction seminar that we have three times a year, and
the teachers are told the room so it is a safe space for kids
to talk.
Mr. Krishnamoorthi. Did most of your classmates believe
JUUL was safe prior to the presentation?
Mr. Berkman. I think many kids were already JUULing and had
their doubts to if it was safe, but I think a lot of kids still
thought it was possibly dangerous.
Mr. Krishnamoorthi. Did the presenter ever mention his
connection to JUUL, and were your teachers in the room when he
spoke?
Mr. Berkman. He did mention his connection to JUUL, and my
teachers were not in the room when he spoke.
Mr. Krishnamoorthi. Did the presenter ever say that JUUL
was safe?
Mr. Berkman. Yes.
Mr. Krishnamoorthi. Did the presenter call JUUL ``totally
safe'' more than once?
Mr. Berkman. Yes.
Mr. Krishnamoorthi. What impact did those ``totally safe''
comments have on your classmates, some of whom may have already
started vaping?
Mr. Berkman. For my classmates who were already vaping, it
was a sigh of relief because now they were able to vape without
any concern.
Mr. Krishnamoorthi. Were there kids who had never been
JUULing that were more likely to try after hearing it was
``totally safe?''
Mr. Berkman. I can't say for sure, but I believe that after
this meeting, kids were more inclined to vape because now they
thought it was just a flavor device that didn't have any
harmful substances in it.
Mr. Krishnamoorthi. You and Phillip approached the
presenter when the assembly concluded. What motivated you to
even approach him in the first place?
Mr. Berkman. I believed the presenter was sending mixed
messages by saying JUUL is totally safe and following up every
``totally safe'' statement with ``but we don't want you as
customers.'' I saw a mixed message being sent, and I believed
that the presenter was playing on the rebellious side of teens
where when teens are told not to do something, they are more
likely to do it.
Mr. Krishnamoorthi. Phillip, let me ask you a couple of
questions. What was your experience speaking to the presenter?
Mr. Fuhrman. So we went up and talked to him, and Caleb
asked a question about what can you do if your friend is
addicted to nicotine.
Mr. Krishnamoorthi. Phillip, were you addicted to JUUL at
the time of this presentation.
Mr. Fuhrman. I was.
Mr. Krishnamoorthi. And when Caleb asked the presenter what
he should do if he had a friend that was addicted to nicotine,
was Caleb referring to you?
Mr. Fuhrman. He was.
Mr. Krishnamoorthi. How did the presenter answer Caleb's
question of how he could help his nicotine-addicted friend,
namely you?
Mr. Fuhrman. Since Caleb was not specific on what kind of
nicotine he was addicted to, whether it was an e-cigarette or
cigarettes, the speaker thought that he was talking about
cigarettes. And he said that he should mention JUUL to his
friend because that is a safer alternative than smoking
cigarettes, and it would be better for the kid to use.
Mr. Krishnamoorthi. So let me get this straight. He wanted
you to switch from a combustible cigarette to JUUL.
Mr. Fuhrman. Yes.
Mr. Krishnamoorthi. Did the presenter demonstrate the
product to you?
Mr. Fuhrman. He didn't use it, but he did take it out and
show it to us.
Mr. Krishnamoorthi. Okay. This is very disturbing behavior
to say the least. A person connected to JUUL pulled out a JUUL
device to demonstrate its safety to teenagers, and then lied
about the product being ``totally safe.'' Did he say anything
else about whether the government had approved JUUL?
Mr. Fuhrman. He mentioned that the FDA was about to come
out and say that JUUL was 99 percent safer than cigarettes, and
he said that that would happen very soon, and that it was in
FDA approval while the talk was going on.
Mr. Krishnamoorthi. Thank you, Caleb and Phillip. Let me
ask Dorian, Phillip's mother, to say a couple words here.
Dorian, thank you for coming today.
Ms. Fuhrman. Hi. Thank you.
Mr. Krishnamoorthi. Your son, Phillip, just stated he was
addicted to JUUL.
Ms. Fuhrman. Yes.
Mr. Krishnamoorthi. How did his addiction impact your
family?
Ms. Fuhrman. It was difficult, and at first we didn't
understand what was going on. As a young 14-year-old, he was
interested in so many different things from surfing to cooking
to his little sister. And I started to find these flash drives
and these green plastic caps in his pockets, and I didn't
really know what it was at first. So he kept saying, you know,
they belonged to a friend, and we would have fights about it.
I figured out what it was because I Googled the name on the
side, and it was difficult. He changed kind of overnight. He
started spending a lot of time in his room in the dark. He
became moody. We had a very contentious relationship. I became
very suspicious obviously. I think he didn't really understand
what was going on himself, and neither did we.
Mr. Krishnamoorthi. Thank you, Dorian.
Ms. Fuhrman. Thank you.
Mr. Krishnamoorthi. Let me now recognize Ranking Member
Cloud for five minutes of questioning.
Mr. Cloud. Thank you, Chairman. Ms. Berkman, I am curious
at the reaction. I assume you approached the school board, the
principal? Was the reaction?
Ms. Berkman. The school had no idea that the outside group
had brought a JUUL representative into the school. The school
had no idea.
Mr. Cloud. So the school had hired a group that had----
Ms. Berkman. Yes, and we believe that the outside group was
naive definitely, but in good faith, because when I called to
ask about this presentation, the staffer who answered the phone
said, oh, you found the right person. I was researching anti-
JUUL education online, and I came across the name of a woman
named Julie Henderson, who was listed then, no longer, on the
JUUL website as its youth prevention coordinator. Then she
called, and this woman, Ms. Henderson, said I have the perfect
person and sent Ali.
Mr. Cloud. Okay. Thank you. Dr. Niaura. Did I pronounce
that right?
Mr. Niaura. Yes.
Mr. Cloud. Okay. Could you explain the difference from a
health perspective, I guess, between a traditional cigarette
and an e-cigarette? Is there one?
Mr. Niaura. Yes, there are many differences. You know,
traditional cigarettes consist of a preparation of tobacco
leaves, which when burned create, you know, smoke and contains
roughly 7,000 different chemicals, most of which are not good
for the human body. E-cigarettes contain far fewer ingredients
in addition to nicotine, usually something like propylene
glycol glycerol which are, you know, commonly found
ingredients, for example, in food stuffs, and some flavorings.
This, in general, just the difference in terms of the
number of compounds in e-cigarettes make the e-cigarettes in
general safer, although they probably can vary from product to
product. A lot of the safety of e-cigarettes depends on
temperature controls, so, for examples, if products have
adequate temperature control, they tend to be, you know, less
toxic.
Mr. Cloud. Okay. I guess we have known cigarettes for a
while cause cancer, and talking about prevention, I remember in
3d grade seeing lungs sitting in a jar of somebody who had
passed away from cigarette use. But I guess what I am trying to
do get down to is what are the health effects of the
combustible side of it and what is the health effects of the
nicotine side?
