Vaping 20 of High School Students now vape. The lingering question is why and what was the role of juul, the countrys dominant maker of ecigarettes with almost 80 of the ecigarettes market share and the dramatic rise of vaping. The panel assembled today will todays address these where and with part two tomorrow monseesl founder james will testify. Today we will look at why it makes it irresistible to kids. Is a preeminent tobacco advertising scholar in the country and will help us answer that question. We hope to understand how juul whileed to youth simultaneously avoiding detection by adults. We will hear about juuls average including how juul entered schools under the guise of antivaping conversations. Then went the juul presenters told kids that their vaping tools were safe. We will hear from the parents of kids who sat through one such presentation. Were soted mothers angry that they founded a nationwide advocacy group. Although the schools that juul entered, it incited the righteous anger that only comes from parent to feel that their kids are being exploited. They arelso hear that targeting vulnerable populations not limited to kids. Will describe that. Tribe toto pay her give Free Products to members. That theed product was healthy. L appeared to think that it could get away with this on tribal land. Contains veryself high nicotine levels, three to 36me the nicotine times, ando six massed it with flavors that appealed to youth. Kids do not grasp this. Aged 15 to 24 do not know that it contains nicotine. They mistakenly believe that the product is not harmful. One of our doctors will help to explain. Perhaps we can better understand the led parents sending Company Letter is like one from last year saying quote, might my daughter is highly addicted. She is 16 and now has addictive behaviors that she never had before juuling such as stealing juuls. Nd other teens she also lies and sneaks out at night. Perhaps we can understand why a therapist wrote to juul last year disheartened about how many herer teen clients came to saying quote, how desperately they needed to vape. Aboutpressed her concerns quote, helpaping to with depression. That noscrete and a way cigarettes are prior ecigarettes were. Ofputs off a limited cloud aerosol and it smelled is not linger. It is small and before it was a household name, parents could have looked right past it inking it was a thumb drive. My hand ive had one in during this entire statement. Juul has not provided satisfactory answers to these open questions. It is my sincere hope that our hearings today and tomorrow will help us better understand juuls role in this terrible epidemic and point Us Toward Solutions to prevent teen vaping addiction. Thechair now recognizes distinguished Ranking Member from texas, mr. Clout for five minutes for an opening statement. Mr. Clout thank you, chairman. Thatecades, we have known smoking is dangerous and linked to cancer. It results in 4000 preventable deaths every year. They are only preventable if individuals are able to stop smoking. For years now, smoking has been on the decline. It is clear that the methods for turkey,n, quitting cold using nicotine gum, our simile not enough. Recent studies suggest that Electronic Cigarettes could be a part of a broader Tobacco Control strategy and could be considered viable components to cessation. There is a growing can statio growing sensation that Electronic Cigarettes are more harmful. A study in england found that lessarettes were 29 harmful than tobacco cigarettes. Many have turned to ecigarettes as a cessation aid. Determines yet to that. Other studies have found that ecigarette use was associated the percentage. 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 advertisement. It is illegal for anyone under 18 to purchase or consume these products. The Tobacco Control act of 2009 applies to ecigarettes. Members of Congress Draft that process should always begin with a strict fidelity, facts, and research. In order to obtain these facts, the questions i hope that answers to today are are the Public Health benefits, what are , if any, the Public Health benefits of ecigarettes . Can it be a part of an overall Tobacco Control strategy . And how do we do so in a way that ensures that kids are protected . And many more questions that i hope for the answers to today. Said, two thirds of adults smokers said they want to quit, they know it is hard, and they tried many times. We must recognize the potential for innovation to lead to less harmful products. If two thirds of smokers in this country want to quit, members of engagement by parents, schools, and local communities to educate children about the risks and ensure healthy lifestyles. I hope we have a healthy discussion today. Thank you. Thank you. Now i would like to turn to our witnesses. Thank you all for joining us today. We very much appreciate democrats you taking time out of your busy schedules, and thank you to all of you in the audience for coming here on none otherwise slow fake news day. [laughter] are joined by Meredith Berkman, the cofounder of parents against vaping ecigarettes. Also mr. Ray oleary, a member of the Turtle Mountain band of the chippewa, and a public researcher. Jonathan, a member of the American Academy of pediatrics. Ckler, the ja departmental chair at Stanford University medical school. And a practicing surgeon. ,nd finally, dr. Raymond niaura of the department of social and Behavioral Sciences of the college of Global Health at new york state 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 . Thank you. Let the record show that the witness is answered in the affirmative. Please be seated. Without objection, your written statements will be made a part of the record. Kman, you are. Ber recognized for five minutes. Let me 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 stop lights, yellow means speed up, and red means stop. With that, please begin miss berkman. Ms. Berkman thank you. Yourmorning, thank you for words and distant with members of the House Oversight committee, i am Meredith Berkman and i represent parents against vaping ecigarettes, called pave. It was founded over a year ago by three concerned moms. We have groups of activated parents from across the country from california and new york and places in between. We have people with us from texas, georgia, new jersey, new york. Are behind me with members of our families between us, we have nine kids. Also, my friend and i created pave in response to the juuling epidemic that seems to come out of nowhere, yet, experts consider it one of the serious adolescent Health Crises in our country. Our goal today is to give voice to the 3. 