Good morning. The subcommittee will come to order. Without objection, authorized to declare a recess of the committee at any time. I would like to have a few members, congressman jordan, congressman meadows, and the subcommittee to recognize questioning the witness. Without objection so ordered. I recognize myself or five minutes to give an opening statement. We are here to amplify the recent Health Warning for the centers for Disease Control related to 530 ecigarette related incidents of lung disease on 38 states. I want to make clear, this emergency hearing at the beginning of this time. On august 23rd officials from illinois recorded the first death due to a mysterious vaping related lung illness and since then a total eight individuals tragically died. In response to this crisis the cdc considering putting the American Public not using ecigarette. Because the subcommittee investigated the use vaping epidemic we feel it is our duty to draw attention to the recent government Health Warnings about the dangers of ecigarette use. The longterm Health Effects of continued vaping is unknown but what we do now should give us pause. State and Health Department conduct retroactive analyses to better understand exactly when this outbreak began. As they do the number of affected people will grow. Unfortunately illness related to ecigarettes is not new. The fda has received 127 reports of seizures and other neurological conditions caused by ecigarette. When a product is released to the market without safety testing or Clinical Trials this is what we fear. A problem exacerbated by Cigarette Companies that make what appears to be unfounded and illegal claims that their products are safer and healthier than combustible cigarettes. People trust and rely on those claims even when there is no evidence to back them up. That is why the subcommittee wrote a detailed letter to the fda outlining our plan on juul illegally marketing this product as safe, healthy and the Smoking Cessation device. Fda agreed with us days after our letter responded with its own letter to juul declaring juul had broken the law. Juuls response is due next week on september 30th. After that the fda will have the opportunity to act. I encourage all of you to follow that development closely and we certainly will. In just days after the fda responded to our letter to the administration citing our investigation, they would move to ban all ecigarette flavors including menthol. The fact that flavors, a point the subcommittee hammered home, the administration citing our hearings as rolling out a proposal, we should all be encouraged democrats and republicans are coming together to help our nations use. Today as we focus on tragic outcomes of this lung disease outbreak we must view it as another chance to come together to protect Public Health. At the heart of the recent vaping related outbreak, our families are being blindsided. With us today is a mother of 7 from chicago, this august as she prepared to drop her oldest daughter off to Start College already a stressful time, the Johnson Family faced a terrifying prospect. Instead of moving into a dorm room her daughter moved into a hospital bed far from home where she stayed for what would have been her first week of classes. Rubys daughter could have died. Thankfully she recovered from a bout of lung disease but still has trouble breathing and doctors cannot tell her how much longer that may last. Mrs. Johnson, thank you for coming to share your familys harrowing experience. We are joined by leaders from the Public Health community to provide a neutral assessment of the outbreak and provide advice to the public they serve. We have doctor Anne Schuchat from the cdc and the Illinois Department of Public Health and doctor albert rizzo of the American Lung association. Thank you all for joining us today. We look forward to learning more about how we can avoid more preventable deaths and with that i recognize the Ranking Member, mister cloud of texas for five minutes. Thank you, mister chairman. It has been clear abusers of certain vaping products, some tragically to the deck of death. I greatly appreciate the authority to get to the bottom of what is causing serious illnesses. The centers for Disease Control and prevention update, the number of those sick reached 530, eight deaths have been confirmed. This is very concerning and it is clear that we need to examine the cause and what can be done to prevent it. The best information available, many of these cases use products that present themselves to be something they are not. Based on the limited Data Available about those impacted by this mysteries lung illness, 16 turned 18 years of age and while each life is important, these recent incidents also serve to further indicated epidemic increase in vaping with 20 of High School Students vaping. After that, the decadelong epidemic of addiction to traditional tobacco smoking which will be 5 people dead by the end of these Opening Statements. As a father of 3 this is very concerning. I wish we had a quick fix to ensure each child is protected, that no american find themselves bound and all of us are able to find complete personal fulfillment and experience and the purpose for which we are created. We are here to discuss the appropriate response to lung illnesses associated with certain vaping product. Complicating this discussion is lack of Scientific Data studies available. Counterfeit products, untraceable lines, lack of enforcement that passes the book of accountability. Data available leads us to indicate most of the 530 cases involve vaping product. I hope the good work for which the investigating committee, and i appreciate the chairmans heart of this, and to find the solution to end teen vaping, there is unity. And the condolences to those at that level. We recently started a bipartisan bicameral and i use vaping caucus. That happens to be National Recovery day, bipartisan endeavor to recognize folks in our lives who may be affected by Substance Abuse disorders and our attempts to wean them off of their addiction. I just hope vaping is not the next Substance Abuse disorder. We are joined by doctor Anne Schuchat, Principal Deputy director of the cdc. If you would raise your right hand, we will begin by swearing you in. Do you swear or affirm the testimony you are about to give is the truth, the whole truth and nothing but the truth so help you god . Let the record show the witness answered in the affirmative, please be seated. Microphones are sensitive so please speaking to them. Your written statement will be made part of the record. You are recognized for 5 minutes. Ranking member cloud and members of the subcommittee. Thank you for the opportunity to testify today about the investigation of a lung injury, for vaping products. I will discuss with you about what we know or dont know, discuss efforts on the epidemic of ecigarette use or vaping. I want to make four key points, as we learned about lung injury, cdc is working hand in hand with state and local Health Departments and find the cause. Our ability to do this type of investigation relies on a critical underlying Public Health infrastructure including data systems that need modernization and third, the cdc made important recommendations to the public, including the following. This investigation is ongoing, people who are concerned about lung disease associated with ecigarette use or vaping could consider refraining read using them. And should not quantify them. Adults who use ecigarettes, should not return to smoking cigarettes. We have a need to address the epidemic of youth use of ecigarettes and reinforces the need to reduce the epidemic. What do we know so far . Several hundred cases have been reported from nearly all states, we had a number of deaths. Cases are occurring in young people. People present chest pain and symptoms like nausea and vomiting, fatigue or fever. Most of the cases with information so far have reported use of thc or nicotine containing products. Some reported nicotine only. There may be some challenges with the history of exposure of some patients. What do we not know so far . The most important thing, we dont know the cause. No single product, brand, substance or additive has been linked to all cases. This investigation is ongoing and very dynamic. What are we doing to respond . Cdc is working closely with state and local Public Health, with the fda and getting to the bottom of this. We have deployed staff, assistants to help with their investigations, provided technical assistance, developed a Case Definition, standardized clinical guidance and reporting systems and are working every day on coordinating with parts of the investigation and response. We set up a Management System and activated our Emergency Operations center as we do another Public Health situations and we have convened Public Health clinical and media numerous times to share what we know and what we dont know and how they are part of this. One example is clinical outreach and communication activity call the we held in the last few days that had 2500 lines active, listening to the latest. We are working closely with the fda on the Laboratory Aspects to trace back and study the products from affected patients. There are challenges with this response including the nature of the outbreak itself. Many states, some of the cases support using illicit product and may not be forthcoming. The marketplace for ecigarettes is wide and diverse with a multitude of product that may be very complicated to tease out problematic exposures. In Public Health Data Collection system in need of an upgrade. In terms of ecigarette use we are seeing an epidemic. I would be happy to go into more detail about that but our most recent data for 2019 is continuing to be concerning. I will leave you with this. Cdc is dedicated to working around the clock with fda and state and local Health Officials to identify cause or causes of the outbreak and will update you during the cost of the investigation. Thank you very much. I recognize myself or five minutes questioning. Anne schuchat, thank you for the work you are doing. The cdc has been clear it is not yet possible to determine the cause of the vaping related lung disease outbreaks. Cdc has recommended people consider not using any ecigarettes. From that we gather that nothing is off the table as a possible cause. Lets first describe the general types of ecigarettes out there. I understand there are two major categories. First, nicotine ecigarettes which have the focus of the subcommittees hearing up to this point and the second, thc ecigarettes replicate the effects, you are examining both of those types of products factors in the current outbreak of lung illness. Is it correct to say you cannot rule out either as contributing to the outbreak . That is correct at this point. We are getting new information in every day but very important until we know more that our recommendations be rod. Separate from this outbreak we are concerned about the rise of nicotine containing ecigarette use among youth which is epidemic. For this particular outbreak we dont know yet what the product or products are or whether component of the product that might be contained in both nicotine and thc containing devices. I want to focus on nicotine for a second. In illinois and wisconsin, almost 20 of the victims were using only nicotine ecigarettes and overall 61 of the victims were using, among other ecigarettes, nicotine ecigarettes as well. There may be people out there who would like this to be a thc only problem so they can go back to vaping nicotine ecigarettes. Almost 20 of victims are using only nicotine ecigarettes. Do we need to be concerned about all ecigarettes at this point . At this point the question regarding all products is recommended. It may not even be thc or nicotine part, it may be additives or substances that may be common. It may be material that is not labeled appropriately so we really do think consumers need to be cautious. You cant rule out any brand of ecigarettes. Nosing the brand, has been ruled out as of today. I would like to better understand the possible contributing factors to the outbreak you are considering. First of all on august 22nd, cdc said, quote, even though the cases seem similar it is not clear these cases have a common cause or if they are different diseases with similar presentations. Does that mean it could be multiple separate problems with ecigarettes causing similar results . Yes, that is right. The respiratory symptoms are very nonspecific and the xray findings are diverse. We also have nearly all states at this point, whether the products in one state are the same as problematic products in another or the manipulation of the products, we dont know. We have to have a very open mind. We dont know the full impact of vaping. If so many vaping products cause the same results, could be common link possibly be the process of vaping itself, inhaling aerosolized liquid particles into our lungs . We dont know enough about the aerosol vaping produces in terms of the short and longerterm Health Impact and products, it may be the process itself is risky. All ecigarette in view of solvents like vegetable they are considered safe in food, a recent study found those solvents when inhaled reduce the lungs ability to fight infection, increase chances of getting the flu and dying from it. Is in all ecigarettes, can the cdc will amount is a factor in the current outbreak . We have not without any substance within ecigarettes or vaping product. Money victims were using flavored products. To add flavor to any cigarette requires additional chemicals on top of the solvents we talked about. Can cdc rule out the chemicals and flavors as a factor in the current outbreak . Now we cant. I just want to remind everybody you took a farreaching one or admonition to the public, the cdc advises considering not using any ecigarettes. The cdc also advises those who do not vape not to start, children and pregnant women never use ecigarettes and those trying to quit smoking use fda approved cessation device. Ecigarettes are not approved by fda. With that, thank you and i recognize mister cloud for five minutes of questions. Thank you. Previously the cdc said the illnesses we are seeing are not a result of infections the Chemical Exposure. Do you maintain that . That distinction . Or is it possible Chemical Exposures can be reduced immune systems leading to infection . Part of the Case Definition is to rule out infection that they cause. People presenting shortness of breath and abnormal xrays often have an infection but in these episodes we dont believe infection is causing the problem. We think it is one or more. Do patients generally have symptoms after