Mr. Niaura. Well, yes, and that is actually an important,
you know, point to raise. So if we look at nicotine in and of
itself, it is not risk free, but it is probably a lot less
toxic compared to the other chemicals that come out of
cigarette smoke. So, for example, nicotine probably does not
cause cancer. It may have some small effects on existing
cardiovascular disease and so forth. You know, the brain might
have to adapt to, you know, having a drug on board. These are
neural adaptations which are true for any drug. But the
nicotine itself is not the culprit when it comes to things
like, you know, cancers, at least as far as we know.
Mr. Cloud. We seem to have a kind of a competing set of
facts here. We have data that shows that teen e-cigarette use
has gone up a lot, and then Dr. Niaura, you mentioned that a
lot of that is, I guess, transitional or is it not? Is it new
use? I guess, Dr. Jackler and Dr. Niaura, if you can kind of
clarify that a little bit for us to have a better understanding
of what is new use, what is transitional use.
Mr. Niaura. Yes, that is an important question that I don't
think we have a good handle on yet because a lot of the surveys
that we look at are what are called cross-sectional, meaning it
is a dipstick or a slice in time. You know, we see kids that
report to us, oh, they are using one or two days or, you know,
every day and so forth. What we need are studies that track
kids over time to actually see whether the ones who are
starting out, you know, one or two days go on to use more.
But, you know, once again, we don't know what the real
implications are of these different patterns of use, and, you
know, I would want to emphasize and share the concern that, you
know, kids shouldn't be trying these products, and they
shouldn't be using them. Certainly shouldn't be using them on a
frequent basis.
Dr. Jackler. The CDC data show a huge use, over 2 million
American high school students and many hundreds of thousands of
middle school students. A fraction of them, of course,
experiment and others become regular users. I just want to
touch as a physician on the healthfulness of vaping. You know,
if you start smoking today, it is 20, 30, 40 years before you
get emphysema or lung cancer. Nobody knows what it does to the
human lung to breathe in and out aerosolized propylene glycol
and glycerin over and over. It is an experiment frankly. We
will find out years from now the results.
The flavoring industry knows that the compounds that we put
into our food that are safe in your intestinal tract, when you
breathe them in, so, for example, the classic example is
buttered popcorn, microwave butter popcorn. The diacetyl
compounds in the industrial setting cause severe restrictive
lung disease on the part of the industrial workers. The e-
cigarette industry has taken flavored chemicals, thousands of
different ones--cotton candy and cookie flavors--mixed them
with propylene glycol, and then they are exposed over and over
into the lungs. We just don't know yet the long-term results.
There is no doubt in my mind that vaping is safer than
conventional smoking, but that doesn't mean that it is safe.
Mr. Cloud. Thank you.
Mr. Krishnamoorthi. Thank you, Mr. Cloud. I now recognize
Congresswoman Tlaib for five minutes of questioning.
Congresswoman?
Ms. Tlaib. Thank you so much, Mr. Chairman. I want to thank
all of the witnesses for being here. And, Ms. Berkman, as a
mother, I can sense your frustration. I just want you to know
being here just a short seven months and kind of hearing, you
know, some people call it rhetoric to kind of discredit a lot
of the things that we are pushing forward. I just want you to
know you have the truth on your side. And just be stronger for
that because we don't need more studies. We already know the
truth here.
In the few years after JUUL was founded in 2015, it
dominated the market through a targeted advertising campaign
that seems to be a winning strategy as JUUL now accounts for 76
percent of the U.S. e-cigarette market, which is simply
staggering. What I find troubling is that in the same
timeframe, the rate of teen nicotine addictions skyrocketed.
The CDC found a 75 percent increase in e-cigarette use among
high school students from 2017 to 2018. So it is no coincidence
to me that teens who use e-cigarettes almost exclusively refer
to the activity as JUULing.
So, Professor Jackler, you have studied JUUL's marketing
practices since the company started in 2015. Based on your
expertise, should JUUL have been aware its marketing campaign
would appeal to youth and teens?
Dr. Jackler. Absolutely. You know, huge teenage fads don't
happen by accident, you know. The Beatles and beanie babies
were products of very clever promotional activities, and so is
JUUL. Now, JUUL engaged ad agencies, which are professionals,
and ad agencies understand very well the difference between
marketing to baby boomers, like newspapers, radio, broadcast
TV, and Gen Z-ers, who will sit all day long on their phones
looking at social media.
Now ad agencies follow the instructions of their clients.
They don't work independently. Certainly the company knew very
well when it chose to use Instagram who the heaviest users of
Instagram were. It is the underage youth by and large, and the
``Insider Report'' from the New York Times validates it. So I
think there is any question that JUUL knew that its actions
were perpetuating the youth epidemic that happened within JUUL.
Ms. Tlaib. You are a professor at Stanford, the same
university that the founders of JUUL attended as students. Have
you ever met James Monsees or Adam Bowen?
Dr. Jackler. Yes, James Monsees. And my research team, we
went up JUUL last summer in August. You know, he was quite
interesting. He thanked us for the data base that we have of
50,000 traditional tobacco ads online. He said they were
helpful as they designed JUUL's advertising, and this struck us
so much that as the seven of us left the two-hour meeting was
the very first thing we talked about, how surprising it was
that he indicated the JUUL was grounded in traditional
advertising.
In fact, we know very well, having studied tobacco
advertising, that JUUL's marketing faithfully recapitulates the
methods used by the tobacco industry to target young people.
That includes brands such as Marlboro, which they closely
emulated, American Spirit, Newport. There are direct
derivatives' advertising in those.
Ms. Tlaib. Thank you. So JUUL's mission statement asserts
that it aims to ``improve the lives of the world's 1 billion
adult smokers.'' Do JUUL's marketing practices, which you have
studied for years, align with that stated mission?
Dr. Jackler. Well, not for its first three-and-a-half
years. On the fourth year, at that point when already the youth
fad was raging, their ads became more calibrated to an adult
audience, and the channels that they used it as well. They have
now switched campaigns depicting middle-age and older adults.
It is in printed newspaper and on television, and no longer
they are promoting on social media.
Now, this only happened long after there was a youth
epidemic, and it was because of the unwanted and intense
attention by regulators. Also interestingly, as Mr. Monsees
pointed out when we visited with him, they were concerned about
their investors, particularly national companies, like
Fidelity, who was an investor, who certainly didn't want to be
associated with products that were widely seen----
Ms. Tlaib. No, it always leads to profits. So last
November, JUUL deleted its Instagram and Facebook, as you
accounted to, but the explosion of their marketing had already
had an impact on youth. How do we continue to see initial
marketing campaigns' influence on kids on social media today?
Dr. Jackler. Yes. So JUUL taking off its own marketing
didn't stop all of the JUUL-branded hashtags, and there are
dozens of them. #JUUL alone in the first three years and five
months, June 2015 to November 2018, there are about a quarter
of a million posts, mostly by young people on #JUUL. Since last
November to now, it doubled to over half a million.