6 million teens who are vaping, most of them juuling. This most recent figure is outdated. As you said, between 2017 and rise ofere was a 78 the use of these products by High School Students, and 48 in rise by students of middle school. The new figures due this fall will likely be much higher is what experts believe because nothing has happened to have them go down. Were from a desperate parents every day to contact us seeking resources, information, and help for their juuldependent kids. But there is not yet any fda approved treatment for this kind of teen nicotine addition. Addiction. I will share briefly one or two stories because they are heartbreaking and they come from every state represented on the panel and probably for every state of people in this room. Are ourusetts, describing how he developed a cough and complained that he was not able to breathe while skating. Kelly said that we began living with are straight a students grades dropped to fs. It was the extreme anger. It turned out that our 14yearold had a Substance Abuse problem and that substance was juul. I want to share a personal story, the story of how juul went after our kids and their friends by coming into the school. Without the knowledge of the school or concerned parents, juul sent a representative to talk to our kids about its product under the guise of education. 20 17, my then 15yearold son caleb told us there had been an antiaddiction talk at school. 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 he was done, caleb and his friend went up to talk to him. Was forated that juul adults, not kids, and he took out the sleek looking juul, and called it the iphone of vapes. That is when we moms decided to fight back. We had discovered a few months before that our kids were juul ing at home right under our noses. It is very common. It does not mean that you are a bad parent if your kids are juuling. We need that nicotine was harmful to our kidsbrains, and as we researched and put pieces together, we learned that juuls Deceptive Behavior was a part of marketing strategy. Schoolfornia, a retired superintendent was offering schools in his state and in massachusetts money if they would implement the anti juul curriculum. A man named bruce was offering it on juuls behalf. School across a stanford toolkit with an odd disclaimer, that realized it was juul taking information it should not have. None of this is surprising. Juul is stealth by design. Restockso longer orders of the flavor is that researchers have proven is attracting kids. But just the other day in a one block radius in two different stores, i was able to buy these says are nohat juul longer on the market, but they are still online. That is the problem. If juul wants to slow the vaping epidemic, they will immediately remove all flavors from the market including willol and mint, and they stop spending millions of dollars on lobbyists. To oppose sensible parentsion that pave and our Coalition Partners are fighting for to restrict youth juul and other products. We hope this motivates members on both sides. We all care about kids, but to hold juul accountable for predatory practices and causing harm to so many kids in this country. It is not a political issue but a moral one. If we do not take action now, we face an entire generation of who addicted to nicotine are human guinea pigs for eight juuls experiment overall. Chairman krishnamoorthi thank you. Oleary good morning. Thank you for the opportunity to explain. Ary, and i rea ole of the founder Tobacco Coalition which is an antiTobacco Coalition on the reservation. Allpposes the use of Tobacco Products because of the disparity on the Cheyenne River reservation. Three representatives from juul used a historic tactic by handing out Free Products and offering a switching program to the Health Committee. They proposed that health care fresheners referred smokers that are 21 years or older to their switching program. Using the referral, american native american populations would use their data proposed a self starter kits at 50 to the try for five dollars apiece. The tribe would then provide free juul starter kits. Throughout their presentation, they made multiple claims that their product is effective for Smoking Cessation and less harmful than Tobacco Products. All clearms are violations of the family smoking act. Tribally, some Council Members were convinced that it could help some members quit smoking and eventually resulting in fewer Health Care Costs to the tribe. The Health Committee members widely requested documentation for the juul proposal. Juul did not provide it, but they sent a neutral nondisclosure agreement with information that the nondisclosure agreement had already been discussed by the Health Committee. The nondisclosure agreement was not signed. Has notult, juul returned to the tribe. Earlier this month, the Health Committee approved a resolution that says that crc should no. Onger solicit or sponsorship this resolution is currently being considered by the Tribal Council as well as other tribal nations and the National Indian health board. The coalition emphatically madees the offer that juul including great safety concerns and nicotine to children. And the knowing the probable longterm health risks. Even though the switching program is intended for adult smokers, the commission has great concern that the American Indian youth will be using juul do to access and highly pleasurable product. American indian middle School Students in south dakota are using juul three times more than their white counterparts. And there is a growing body of evidence that juul users smoke more and quit less. It is true that some smokers have quit smoking by using juul, but for everyone adult smokers at quit smoking, 81 adolescents will initiate ecigarette use. Clearly juul are being used for more than an alternative to smokers. Easyy have looked as an target for juul because of our 51 adult smoking prevalence coupled with our genetic repent city to addiction. Genetic propensity to addiction. Did not provide an acceptable justification with the choice to offer the switching program to tribal nations. I would challenge the members of the subcommittee to uncover white juul to uncover why to the tribes. Et woman, irican indian am putting my word on the record that the scenario of the tobacco hasstry targeting indians played out for far too long. I put a great deal of thought into my decision today. In the end, it was the core generational belief that help me reach my decision to testify. What happened at the tribes is 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. I challenge you to learn from the seven generation belief that in every decision, leaders must consider how