vaping . Do they appear later . We understand from the early reports there is a progression between days and weeks of worsening symptoms until the difficulties are severe enough for hospitalization. Nearly all the cases required hospitalization. Many of them required intensive care units and sadly several cases. You have been able to investigate some bylines. What i have read it seems like it has been very difficult to backtrack where a number of these products are coming from. This is a very active investigation. Fda is leading the product trace backs and they are working with dea in that effort. We are trying to gather information on products individuals have used, many used more than one product and they required a variety of retail, Online Sources on the street. When it comes to teen vaping do you have a sense of where teens are acquiring product . I dont have that data but we see a significant rise in the use of ecigarettes of teenagers, middle school and High School Students and one of the things we see in common is the role of flavors. The flavors are bigger tractor to teenagers and usually the first product people are using is flavor. In terms of where they are getting that i dont have the data. Sometimes it is just a friend or a p or. In most states it is illegal for teens to acquire vaping products. That is right in terms of ecigarette use is not supposed to be for anyone under 18. Is there any effort underway in the realm of enforcement prosecution for those who are getting product to teens . That would be the realm of the fda, the federal legislation. There certainly, the issue of access to products is a key barrier to the use of ecigarettes among youth and the stricter it is the better. We very much support making it extremely difficult for young people to get products they are not supposed to have. What are some of the recommendations you have when it comes to that . There are a variety of strategies shown to be effective to limit access for cigarettes or ecigarettes at this point. What issue is the advertising that is particularly appealing to use, that is a problem we saw with cigarettes decades ago and we are seeing again with ecigarettes more recently. Another is the retail sites require proof of age. There are a number of efforts in raising that we dont do but states collect strategies like raising the price as well as using efforts to educate in schools and so forth. Talking about product lines. Do you have any sense how much is coming from counterfeiting places from china when it comes to freight and airfreight and products coming in . Any hints of where the products are coming from . This is an extremely dynamic market. The legal market and the illicit market are both very dynamic. We have seen huge changes in market share for ecigarettes in the last couple years and i believe there is likely to be an illicit market in that market. I want to recognize congressman desaulnier for five minutes of programming. Thank you for having this hearing and for the work you are doing and being here. On september 6th the cdc issued the following statement during a press Conference Announcing this investigation, the investigation is ongoing, cdc advises individuals consider not using ecigarettes. As of now this is the primary means of preventing this type of severe lung disease and ecigarette use is never safe for use, a young adult or pregnant women. During the same press conference you announced you were setting up your Emergency Operations center. Could you describe to the committee what factors led the cdc to that decision of what kind of expertise will result from that . And given the lifethreatening emergency we are faced in, how do we make sure that we dont lose anyone else . This is a fastmoving and serious outbreak of a new condition in primarily young people. Cdc establish the Management System to respond to the outbreak and took the additional step of activating our Emergency Operations center. We have more than 100 people responding to the outbreak right now in atlanta and deployed to different states and we took the step of activation to better support the state and local Public Health on the front line of this. We have hundreds of cases being reported from across the nation in order to work efficiently and effectively with the state and the fda and others, the eeoc activation facility. Im from the San Francisco bay area. Juul is spending 40 million in overturning local ordinance by the San Francisco municipal government that merely says ecigarettes are banned until the fda comes up with the end of their investigation. Recently we had an executive and founder of juul from my perspective try to say ecigarettes, their product is keeping people away from tobacco. In richmond, california, in my district, they passed a similar ordinance. In the second panel, theres a preventative cautious approach, the product is misleading at best. What could we do further is congress to make sure this doesnt happen . The company in my view that has in the business of addicting people particularly young people and is willing to spend 40 million on the fda announced the Criminal Division is investigating them and i hope the investigator Political Consultants as well. They are shameless when it comes to in formation. Given that you are getting Public Health officials involved, given that this committee is actively involved, to try to make sure the public actually understands particularly young people who are vulnerable as you alluded to in your Opening Statements to advertise with this. I appreciate the committees interest that you have given to this. We know that youth should not use ecigarettes, nicotine is one of the most addictive substances that there is and nicotine is dangerous for the developing brain in adolescents and young adults. We also know that flavors are major attraction for young people and they often are the first ecigarette type the children use and the latest generation of ecigarettes has higher available nicotine level that is particularly addictive. The last few years of data, in terms of the epidemic i appreciate all the cdc is doing to address that. More Statutory Authority . When young people in life and death, will it be helpful for Statutory Authority not just to encourage people to use it but prohibit people using this until your investigation is done. The cdc doesnt typically have Regulatory Authority over this matter, the fda does. The fda is taking measures in light of this epidemic. The epidemic of vaping and injury. One of the key things that would help in this investigation in terms of the outbreak is modernization of our data systems that are really outdated, slow, the epidemic is moving faster than our data gathering and we are losing people in the meantime. I appreciate that. I asked the question to ask that the fda is moving too slowly. Or efficient if the cdc actually had the authority to say the product should be removed. Thank you, mister chairman. I now recognize congressman grassley for 5minute of questioning. How long have they been on the market . There are a number of different products and we are on the fourthgeneration. How many years . In 2011 we were working on a product and by 2012 there was a doubling of their use. First round market in 2011 . We started measuring. Excuse me, this just in. 2007. You said 80 of the people got sick from thc in their ecigarettes. How do you determine the substance . The information you are citing is based on individuals who said what they thought they were using, there has been some testing of products that are still available. You are the one who testified 80 of people got sick when you had thc in the product because thc is illegal in most states in the country and i assume some people dont volunteer they are doing something illegally. I wondered whether that is a hard number or closer to 100 because some people when asked dont admit they are breaking the law . The number you are citing is from an illinois wisconsin report in the new england journal of medicine about what a small number of patients prescribed use, we acknowledge individuals may okay. Next question. You guys report 72 of people who got sick were male. Could you tell me, ecigarettes overall, what percentage and what percentage our mail . More males by ecigarettes been females. It was a high number. The statistics on the proportion of these lung injury cases that are male has been decreasing as we get more cases reported to us. We will update those. You are right that so far nearly three in four of reported cases are like that. How about people who buy ecigarettes to prevent smoking . We have a way to prevent people, 400,000 people a year die and 10 years ago this was perceived as a good thing. Of people who buy ecigarettes. We know that ecigarette use is more frequent in young people than adults. I dont have a breakdown of those who are using ecigarettes. And most states thc is illegal but over time more states are legalizing marijuana in illinois rvs cartridges or these new things legal in states which legalized marijuana . The legal provinces in states were quite different right now. It is a very diverse one and i dont have specific for an individual states. I wish you would look into that. I am concerned. In illinois, making marijuana legal, whether the illinois statute will make these legal are not. The key thing about the investigation is the substance or additives linked to the cases in this outbreak. But you dont know . Which stuff . Thc cartridges. I dont know. I would like you to look into it as something we should know. Sounds like something. Could you explain, we dealt with these a little bit when i was in the state legislature. Why is this a new thing now when we never heard of it eight years ago. Do you mean you taping vaping or lung injury . People dying. We dont know, but we know the products out there have changed a lot and the use has increased but we dont yet know if there is a new particularly risky product or substance in the product, manipulation that is dangerous. There is a fourth generation of ecigarette products that might be related to this but we dont know yet why this is occurring in this particular epidemic. Thank you. I recognize congresswoman hill for five minutes of questioning. Anne schuchat, la county had his first reported vaping dev, the week before, a teenager began an antiabca10 campaign for hospital the government failed and she had to be put on a ventilator. Doctor davis compared the revelation of ecigarettes to the danger of cigarettes several decades ago. Across, you there have been 57 cases of acute lung disease among people with a recent history of vaping since late june according to state Health Officials. Parents, kids and adults are scared by the outbreak of lung disease sweeping the country and claiming lives. The cdc and state healthy permit, illinois at the forefront, working together to investigate the outbreak. As of a couple days ago cdc reported 530 confirmed and probable cases of lung disease in 38 states. Are those numbers expect it to grow as stated similar cases against the current Case Definition . We are seeing more cases each day. I expect the next weekly numbers will be much higher. How does the cds present itself . People have days of worsening breathing problems, cough, shortness of breath sometimes with fever or nausea and vomiting. What do we know about the time range for symptoms . We dont have a lot of details, maybe days or weeks. For those affected by the lung disease how long are they being hospitalized . The average hospitalization link so far is 6 days. Many are in intensive care. Many require hospitalization. How many patients require medical intervention . A large proportion. What has been successful in treating them . As of now we know antibiotics dont have an effect, consistent with the idea it is not an infection. Some are seeing improvement after use of corticosteroids or steroids. We dont have evidence yet about the benefits and risks but we do think individuals should consider use of corticosteroids in treating patients on an individual basis. Potentially inflammation. Thats right. The joint study by illinois and wisconsin found the median age of 19 years old and 32 of those affected are under 18. Why is this affecting young otherwise healthy kids . We dont have all the answers and as we gather more data, individuals who are older also at risk. We see half of the cases under 25. Deeply alarmed by the 9 dont think anyone reported last night, with a short span of its outbreak. And what we can do to avoid it . We are looking into that closely. We do expect more. That is one of the reasons we have been trying to get Health Recommendations out there. People who are concerned about their health risks for using ecigarettes are considered that. Is it possible this disease has been going on longer than we thought it is just being linked to ecigarette use . It is less likely that large scale we have seen this, we are seeing this to look back in time at Emergency Department visits and we have evidence that things started to pick up spring or summer but there probably have been individual instances we missed. When we think of families whose kids are vaping and we are deeply concerned this is one of the most important questions. When should someone go to the doctor and what information should they convey . If youve used these and you have difficulty breathing or cough or the symptoms we described you should talk to your doctor about that. We dont know how rapidly people progress but we are concerned about the cases we have seen in young people. We heard from some patients the doctors have not uniformly asked about vaping or juuling, do you think doctors need to change the questions they ask the patients . We recommend doctors not only ask about ecigarettes or vapor vaping products. It is important to educate themselves about the products out there. They are told they do we know whether the outbreak will result in longterm or permanent lung damage . I fear that it may but we dont know that and we recommend clinicians do regular followup of individuals, the biologist and so forth are studying patients and it is so new that we dont have longterm followup. I yield back. Thank you. I now recognize congressman comer for five minutes of questions. I want to talk about cbd because i believe there is a lot of misinformation and confusion about what cbd is and what thc is. Cbd is canada diol and it is something a lot of people take. A lot of people in Congress Take cbd. Millions of americans take cbd. I take cbd. These are two of the cbd product i take and i will talk about that in a minute. There are two sources of cbd. Hemp and marijuana. Hemp and marijuana are two different plants in the same family like