Ms. Tlaib. And, Professor, yes, I really do appreciate
that. But, Chairman, it is important to note what astounded me
the most is they deleted Facebook and Instagram, but JUUL's
Twitter followers, half of them are under the age of 18.
Dr. Jackler. Yes, and if I might say, just because you
delete them, doesn't mean it never happened.
Ms. Tlaib. No. Thank you so much.
Mr. Krishnamoorthi. Thank you, Congresswoman. Next, Mr.
Comer, you are recognized for five minutes.
Mr. Comer. Thank you, Mr. Chairman. The topic of the
committee hearing today is youth's use of electronic
cigarettes, and it has been mentioned today the potential
possible correlation with tobacco and cigarettes. Dr. Niaura,
you conducted a lot of research and published several studies
on this very topic. How reliable of a predictor of future use
of tobacco products is current use of vaping for youth?
Mr. Niaura. Well, there is a statistical association
between, you know, use of e-cigarettes and subsequent cigarette
smoking. But what we looked at, and we looked at this in the
Population Assessment of Tobacco and Health Study, which is
funded and sponsored by the FDA and the NIH. So we did find
that, but then we also found that if kids had, in fact, started
with a cigarette, they were 20 times more likely to continue
smoking a cigarette.
So the message that we take from this is that, you know,
use of all or any nicotine or tobacco containing products for
kids probably will increase the risk for subsequent cigarette
smoking. The worst thing to start with would be with a
combustible product like a cigarette.
Mr. Comer. Has the rate of decline in smoking among adults
and youth decreased or increased since 2010 when e-cigarettes
started to rise in popularity?
Mr. Niaura. Well, we have seen steady declines in, you
know, cigarette smoking, both in youth and adult populations,
which we should, you know, take as good news.
Mr. Comer. Absolutely.
Mr. Niaura. We certainly have more work to do.
Mr. Comer. Right.
Mr. Niaura. Yes, there is, you know, sort of a diverging of
the trends with e-cigarettes picking up and use of cigarettes
going down. That is the area of active research - to see
whether those two things are actually connected with one
another.
Mr. Comer. Mm-hmm. If e-cigarettes were a gateway to
smoking, wouldn't evidence show a substantial increase in
smoking among youth and young adults by now?
Mr. Niaura. Well, again, we have seen, you know, a decrease
in use of other tobacco products, cigarettes, in particular, in
youth. So right now at least it doesn't appear that e-
cigarettes are translating into subsequent use of cigarettes,
at least as far as we can tell right now.
Mr. Comer. Does evidence show that teens are diverting to
e-cigarettes instead of taking up smoking?
Mr. Niaura. Well, that is an important question that I
think we need more research to address. Kids are trying a lot
of different products, you know, including vaping. We need to
understand more about who are the high-risk kids who, you know,
might try a lot of products, who may inadvertently become, you
know, more addicted to nicotine. We really need more and better
understanding of those factors so that I think we can do a
better job at, you know, doing some kind of intervention.
Mr. Comer. Mm-hmm. Well, I just want to make a point here
that I am certainly opposed to youth vaping. I am opposed to
youth smoking. I am not a smoker, never have been, but I am a
farmer, and I do represent probably the biggest tobacco-growing
district in America. Without a doubt this is something that has
been a big economic boom to Kentucky. Having said that, we
recognize the risks and the danger and the bad effects of
cigarette use and tobacco use.
The industry, I think, has tried to do things to curb
underage smoking. I know that Senator McConnell has a bill that
I support to raise the minimum age to purchase cigarettes, and
I think that that is something that needed to be mentioned
today, that, you know, tobacco is still legal. I know this is
about e-cigarettes, but I have to conclude with this because it
is a big industry in my district. You know, in Kentucky, you
are not able to grow fruits and vegetables because of the
climate, so you are limited as to what types of crops you can
grow.
It is still a legal industry, and as long as it is still a
legal industry, I would rather the tobacco be grown in Kentucky
by middle class farmers, small farmers, which is who grow
tobacco, than importing tobacco from other countries. But
having said that, I certainly want to work with my colleagues
on both sides of the aisle to make sure that youth use of e-
cigarettes goes down, and certainly as I have always been a
proponent of doing everything we can to prevent underage
smoking. With that, Mr. Chairman, I yield back.
Mr. Krishnamoorthi. Thank you, Mr. Comer. Congresswoman
Pressley, you have five minutes.
Ms. Pressley. Thank you, Thank you, Mr. Chairman, and
thanks to all of our witnesses for sharing your expertise and
sounding the alarm on this. In addition to the experts and
those that are at the dais here, I did want to just acknowledge
and recognize representatives of the African-American Tobacco
Control Leadership Council who are also in the room with us
today, and we thank you for your good work.
The growing youth vaping epidemic has taken the
Commonwealth, which I represent, by storm. Across the state, it
is estimated that nearly one in five high schoolers and one in
20 middle school age kids are using these products. Student
advocates report school bathrooms have turned into JUUL lounges
that smell fruity and minty. I have spent the last 10 years of
my life as an elected official advocating for a school nurse in
every school, and we have learned from our school nurses that
80 percent of high school students are vaping. That is from
their youth risk behavior surveys.
Leaders at the local and state level in Massachusetts, from
our city council to our attorney general, who was the one to
initiate at the first investigation into JUUL's problematic
marketing and sales practices, and our Boston City Council is
looking to push for a hearing on banning flavored vaping
products. But we have to act on the Federal level.
So I would be remiss not to highlight how similar many of
JUUL's tactics seem to be right out of the big tobacco
playbook. For decades, big tobacco targeted black communities
to the point where almost 90 percent of all black smokers use
menthols. Nearly 45 percent of black menthol smokers state they
would quit smoking if menthols were all together banned. So it
is extremely disturbing. We have been here before. We don't
need a bunch of studies. The only studies we need are the
millions of casualties that are behind us and that we run the
risk of seeing ahead of us. So this is very disturbing.
The flavor crisis is even worse for children, 66 percent of
whom the National Institute on Drug Abuse found believed e-
cigarettes only contained flavors, as we learned from the youth
who spoke today, and we thank you for telling your story. It
seems obvious that the elimination of flavors would help
eliminate this confusion.
So, Dr. Winickoff, why are menthol-flavored tobacco
products particularly exploitive in the context of e-
cigarettes?
Dr. Winickoff. Well, thanks for the question. The tobacco
industry has a long history of targeting mint-and menthol-
flavored tobacco products to African-Americans, and
specifically African-American children. A recent study in the
American Journal of Preventive Medicine, however, showed that
the majority of Americans believe that mint and menthol should
be banned as a flavor in tobacco products.
Now interestingly, and contrary to what the tobacco
industry and the tobacco product industry claims, if you just
look at the opinions of blacks and African-Americans, an even
greater majority believed it should be banned. So I think no
one is fooling anybody here.