it will affect our descendents seven generations into the future. Thank you. Chairman krishnamoorthi thank you. Good morning. Members of the subcommittee, my name is i am a practicing pediatrician. Years ofer 20 experience caring for children and adolescents. I am here today representing the American Academy of pediatrics representing over 67,000 pediatricians across the United States. Use among adolescents have reached epidemic proportions. Everyone one of my teenage my preteend even patients either use ecigarettes or have friends that do. They know that cigarettes are dangerous but believe that juul is harmless. Ecigarettes are also not good for growing lungs. They are particularly bad for children with asthma. Cause serious lung conditions including hypersensitivity lumenitis. It tends to impact areas of the brain that control executive function, and mood. Take holdddiction can and only a few days, especially the adolescent. The ecigarette condition concerns us because it can lead to combustible tobacco use. Compared adolescents who do not use ecigarettes, those who use ecigarettes are three times more likely. Nicotine withdrawal can find doctors yet doctors have found the only surefire way is to stop it before it starts. Luckily, we already know what needs to be done. We need to make ecigarettes less appealing to children, make it harder for children to access, and we need to make them regulated appropriately by the fda. First and foremost, we must address juuls juul flavors. Flavors. Uls ecigarette flavors are one of the primary reasons that teens try the flavors. L has chosen to keep meant and menthol flavored pods available everywhere. It is completely false to suggest that mint is not attractive to children. From candy canes to toothpaste, children are introduced to mint at a young age. Makeso products, menthol it easier for children to inhale the poison. When juul removes some of his other flavors from the stores, i saw the majority of my juul using patients switch to mint. They are still gaining access to even flavored juul pods though they are now sold online. If they 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. Mr. Chairman, members of the subcommittee, juul is a fatally flawed product. Toecent study showed that 15 17yearolds are 16 times more then 25 to 34yearolds. 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 believes that juul is a Public Health threat that must be removed from the market as soon as possible. Juul and products like it are the progress made in teen tobacco use. Ul must be held to account for the epidemic it has created. And theress, Administration Must take action to end it. Thank you. Thank you. Dr. Have five minutes, jacklar. Jackler thank you for the opportunity to testify today. Almost all smoking begins during adolescence. It is a part of teen rebellion commencing through and 19. It would be a rare 40yearold who woke up and said i think i will start smoking today. Once a teenager becomes haakon nicotine its exceedingly difficult to quit. Many are stuck with a lifelong addiction juul. From the beginning juul, fetanyl mission of improving the lives of one billion smokers. Antead they have spurred epidemic of nicotine addiction amongst youth. Farhow did juul stray so from its stated mission . As a majority of smokers in america are ages 30 to 60, they should have designed their advertising to connect to a middle age audience. Over the first year can we have the slides please, garrett . Ok. Over the first year after juul launched in 2015, it held at 50 highlyries of stylized parties with youthoriented entertainment and six in cities across america. Thousands were given free juul by attractive young girls come often. Their initial campaign called vaporize was designed by an Advertising Agency whose goal it was to create a cult like following and they succeeded beyond their wildest dreams. They featured models in their 20s into trendy poses and exhibiting behaviors more typical of underage teens than mature adults. Advertisers have long known that these images are exactly how to target underage kids. Just last week in a televised documentary on cnbc, juul cofounder adam but one claimed that the 2015 vaporize campaign only lasted less than six months and was lifestyle oriented and had no impact upon sales. Lifestyle oriented . It was obviously, if we can see the images, its obviously youthoriented in that way. Contradicting mr. Bowen, the juul cofounder, james monseys, seven months after launching bragged that they are the fastestgrowing ecigarette company in the world. Today they say the early advertising that was patently youth oriented made the difference but at the time they were bragging that it was their most rapid growth in the world. This is either revisionist history or intentional deception. I will let you be the judge. From its inception, juul mostly advertised the social media, mostly instagram, skewing heavily towards youth. Juul paid influencers or social media stars to praise the product. They multiply the reach by using hashtags that became online gathering places for teenagers. Under intense regulatory pressure, juul halted its own social media postings in november of 2018, however this was a hollow gesture. It didnt matter much and the reason was that viral peertopeer promotion amongst teens showed massive visibility of their products on an ongoing basis. For example, after juul quit its own postings last november, the surged, tripled, and other are 530,000 posts and millions of views of the youthful material. Juul leadership claims they were completely surprised by youth usage of the product. The cofounder brags were the most educated company, the. Ost diligent they are datadriven company amps company. They know the identity of the customers. The New York Times interviewed a former manager of juul who said that they knew that their products were becoming popular among underage users within a few the first few months on the market. A, juul professes to be technology that disrupts big tobacco, but like many Tech Startups once the money starts rolling in they made many compromises to their grand vision. What should have become an offramp for adult smokers has instead become a heavily traveled on ramp to nicotine addiction amongst teenagers, 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, their recent partnership with austria combines the leading youth initiation cigarette with the leading youth initiation ecigarette. The agreement specifies joint marketing is of grave concern. Juul has been unmasked for its hypocrisy, rather than making big tobacco obsolete, they are very much part of it. It is as though they lit a kindling, stood by making no effort to