broccoli and cauliflower. If you can imagine what broccoli and cauliflower look like they have some similarities but they are also very different. That the way it is with hemp and marijuana and the nearest thc, thc is an acronym that measures the level of psychoactive material in cbd. So if you look at cbd, the majority of cbd most americans are taking and they are having really positive affect coming from hemp, not marijuana and the hemp cbd has little to no thc. That is something there is a lot of confusion when i hear people talk about cbd and thc. Prior to coming to congress i was commissioner of agriculture in kentucky. We were the first state, this was something platforms for mine when i was elected commissioner of agriculture to make Industrial Hemp a reality in america. We werent growing hemp in america. America was only industrialized nation that didnt grow Industrial Hemp. In kentucky, we became the first state to grow hemp. Can take kentucky is the leading hemp producing state in the nation. There are at least 15 hemp processors in kentucky that are making cbd. I have been in these two products i take, i have seen their labs. And producing a good legitimate product. We vote for the industry to be regulated. There is no fda regulation on cbd oil and the legitimate, credible companies on regulation. I have worked with congresswoman pressley and we had a bipartisan letter for other members of congress, both parties asking fda to hurry up and issue fda regulation with respect to cbd. Juul does not sell any cbd pods. All their pods are nicotine pods. The success that happened in the death that came from cbd from people juuling or using ecigarettes were counterfeit pods and the people that were using these pods not only were counterfeit but they dont know what levels of thc they were putting in the pod because there was no regulation. Ere was no regulation on it. It is a good industry, it is a good product, but there need to be regulations. Normally i am a guest weulations, but sometimes need regulations. A young man in my district was recently hospitalized from vaping cbd with an excessive amount of he bought the pods from a friend. They released him from the hospital. He got sick again. It was hospitalized again with a collapsed lung and had to be put on life support. I ask unanimous consent this articleha detailing my constituents story bee inserted into the record. Without objection. The ap has tested 30 Paper Products over marketed containing cbd and found 3 ten f the 30 contained synthetic marijuana, 22 of the 3030 contained very little or no cbd. The cbd, the cbd producing in my Congressional District has no thc. Zero thc. Theres a lot of misinformation and confusion about cbd that i wanted to make sure that everyone understood. The Associated Press also reported on testing that the dea had done and found 128 of the 350 cbd products they tested contain synthetic marijuana. Three of these tested products contain fentanyl. So, try to asking unless consent the two articles from the Associated Press be inserted into the record. Without objection. And mr. Chairman, if io may conclude by saying that i think there is, there are a lot of positives, positive benefits from cabot oil but this Industry Needs to be regulated. This industry is very prevalent in my Congressional District, and they want regulation to make sure there are no bad actors come to make sure there are no flybynight companies that are coming in producing the oil with excessive amounts of thc. Thats something that im working on. Chairman Collin Peterson in my Congressional District sunday visit some of these processors. Our offices what with usda and fda to try to see that we have good regulations that protect the consumers while helping the industry grow. Thank you, mr. Chairman. I yield back. I now recognize five minister questioning. Thank you, mr. Chairman. And thank you for your leadership on this issue. Dr. Schuchat, is a true 28 of the nations reported vaping nicotine of us oncegr in the pat 30 days . Those data are from the preliminary result of the 2019 nationale Youth Tobacco survey. The final results are not available. Is a statistic analysis the found for one smoker that successfully quits thanks to ecigarettes, 81 jan ecigarette users will become traditional cigarette smokers . I dont have that statistic but what i can say is that ecigarette used is much more frequent among young people than it is among adults. Are you smarter people use ecigarettes end up going and using regular cigarette . Thats right. The National Academy of medicine looked at that in terms of whether ecigarette use may lead to tobacco, lead to smoking cigarettes and theres moderate evidence about that. The newest generation of ecigarettes isnt really covered under that study and the news generation seems to have a number of factors that make it even more addictive are even more popular among youth. We dont really have a longterm followup on that. On september 11, twinengine, President Trump announced a ban on flavored ecigarettes. Finally did something i agree with. And it has been implemented yet at the fda. My understanding is the cdc came out in strong support of the flavor band. With the director stating its needed to reduce the epidemic. Washington the Third Political place, and so nowl you have the president s advisors telling him that this is going to hurt his reelection in battleground states because there are hundreds of thousands of people in battleground states. What would you tell the president about that argument that his advisers are making and whether he should stick to his original ban . Let me just s say that the regulation of Tobacco Products is under the fda, not the cdc. As a Public Health expert and the leader at the cdc, i can say we are extremely concerned about flavors and the role they play in hooking young people to life of nicotine and that we really want to avoid another generation being addicted to nicotine. So addressing flavors directly is ago good idea in terms of the role they play in young people particularly middle school and High School Students beginning to use ecigarettes. On a substantive level i what you and to the for people say we agree with you on children not having these flavors and thats why i support a ban and thats why what people support a ban, but what you say adults should do the want to transition off cigarettes . Are there ways they can still usee ecigarettes without the flavor with only the tobacco flavor . Is or any evidence to suggest it would diminish their ability to reduce their addiction to cigarettes . We dont think flavors on the critical factor in ecigarettes for adult who are trying to get off of smokingr cigarettes. We think the nicotine level is the principal issue there. We encourage adult to quit smoking and use fda approved devices or approaches to do that, behavioral counselors also recommended and theres emerging data that is being looked at about the role of ecigarettes. None of the eCigarette Companies havebo applied fda toe approved as a cessation device as of yet. So would it be fair to say then that you do not think banding flavors in ecigarettes would in any way harm adults who seek to quit regular cigarettes by using ecigarette products . I think the way youre characterized that i would agree with. I have no further questions. With the gentleman yield . I dont. Dr. Schuchat, generation devices. What are those . What im trying to imply is related prodigies nicotinehe salts which can leado much more available nicotine. We believe they can cross, the product can cross the blood brain barrier and lead to potentially more effect on the developing brain in adolescents. And when was this fourthgeneration introduced in the market . The juul itself was 2015, but the market share really ratcheted up more recently. So the 2018 data was 78 higher than 2017 for High School Students, and the preliminary data is even higher for 2019. Thats based on the fourthgeneration device really taking off . Right. We know juul but up to over 70 market share more recently than 2015. 2015 had a tiny marketshare tiny market share. Okay. Thank you so much. I now recognize ms. Miller for five minutes amu question. Thank you, mr. Chairman, and Ranking Member cloud, thank you for venturech today. There are two key issues that we must keep in mind surrounding ecigarette usage. First, we must do everything we can to keep ecigarettes out of the hands of those poor under age. Secondly, we must also recognize ecigarettes Critical Role in Harm Reduction. We can both prevn from using ecigarettes, while also ensuring that there remain available for those adults who choosing to quit smoking and trying to do it through such a mechanism. We have to Work Together with our federal agencies to curb the online procurement of ecigarettes, pods and vape fluid by underaged individuals. Unregulated black market doesnt have any of the protections for those to use their products and or pose a safety risk and they pose a safety risk for the public. I understand that there are companyies who sell in the United States that have taken a proactive and positive step to prevent underaged individuals from procuring their products both online and in stores. Dr. Schuchat, can you first discuss the dangers of buying illegal or counterfeit vape Products Online . Dr. Schuchat we think it is really critical to know what you are using, and it is very difficult right now in terms of Online Purchases or off the street purchases, or getting products from a friend, to know what you have. We also know that labels may be misleading and counterfeited. So right now, the products are , and vastly changing, and it is really one of those errors where consumers have to be aware. We do think that Retail Stores giving you to be enforcing the rules about not selling to underage individuals, and we companiessure that are not marketing to youth directly or indirectly through influences on social media. There has been a lot of evidence that a that are attractive to use help themds begin ads that are attractive to youth help them begin. Testing found that some black market dhc cartridges contained more than 30 vitamin d acetate come and some just positive for pesticides. What would substances like this do to the lungs of an unsuspecting user . You point out a couple of different substances that nobody would want to have in the middle of their lungs. Right now we are working vigorously on trying to understand what other products that individuals who come down with this lung injury use, and what was in them in a lot of other products. So the fda laboratories are working very hard on that issue right now. Rep. Miller is that something that the cdcs monitoring right now, isnt it present in those cases . Dr. Schuchat we dont have full data yet. It is important to know that there may not be much remaining product from an individual who may have used up the pod, and there may be differences in what you measure in the pod, and what the lungs are exposed to when the substance is heated to a very high temperature. So there are sophisticated studies going on to try to analyze both the product, and potentially the vapor or the aerosol as well, so we cant say that any particular substance has been linked to all cases or a majority of cases as of yet. Rep. Miller is there a name of this disease people are getting . Dr. Schuchat we are calling it lung injury associated with e cigarettes or vaping. Its not particularly catchy, so we dont have a name thats shorter yet. Rep. Miller lung disease. Dr. Schuchat were saying lung injury because it really looks like an injury, not a longterm disease. Like emphysema. Of course, longterm, there may be consequences of the injury that were seeing. Rep. Miller isnt it true that counterfeit products sometimes design their packaging to look like legitimate manufacturers , and is the cdcs seeing cases of pulmonary illness coming from these counterfeit products . Dr. Schuchat i dont have information about counterfeit products, but thats exactly why counterfeit products make labels to deceive the consumer. Rep. Miller okay. I yield back my time. Thank you. Krishnamurthi i now recognize congresswoman pressley for five minutes of questioning. Rep. Pressley thank you, mr. Chairman for your leadership on this committee on this Public Health crisis. I heartened to see the am bipartisan interest and commitment to address what is a fastmoving outbreak and am hopeful we will show similar and equitable outrage when it comes to gun violence, which is also a Public Health crisis. Dr. Schuchat, thank you for being here, and rank you for your efforts in addressing this outbreak. I wanted to revisit the line of questioning from representative khanna in talking about the trump administrations intent to ban all th ecigarettes from the market. It states that mint and menthol will be included and i wanted to get this answer on the record. Mint and menthol are, of course, flavors, correct . Dr. Schuchat correct. Rep. Pressley yes or no. To be effective, do you agree the ban needs to include mint and menthol . Dr. Schuchat yes. Rep. Pressley thank you. Im encouraged on banning flavors especially as flavors continue to be a main driver of why youth are using these products. I want to do a special bit of acknowledgment, my home state, the commonwealth of massachusetts, our attorney oferal, and leadership cities like summerville and cambridge. Even where 63 of juul users ages 15 to 25 have no idea the product contains nicotine, they think it just has flavors. A dangerous misconception considering all juul products deliver nicotine and according to the companys website, a single juul pod is e equivalent to smoking one pad of cigarettes. Are you familiar with term nick said . Dr. Schuchat no. Rep. Pressley what about nicotine poisoning . Dr. Schuchat yes. Rep. Pressley can you describe how these syndromes might present themselves in children with a high intake of nicotine . Dr. Schuchat the variety of things that can occur is scary. The specifics, i will probably have to get to you. But we are aware of a number of poison control calls related to ecigarette use and overdosing, if you will, and then in terms of usurers having been reported as adverse events. But for the specifics, i would have to get back to you. Rep. Pressley what impact are the harms of high dose nicotine when it comes to adolescent development . We talked about how it might more acutely present, but whats the impact on development . Dr. Schuchat the concerns about the developing brain in adolescents are that nicotine can lead to difficulty with memory, learning, and attention. Andan also prime the brain the body for addiction to other substances, and that is a particular concern. Rep. Pressley i am