Ms. Pressley. Agreed. And aside from potentially preying
upon the black community, JUUL's marketing playbook, as we
learned from Ms. O'Leary, has targeted children in native
populations. Ms. Berkman, you were so disturbed by JUUL's
practices that you created an organization to spread awareness
of JUUL's dangers to families across the country. You know that
expression, ``Hell hath no fury like a woman?''
Ms. Berkman. Yes.
Ms. Pressley. They need to make up one about moms, okay,
because that is next level. And so, you know, we thank you for
your fierceness and your advocacy.
Ms. Berkman. Thank you.
Ms. Pressley. What have parents told you about how JUUL's
marketing influenced their children's use of the product?
Ms. Berkman. Well, I wish we had those slides because I
hope everyone will get to see them. When you see the sexy young
influencers that were giving this product away, when you see
how similar the old tobacco ads, they are almost identical, so
JUUL knew what it was doing. What we tell parents is, you know,
you are not a bad parent because unfortunately, as you said,
the old ``everyone is doing it.''
The scary thing is in this case, it is true. It is stealth
by design. As you said, we are very upset. These are kids who
would otherwise not have been initiated into tobacco use. We
are talking about kids, known harm to kids versus potential
benefit for adults. I hope there is a potential benefit for
adults in general, but known harm to kids who can't make those
decisions for themselves because they are being deceived
through the use of social media. That is a problem.
Ms. Pressley. Thank you. I want to pick up on the deception
and how that affects adults. Ms. O'Leary, did JUUL make any
claims to Cheyenne River Sioux Tribe about its product helping
people quit smoking? Did they claim that these products were
healthy?
Ms. O'Leary. Yes, you can see in slide 21 from my
attachment that it states, ``Have smokers that can't quit? JUUL
has created a program where you can help them switch with
minimal cost to you.'' So using words like ``quit,''
``switch,'' cessation is implied, and that was the impression
of the tribal council members who were on the other end of this
presentation. I think that the other claim that was made was
the harm reduction. In slide 6 of their presentation, they
state ``Elimination of combustible cigarettes is crucial to
reduce the risk of harm,'' and on slide 12, ``Vaping is a
fraction of the risk of smoking, at least 95 percent less
harmful.'' But I want to point out that in that study that
found that that this was done with not JUUL, but other e-
cigarettes, that had much less nicotine content.
Ms. Pressley. I can't tell the clock. Do I still have time
here? Am I at time or do I still have time?
Mr. Krishnamoorthi. You are out of time.
Ms. Pressley. Okay. All right. Thank you, Mr. Chairman.
Hopefully I will a second----
Mr. Krishnamoorthi. Thank you, Congresswoman. Congresswoman
Miller, you have five minutes.
Mrs. Miller. Okay. Thank you, Mr. Chairman, and thank you
all for being here today. My home state of West Virginia ranks
among the top states in the Nation for the highest percentage
of adult smokers, about 26 percent of our population. Thirty-
eight million people in the United States smoke. I agree that
we need to ensure that we keep nicotine products like e-
cigarettes out of the hands of youth, but we must also ensure
that we do not overregulate this industry to the point that
they are no longer available for those people of legal age who
would like to use them either recreationally or as a means to
quit smoking.
When I was a child, one of my chores was to empty the trash
every day. Both of my parents were smokers. That was really
icky. I will tell you, if anything would keep you from smoking,
it would be emptying ashtrays every single day. And I believe
it was in 1963 when the surgeon general came out and said that
cigarette smoking caused cancer, and both my parents quit. My
father just plain old quit cold turkey. My mother smoked three
quarters of a cigarette, then half of a cigarette, then a
quarter of a cigarette. She did it very slowly. But that
ashtray thing is what really kept me from ever wanting to
smoke, and coming into a house that smelled like smoke. It was
really nasty.
Dr. Niaura, in you research, do you find that most used to
vapor also utilize other nicotine or tobacco products as well?
Mr. Niaura. Yes. As I indicated in my testimony, close to
three-quarters of kids, at least based on the most recent
survey data that we have, have also, you know, tried or are
using, you know, other tobacco products.
Mrs. Miller. Is the use of e-cigarettes by youth correlated
to them smoking cigarettes later in life?
Mr. Niaura. Well, that is that is the million-dollar
question that we are all concerned about and trying to figure
out. At least, as I mentioned, you know, there is some
statistical correlation. I don't know if we can say that one
causes the other. That is a pretty high bar to prove
scientifically. But, you know, nonetheless, you know, I
maintain my position, and I am in amendment with everyone, you
know, kids should just not be using any tobacco or nicotine-
containing products.
Mrs. Miller. I know when I went to college, the girls all
had little cigarette cases and little things that they always
carried, and oftentimes I felt like is it more of a crutch
because you wanted to do something with your hands, or was it
because it really was addicting. Often younger people, you
know, they want to carry keys or they just want to have
something to do with their hands, and that is more of an
observation than a question.
In your testimony, you talk about protecting youth from
accessing nicotine products and giving smokers a useful tool to
quit smoking, and it shouldn't be a tradeoff, and that we can
do both of these things at the same time. Could you elaborate
on suggestions on how you think we could accomplish both of
these goals?
Mr. Niaura. Well, I wish I had all the answers, but I am I
am hoping, you know, that the FDA with, you know, the power of
the Tobacco Control Act, can work hard, and I know they are
working hard, to figure out how to achieve, you know, both
goals, which is to minimize, if not eliminate, youth use and
maximize the ability of adult smokers to access, you know, safe
and effective products. I think we are still in the early
stages of figuring out, you know, which e-cigarette type
products are going to prove to be the most useful. But, you
know, that is what the FDA is there for, you know, to review
applications and use their scientific powers to determine which
products are, in fact, fit for approval.
Mrs. Miller. In regard to adult smokers, how can the health
risks associated with cigarettes be mitigated by the use of e-
cigarettes?
Mr. Niaura. Well, the major thing is if cigarette smokers
can switch completely to an e-cigarette product, we know that
that, in fact, will result in pretty quick changes in
biological markers of harm that are normally associated with
smoking cigarettes. So in other words, we have signals that
their bodies are actually kind of getting better and improving.
But Dr. Jackler is right in saying that we need more
information about long-term effects of use of these products,
and so that is an area of active research. But at least in the
short term, it looks like, you know, if people switch to these
products, they actually are in some ways improving their
health.
Mrs. Miller. You mean like coughing?
Mr. Niaura. More like, you know, biological markers that
are associated with higher risk of cancer, so blood levels of
certain chemicals, things like that.
Mrs. Miller. Okay. Thank you, Mr. Chairman.
Mr. Krishnamoorthi. Thank you, Congresswoman. Now Mr.
DeSaulnier for five minutes.
Mr. DeSaulnier. Thank you, Mr. Chairman. Thank you for
having this hearing. I must admit the longer you have these
political jobs, the more depressing you get sometimes when you
see human beings doing things to other human beings. I am old
enough to remember introducing a second-hand smoke ordinance as
a restaurant owner in Concord, California 30 years ago. I am
also old enough to remember doing an ordinance at the county.