contain the resulting fire, even stoked it, and when the Fire Department came, dismay aboutck and the resulting major conflagration while loudly protesting that their actions had nothing to do with it. Thank you. Thank you. Doctor, you are on the clock. Thank you. Mr. Chairman, members of the committee, thank you for holding this important hearing on a topic of grave concern for the nations Public Health. I am privileged to appear before you this morning to testify about the challenges we face when it involves youth use of ecigarettes and other Tobacco Products. I am a clinical psychologist, a 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 , i too share concerns about Youth Tobacco use, including vaping. I dont believe that any youth should be using any 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 the companies that manufacture and sell these products should do all they can to make sure that products are marketed only to adult smokers. And 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. Of 2018, the fda and the u. S. Centers for Disease Control and prevention expressed vaping. Rry over youth an evident. Reinforced byas data coming from the national Youth Tobacco survey in 2018. When the data were eventually released to the public, we look at it ourselves and we can indeed confirm that past 30 days , vaping had increased from the prior year. While the increasing use is of concern, the analysis showed that most adolescent vaping was occasional and most regular use was concentrated in adolescents who had already been smokers. I think that 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 look at youth who had never used Tobacco Products and, thankfully, the numbers were quite low. Again, this is not to minimize the importance of concern about youth vaping. Smoking remains the major concern here in the United States of america. Id like to also emphasize another point, which is that ecigarettes have the potential to help adult smokers stop smoking and we have seen evidence accumulated showing that adult smokers who use these can quit smoking regular cigarettes. Studies have come out in the new england journal of medicine indicating the same. Just last week a survey reported that smokers who switched to ecigarettes and use them every day were significantly more likely to quit smoking compared to those who did not use ecigarettes. Importantresults are because we know that despite their effectiveness, smokers dont often use quitting methods like nicotine replacement therapy and other medications. As they stand now, these are a Consumer Product 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 at 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 to be a huge Public Health priority. I would like to close by saying i i think that this set of issues, both Youth Tobacco, nicotine use, and adult smoking have been poor trades at at odds with one another and they really should not be and that we in the Public Health community and congress ought to find ways where we can do both. I think we are smart enough to figure out how. But i dont think we have all the answers yet. Thank you very much. Thank you, doctor. I now recognize myself for five minutes of questioning. First of all, mrs. Furman, mrs. Bergman, after you discovered juula presenter represent gave a closed assembly at your school, you warn parents around the country about the dangers of ecigarette use. Thank you for your concern continued advocacy. As a parent myself, i was shocked to hear that juul had access to teachers without parental to students without teachers or administrators. Its important to understand what outreach looks like on their part. Berkman, mrs. Furman, i would like to ask a couple of questions of your sons of thats ok. Philip, caleb, can you please come to the table for a couple of minutes . I would like to first address caleb. Caleb, what grades were you and philip in the year of the . Resentation by juul ninthgrade. Can you speak directly into the microphone . Ninthgrade. What works students told before began. That we were having a Mental Health addiction seminar that we have three times a year. Teachers are told to leave the room so that its a safe space for kids to talk. Did most of your classmates safe priort juul was to the presentation . Already usingere the product and have doubts as to whether it was safe but a lot of kids still thought it was possibly dangerous. Were your teachers in the room when he spoke and did he ever mention his connection to juul . Eat it mention the connection and my teachers were not in the room. Did he say that juul was safe . Yes. Did he call it totally safe . More than once . Yes. What impact did those totally safe comments have on your classmates, some of whom may have already started vaping. For my classmates who were already fading it was a sigh of relief because now they were able to vape without any concern. Were their kids were likely to try after hearing that it was totally safe . I cant say for sure, but i believe that after this meeting kids were more inclined to vape because they thought it was just a flavor device that didnt have in it. Mful substances u. N. Philip approached the presenter when the assembly concluded. What motivated you to even approach him in the first place . I believed the presenter was sending mixed messages by is totallyt juul safe and following up every totally safe statement by saying that we dont want u. S. Customers. I believe that the customers were playing on that stood as a presenter was playing on a rebellious side of teenagers who are more likely to do something when told not to. Philip, what was your experience speaking to the presenter . So we went up and we talked to him and caleb asked a question about what can you do if your friend is addicted to nicotine. Philip, were you addicted to juul at the time of this presentation question mark i was. When caleb asked what he should do, was caleb referring to you . He was. Like how did the presenter answer the question about how he could help a nicotine addicted friend, namely you. Since he was not specific about the kind of nicotine he speakercted to, the thought that he was talking about cigarettes and he said that he should mention juul to his friend. Because that is a saver alternative than smoking cigarettes. Let me get this straight, he wanted you to switch from combustible cigarettes to jewel juul. Yeah. Dide didnt use it how he presented . He didnt use it, but he took it out and showed it to us. This is disturbing behavior to the to say the least. A person connected to the company pulled out a juul device to demonstrate its safety to teenagers and lied about the product being totally safe. Did