curious, have any other states observed improvements of any of the 530 cases since they fell ill . In other words, are you noting any improvements for those that have been diagnosed with a lung injury . And what best practices would you recommend to states and homt hospitals as they begin to track longterm impacts . Dr. Schuchat we know that in small numbers, the use of steroids during treatment may improve outcome, but we dont have Scientific Data or large scale numbers yet on that. Were recommending now that clinicians individualize care, but they consider the use of steroids in terms of its benefit and its potential harm since sometimes steroids can be risky if you do think theres infection going on. We also recommend that clinician clinicians follow patients after discharge including with pulmonary function tests to see whether the lungs really come back fully to what you would expect in an otherwise healthy young person and clinical communities are gathering the day the to come out with more official recommendations. Chairman krishnamoorthi thank you. Will the gentlewoman yield her time for questioning fourth the issue is easier access of nicotine topo the brain, may hae more,gh high risk of leading to the issues i mentioned, the learning difficulty, the attention problem. Memory issues. And so as well as priming for addiction. I think the brain is pretty central an issue of addiction as well as in cognitive functioning. And were concerned that higher dose of nicotine getting into the brain may lead to larger problems. That fourthgeneration is not just juul but its the other pod mod combos. The devices, they are ones that are very easy to conceal. You can have them in the classroom. The teacher doesnt even know that you are using the ecigarette. So between the very high levels of accessible nicotine and the discreet use of the products, we think that the rise in teen use is particularly dangerous. Chairman krishnamoorthi thank you. I know recognize Ranking Member jordan for five minutes of questioning. Rep. Jordan thank you, mr. Chairman. Doctor, 530 cases and then is it accurate deaths as well have , eight been thats associated with the lung illness and vaping . Dr. Schuchat yes, its even more than that now, but well be updating the official numbers on thursday. We believe that probably hundreds more have come in since the numbers we released last week. Jordan no additional people passed away, right . Dr. Schuchat there may when a death occurs, the state investigates to identify whether they do believe its related to this condition. And then they report to us and so we let the states report publicly before we report on the amassed number. I think were above eight at this point. Rep. Jordan ok. Lets stick with the numbers 530 and 8. You said this about the 530 case cases. Most patients have reported a history of using ecigarette products containing thc. Many have reported using thc and nicotine. Some have reported the use of e cigarette products containing only nicotine. Most, many and some. If i get the distinctions right. Can you give me percentages on each of those . So, most of the 530 have used e cigarette products with thc. What is the percentage is that . Dr. Schuchat actually, those terms are related to the very small number that had been described in the illinoiswisconsin series. This is really about less than 50 cases. Most were about 80 , many was about 60 , and some was less than 20 . But we will be updating the numbers. Rep. Jordan you dont have the percentages on the 530 . Just on the smaller population sample in illinois and wisconsin . Dr. Schuchat thats right. Rep. Jordan any guess at the 530 . Would you think it would be similar . 80 have used, do you think it would be similar, that 80 of the 530 cases were using the thc . Dr. Schuchat the trend continues in the preliminary numbers, but i dont have the precise, final numbers yet. So i do believe that the majority report use of thc or thc and nicotine products. Then, ofan and course, there is the issue that the gentleman from wisconsin raised that the people who say they on the used ecigarette products containing only nicotine may not be totally forthcoming, that they may be fudging a little bit on that. Dr. Schuchat absolutely. Rep. Jordan ok. So it could be potentially that this thc is linked to all cases of a health concern. Now do you have the data on the eight people who have passed away . Do you know if it was, do you have any data on those, or theyre using thc or not . Dr. Schuchat i dont have that data, but a really important point is that it may not the thc or the nicotine, but it may be something associated with those products that people are using. Rep. Jordan you just dont know yet . Dr. Schuchat right. Rep. Jordan okay. Now you also said you talked about the epidemic at the youth level particularly high school level. What were the numbers and i agree, i dont want any kids using this product, a bunch of other things are there, but what was the number of High School Students were using the product . Dr. Schuchat the preliminary data that was reported from the fda preliminary look at 2019 data was about 28 of High School Students reported using e cigarettes, which is a big jump from about 20 the year before. Rep. Jordan that is. Do you know the numbers for High School Students who have used marijuana . ,r. Schuchat it is less common but i dont have the numbers right in front of me. Rep. Jordan my understanding is that it is over 20 as well. Is that right . Dr. Schuchat i think you need to differentiate numbers used in the past year versus the past month. The numbers i was giving you for ecigarettes was used in the past month, but i dont have the numbers for marijuana. Rep. Jordan is it over 20 as well . Dr. Schuchat i dont know. Im sorry. Rep. Jordan okay. Okay. I mean, i figured it was. I just was curious on some of these numbers. It seems to me we got an epidemic with marijuana use, vaping, all kinds of things and we should be talking about all of those issues that are of concern to for young people. With matt, i yield back, mr. Chairman. Actually, sorry, i did find the number. I knew that i had seen it. The number that i have for adolescents use of marijuana is 12. 5 in the past year. So a bit less than the 28 in the past month for ecigarettes. Rep. Jordan ok. Chairman krishnamoorthi mr. Jordan, would you yield your remaining 14 seconds for questioning . Okay. Dr. Schuchat how many of them were related to fourth generation devices . Dr. Schuchat i dont have that data yet. Chairman krishnamoorthi okay. Thank you. I now recognize congresswoman talib for five minutes of questioning. Rep. Tlaib thank you, mr. Chairman. Earlier this month, my home state of michigan became the first to ban flavored e cigarettes, this after news of ecigarette smokers showing up in Emergency Rooms with shortness of breath, chest pain, coughing, vomiting. Nationally, we have seen as we have repeated, at least 530 cases of lung disease in 38 states, users in and it exposes just how little we know about these products. Nicotine ecigarettes were allowed onto the markets with regulation, and advertises better practice of ecigarettes. In truth, i believe we have become a testing ground, most notably our American Youth, and there is so much we dont know about the longterm impact of ecigarettes. But what we know now currently is pretty alarming. Believechat, why do you ecigarettes have not been improved as cessation methods . Because they are advertised that way. Dr. Schuchat to my knowledge, the companies have not submitted the data in support of getting them approved as cessation devices . Rep. Jolly so why . Dr. Schuchat the Companies Need to answer that. The companies would need to answer that, but it can be a costly process and it may be that they would also need to describe the Public Health standard being met and that may be difficult at this time. Rep. Kelly yes or no. Is it ever safe for kids or young adults to use ecigarettes . What about traditional cigarettes . Dr. Schuchat no, and no. Rep. Tlaib the c. D. C. Has stated that ecigarettes harm the part of the brain that control attention, learning, mood, impulses. Could that account for why weve heard so many teen juulers complain about mood swings, spouts like anger, depression and trouble concentrating . Dr. Schuchat well, theres a lot going on in adolescents, but it may be part of that. Rep. Tlaib we have also heard from many people who believe ecigarettes were safe and its easy to see why as weve continually see the misleading and analyze to the American Public. Earlier this month, we wrote a letter to the fda outlining our finding of instances of juul , telling the public that its products were safe. They included testimony at our went torings but juul schools and told night graders that its products were totally safe. They used the word totally safe. We were pleased to see the fda answer our call by declaring that juul broke the law and issuing a warning letter, they gave them until september 30 to respond. To those listening, please Pay Attention to that response and what we hope will be prompt action by fda to hold juul action by fda to hold juul accountable. Dr. Schuchat, the c. D. C. Has asked the public to consider not using ecigarettes. Has the industrys false safety narrative made it more difficult to get your message out . Dr. Schuchat we know that there is a lot of noise out there, and have been repeating our messages. We hope the seriousness of the disease, including death, is getting attention, but there are a lot of competing messages. Rep. Tlaib as much as eCigarette Companies imply they are a smoke Smoking Cessation products, none are approved by the fda for that purpose. The c. D. C. Has recommended that adult smokers to quit smoking should instead use evidencebased treatments, including counseling and fda approved medications. Has there ever been any outbreak of lung disease associated with fda approved devices like patches and gum. Dr. Schuchat not to my knowledge. Rep. Kildee thank you so much and i yield the rest of my time. Chairman krishnamoorthi thank you, congresswoman talib. Without objection, miss watt wassermanschults. Gentleman from florida will be permitted to join the committee and is promoted to asked questions for five minutes. Rep. Wasserman schultz thank you, i thank the committees indulgence for including me. Doctor, welcome and thank you so much. Ive had the honor of working with the c. D. C. On a number of different important initiatives and work of you and your colleagues is really remarkable. I want to ask you a couple of basic questions and a few ill illustrative ones. Is there evidence that nicotine addiction is harmful to an individuals health . Dr. Schuchat yes. Rep. Wasserman schultz could you elaborate . Dr. Schuchat were particularly concerned about nicotine use in youth, in women who are pregnant or more and in adults who are not using already using cigarettes. The issue is the developing brain. The developing fetus. And the risk of going on to cigarette smoking. In the developing brain, i think its key most people dont realize, the brain continues to develop until age 25 in most people. And nicotine can cause many problems. Including difficulties with attention, memory, learning problems. It can also prime the individual for addiction to other substances. Rep. Wasserman schultz i asked you that because sometimes you ask a question that you already basically know the answer to, but as a parent of twin 20yearolds and a 16yearold, having children and young adults in the target audience for these vaping products, thats Important Information to note. Particularly in light of the fact that we had juul executives testify here in what i found to be a very deceptive way including a direct answer to a question of mine in which the juul executive that sat where you are sitting actually had the audacity to say they didnt market their product as a smoke Smoking Cessation product splitting hairs between the idea they are a safer alternative to smoking, versus marketing it specifically as a Smoking Cessation product. That, to me, is a distinction without a difference. So having neck spurt, a Public Health expert actually say that no Health Benefits to nicotine, in fact, nicotine addiction is harmful, particularly to the developing brain, is critical. Particularly because we have a very real human impact of this outbreak and i think its important that it not be lost. There is a story that i want to share of a mother of three in abilene, texas. Sheree, who nearly died from vaping. She had never smoked cigarettes before. She tried ecigarettes because she liked the taste of the flavors, and she became addicted. She initially thought she had the flu, but within days, she had to be rushed to the emergency room and put in a medically induced coma. There are now countless people who have had to be put into toically induced comas due the impacts of vaping and she spent nearly a month in the hospital. She was a nonsmoker drawn to ecigarettes by their flavors. Is there evidence that you found that other nonsmokers are being drawn in by the attraction to flavors . Dr. Schuchat yes, thats right. Among youth right now, were seeing that ecigarettes are more common than cigarettes and that flavors are pretty much always what brings the youth in. Rep. Wasserman schultz and you think a ban on flavors of any type would bring a dramatic reduction to to people who either might be attracted to begin vaping or if they were no longer available have people cease to vape . Dr. Schuchat we know flavors are a attract attractant so i hope if flavors were not there, fewer people would take the product up in their teen years. Rep. Issa rep. Wasserman schultz ecigarette use is still relatively new. I support Harm Reduction Public Health activities, advocates often describe ecigarettes as a Harm Reduction for cigarette smokers. Im concerned that we dont actually know enough to say with confidence that ecigarettes reduce harm and in fact, there have been juul is being federally prosecuted because of their criminally deceptive practices. Can you talk to us about the challenges of being able to accurately assess the safety of ecigarettes . Dr. Schuchat the products have been changing quite a bit over the past several years, so the shortterm effects might have been looked at, but the longterm effects, we dont know yet. The aerosol ecigarettes have can have a lot of substances in it, and the longterm effect we just dont know. Rep. Wasserman schultz its not just the nicotine thats the Public Health problem and the threat. So, i mean hyperfocusing on , nicotine or any other substance that is found to have been mixed in with all of the other chemicals that could be harmful and likely are harmful, is