It was a public health ordinance. And our hearings then showed
very clearly the tobacco industry was marketing directly
through retailers all across the country, where they put their
placement of advertising. So how close it was to other products
that kids would be drawn to. Literally research that they had
done showing the height when kids came in.
I also remember being a restaurant owner - having owned
multiple liquor licenses - that when we went through Mothers
Against Drunk Driving where colleagues of mine in the
restaurant business said, "well, if we try to assume more
liability, then we will go out of business, we should protect
small business," and thinking and talking to colleagues at the
California Restaurant Association saying, "well, why would we
want to be in business if that is what..." and, of course, we
passed laws that have helped with that.
So here we are again, and, Ms. Berkman, I have had some
fairly regular group of young people that is growing in my
district in the San Francisco Bay Area come into my office, and
they are trying to do similar things that we did with tobacco
settlement money, getting young people to help advocate. But
they are also telling me stories pretty compelling that on
their campuses, this is pervasive, and there is a reinforcement
from the marketing, from peer to peer that it is not dangerous,
that people have taken care of all that. You have had the same
experience I take it.
Ms. Berkman. Yes, and actually we have a PAVe group,
Parents Against Vaping group, in San Francisco where we are
working all the time. But, yes, peer-to-peer, even now when
there has been so much talk about the harmful content of these
sweet JUUL pods, the known toxins, the nicotine, kids still
don't get it, right? They think it is water vapor. I mean we
heard those numbers earlier. And you said, we have been here
before and we should not be here again.
We don't want our kids to be guinea pigs for this
experiment, especially when we saw what happened the first time
around when big tobacco 1.0 targeted our kids. JUUL is big
tobacco 2.0, and we can't wait. This is a race against time. If
we don't act soon and take the flavors off the market, because
the flavors continue to hook the kids, then the generation of
nicotine addicts and worse.
In West Virginia, for example, I know that the member just
left the room, but there is research that has given conclusive
evidence of cardiovascular damage caused by e-cigarettes. So
there is known damage, not only to developing brains, but
cardiovascularly. And I keep hearing over and over we don't
know yet, we are waiting. These are kids. There is known harm
now. Why wait and, God forbid, see what happened the time
around. We don't have that time, so thank you.
Mr. DeSaulnier. Dr. Winickoff and Dr. Jackler, so
secondhand smoke. It t strikes me, and this is where we were
effective with tobacco, and particularly, say, in Northern
California where it started in California, as a public health
issue to employees. Having been in the restaurant business in
the 70's--I am dating myself--you couldn't wear your clothing a
second day because of the stench of tobacco, someone who has
never been a smoker. Why should it take long for us to look at
the measurement and the content of what is in these products
and measure it against what we already know about secondhand
smoke?
Dr. Winickoff. Pediatricians worry a lot about this, and in
the family context, we have some smokers which have gotten the
message and smoke outside, but for parents, they will be vaping
right next to their child. Those ultra-fine particles are
getting into their children's lungs. And, in fact, when they
vape indoors, the entire surface of that home becomes coated in
an ultra-fine particulate of nicotine and other chemicals. Now,
kids interact with their environment in a very intense way.
They exhibit mouthing behavior. They breathe from close down to
the floor, and they may only way a 10th as much as adults, so
they end up eating house dust and getting in a level of toxic
aerosol that is probably 20 times higher than what a nonsmoking
adult in that household would get. And that is concerning for
us.
Mr. DeSaulnier. Doctor, do you have anything to add just
quickly?
Dr. Jackler. Well, just the place of use regulations around
smoking and vaping need to parallel. Otherwise, what happens is
that smokers will use them in the workplace, in recreational
places, in automobiles with their kids and things, and that is
not a good thing. So those local policies are very important to
parallel.
Mr. DeSaulnier. Ms. O'Leary, can you talk a little bit
about how the industry has targeted Native Americans and the
tribal community?
Ms. O'Leary. I think there has been historical tactics by
the tobacco industry to target many groups that are at risk,
including American Indians, as well as others that have been
stated already. But I think the main thing is, you know,
getting product to the reservation. I think that tobacco
industry feels a little bit invisible on the reservation. We
have, you know, no compliance checks that happen on the
reservation by FDA because it is a sovereign nation. So there
is great concern about what JUUL coming to the reservation and
trying to hide behind nondisclosure agreements could result in.
I have heard that there are multiple other tribes that have
been approached by JUUL, but I have really struggled to find
anybody that is willing to speak with me about it, and it is
likely because that there has been NDAs signed by these tribes.
So I think that it is ruthless the attempts that are going on
to embed these at-risk populations. Thank you for your
question.
Mr. DeSaulnier. Thank you so much, and thank you to all the
panelists. I yield back, Mr. Chairman.
Mr. Krishnamoorthi. Thank you, Congressman. Congressman
Grothman, you have five minutes.
Mr. Grothman. Okay. I don't know a lot of people use e-
cigarettes. You sure don't seem around like you used to see
cigarettes around when I was a child. Good grief, when I was in
high school, they had a smokers lounge in the high school. But
at least one person I know well who vape credits this with, you
know, stopping smoking cigarettes. And I wonder do you feel in
this an effective way? If that is true, we are saving lots of
lives aren't we? Could you respond to the idea that this is an
effective way to stop smoking?
Dr. Jackler. There is certainly potential that electronic
cigarettes, particularly those that are high nicotine, that
when the user breathes them in has a similar spike in nicotine
that the----
Mr. Grothman. Well, people know about by now. Does it work
or not work? Is this an effective way to stop smoking?
Dr. Jackler. We actually don't know scientifically very
well. There are certainly anecdotes, as in your friend. Some
adults will dual use smoke and vaping and keep their nicotine
levels high even in places they can't smoke. So it can be a
deterrent to adults. Certainly it is probably better than
patches and gums, but still marginal.
Dr. Winickoff. And I would just add that we have not seen
strong evidence that flavored e-cigarettes are necessary for
adults to stop smoking. I think if a manufacturer develops a
flavored e-cigarette that generates data and proves that it
would help adults quit smoking and not attract children, then
the manufacturer is able under the law to ask FDA to approve it
as a cessation device or authorize it as a new tobacco product.
But for now, the evidence is strongly in favor of taking
flavored products off the market.
Dr. Winickoff. Doctor, you wanted to speak.
Mr. Niaura. Yes, so I just take issue with the notion that
there is not strong evidence. We do have, you know, the results
of a randomized controlled trial, which is the gold standard
for scientific evidence, published in probably the most
prestigious medical journal in the world, the New England
Journal of Medicine, earlier this year, demonstrating that, you
know, smokers who managed to switch to e-cigarettes quit at
twice the rate compared to those who use nicotine replacement
therapy. So the evidence base is building so, you know, I don't
think we can any longer say that we don't have evidence that
these products that can help smokers quit.