he say anything else about whether the government had approved it . He mentioned that the fda was about to come out and say that juul was 99 safer than cigarettes and that that would happen very soon and that it was in fda approval while the talk was going on. Thank you, caleb and philip let me ask dorian, philips mother, to say a couple of words here. Thank you for coming today. Thank you. Your son, philip, just stated that he was addicted to juul. How did the addiction impact your family . It was difficult and at first we didnt understand what was going on. As a young 14yearold he was interested in so many different things, from surfing to cooking to his little sister. Flashted to find these drives, these green plastic caps in his pockets and i didnt know what that first. So he kept saying that they belonged to a friend and we would have fights about it and i figured out what it was because i googled the name on the side. It was difficult. He changed kind of overnight. He started spending a lot of time in his room, in the dark. He became moody. He had a very contentious relationship and i became very suspicious, obviously. I think he didnt really understand what was going on himself. And neither did we. Thank you, dorian. Let me recognize Ranking Member cloud for time of questioning. Thank you. Im curious to the reaction and i seem to approach school board, principal, what was the reaction . Idea thatool had no the outside group had brought a juul representative into the school. The outside group was naive, but in good faith because when i called to ask about the , the staffer said you found the right person. I was researching antijuul Education Online and i can Julie Henderson who was no longer listed on the and she called and she says i have the perfect person. Thank you. Dr. , could you explain the difference from a Health Perspective . Is there one . Yes. Traditional cigarettes consists of preparation of tobacco leaves which when burns create smoke that contains roughly 7000 different chemicals, most of which are not good for the human body. The cigarettes contain far fewer gradients ingredients. This general is the difference in terms of the number of makesnds in ecigarettes the ecigarettes in general safer, although it can very from product to product. Depends one safety temperature control for example. Toxic. Nd to be less we have known cigarettes for a while cause cancer. I remember thirdgrade seeing from sitting in a jar someone who have passed away from cigarette use. What im trying to get down to is where the Health Effects of the combustible side and the nicotine side . That is an important point to raise. If we look at nicotine and another itself, it is not riskfree, but probably a lot less toxic than compared to the other chemicals that come out of cigarette smoke. For example, nicotine does not cause cancer. It may have some small effect on disease cardiovascular and so forth. The brain might have to adapt to. Aving a drug on board itself is not itself when it comes to things like cancer terrific we seem to have a competing set of facts. We have data that shows teen ecigarette use has gone up. You mentioned that a lot of it is transitional. Clarify that [inaudible] a lot is crosssectional. We see kids using one or two are and what we need studies that track kids over time. Once again, we dont know what the applications are and i want to emphasize that i share the concern that an kids should not be trying the rocks and using them on a frequent basis. Cdc data shows over 2 million High School Students and hundreds of thousands of middle schoolers have activists and become a user. If you start smoking today, it. S dirty, 40 years it is an experiment. We will find out years from now the results. The compounds we put into our food that are safe in your intestinal tract, when you free the men, the classic example is microwaved butter popcorn. It causes severe lung disease. The flavor and chemicals, cotton candy, mixed them with that and they are exposed over and over. We dont know the longterm results. Theres no doubt my mind that taking a safer than conventional smoking, but that doesnt mean it is safe. I now recognize Congress Know congresswoman to leave talib. I can censor frustration. Rhetoric to it discredit a lot of things we are pushing for you i just want you to know the truth is on your side or it be stronger for that studies. Nt need more washe few years after juul founded, it dominated the market through a targeted campaign. It now accounts for 76 use of the ecigarette market your it when i find troubling is that in the same timeframe, the rate of teen nicotine usage skyrocketed. The cdc found a 75 increase in use among High School Students between 2017 and 2018, so it is no question that teens who use ecigarettes almost exclusively refer to the activity as juul ing. Shouldn your expertise, they have been aware of its marketing use when it comes to teens . Absolutely. Huge teenage fads do not happen by accident. Agencies and at they understand the difference ,etween marketing baby boomers io broadcast tv and jen spend all their time looking on their phones. Inside report from the New York Times validates it. I dont think theres any question that juul they were perpetuating it. You were a professor at stanford. James monthly . Et muncie . Yes. Interesting. E thanked us for the database he said they were very helpful as they designed the advertising. The seven of us left the twohour meeting the very first thing we talked about. It was the first time he indicated juul was allowed in traditional advertising and we knew having studied that it [indiscernible] the methods by the Tobacco Industry to target young people which include marlboro. Ofy are direct derivatives the advertising. The lives to improve of the one billion a bill smokers. Year, their ads became more calibrated to an adult audience. May have now switched campaigns in imprinted newspaper. No longer are they promoting on social media. This only happens long after it was a youth epidemic and it was because the unwanted attention by regulators. They were also concerned about investors, particularly Companies Like ability who did not want to be associated with products widely seen no, it alls always leads to profits. The explosion on the market already had an impact on youth. Additional Marketing Campaigns influence teens today . It did not stop all of the ags. Branded hasht there were about a quarter million posts with those. Since then, it has doubled. What astounded me the most is it fromete instagram, but happy users are under age 18. Just because you delete them does not mean it never happens. Thank you. Cromer. Mr. Thank you. The topic is