misleading. At best. Dr. Schuchat mhmm. Rep. Wasserman schultz thank you. Thank you for your indulgence, mr. Chairman. I yield back. Chairman krishnamoorthi thank you. Now i recognize congressman cox for five minutes of questioning. Rep. Cox want to thank chairman murphy, cloud for allowing me to i want to thank chairman krishnamoorthi, and Ranking Member cloud for allowing me to waive on to this very important hearing. As youve pointed out, the recent cdc effort show that at least 500 people have experienced vaping lung related injuries and at least eight people have died. I represent the Central Valley of california. One of those most recent deaths was from one of my communities. I am troubled to hear that we have yet another Health Crisis in our hands, and this one is a special threat to our children and our families. We need to know why that has happened. We need to understand what your agency is doing to combat this epidemic, and certainly, we need solutions to prevent this from happening again so not one more american dies needlessly. I understand that your agency is in coordination with others. Last week there was an individual who was struck by this disease. We called to see what happened to this individual, and they didnt have much information. Im concerned about the collection efforts were from using the product. No disrespect, but to me that sounds like pretty weak key. Would you be more accurate to state simply that the use of the product could cause of death . Were trying too be careful when we dont know what the substance thats at risk is and were trying to sustain credibility against those who may think were exaggerating. We know people are dying right now in this outbreak of lung injury and we want people to protect themselves and not take risks unnecessarily. Im sorry, dr. Schuchat, but im really looking for yes or no answer. We to be accurate to state use of this product could cause death . This product part is hard to say. One of these vaping products. Right. Our recommendations are very broad, because somethinge thats in ecigarettes or other vaping products is leading to death. So use of whatever that substance or brand or attitude is can cause death. So yes, i think you, is right. When we dont i have specific product, consumers may not take action so were trying to make them takeou this seriously in te way they would believe us. I think the admonition that it could cause death could be aa warning that they should take seriously. Really, more and a broader sense is regulations in my mind i really i really protections. When this administration boasts ofdm regulating things which really happening is that protection of being eliminated and these deaths could be prevented if we enforce preventive Public Health measures, evaluating the product before they hit the market, especially products with known products like nicotine. So the question is why is the default procedure forto letting products into the market first and then evaluating whether or not they present a Public Safety or health risk . I dont know. All right. True, right . I can tell you is that do you think that any product delivered through inhalation should be rigorously evaluated before marketing . Yes. Thanks. I can tell you that the cdc in c this regard in my patent h to find its voice again and we in congress are committed to helping you do just that. Further, some of the specifics about what the cdc is currently doing, id like to know a little bit more about the individuals that have gotten the confirmed lung illnesses from ecigarettes and although very little is known about the longterm Health Consequences of using these products, what is the cdc going to do about tracking the consequences and so on . The individuals who have a condition rightht now, majority, are male, half are under 25, many are previously healthy. We are just gathering the data now in more detail but were working with a Clinical Community including lung specialists to try to understand what longterm followup should look like and how that information should be collected. We are also working with the nih in terms of some of the research questions, but the pulmonary community may help come up with guidance for systematic evaluation and followup. Thanks so much. We really appreciate what you and the cdc are doing on our benefit. Thank you, dr. Schuchat. I think that concludes have one and we will now commence panel two. Thank you again for your testimony. Id also like to remind everybody the witnesses are reminded there may be additional question for the record and the Committee Requests you answer them promptly. If the second. How could please come forward. We are pleased to have you here. Thank you so much. We began our second panel here. We have dr. Ngozi ezike, director of the Illinois Department of Public Health. Thank you. Dr. Albert rizzo, chief medical officer of the American Lung association. Ruby johnson, that parent of a teenager affected by ecigarette related lung disease outbreak, will yield to my colleague mr. Grothman two introduces constituent. [inaudible] id like to take this opportunity to introduce a good friend from wisconsin, a passionate advocate for tobacco Harm Reduction. Shed helped countless people smoking my sharing her story. Vicki porter. Thank you so much. If you would all please rise and raise your right hand i will begin by swearing you in. [witnesses were sworn in] let the record show that the witness is answered in the affirmative. Thank you, and please be seated. The microphones are sensitive simply speak directly into them. Without objection a written statement, written statements will be made part of the record. With that, dr. Ezike, you are now recognize for five minutes. Chairman, Ranking Member cloud, distinguished members of the subcommittee, thank you inviting me to discuss this very concerning situation where hundreds of people across the country including 69 in illinois have experienced severe respiratory illness after vaping or using ecigarettes, tragically there has been one death in illinois. An additional suspected cases are being reported to the department every day. Our patient in illinois have ranged in age from 1542 with a median age of 22. The majority of the patients have been male, representing many counties throughout the state, both rural and urban areas. Over 95 of our of our cases have required hospitalization. Threefourths have needed placement into intensive care unit, and over a third have quite mechanical ventilation. While we a have yet to clearly define the causative agent, what is clear is that there is nothing healthy about vaping and there are heightened consequences for youth. Dr. Schuchat has covered the details of the outbreak and its imperative that Investigation Continues so as to definitively identify the etiology of acute illnesses, but there is anothr matter that needs to be addressed if we need to address that in payable to the illness investigation and that matter is the youth vaping epidemic. Perhaps Public Health should have run the alarm even louder as the epidemiology showed rising rates of vaping. Even so, the current investigation has highlighted the creation of the next generation of nicotine addicted americans. Ecigarette use increased 900 amongst middle and High School Students from 20112015, according to a june 2018 report. The 2019 national Youth Tobacco survey showed 68 of youth vapors use flavored ecigarette products. In december 201818, the u. S. Surgeon general did discuss these alarming trends, noting research that found that more than 3. 6 million youth were using ecigarettes. Action is required now to protect our youth. I have led youth focus groups in this state and have heard recurring reports of symptoms that depict nicotine withdrawal in middle and High School Students, many had been vaping for as little as three to six months. We must permanently change the narrative around vaping and ecigarettes. Ecigarettes are harmful. They are highly addictive, highly addictive because they are so efficient at delivering nicotine directly to the brain. And nicotine has no redeeming qualities for youth and young developing brains. In 2018 traditional cigarette smoking among illinois Higham School seniors was down to 5 . But also in 2018, ecigarette use was already at 27 among High School Students. Our top priority has to be keeping these harmful products out of the grasp of our nations youth. Most youth that are currently vaping never smoked traditional cigarettes beforeef they took their first hit on ecigarette. Contemporary product designs, attractive technology, they can sync up with her iphones. The merchandise, all of this is targeted to youth. There are ads one snapchat. There are hoodies that allow the wearer to take a hit from their ecigarette using the drawstring of the hood. Clearly a tool to conceal the vaping. We cannot stand idly by and watch the hightech ecigarette erase the progress against Youth Smoking, with enticement to the marketing of trendy devices, cool accessories and flavors like strawberry, watermelon and mango. In the state of illinois, the governor supports moving forward with strong and effective legislation too ban flavored vaping products. Which are exceedingly popular amongst young people. We need revised healthav curriculums in elementary and middle school to discuss the dangers of vaping. I urge congress toit take similr initiatives to protect our youtl and to support our message urging all people not to vape, especially while this National Investigation is ongoing. Thank you. Thank you, dr. Ezike. Next is dr. Rizzo. You are now recognize for five minutes. Mr. Chairman, Ranking Member cloud, and members of the committee. Thank you for the opportunity to testify today. Im dr. Albert rizzo, chief medical officer of the americann lung association. I still see patients in my pulmonary practice and deliver a privilege to be aon to speak abt the dangers of ecigarette use. For more than a decade the American Lung association has been raising the alarm about ecigarettes. We will continue to reiterate our recommendation that the public not use any tobacco product including ecigarettes. Our nation is currently in the midst of two different ecigarette prices. First, according to the 2019 National Tobacco youth survey, 27. 5 of youth are now using ecigaretteses which is 135 increase from just two years ago. Ago. According to cdc study one of the primary reasons teenagers use these products are because the candy and food flavors are so appealing. This i use flavored ecigarette among use this alarm requires urgent and immediate action. The American Lung association mens President Trump for the announcement that the fda will remove all nontobacco flavored ecigarette from the marketplace. We believe this this is a vitad positive step to address the epidemic and we urge fda and congress toe act. The second Health Crisis is the current cluster pulmonary illnesses related to vaping. As weve heard today cdc and state and local Health Departments areth conducting an Ongoing Investigation of these pulmonary related illnesses due to vaping. Both crises are caused by the failure of two different different administrations to fold them in the Tobacco Control act of 2009 and protect the Public Health. The delay fda to implement Tobacco Control act has t left unregulated products with unknown chemicals on the market. Some of the chemicals found in ecigarettes are carcinogenic. With the use of ecigarette cause cancer . With the inhalationre of chemics cause lung diseases such as copd . How do ecigarettes infect people with asthma . The latest question is what will be the longterm Health Consequences of those who have been hospitalized as we deal with the pulmonary ecigarette operate. The Surgeon Generalre released e first report on Health Hazards of smoking concluding smokingud cigarettes caused lung cancer. 50 years later the Surgeon General 2014 added even more smokingrelated diseases. Its hard to predict the possible Health Consequences we will see another 50 years from the result of ecigarettes. We are troubled by what we see so far. Ecigarettes contain nicotine in addition to being extremely addictive it can increase blood pressure, heart rate and according to cdc nicotine use among youth, adults can alter brain development, cause memory and learning problems. Two of the other ingredients found in ecigarettes can expose you to high level of toxins and these chemicals can cause irreversible lung and Heart Disease. Flavors attract kids which is why the American Lung association has long advocated for the removal of flavoredTobacco Products from the market. According to the study, 81 of youth who have averages Tobacco Products initiated with a flavored product. The American Lung association believes are going to use Tobacco Productsey can quit if they use proven, safe and effective drugs by the fda. The fda has not had any ecigarette to be safe and effective in helping smokers quit. We are often asked about a study from earlier this year in the new england journal of medicine compared ecigarettes to nicotine replacement therapy. Over 90 of the smokers using nicotine replacement therapy quit smoking. In contrast, 80 smokers using ecigarettes did not quit but switched and instead remain addicted to ecigarettes and, therefore, nicotine. Switching is not quitting. Quitting means ending her addiction to nicotine which can be difficult. I have patients a switch to ecigarettes believing they had quit. Some remain addicted to nicotine, some have been doing users and some have returned to regular cigarettes. In conclusion, the American Lung association support President Trumps called in flavored ecigarettes. Ecigarettes have been shown to be safe. They are responsible for the possible loss of another generation of American Youth to tobacco use, death and disease. Thank you for the opportunity to testify and ill be happy to take questions later. Thank you, dr. Rizzo. Next, we have ms. Johnson. You are recognized for five minutes. Thank you so much for having me. My name is ruby johnson and im a mother of seven children ranging from 18yearoldld colle freshman all the way down to a fiveyearold kindergartner. I do to tell you about the biggest blessing in my life which is a fact my oldest child is still alive. As you will hear, they could easily not beenha the case. On august 16 i loaded up our daughter and all the makings of a dorm room to driver from illinois to colorado to begin her freshman year of college. As we said that she began to cough, complainant pain in her chest when she took a deep breath and shiver like she was running a fever. She also admitted to me that she had been vaping. What started as an exciting rite of passage turn into a terrifying your death experience that