Mr. Grothman. Well, you know, America, at least we are told
is supposed to be a free country. Why do you think, what is the
reason for these other people then to not want to allow people
to use e-cigarettes if there is some strong evidence out there
that it is a way to stop smoking? What is their motivation? Do
you know?
Mr. Niaura. Well, I don't know. I think a lot of this has
to do with, you know, these are these are relatively new
products. There are a lot of unknowns, and I understand the
tendency to want to rely on, you know, proven methods such as,
you know, medications and nicotine replacement therapy. But
this is now a consumer product that has kind of taken things by
storm, and again we are seeing signals that are positive.
So from my point of view, if this is a type of product that
actually is consumer friendly and is more apt to be used by
smokers compared to some of these other products, then we ought
to look for ways to leverage that opportunity to help smokers
switch.
Mr. Grothman. Okay. I have one general thing. You know,
they give us all this data, and I am not sure whether this is
right or not. I guess in 2018, the FDA claimed that 20 percent
of high school students vaped in the last 30 days, but I know
how, you know, the world works. If your buddy has got a vape,
maybe you vape. It also says here that only six percent use it
more than 20 days per month, and only four percent described
themselves as daily users. So, you know, it seems like one of
those things that kids have when they pass it around, but
really we are under four percent. Does anybody think those
numbers are wrong?
Dr. Winickoff. That is exactly how tobacco use starts.
Tobacco products begin as an intermittent use, and they
graduate to daily use. So there is nothing surprising about
that data. In fact, the standard, the gold standard for
assessing adolescent current tobacco use is past 30-day use. So
there is nothing unusual about that data.
Ms. Berkman. Congressman, if I may?
Mr. Grothman. Yes.
Ms. Berkman. I am a mother of four children, of four teens,
and I can tell you that this is rampant. You can ask. I mean,
we are trolled and harassed and threatened all the time by the
pro-vaping community. We are not prohibitionists. We want the
flavors that are hooking the kids off the market.
Mr. Grothman. I am going to run out of time, so I am just
going to ask you. So you are saying that when I have this FDA
data that less than four percent of the kids vape every day,
you think that FDA data is wrong.
Ms. Berkman. I am telling you that kids under report. They
don't admit it. Then some of those early studies, unless you
ask someone if they are JUULing. If you ask them if they are
vaping, they will say no because kids do not associate vaping
and JUULing. It is, like, Kleenex or band aids. And there have
been articles written about this and studies written about
this. I know because my son and I have commented on those
stories. Kids think they are JUULing. They don't think they are
vaping. They don't think they are using e-cigarettes. They just
know that they are JUULing. That is the truth.
Mr. Grothman. Thank you.
Mr. Berkman. I also ask you, would you say that nicotine
addiction is something that goes away after a couple of days or
it just a fad?
Mr. Grothman. Well, I don't know, so I don't have an
opinion.
Mr. Krishnamoorthi. Well, thank you. We have two final
lines of questioning, three minutes each. This is going to be a
little bit of a lightning round here. Congresswoman Tlaib, you
have three minutes.
Ms. Tlaib. But it was getting so good, Mr. Chairman.
[Laughter.]
Ms. Tlaib. Mr. O'Leary, thank you so much for being here,
and I want to give you majority of the time because I read on
February 1, JUUL came before your health committee of your
tribe, and they were proposing the product and so forth. But,
you know, one of things I would love for you to talk about is,
you know, the statement that they said is that the letter said
from JUUL, the tribe said it was to promote JUUL as a healthy
way for patients for patients to quit smoking. JUUL wanted the
tribe's health department to provide the JUUL starter kits for
free of charge to tribal members trying to quit smoking as part
of our smoking cessation program. And so if you can talk a
little bit about that, and, you know, who was in the room. I
know some people had to sign some sort of right to be able to
come forward and disclose.
And, Mr. Chairman, as Ms. O'Leary starts, I think for the
record, you know, JUUL, from a number of folks up here, has
misled the American people, has lied, has used our broken
system to honestly target and then manipulate and say that it
is not going to cause certain things. We can continue to say we
are going to study, study. But I can tell you when I go into
kids because I say well, you know, they always ask me what I do
for a living. I tell them, you know, I make laws and things,
and they are still looking at me. I say, you know, when I was a
kid when I went to a restaurant, they would say, "okay, how
many people in your party?" The second question they would ask
is, "do you want a smoking or a nonsmoking section?", and all
the kids look at me. These second and third graders, they are
like, "what are you talking about?" I said, yes, they used to
smoke in restaurants. "No way!" Oh, they used to smoke on
airplanes. Uh-uh. In hospitals. "Eww."
You know, and it is like [to] these kids that is crazy, but
they used to gaslight us to believe that secondhand smoking
wasn't killing us. And I am not going to get here and allow the
committee to be used by anybody, even from the other side, to
say that e-cigarettes, vaping, JUUL is not killing our people.
They are. It is leading to health harms, leading to addictions
that are going to hurt people.
So with that, I am so sorry, Ms. O'Leary, you can have the
rest of my time. I really do want to put it in the record what
they did in your tribe.
Ms. O'Leary. I share your passion. Thank you for your
comments. So what happened is when they came, it was in front
of initially the tribal council, and that is when they handed
out free product to our decision-makers. Free product. And we
have council members now who are regular users of JUUL when it
was initiated at that meeting. They were then re-routed back to
the correct process, which is through the committee level of
the tribal governments system. So they went to the health
committee, and at that meeting, that is when they made those
claims of less harm and smoking cessation. I will reiterate
that that is not allowed. They cannot claim smoking cessation
or at less harm at this point.
I also want to say that, you know, there has been a lot of
questions about that it might be effective for smokers, but
there is also data that suggests that for every one person who
is able to quit using JUUL, 81 kids will start. So the rate at
which the smokers are finding this product helpful, it is
incredible the amount of uptake that we are seeing in our
youth. And I think that the tobacco industry in general, as
well as JUUL specifically, targeting at-risk populations, like
American Indians and African-American, and youth, it is, again,
I say ruthless. There is no end in sight for these companies
unless there is some regulations that take place by Congress.
Ms. Tlaib. Mr. Chairman, I hate calling it regulations
because they have hijacked that word. It is called
accountability. Thank you.
Mr. Krishnamoorthi. Thank you, Congresswoman. And our final
three-minute line of questioning, Mr. Cloud.
Mr. Cloud. Well, with that buildup, I just had three
questions. We will try to get through in three minutes. I
wanted to clear up the data. I guess teen vaping use is up. We
talked about that. Overall, teen cigarette use is down.
Dr. Winickoff. No.
Mr. Cloud. No?
Dr. Winickoff. In the latest year, actually for the first
year----
Mr. Cloud. My question was overall tobacco use.
Dr. Winickoff. Yes, teen use is increasing actually in the
last year according to national data from the CDC.