used of electronic cigarette. , ahas been mentioned today potential possible correlation with tobacco and cigarettes. You conducted a lot of research and studies on this topic. Predictor isof up current use . There is a Statistical Association between use of ecigarettes and subsequent cigarette smoking. Is the health at study which is funded and sponsored by the fda and nih. We did find that and also found that if kids had started with a cigarette, they were 20 times more likely to continue to smoke the sacred. The message we take from this is the use of all or any nicotine tobacco containing products will increase the risk. The worst thing to start with would be a combustible product like a cigarette. Has the rate of smoking since 2010 increased when ecigarettes started to rise in popularity . Declinese seen steady in both youth and adult populations of cigarette smoking which should be taken as good news. We certainly have more work to do and yes, there is a diversion ecigarettes with and use of cigarettes going down and that is the area of active research to see if those two things are actually connected with one another. If ecigarettes for a gateway to smoking, would that show existential increase . Decrease ineen a use of other Tobacco Products, so right now, it doesnt appear that they are translating into subsequent use of cigarettes, at least as far as we can tell right now. Is evidence show that teens are diverting to ecigarettes . Questions an important that we need to address. Kids are trying a lot of different products, including vaping and we need to understand more about who are the highrisk kids who might try a lot of , may inadvertently become more addicted to nicotine. We need better understanding of those factors so that we can do a better job at doing some kind of intervention. I just want to make a point that im certainly opposed to youth vaping. Im not a smoker and never have been. Representmer and i probably the biggest tobacco in this to back her district in america. Beenis something that has a big economic boon to kentucky. Having said that, we recognize the risk and the dangers and effects of cigarette use. Has triedry i think to do things to curb underage smoking. I know senator mcconnell has a bill that i support to raise the minimum age to purchase cigarettes and i think that is something that needed to be mentioned today. And tobacco is still legal i know this is about ecigarettes and i have to conclude about this because it is a big industry my district. In kentucky, youre not able to grow fruits and festivals, so you are limited to what types you can grow. It as long as it. S a Legal Industry certainlyd that, i want to work with my colleagues use of ecigarettes goes down and i have always been a proponent of doing everything we can to prevent underage smoking. With that, i yield back. Congresswoman pressley, you have five minutes. Thank you to all of our witnesses. In addition to the experts and those here, i wanted to acknowledge the control Leadership Council and we thank you for your good work. Epidemic has taken the commonwealth by storm across the state an estimated nearly 15 High Schoolers and one in 20 middle school kids are using the products. Into juulhave turned lounges and have spent the last 10 years of my life advocating for a school nurse and we have learned from our School Nurses that 80 of High School Students are vaping and that is from the youth risk surveys. Levels whothe state are going to initiate the investigation into the market looking to push for hearing, but we have to act on a federal level. I would be remiss not to how many of them seems to be right out of the tobacco playbook. Almost 90 of black smokers use medals. Menthols disturbing. Ely we have been here before. We dont need a buddies. Run the risk of seeing ahead of us, so this is very disturbing. It is even worse for children. They found that ecigarettes only contain flavors as we learned from the youth and thank you for telling the story. Elimination [inaudible] why are Tobacco Products exploited in the context of ecigarettes . They have a long history of targeting menthol products to africanamerican people and children. It shows the majority of americans believe that minted menthol should be banned as a flavor in Tobacco Products. Therestingly, contrary to Tobacco Industry and the tobacco product industry. If you just look at the opinion of blacks and africanamericans, and even even Greater Authority believe it should be banned. Theside from preying on black community, have targeted children and populations. You are so disturbed that you created an organization to spread awareness. We thank you for your advocacy. What have parents told you about how juuls marketing has influenced their children . When you see the sexy, young influencers giving the products away. When you see the old tobacco ads, they are almost identical. Juul knew what they were doing and what we tell parents is you are not a bad parent because as you have said, everyone is doing it and in this case, it is true. Upset. Very these are kids who would otherwise not have not what have initiated tobacco use. Kidse talking about knowing harm to potential benefits to health. Kids who cant make those decisions for ofmselves through the use social media. Make any claims about helping people quit smoking . Did they claim the products were healthy . You can see slide 21 for my attachment, they have smokers that cannot quit. Thathave created a Program Helps them quit. I think that the other claim was the Harm Reduction in the elimination of combustible cigarettes to reduce harm. To point out that it was done with not just juul, but other ecigarettes that had less nicotine content. And my time or do i still have time am i at time or do i still have time . Thank you. Congressman miller, you have five minutes. Thank you. And thank you all for being here today. Virginiatate of west rates among the top states in the nation for the highest 26 entage of adults, about of our population. 