involve a weeklong hospital stay where my daughter went from a healthy, vibrant 18yearold to a patient who needed rapid increasing amounts of oxygen and medications to treat her declining health. When we arrived in her college duncan we went directly to the hospital. She was nauseous, tachycardic, coughing, running a high fever, couldnt take a deep breath without intense pain and struggle to keep her oxygen saturation up to even the mid80s. A ct scan showed what the doctors called a diffuse pneumonia all over her lungs. Though antibiotics were appropriate for pneumonia were started immediately, or condition continued to worsen as her oxygen needs increase steadily and she was transferred to the icu in case more extreme measures n to help her picking necessary. With every dr. King the same question, have you traveled out of the country recently . How you had a cold . And the milliondollar question, are you smoke or . The answer was no. Finally the as, how about ecigarettes . Her answer to the question was if yes, that was until we got to the third doctor to see her that it actually seemed to be taken seriously. It was that doctor paid attention to the fact she said shed been vaping and she was not expecting symptoms that matched with the new reported cases of the mysterious lung illness popping up. He did his research by contacting doctors and hospitals that already seen similar cases in order to determine the best course of treatment. Ill never forget watching her cry ast she literally couldnt breathe without excruciating pain as she was pumped full of iv fluids, antibiotics, steroids, pain meds, at that nausea meds, and a diuretic to clear fluid from her inflamed lungs. She couldnt even get up to walk to the bathroom without her alum screaming because oxygen saturation was dipping solo. Her belly was dark purple from the nightly injections they gave her to prevent blood clots patiently in a hospital bed. Our daughter ended up being one the lucky ones in this case because you got to leave the hospital, and can breathe without supplemental oxygen and it could have easily been a totally different tragic outcome. Her pulmonologist said he feared had waited another 24 24 hourso seek medical attention she would most likely been unresponsive on a ventilator. We are grateful to receive the care she did all that we dont know what the future holds in terms of permanent damage. Its hard enoughth to be a pare. We all know teenagers will inevitably make bad choicest and we hope they learn from them but its scary to think theres an industry full of largely unregulated products that with zero longterm Health Studies that are so attractive and easily accessible to use. The ecigarette industry has is actively targeted our kids to social media campaigns, advertising on a popular homework site for younger kids, and through flavors that were clearly created to appeal to young people. This committee knows better than anyone how youth have been fooled into believing this products are safe to companies that act as if they could care less about their health and wellbeing of these kits. Consequently, we have the most serious adolescent Public Health crisis our country has faced in decades. These products are designed to andidden from parents teachers and they accomplish that goal. With smells of papers that disperse quickly as they appear and devices that look like flash drives and apple watches, it would seem we are fighting a losing battle. You may read juuls ceo addressed this epidemic in the recent Magazine Article by saying blank happens. Well, blanck happened to my family and im joining the movement of moms who, as parents against vaping ecigarettes are saying enough is enough. Our kids should not be the guinea pig. These products flooded the market that anyone knowing how they would cause damage and now we tried to clean up a nest that involves a cocktail of ministry toxins and proprietary flavors come devices that are easily tampered with and a generation of teenagers addicted to nicotine. If this was romaine lettuce the shelves would be into. We desperately need awo legislar to a post by banning the flavors that are drawn in youth like my daughter including mint and menthol. What happened to my daughter is this outbreak it points to the bigger crisis, r kids are being put by flavors. Kids wouldve never picked up aa cigarette instead starting using flavored ecigarettes and nicotinene becomes a gateway to other substances. The fda has allowed these markets to proliferate, flourish and remain for purchase and consumption without premarket review. This was a terrifying experience and something that probably wouldve been easier to keep private bottom here today to share our story with hope that no other family will have to live this same nightmare. Im a mom whose inner teenagers business constantly and i did all of the right things and it still happened because our youth are being actively targeted by manufacturers with appealing flavors and theyre able to satisfy their nicotine addiction using devices that are designed to be secretive. Its time we do something about it. This goes beyond party lines because these are all of our children. Thank you, miss johnson. Ms. Porter, you have five minutes for your opening statement. Thank you very much. My name is vicki porter. I from lake mills wisconsin. Im 51 use older i started smoking cigarettes in college. I even remember that i was listening to jazz records drinking irish coffee. Spot a pack of benson and hedges ultralights that a friend of left behind ind my dorm room. The feeling invincible i took out one of those cigarettes and i admit it. Because work is better with whiskey and jazz, wh, right, tha cigarette. In a few weeks i was addicted to cigarettes and began a lifestyle of smoking that lasted for 23 years. After a few years of this smoking lifestyle, i realize its not cool. It was revolting and embarrassing and deadly. But quitting smoking is very, very, very hard. Nobody tells you that. Over the years i tried to quit many times, using many techniques. I tried cold turkey. Nicotine gum, nicotine patches, i try to make fda approved drugs can even tried one of those drugs twice. I tried hypnosis twice. I tried some hocuspocus called laser acupuncture. All failures. By now i was around 40 years old and is a good i just learn to be content to die a smoker probably gasping for air like my grandmother and mother did when they died of lung cancer. Years ago a coworker of mine showed me an online ad for ecigarettes. The promise was, smoking without the harm or smell. So i i ordered one because i thought can what if its real . What if its real . And as it turns out its actually real. Around 2010 i stopped smoking, only because of ecigarettes. It literally changed and probably saved my life. Nine years later my doctor says my lungs are healthy. I can climb stairs without being winded. I exercise four times a week. I can walk for miles and miles. I can do things now i have done before my lungs became overwhelmed with the filth and deadly toxicity of cigarettes. Vaping is a health miracle to me because without it i would probably be on my way to a lung cancer diagnosis. Two main reasons why ecigarettes work. First, the inhalation of a far less harmful, not safe, less harmful nicotine dose similar to smoking. Consumers, adult smokers like me came up with the idea of flavors. We demanned it. The tobacco flavors that everybody seems to think are so wonderful in the early ecigarettes were awful. Those mimicked the taste of cigarettes and were poor imitation of the cigarettes we liked to smoke. We dont want our vapor to taste like cigarettes. We want something to tastes good. Flavors keep us not smoking. I took a survey of my Facebook Page, and less vapors. And this is not scientific. At last count approximately 90 use flavors other than tobacco, middle age or older smoke flavors, demanded by adults, sold by adults, consumed by adults and were not alone. According to a recent survey of 69,000 vapors, 92 preferred nontobacco flavors. Now, much has been made of the lung illnesses tied to vaping, but its manifestly dishonest to blame ecigarettes and liqui liquids. All suggest that the illnesses have nothing to do with nicotine vapor products, but street products, oilbased thc. Ive been vaping for nine years and none of the vaping products i use contain oil. Ecigarettes is a miracle that america is about to squander from misinformation and disinformation. Let me remind the committee members, the fda and local communities absolutely need a better job of enforcing obligations to ensure at that kids dont use ecigarettes. You dont need to ban the product to make progress on the mission. And in u. K. , there was a comprehensive scientific report that concluded that vaping nicotine can eliminate almost all the harm from cigarettes and recommended promoting the u. S. Of ecigarettes to smokers as widely as possible and the report indicated that vaping nicotine is at least 95 less harmful than smoking. Public Health England concurs and the American Cancer Society is beginning to understand the Harm Reduction. And they encourage adults who failed other fda approved methods to switch to ecigarettes. The ecigarettes were the only thing, the only thing that worked for me to quit smoking. This product probably saved my life. Vaping has helped more than 8 million adult smokers quit completely when other options failed for them. Thats incredible. 8 Million People quit smoking. On behalf of former smokers, i hope youll reject the general war on vaping and urge you to proceed with these comments in mind. Thank you for your consideration. I need to correct the record on a couple of things. There is nothing to suggest that ecigarettes are safer than cigarettes and thats why the c d. D. C. Doesnt know the cause of the current outbreak and did not rule out ecigarettes. May i respond . No, were about to start questioning and you can respond then. I will recognize myself for five minutes, im sorry, miss Wasserman Schultz for five minutes first. I thank the chairman for his indulgence. Doctors and to the panelists for joining us. My initial question is directed to the experts in Public Health. Is there any evidence, im asking you the same question that i asked doctor shue cat, are there any Health Benefits at all including the reduction of likelihood of smoking cigarettes to inhaling nicotine on a shortterm or longterm basis . There was no evidence that nicotine is helpful at all to young kids or their yelling brains. Doctor rizzo. I degree with that. What was the second part of the question. Is there any indication that nicotine addiction is harmful to an individuals health. It is harmful. Individuals of any age. Nicotine itself affects the vascular system, heart rate and can cause heart and lung disease by itself, and in the elderly. Do we have evidence that its harmful combined with other chemicals used with nicotine with vaping products. I was referring to nicotine itself, but certainly when its combined. The accelerants, the chemicals, its not just nicotine inhaled. Correct. When using a vaping product. Are there negative Health Impacts including potential for death through the combination of chemicals in vaping . Yeah. Thank you. The c. D. C. Has identified 530 cases of lung illness associated with the use of ecigarette products in 38 states and one u. S. Territory. It is important that we hear from partners like you at the state level collaborating with the federal government to stop what is a National Outbreak of lung illness. Dr. Aziki. Am i pronouncing your name directly. And this is when it sprung up in your state. Can you describe those instances and why your state acted. As you collaborate with the c. D. C. D. C. , what has illinois done to identify lung incidents even prior to this summer . Unfortunately, we did find ourselves at the epicenter of this jut outbreak and through what the Wisconsin Department of health released, people were in tune to the possibility of the illnesses not well described, but had a connection between Young Healthy people without a reason otherwise, who presented with severe respiratory illnesses and had a connection with vaping. So he when our first case came and was reported to the department of Public Health we didnt waste any time and we were able to send out alerts to the medical professionals, sending out an alert to pull monologists, e. R. Doctors, pediatricians encouraged them to report any suspicious cases directly through their local department which would then come to the state department. So putting out press releases. Putting out our social media, connecting with the state board of education and working with your advocates in the community who put messaging out to doctorsments i just want to piggyback on my question and im running out of time. You put out details of those struck by the disease and 61 reported nicotine cigarettes and nearly 20 were using only nicotine ecigarettes and many reported thc use. Is it possible you cannot rule out any contributing to the outbreak. Thats correct. And your advice like the c. D. C. Is for people not to use any ecigarettes products. I assume a decision like that is not made lightly can you tell us how that decision was made. Our role to protect the public, not known, but the commonalty was vaping, and we know that the vaping activity, whether the product, the product device, the brand. Something therein was the culprit and not knowing specifically was to give a broader warning until we could get more information out. Lastly before my time expires, the aerosol in all types of vaping is not harmless. Why is it dangerous for individuals. The chemicals within the aerosol are usually irritants to the lungs. The lungs then responds with different kinds of reactions that were seeing in some of the patients, which is obviously affects the oxygentation and sometimes results in sometimes needing the breathing machine to perform that oxygenation. Thank you, i know my time is expired, but i want to confirm my understanding is that the testimony of miss porter is anecdote cal related specifically to her opinion and she is not a Public Health expert. Thank you. I think thats correct. I yield back. I recognize congressman grossman for five minutes of questioning. First of all, doctor, azike, okay. I know you recently legalized marijuana in the state of illinois. Are thc cartridges now legal under the new law or not . Thc cartridges are legal through the medical cannabis act. Patients on the medical Cannabis Program thc cartridges are available. That was a mistake . Pardon . That was a mistake . We have no cases are in the registry from cannabis patients. Im in our theyre not, but once theyre legal theyre out there and implies theyre okay. Again, were