Mr. Cloud. There are different sets of data. Does everybody
agree with that?
Mr. Niaura. There may be a flat line, but it is not
increasing.
Dr. Winickoff. The data show that it is increasing, but we
can show you the data. We will submit it.
[The information referred to follows:]
Mr. Cloud. Overall tobacco use. Overall tobacco use? I
would be interested to see the study, Mr. Niaura.
Mr. Niaura. It is in my written testimony.
Mr. Cloud. Right, okay. Yes, I looked at that. Why the
increase? Why the decline, I guess, if you can----
Dr. Winickoff. Well, I think that what we would have seen
had JUUL not been around, had e-cigarettes not been around, I
think we would have seen a very steep decrease in adolescent
tobacco use. Unfortunately, what we have seen is a flat line,
as Dr. Niaura mentions, a slight uptick in the past year. This
is a problem because when I ask kids do you like----
Mr. Cloud. I only have a little bit of time. I have to move
on.
Dr. Winickoff. Yes, go ahead.
Mr. Cloud. I think we covered most of what you are saying.
Mr. Niaura. Well, if you look at the----
Mr. Cloud. I understand there is a decline. Why is there a
decline?
Mr. Niaura. Yes, if you look at the patterns over the past,
you know, four or five years, again, we are record lows for
youth smoking, which, you know, is hard to reconcile with the
fact that, you know, teen vaping is up. Those are just the
facts.
Mr. Cloud. And when you say ``youth smoking,'' that
includes vaping?
Mr. Niaura. Cigarette smoking. No, no, just cigarettes.
Mr. Cloud. Yes, that was my question.
Mr. Niaura. Cigarette smoking.
Mr. Cloud. Okay.
Dr. Winickoff. Total product use is up dramatically in the
last few years.
Mr. Cloud. Okay. That is----
Mr. Niaura. But that includes vaping.
Mr. Cloud. Okay. That was the question I was trying to get
to. Thank you. Both Jackler and Niaura, you touched for a
second on patches and others. Could you touch about 20 seconds
on e-cigarettes compared to those other alternatives, patches,
what have you?
Mr. Niaura. Right. So, you know, nicotine patches are a
form of nicotine replacement therapy, proven to be effective to
help smokers quit. Again, this one study appears to show that
e-cigarettes are even better than nicotine patches. But my
interpretation of that is that e-cigarettes are actually a form
of nicotine replacement therapy. They are just more efficient.
They are better at doing it compared to products like patches.
Mr. Cloud. Okay. And of course we are all talking outside
the context of teens when we are talking----
Mr. Niaura. Yes. No, this is for adults.
Mr. Cloud. Right. How can policymakers ensure that non-
combustible nicotine products, like electronic cigarettes, are
available for smokers wanting to make a transition while
limiting the access of unintended users like youth? What are
your recommendations?
Mr. Niaura. I don't have any concrete recommendations
because I think this is a very tough issue. We are seeing a lot
of suggestions coming out from folks in terms of different
types of, you know, restrictions in terms of where products can
be sold, maybe restricting flavors and so forth. I think these
are important conversations that we ought to continue to have
to figure out the best road forward.
Mr. Krishnamoorthi. Thank you. I will let Dr. Jackler
finish.
Dr. Jackler. So high nicotine products like JUUL, and it
has exceptionally potent nicotine, from my point of view,
should be available by doctor's prescription for adult smokers.
I care very much about adult smokers and would have like to
have products that help them quit, and I think it is a superior
product compared with patches and gums. But they should not be
on the market to be bought over the counter in sweet and fruity
flavors by kids.
Mr. Krishnamoorthi. Thank you very much, Doctor, and you to
the first panel for their testimony. With regard to the
panelists, if you could please come back to the anteroom. We
are going to switch out, and we are going to have our final
panelist, Senator Dick Durbin, and we will hear from him. So we
will take a two-minute break just to switch out the panelists.
And please, audience, please stay seated for Senator Durbin.
Well, welcome, Senator Dick Durbin, to the Committee on
Oversight and Reform, Subcommittee on Economic and Consumer
Policy. My favorite senior senator from my home state of
Illinois.
[Laughter.]
Mr. Krishnamoorthi. Senator Dick Durbin needs no
introduction on the issue of his valiant advocacy efforts to
combat smoking among youth, and also to combat smoking in
general. He is the author of the Ban on Smoking on Flights in
America, which came into being in 1990, 29 years ago, when he
was a member of this House. At that time, powerful interests in
the tobacco industry fought his efforts to put this law into
place, but now we know the tremendous positive impact of that
law. And we have Senator Durbin to thank.
But he has also been an outstanding advocate on the issue
of fighting e-cigarettes for youth, and so we welcome him to
our committee. Without objection, sir, your written statement
will be made part of the record. And with that, Senator Durbin,
you are now recognized for your statement.
STATEMENT OF HON. RICHARD DURBIN, A UNITED STATES SENATOR FROM
THE STATE OF ILLINOIS
Thank you, Chairman Krishnamoorthi and Ranking Member
Cloud, for holding this important hearing. It is good to be
back in the people's House of Representatives and also to be at
a hearing flanked by the Campaign for Tobacco Free Kids. It
seems like old times. But I know today you are taking a close
look at the role of JUUL and the FDA and how we have reached
this point where we are facing literally, in the words of the
FDA, a vaping epidemic.
You know the numbers. In the last year alone, 80 percent
increase of high school students vaping, 50 percent increase in
middle school students using e-cigarettes. Today because of
devices like JUUL and the accompanying kid-friendly flavors, 4
million children nationwide are vaping. JUUL and other e-
cigarette companies like to claim that their products are only
meant for adults looking to quit cigarettes, but a look at the
facts quickly dispels that notion.
Here's the starting point. There is no clinical trial
proving that JUUL devices help adults quit smoking cigarettes.
None. Despite all the marketing claims and all the paid
testimonials, there is no credible medical evidence of JUUL's
most fundamental marketing claim. None. Further, more than 20
percent of children under the age of 18 are using e-cigarettes
compared with less than three percent of adults. JUUL knows
exactly where the money can be found, and it's not from adults
looking to quit smoking. It's kids.
Today's youth vaping epidemic is a new version of an old
battle that I'm personally familiar with. I won't go into the
details, but on Friday, November 13, 1959, one week before my
15th birthday, I stood at my father's hospital bedside as he
died from lung cancer - two packs of Camels a day. He was 53
years old. When I came to Congress, I decided to make tobacco
my issue. We had some success, as you noted.
In 1987, in my third term in the House, second term on the
Appropriations Committee, I successfully passed an
appropriations amendment banning smoking on 80 percent of
airline flights in the United States. It was a major miracle.
No one expected this young Congressman from Illinois, with the
opposition of both Republican and Democratic leadership, to
pass this measure on the floor. What they failed to understand
is the House of Representatives is the largest frequent flyer
club in America, and they sick and tired of secondhand smoke on
airplanes and voted with me. The bill was signed into law by
President Ronald Reagan despite big tobacco fighting all the
way. They called my ban ``an intrusion on individual rights.''