38 Million People in United States smoke. I agree we need to ensure we keep Nicotine Products like ecigarettes out of the hands of the youth, but we must also ensure that we do not over regulate the industry to the point that they are no longer available for people of legal age who would like to use them recreationally or as a means to quit smoking. When i was a child, one of my chores was to empty the trash everyday. Both of my parents were smokers. That was really achy. If anything would keep you from smoking, it would be emptying ashtrays ever single day. I believe it was in 1963 when the Surgeon General came out and said sigrid smoking causes cancer in both of my parents quit. My father quit cold turkey and my mother smoked three quarters half,igrid come a than then a quarter. She did it so late. The ashtray thing is what cap me from ever wanting to smoke and coming into a house that smelled like smoke. It was really nasty. Research, do you find fate t to they vape use other Tobacco Products as well . Yes, close to the recorder three quarters have also tried or using other Tobacco Products. Is it correlated by smoking cigarettes later in life . That is the milliondollar question that we are all concerned about. As i mentioned, there is some statistical correlation. I dont know if we can say that one causes the other. That is a pretty high bar, but nonetheless, i have maintained kids should not be using any tobacco or nicotine containing products. , often i went to college times, i felt is it more of a crutch because you wanted to do something with your hands because it really was addicting. Often, younger people, they want to carry keys or save this has 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 excessive Nicotine Products. Andhouldnt be a tradeoff we can use both of these things at the same time. How youu elaborate on think we could accomplish both these goals . I wish i had all the answers, but im hoping that the fda, tobacco power of the control can work hard and figure out how to achieve both goals which is to minimize use and of thee the ability adult smokers to access safe and effective products. I think we are still in the early stages of figuring out which ecigarette products are the most useful. That is what the fda is and use their scientific powers to determine which products are fit. How can the health risks be medicated by the use of ecigarettes . Ifthe major thing is cigarette smokers can switch completely to an ecigarette product, we know that will changesn pretty quick that areical markers normally associated with smoking cigarettes, so no doors, we had signals that they are Getting Better at approving improving. At least in the shortterm, it looks like people switch to the products, they are actually in some ways of proving their health. You mean by coughing . More like biological markers associated with high risk of cancer, things like that. Thank you. Thank you for having this hearing. The longer you have these political jobs, the more humansing when you see beings doing things. It 30rn up to remember years ago. I remember a Public Health ordinance and are hearing showed retailersly it is across the country where they put their advertising. Research showing when kids came in and i also remember owning multiple liquor licenses when we went against mothers against drunk driving. Liability,o assume [inaudible] why would we want to be in business. We passed laws that have helped with that. I have had again and some fairly regular group of young people in my district in the San Francisco bay area. They are trying to do similar things in getting young people. O help advocate there is a reinforcement from the market from peertopeer that it is not dangerous and people have taken care of all that. Youve had the same experience i take it . Group in sanvaping francisco. We are working all the time. Even now, when there has been so much talk about harmful content podsese jewelbox juul still dont get it. They think it is water vapor. We have been here before and we should not be here again. We dont want our kids to be guinea pigs for this experiment, especially when we saw what happened the first time around with big tobacco. We cannot wait. This is a race against time. Flavorsnt act soon, continue to hook kids, then this is a generation of nicotine addicts and worse. Is research that has given evidence of cardiovascular damage caused by ecigarettes, so there is no damage to healthy brains, but also cardiovascular. These are kids. Bid seeingd got for what happened the first time around, we dont have that time. Thank you. Secondhand smoke, it strikes as a Public Health issue to employees. Having been in the restaurant business, you could not Wear Clothing a second day because of the stench of tobacco. Why should it take long for us to look at the content of what todays products and measure against Secondhand Smoke . Context, we have some smokers who have gotten the smoke outside, but parents will be vaping right next to their child. The particles are getting into. Heir childrens songs lungs the entire surface of the home becomes coated in nicotine and other chemicals. Kids interact with their environment in a very intense way. They breed from close down to the floor and they may only way a tent as much a 10th of a so they end upt breathing toxic aerosol that is probably 20 times higher than a nonadult household will get. Use regulations need to be parallel. Aherwise, smokers will use workplace and recreational places and automobiles with kids and that is not a good thing. Local policies are important. About how thek industry has targeted native americans in the travel community and the Tribal Community . [inaudible] ishink the main thing getting the product to the reservation. I think the to the product feels invisible. On the reservation, we have no compliance by the fda. There is great concern about coming to the reservation and trying to hide behind nondisclosure agreements. Ive heard there are multiple other tribes that have been approached, but really struggled to find anyone. I think it is ruthless, the attempts theyre going to embed the everest operation. Thank you, i yield back. Congressman grossman, you have five minutes. I know a lot of people use ecigarettes. You dont see them as much, but vapesne person who credits this with stopping smoking cigarettes and i wonder, do you feel it is effective . Ofld you respond to the idea is it an effective way to stop smoking . There is certainly potential that Electronic Cigarettes, particularly those high nicotine , when a user reads them in has breeds the m [inaudible] scientifically. Use both andill keep nicotine levels high, so it can be a deterrent. Certainly, probably better than patches or gums. We have not seen strong evidence that it is necessary for adults to stop smoking and i developsa manufacturer flavored ecigarettes and provides data, then the manufacturer is able to ask the fda to approve it or authorize it as a new tobacco product, but for now, the evidence is strongly in favor of taking the product off the market. I just take issue with the notion that there is not strong evidence that we have the result of a randomized controlled trial which is the standard for Scientific Evidence in probably the most prestigious medical demonstrating smokers to manage who switch to thoserettes compared to with replacement