waiting to identify the exact eatology. You mentioned in your study, 80 of people who have a Health Problem selfreported that they had some thc in there, but as i asked the last panel, i assume people dont usually admit that theyre doing something illegally. If 80 admitted that they were using a product with thc in it, is it possible that the actual number is higher . Significantly higher . The numbers could be higher, but we have interviewed and reinterviewed the patients. That wasnt a single go round. So there have been persistent conversations with these people and so people have reported more use. Now, ms. Porter, you wanted to respond to some of the other congressmen. Id like to give you an opportunity to say what you wanted to say. What i wanted to say was with regard to the chairmans comments that theres no evidence that ecigarettes are less harmful. Thats simply not true. It was a comprehensive scientific report that was generated by the United Kingdoms Royal College of physicians. It wasnt just an opinion, it wasnt anecdotal as it were, it was a scientific report. Also, im not sure how many people got a chance to see this on cbs morning last week, dr. David abrams from the college of Global Health indicated abundant evidence exists that the Cancer Biomarkers associated with ecigarettes are vastly lower than the ones associated with smoking. I would also like to ask if somebody could please answer me this particular question, what is the particular mechanism by which pg and vg could possibly cause disease . I recall dr. Rizzo said something about pg and vg causing disease. What the particular mechanism that Vegetable Glycerin or the other could actually cause disease. I dont think youre supposed to ask the questions, but ill answer that question, doctor. A short answer, but ill expand we really dont know anything about these devices because they havent been studied in any rigorous manner. When you heat the temperatures ecigarettes do. You no longer have the compound of the properties that we had before. Its now vaporized and inhaled in the long which is much different than the stomach. In sort we dont know what the toxins are doing. We know at that toxins are created and even if we say that toks toxins are less than cigarettes, thats a low bar to beat and 7,000 chemicals in tobacco means theres still 350 in 5 of ecigarettes. Miss porter, if we banned ecigarettes its obviously important for you not to smoke. What would you do . What would be your fallback . If i may, the 7,000 chemicals that the doctor was talking about are actually or sem chemicals when tobacco is burnt, the nicotine extracted does not generate 7,000 chemicals in 5 solution. Thats when you light something on fire and inhale the Carbon Monoxide and into your lungs. I know this because i smoked and i decide today learn about it. What would i do . I would probably just find a way to get my ecigarettes, thats what i would do. Thats me though, im a very im a very knowledgeable user and a very knowledgeable navigator of this marketplace. Id probably order from china. Most people, and in fact, anecdotally again, but most people ive spoken to who vape would just simply go back to smoking because the reason were vaping instead of smoking is because all of the fda approved quit methods have failed for us multiple times. Thats the short answer. I would probably order from china, but other people would probably start smoking. Thank you. Thank you, mr. Grossman, i am going to recognize myself for five minutes of question. Could you care to comment to the claim that the ecigarettes are safer than tobacco. The United Kingdom, if you read the articles how that was made a group of experts got 0 together for two days in europe and several experts admit today being working for the vaping industry and the lancet editorial and 14 professional societies in this country wrote letters to the United Kingdom saying they dont agree with that Public Health decision and also in the United Kingdom theres a much different aspect of ecigarettes, theyre controlled and regulated much more strictly than this country. The tobacco flavors are not there. You really cant compare what happens in england to this country and its faulty science. Right, so that was a bogus study. Whats the nicotine levels allowed for nicotine ecigarettes in u. K. Versus in america . I can get the exact number, i think 18 to 20 milligrams is most thats recommended in any cigarette in england. Here its 59 . I believe its correct, yes. So roughly almost three times the amount of nicotine here in the u. S. In any enicotine ecigarette pod compared to in britain. Now, mrs. Johnson, i want to ask you a couple of questions. How old is your daughter now . Shes 18. And when did she first start vaping . After all of this happened, she told us that she tried it the first time when she was a sophomore in high school and that she had tried it on and off for about 18 months before she became ill. And what devices had she been vaping . She started using a juul and the vast majority of what she used was nicotine ecigarettes. She did try vaping thc as well and used mostly nicotine in the weeks leading up to her illness. Now, mrs. Johnson, i presume how is she doing now . Shes doing better. Shes, you know, adjusting to life as a college freshman. Shes still out of breath when shes got to walk quickly or far and well just see what the future hold for her. Are you saying that theres some kind of permanent injury associated with what happened due to the vaping . Unfortunately with this being such a new thing, the doctors really cant make any promises that there wont be permanent damage so well continue to follow up with repeat ct scans of her lungs and see what that reveals as time goes on. And how did she first begin vaping in high school . She said that a friend offered her offered it to her to try. You know, theyre pass around the bathrooms in the high schools, even the junior highs. I mean, ive got two sons in high school as well and its kind of common for the High Schoolers to refer to the bathroom as the juul room because thats what goes on in there most. Now, 28 of High Schoolers today are vaping and 5 of middle schoolers are vaping. What do you say to parents to are concerned about their children getting hooked on ecigarettes . Well, i think that its super important to keep the conversation open and as parents, we have to ask questions, but the problem is that so many of us dont know what to look for so i feel like its also important that we Work Together with our schools to educate parents with what these devices actually look like, what the signs could be that your child is vaping, and to just educate ourselves and our kids. And you said mint flavor was one of the ones that got her hooked . Yes, and shes been super honest as this has all happened because shes terrified and shes said ill never, never touch a vape again, but she said that mint was her favorite. You were very close to losing your daughter, correct . Thats correct. And before they correctly diagnosed what was happening, did you come up with the idea that it was the ecigarettes or how did they arrive at the question of asking about ecigarettes . I think the timing really worked in our favor because there was just enough talk of what was going on and enough cases out there that it was on my radar. I had seen the news articles, like i said, she was 100 honest so she mentioned it to every doctor, but it wasnt until we got to the third doctor that it was really paid attention to and i mean, i remember this night where she just, she cried to her nurse saying it hurt so bad, i cant take a deep breath and the nurse reached out to the doctor and said since he admitted her, he was trying to reach out to other hospitals and doctors, and that was when, you know, they had us wearing a mask at first they go it was pneumonia and thats when the masks came off and said thats what i think were dealing with. Thank you, mrs. Johnson. Id like to recognize Ranking Member for five minutes of questions. Thank you. Dr. Rizzo could you enlighten us a little on the distinction between Infectious Disease and Chemical Exposure as far as lung injury. When someone presents with the symptoms that were mentioned it could be a bacteriaal or a viral pneumonia, meaning that the organism has gotten into the lung and the immune system led to the cells of the body going to the lung to try to fight off the infection. Basically thats inflammation. And when that occurs in the lung and depending on the intensity, it will fill with fluid, pus, and oxygen to the bloodstream is diminished. When its an infection you can culture that media, sputum or a tube is put down in the lung and culture that and look at organisms under the microscope. Once thats ruled out. The history is very important. What could they have been exposed to. In this case the right questioning, putting two and two together, theres a commonalty of vaping. This has been touched on already, could you explain specifically why its much more of an issue for young people to start vaping. The young people start vaping more than the adults because of the flavors. Most smokers from a health perspective, what does it do to their bodies . Flavors inhalation into the lung occurs, does a couple of different things. First of all, the lung doesnt reach its full development until about mid 20s. Youre dealing with a population where the lungs are still growing and developing. All of a sudden now youre having an insult of inflammation and changing the immune system. The body has to try to recover from that, but lost ground with ultimately the Lung Development is going to be. In cases youve heard about, the population will need to be monitored and followed for any permanent damage that may occur. And doctor, could you explain the Legal Framework in illinois right now as it relates to teen vaping . Is it illegal for people under. Right, so we actually have tobacco 21 so its illegal to use products under the age of 21. Okay. And miss johnson, first of all, i have seven children and i have a number of parenting questions that are not appropriate for this setting and happy to hear your daughter is doing well. Do you know where she was obtaining the product from . I do know that so she turned 18 in december and so there was a small period of time where it was legal for her to buy vaping products. And i do know that she obtained some from a local store. I am also fairly certain that that store continued to sell to her after the tobacco 21 law was passed in july and she was no longer legally buying them. So, yeah, like i said, theres a way for the kids to buy them, you know, but also, theyre being passed around in schools, which is a huge problem. Were scared enough as parents, but our poor educators are drowning because the products are not only accessible to the kids, but theyre very discrete. You mentioned a mix of legitimate and illegitimate products, is that correct. Correct. Doctor azike, we had a store that was a bad actor, giving them products whats being done to prosecute bad actors in illinois . Not exactly within our realm, but were working with the Illinois State police and they are very much on top of this issue and they are going to step up enforcement in terms of. Has anyone been charged or no one has been charged sars i know, theyre going to step up sending people into as decoys to come in and try to purchase the products who dont look of age and seeing if theyre getting carded so those investigation and that enforcement is going to be stepped up. And miss porter, youve used ecigarettes for a long time. What kind of regulation do you think is appropriate . Ive used ecigarettes for nine years and just to kind of bring a point, there are 11 million regular ecigarette users who are adults, and obtaining these products legally and i also want to say that the products that i have been vaping for nine years are not 59 milligrams. Theyre 12 milligrams. I think that regarding the product, the manufacturing of the product, insisting on good manufacturing practices, dmp, is something thats important and thats something that i look for in the products that i purchase as someone who has, you know, making sure that nothing gets adull adulterated. And with regard to kid we dont talk much about enforcement. In the state of wisconsin, police would send decoys in to see if young people could potentially buy a pack of cigarettes. And stores would be fined and same with underage drinking and that kind of enforcement i think is quite important that doesnt seem to be really be a priority as folks are neck deep in the opinion panic about vaping. If you get rid of the vaping or vapor products youre standing 11, well, at least 8 million exhadsmokers and 11 million to access to products that work so they dont pick up a pack of cigarettes. With regard to advertise, i think i made a note here, hoodies, who makes this garbage . This kind of stuff obviously, if its marketed directly to children, its appalling, there isnt a Single Person who uses a vapor product as an adult who thinks its appropriate for young people, freshmen, 9th graders or 8th graders or 6th graders to be able to pass around vapor products. And i also think that we need to really understand here that it appears from all indications and no, we dont have evidence, but from all indications these diseases, which are and i dont want one of these diseases, by the way. Thats, i dont want to suddenly wake up one day and not be able to breathe, thats why i quit smoking. Your time is up, thank you so much. , but i do think that we can do something about the adulterated products. Thank you. Congresswoman presley, you have five minutes of questions. Thank you, mr. Chair. An nih funded study found that over 8,000 new liquid flavors are currently on the market some include banana pudding, rainbow candy and hawaiian punch. Dr. Rizzo, do we know how many of the 8,000 flavors have been tested for toxicity . The one study i know was done at Harvard School of Public Health. They looked at about 51 different flavors and 47 of those flavors did have chemicals in them they felt were toxic for the lungs. I dont know about any other larger studies at this point. Dr. Ezike, you have collected samples of those victims in the outbreak and youre in the process of testing those. Those are with the fda. Were waiting for the results. You have not ruled out components of flavors as possible contributing flavors to the outbreak. Thats correct, we have note ruled that out. Doctor, are there any approved by the fda vaping smoking devices . No, theyre not. Doctor, ecigarettes have appli been able to apply, but have not done so. And manufacturers havent conducted Clinical Trials to back up a central claim . Thats correct. Miss porter, im grateful for every one adult smoker that ecigarettes are helping to quit nicotine, but for every one adult smoker that is being helped 81 kids will be introduced to nicotine through ecigarettes and graduate to cigarette addiction as an adult. None of us want that. And thats an impossible statistic. There are 11 million vapors im claiming my time. I was just making a statement. I wasnt posing a question to you. Please let ms. Presley pose a question. And i just wanted your person experiment. Now, dr. Rizzo, we have seen no evidence that ecigarettes are useful for Smoking Cessation. Is juul use safe . No. If someone adds on vaping, is that safe . No. Dr. Rizzo, even if the cigarettes were useful for cessation, have you had seen any evidence that adults who want to use them for that purpose would refuse to use tobacco flavored ecigarettes . No. I yield back. Thank you. Congresswoman presley. Counc. Thank you, i want to thank all of you for being here today. This is very important and miss johnson, thank you for sharing your story and i hope your daughter is continuing to recover particularly after listening to dr. Rizzo say our lungs continue to form into our 20s and thats a positive and i hope and pray that she gets better. Dr. Rizzo, is nicotine addictive . Yes, definitely. Is it also a depressant . Actually two phases. It can initially be a stimulant and then it can be depressive. Its a chemical that acts as a neuro transmitter into our body. And the receptors, theyre all affected by nicotine. People have been smoking for centuries, havent they . Yes. And it wasnt until the 60s when they finally came out and established that it caused cancer. I also remember in the early 60s trucks putting out vapor with ddt driving around my neighborhood and children riding bicycles behind the truck because they thought it was neat. Were there any studies done to see if ddt caused cancer. I would have to look at it as an inhaled. That was another vapor they put out. I vividly remember that happening. Miss porter, you said you smoked for 20some years . 