You may hear echoes of that in this room today.
It was just the first step. I didn't realize that
eliminating this inconvenience was a tipping point, but it was.
It turned out that a lot of people thought, well, if secondhand
smoke is dangerous on a plane, why isn't it dangerous in a
movie theater, in a restaurant, in a bowling alley? We also
went directly after big tobacco's efforts to addict children,
which is why we made cigarettes more expensive with taxes. That
is the single greatest deterrent to children turning to
cigarettes.
We dumped Joe Camel and the Marlboro Man as part of a
national lawsuit. We prohibited kid-friendly flavors in
cigarettes like strawberry and grape. And since these historic
changes, the percentage of youth smokers declined from 28
percent--28 percent--in the year 2000 to less than eight
percent today. However, anyone who believes that the
multibillion dollar tobacco industry would go quietly ignored
the power of their greed, and that is why we are here today.
Losing their precious market share, big tobacco put their
researchers and marketers to work. First, they needed a new
product that didn't carry the moral taint of cancer-causing
tobacco. Even better, if it looked like a USB flash drive, it
could easily slip into a kid's laptop. They needed a campaign
that included an unproven, positive health claim such as JUUL's
current Make the Switch slogan. They relied on a multibillion
dollar, $12.8 billion, investment from an old standby, Altria,
formerly known as Phillip Morris. They needed a special
strategy focused on kids because they knew that children, for a
variety of reasons, are the most susceptible new users of
products. It worked with cigarettes. It was going to work again
with JUUL and vaping.
How did they lure the kids? I have got a bag full here, of
all of the different flavors. I won't go through them all, but
they include Fruit Medley, Gummy Bear, Whip Cream, Unicorn
Poop, Razzle Berry, and Cotton Candy. Now, go tell me that is
all about adults switching from cigarettes to vaping.
Finally, and this is critical, they needed the Food and
Drug Administration to look the other way as their massive
empire mushroomed and metastasized. Unfortunately, the FDA has
been happy to serve as that accomplice, delaying commonsense
regulation of the e-cigarettes industry by years, refusing to
remove illegal products from the market, and standing silent in
the face of these false health claims by JUUL. I have made it
clear to the acting FDA commissioner, Dr. Sharpless, and
Commissioner Gottlieb before him, that FDA's hapless
spectatorship has to come to an end, whether by law,
regulation, court order, or discovering the political will to
get off the sidelines.
So what's been the result of big tobacco and big vape's
efforts combined with the FDA's as abject failure to regulate
the industry despite their authority? Between 2017 and 2018,
the number of American teenagers using any tobacco product
increased by nearly 40 percent. This was the largest single-
year increase in youth tobacco use ever. That's right, all of
our significant, hard-earned gains to reduce youth use of
tobacco products are being reversed because of e-cigarettes
like JUUL and the accompanying kid-friendly flavors. And all of
the full-page JUUL ads decrying children, you know where you
see them? You see them in The Hill, Roll Call, Politico,
Washington Post, New York Times, Wall Street Journal. This
isn't a new tactic. That's exactly what big tobacco did when we
said lay off the kids. They bought full-page ads in the Wall
Street Journal saying we don't want kids to smoke cigarettes.
How many kids do you think get up in the morning to read the
Wall Street Journal? Exactly none. This is just a PR campaign
now by JUUL, once by big tobacco, to try to say that they have
a business model that really isn't directed at kids. The facts
tell us otherwise.
To combat today's vaping epidemic, I've introduced
bipartisan and bicameral legislation to crack down on kid-
friendly e-cigarette flavors. I'm joined by Senator Lisa
Murkowski, Republican of Alaska, and Representatives DeGette
and Raskin. Our Safe Kids Act would give each e-cigarette
companies one year to prove their products meet three criteria.
First, companies would have to prove that their products
actually help adult cigarette smokers to quit. Second, they'd
have to prove their products don't harm the people using them.
Third, e-cigarette companies would have to prove their products
do not cost children to start using nicotine.
If a Federal Tobacco to 21 bill this year, year and I think
it might in the Senate, it's imperative that the legislation
include strong provisions to crack down on kid-friendly e-
cigarette flavors that are addicting our kids.
As someone who lost his father as a kid to smoke-related
lung cancer, I had hoped that e-cigarettes would prove to be a
smoking cessation device for adults. To date, there is no
proof. Instead these devices and the candy dessert fruit
flavors are causing children to develop this addiction at far
greater rates than they're helping adults quit smoking
cigarettes. A recent Dartmouth study found that e-cigarette use
leads to 81 new smokers for every one smoker who quits.
According to the Truth Initiative, 15-to 17-year-olds are 16
times more likely to use JUUL compared to people over the age
of 25. A recent study published in the Journal for the American
Medical Association found the teenagers who start vaping are
three times more likely to go on to smoke cigarettes than
teenagers who don't. And consider this: JUUL is widely popular
with kids and accounts for 70 percent of e-cigarette sales in
the United States.
Make no mistake. JUUL, now partnered with tobacco giant,
Altria, is driving this epidemic even as they come before this
committee and pose for holy pictures. Congress waited for too
long to start protecting children from cigarettes. History is
now repeating itself with e-cigarettes. Our inaction, combined
with FDA's complacency, is dooming an entire new generation of
children to nicotine addiction. Most parents care when their
teenager is lost in a cloud of vape smoke. Does Congress? I
look forward to working with you on a bicameral basis to
address public health epidemic head on.
I will close by saying this. I never dreamed when I went
after taking cigarette smoking off of airplanes in my third
term in the House, for God's sake, that I had a chance to win,
but I did. The net result of it, because of unforeseen
developments, was a change, a dramatic change, in America in
their view toward smoking. We stepped in at that moment finally
and took on big tobacco. The question is can we work the
bipartisan political will to take on big vaping now for the
benefit of the young people sitting behind me and those across
America? Thank you, Mr. Chairman.
Mr. Krishnamoorthi. Thank you very much, Senator Durbin,
for that eloquent statement, and thank you for your efforts,
your lifelong efforts, to combat nicotine use.
I want to thank all the panelists, I want to thank the
entire audience for taking time out of your busy schedules to
be here. Part 2 of this very, very important hearing is
tomorrow when we have the founder of JUUL before us at 2 p.m.
in this very same room.
I ask unanimous consent to insert the following items into
the official record of the hearing: the statements from Dr.
Bonnie Halpern-Felsher of Stanford University, a statement from
Dr. Brian Primack, a letter from Kamal Mazhar, president of
Teens Against Vaping, and a letter from Dr. Frances Leslie of
the University of California, Irvine.
Hearing no objection, so ordered.
Mr. Krishnamoorthi. We are adjourned.
[Whereupon, at 10:55 a.m., the subcommittee was adjourned.]