therapy. , so iidence is building dont think we can say we dont have these products that can help. We are told that america is supposed to be a free country. What is the reason for other people to not want to use ecigarettes if there is strong evidence . What is their motivation . I think a lot of this has to do with these are relatively new products and there are a lot of unknowns. The tendency to methods such as medications and replacement therapy, but this is a product that has taken things by storm and again, we are seeing signals that are positive, so from my point of view, this is a product that is actually consumer friendly and more apps to be used by smokers compared to other products, then we ought to look for ways to leverage the opportunity. , sure this is right or not. Not sure this is right or not , 20 of High School Students va pe. It says only 6 use it for more than 20 days and only 4 are daily users. Does anyone think the numbers are wrong . That is exactly how to select areas that is exactly have tobacco use starts. The Gold Standard for current use is past 30 days, so nothing usual. Im a mother of four children and i tell you that this is rampant. We are trolled, harassed. E want the flavors you are saying when i have 4 vape everyday , using the data is wrong . And someont admit it of the early studies, unless you ,sk someone if they are vaping basic kids do not associated associate it and there have been articles written about this and studies written about this. Kids dont think they are using ecigarettes, they just think they are juuling. Would you say that nicotine addiction goes way after a couple of days . I dont know. I dont have an opinion. Have two final lines of questioning, three minutes each. This could be a little bit of a lightning round here. Thank you for being here and i want to get to the majority of my time. That juul came before the Health Committee of your tribe. One of the things i would love for you to talk about is the which is toat said promote juul as a healthy way for patients to quit smoking. They wanted to provide the juul. Tarter kits free if you can talk about that and who was in the room, i know people have a right to come forward and disclose. Hasink for the record, juul misled the american people, has lied, has used the system to target and and we can continue to say we are going to study. Kids ask me what i do for a living, i tell them i make laws and things. I said when i went to a restaurant, they would say how many people in your party, they would ask smoking or nonsmoking sections. I said, they used to smoke in restaurants. No way. They used to schmoe on airplanes. In hospitals. And its like these kids think we are crazy, but they used to gaslight us that secondhand smoking. And im not going to allow this committee to be used even by the other side that ecigarettes, vaping or juul is not killing people. It is leading to addictions that are going to hurt people. Im sorry. You can have the rest of my time. I wanted to put it in the record what they did in your tribe. When they came, it was in front of initially the Tribal Council and handed out Free Products to our decision makers, Free Products and we have Council Members who are regular users of juul. They were then rerouted to the Committee Level of the tribal government system and went to the Health Committee and at that meeting is when they made claims of less harm and Smoking Cessation. And ill reiterate thats not allowed. They cannot claim less harm at this point. I want to say there has been a lot of questions about that it might be effective for smokers but there is data that suggests for every one person who is able to quit using juul, 81 kids will start. Smokers finding this product as helpful, it is the uptick we are seeing in our youth. And yule specifically targeting like American Indians and africanamericans. There is no end in sight unless there is some regulations that take place. Ms. Tlaib i hate calling it regulations. Its called accountability. Thank you congresswoman. And final three hive minute line of questioning, mr. Cloud. Up cloud i wanted to clear the data, teen vaping use is up. We talked about that. Overall teens cigarette use is down. In the latest year, for the first year teen use is increasing in the last year according to National Data from the c. D. C. Mr. Cloud there are different sets of data . A flat line, but its not increasing. The data shows its increasing. Mr. Cloud overall tobacco use, i would be interested to see the study. Its in my written testimony. Mr. Cloud why the increase, why the decline . I think what we would have seen had juul not been around, i think we would have seen a steep decrease in adolescent tobacco use. And unfortunately what we have seen is a flat line. A slight upparticular in the past year. This is a problem because r. Cloud when i ask kids finish what you are saying. If you look at the patterns over the past four, five years, again, we are at record lows for youth smoking, which is hard to reconcile with the fact that teen vaping is up. Those are just the facts. Mr. Cloud that includes cigarette smoking. Mr. Cloud total product use is up dramatically. That includes vaping. A cloud you touched on for cond on patches and other touch 20 seconds on ecigarettes compared to patches, what have you . Nicotine patches are a form of nicotine replacement therapy proven to help smokers quit. This one study appears to show that ecigarettes are even better than nicotine patches. My interpretation of that is ecigarettes is a form of nicotine therapy. They are better at doing it compared to products like patches. Mr. Cloud we are talking about the context of teens. Adults. Mr. Cloud how can we make sure that Electronic Cigarettes are available for smokers wanting to make a transition while limiting the access to youth, what are your recommendations . I dont have any concrete recommendations. We are seeing a lot of suggestions coming out from folks in terms of different types of restrictions in terms of where products can be sold and restricting flavors. These are important conversations that we ought to figure out to get to the best road forward. Ill let dr. Jackler finish. From Nicotine Products juul should be available for adult smokers. I care about adult smokers and would like products to help them quit and it is superior, but should not be on the market to bought over the counter in sweet and fruity flavors. Thank you for the first panel. If you could come back, we are going to switch out and we are going to have our final panelists, senator dick durbin and well hear from him. Well take a two minute break to switch out the panelists. And audience, please stay seated for