23. When you started did you think that that was really cool . Sure did, i thought it was the coolest thing, i listened to jazz, drinking whiskey and smoking a cigarette. I remember movies about world war ii and everybody had a cigarette hanging out of their mouth and the message that was a cool thing to happen in the 50s and 60s. My movie was house of games. That was my movie. I dont know that one. Thats a good one. Okay. And you are concerned about using ecigarettes . Absolutely. Im concerned about youth using ecigarettes and concerned about Youth Smoking, which is its an amazing statistic that now Youth Smoking is so low and then after todays testimony from multiple witnesses im now very concerned that the 12. 5 percent of youth saying theyre using pot, but, yes, the youth kids are going to do things that are risky, but we should try to make sure that they dont make dumb choices like i did when i was, you know, 18 or 19 years old. I remember our nextdoor neighbor had a katalba tree and kid thought it would be good to light those long things, it was terrible. Once you used cigarettes did you notice how bad your clothing smelled, your hair or your house . Sure, within about two weeks of switching to ecigarettes, i couldnt tolerate the smell of smoking. I couldnt tolerate the, you know the smell of somebody who had been smoking an hour earlier. I became one of those people who just became an annoying exsmoker. Everyone knows what im talking about, but its very obvious. The more obvious change though came about three months after id begun vaping and just to see i went to go to my physician and asked for a chest xray to see if i had done permanent damage. I want today know wanted to know if i was going to be sick and die of lung cancer or the beginnings of copd. I mean, in three months did you think your lungs were going to change . Yeah, because i felt so much better and my doc said your lungs are pretty clear. Good because i quit smoking. She said i can tell. You mentioned a much lesser amount of nicotine in the ecigarettes. Is there like a step down that if you were a theres a lot of misunderstanding of what the marketplace is for the vapor products. The liquid itself. It can go from zero milligrams of nicotine to, you know, with some of the, what they call salts, to as high as potentially 60 milligrams of nicotine. People like me, i dont use salts, i use just regular oldfashioned eliquid i use 12 milligrams. Depending on the device. There are multiple devices, i can use as little as three milligrams of nicotine and eliquid. Multiple variations and concentration of the liquid itself. So it would be possible that you could step down and totally get off. People do it all the time on my Facebook Page when i asked for stories, multiple people said i began at 18, i stepped down to 12, went downtown to 9 down to 9 and then zero, some went to zero and some used the zero point to quit vaping as well. I didnt realize my time was up. Thank you. Thank you congresswoman miller. Now id recognize congresswoman tlaib for five minutes of question. Thank you, mr. Chairman. Thank you all for being here and contributing to this important conversation, as a mother, thank you, miss johnson, for coming here and its not easy even for me speaking publicly to this day my stomach turns, i know how hard it is, even something so personal. I appreciate you being here. Ecigarettes were allowed on the market without fully understanding the longterm effects and without regulation, as you all know. The safety wasnt tested and Big Tobacco Companies like juul touted the products safer than cigarettes and sent representatives into schools to tell students its quote, this is i begin to repeat it because its obvious towards our kids, quote, totally safe. The result is that ecigarette use took off. And now 27. 7 of High School Kids use ecigarettes and those kids are used as guinea pigs. Were just now finding out the health risks they pose, like those who are suffering right now from it and the outbreak of lung disease and so forth. Most ecigarettes hold and produce potentially toxic substances, im going to try to pronounce it, formhyde and benzine found in car exhaust systems. Dr. Rizzo, yes or no, is it safe to inhale these liquids inhaled into your lungs . No. And there are any links to lung damage or Heart Disease . Are there any studies regarding the Health Risks Associated with vaping . There are no longterm studies since its only been in the marketplace here for about nine to ten years. Likewise, cigarette smoking process requires the use tower inhale ultra fine particles that could possibly irritate their throat, eyes and airway. Dr. Rizzo, could these part class exacerbate respiratory alignments that affect our breathing. The particles are similar to air pollution, it can get intoed blood and affect the cardiovascular system in the lungs. Very little is known about the longterm affects of ecigarettes and vaping. But theres consciousness of the nicotine effects on the development of brain and future addiction. Dr. Ezike, could you explain how it Impacts Brain Development . Of course the brain is still developing almost until age 26 and with nicotine, its the receptors in pediatrics they are more susceptible to being addicted so they get addicted quicker and the addictions pri d predispose to addiction down the road. And we see people started at earlier ages. This is very scary and as a mom, i hope that ecigarettes users are aware of this fact and are not waiting for government to declare this kind of a National Crisis right now. That we know from the mere hospitalization cases like in your daughters case and so forth that its unsafe. Weve heard that vaping exposes victims to chemicals and i speak to kids all the time. Second grade and third grade reading class and they ask what do you do . You know, i tell them i work at the capitol and show them the pictures and tell them where it is geographywise and you know when i was your age i used to go to restaurants with my parents and right now you go and how many people in your group. When i was little they said nonsmoking or smoking section and the kid are like what . And i was like, yeah, they would say nonsmoking or smoking because they smoked cigarettes in Public Places like restaurants, hospitals, schools, planes, and the kids eyes are wide, like what . Thats unbelievable. Yes, even though scientists, people were saying secondhand smoking was worse, was worse than directly smoking cigarettes and even though Health Experts and others were coming forward, you had big corporate greed, misleading information out there to the public what the real impact was on health. And so, its so important that you all continue to seek truth about this because the longterm effects it very dangerous especially because theyre targeted toward youth. Miss porter i was reading and i want to know more about your beliefs, we all have different beliefs. You call yourself a converted conservative and reformed marxist, are you a conspiracy theorist. I think my politics are entirely irrelevant to this hearing. Why were you winking at one of my colleagues on the other side of the aisle, why did you wink . I know glenn grossman, he introduced me, a friend of mine. I understand. I didnt know what the winking was, i thought maybe there was a conspiracy thing going on there. I didnt know. You think theres a conspiracy in this hearing, maam . No, i think that people are speaking truth here and you can provide ments may i address the truth . No, no. The well, the truth to you is din for the majority of people in this room who believe that children are. The truth for me i quit smoking with ecigarettes and so did 8 million other people. Youre still smoking. Im not smoking, im not lying under oath. Id like to recognize congressman connolly for five minutes of question. Thank you. And welcome to our panel. It seems to me that this is a new crisis that kind of came upon us real fast and unaware and part of the problem is frankly the lack of any federal structure in which to look at this issue and leaving states like illinois kind of on their own, is that a fair summation of where you think that i believe its always ways for improvement. The support for research around data modernization tools so that we can quickly upload our information and share it across states or with our federal partners is very key to being able to disseminate information faster around these kind of epidemics as they emerge. So if the federal government is not regulating the product and hasnt done the research and analysis of pros and cons, dangers, benefits, it kind of leaves you either to do nothing and wait or to try to take some action to protect the citizens of your state. Isnt that fair . Ethat. Yeah, and so we have a vacuum at the federal level. Fair enough, dr. Rizzo . Yes, i agree. And what steps should the federal this remind me a little bit of marijuana where we havent done our job at the federal level in justifying how we categorize or classify marijuana. We have essentially limited the kind of studies we sponsor at the federal level and who gets to do them with a clear bias towards its dangers, and as a result, weve lost control. So we have 27. 28 states that are moving to legalization of some form, some full legalization, some for medical purposes, but meanwhile the federal control is done. In this case, its the federal government hasnt really been active yet and i just wonder what would be helpful from your point of view from the federal government to jumped take so undertake so we deal with this, smoking it could take 40, 50 years for somebody to have the negative Health Impacts of chronic smoking. What has shocked us about this process, this timeline has collapsed and were looking at young people who have engaged in vaping and according to some medical reports, at least anecdotally, their lungs look like that of a chronic smoker of 40 years. How did that happen . What in the world is at work here that could do that and what must we do to protect the public in a way that doesnt take ten years to do it . Dr. Rizzo . I think the first step with regard to the vaping illness, everything will be continue to be done by the fda and c. D. C. And we hope there will be answer. And we think at the lung association, there should have been a pre market review on anything that comes out in the marketplace to deem whether or not theyre appropriate for Public Protection and i think the lack of that authority by the fda for multiple reasons has been very slow in developing. Doctor e siechlt ezike . I do concur. Miss johnson would that have made a difference . I think so. The fact that nobody really knows how these products are going to affect people, especially young people who i had shouldnt be using them, but have super easy access to them. Its just, its kind of russian roulette. You just dont know whats going to happen and with developing lungs it seems to be even worse. You know, sometimes we have mindless debate about regulations and all of the stats and i bring attention to the fact that my colleague, republican, conservative republican, stated earlier, but sometimes we need it. It aint all bad and sometimes we need to protect the public, as you all said, frankly, absent the vacuum that we created, it wasnt deliberate. Nobody did it with malice, has cost lives and will cost more. So we need to this issue and we need to understand that meaningful regulation protects people and can save lives and here is a great example where thats needed. Thank you for being here today. I appreciate it and my time is up. Thank you so much. Id like to thank our witnesses for their testimony today. Without objection all members will have five legislative days within which to submit additional written questions for the witnesses to the chair, which will be forwarded to the witnesses for response. I ask our witnesses to please respond as promptly as youre able. This hearing is adjourned. [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] the house will be in order. For 40 years cspan has been providing america unfiltered coverage of congress, the white house, the Supreme Court and Public Policy events from washington d. C. And around the country so you can make up your on mind, created by cable in 1979, cspan is brought to you by your local cable or satellite provider. Cspan, your unfiltered view of governme government. On the phone with us is jennifer haberkorn, what did the democrats decide to do recording impeachment. The spoker nancy pelosi announced that they will go with formal impeachment and found like the vast majority of democrats will be on board. After months of debate, the democrats seem fairly united they want