Transcripts For CSPAN3 Hearing On E-Cigarettes Lung Disease 20240714

The centers for Disease Control related to 530 e cigarette related incidents of lung disease in 38 states and the u. S. Virgin islands. First, i want to make clear that we did not plan to have this emergency hearing at the beginning of this congress, let alone this time last month. On august 23rd, officials from illinois reported the first death due to a mysterious vaping related illness. And since then, a total of eight individuals have tragically died in this outbreak. The response to this crisis, cdc is warning the American Public to consider not using e cigarettes of any kind. Because the subcommittee has investigated the youth vaping epidemic and the companies behind it, we feel its our duty to draw attention to recent Government Health warnings about the dangers of e cigarette use. The longterm Health Effects of continued vaping is unknown. What we do know should give us pause. State Health Departments continue to conduct retro active analysis of patient records to better understand exactly when this outbreak began. As they do, the number of affected people will grow. Unfortunately, illness related to e cigarettes is not new. The fda has received 127 reports of seizures and other neurological conditions caused by e cigarettes. When a product is released onto the market without safety testing or Clinical Trials, this is what we fear. This is a problem exacerbated by e Cigarette Companies that take what appear 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 theres no evidence to back them up. Thats why this subcommittee wrote a detailed letter to the fda outlining our finding about juul illegally marketing its products as safe healand health. It was declared that juul had broken the law. The fda will have the opportunity to act. I encourage you all of you to develop that development closely. We certainly will. Just days after the fda responded to our letter, the administration in part citing our investigation announced it would move to ban all e cigarette flavors, including mint and menthol. The fact that flavors hook kids is a point this subcommittee hammered home over our two days of hearings in july. The administration cited our hearings in rolling out its propos proposal. Democrats and republicans are coming together when the health of our nations youth comes under attack. Today, as we focus on the tragic outcomes of this lung disease outbreak, we must view it as a chance to come together to protect Public Health. At the heart of the recent vaping related outbreak, families are being blindsided. Joining us is ruby johnson. As she prepared to drop her oldest daughter off to start college, already a stressful time, the Johnson Family faced a health scare. 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 enough from her bout of lung disease to be released, but she 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. Were also joined by leaders from the Public Health community to provide their advice to the public they serve. We have a doctor from the cdc, a doctor from the Illinois Department of Public Health and dr. 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 preventible deaths. And with that, i recognize the Ranking Member, mr. Cloud of texas, for five minutes for an opening statement. Thank you, mr. Chairman. Over the last several weeks its been clear that users of certain vaping products have become ill. Some tragalically to the point deat death. I appreciate your desire to hold this meeting. In the cdcs september 19th update, the number of those sick reached 530 and eight deaths have been confirmed. This is concerning and its clear we need to examine the cause. To the best information of available, many of these cases seem linked to the use of products that are something they are not. Based on the limited Data Available, about those impacted by the illness, approximately 16 are under 18 years of age. And while each life is affected is important. These incidents also serve to bring attention to what has become an epidemic increase in teaspo teen vaping. Add to that the decades long addiction to traditional tobacco, as a father of three, this is very concerning. I wish we had a quick fix to insure that each child is protected, that no american finds themselves bound by a substance and that all of us are able to find personal fulfillment in experiencing the purpose for which we were created. Were here to discuss what should be the appropriate response. Complicating this discussion is a lack of Scientific Data and studies available. Counterfeit products, untraceable supply lines. Lack of enforcement that allows players to pass the buck of accountability. For example, Data Available leads us to believe that many of the recently reported 530 cases involve vaping cproducts. I hope were able to do the work, i believe theres a lot of bipartisan support for addressing the situation. I appreciate the chairmans heart in this and to the point of examining this to find the solution and our desire to end teen vaping, there is unity. Police know my heart goes out to those impacted and my condole e condolences to those who have lost loved ones. Thank you, mr. Cloud. I should say we recently started a caucus, and today happens to be National Recovery day. A bipartisan endeavor to recognize the folks in our lives who may be affected by Substance Abuse disorders and our attempts to wean their off their addictions. I hope vaping is not that Substance Abuse disorder. Today were joined on panel one by the Principle Deputy director of the cdc. If you would please rise and raise your right hand. Ill swear you in. Do you swear or afirm the testimony youre about to give is the truth, the whole truth and nothing but the truth, so help you god . I do. Let the record show the witness answered in the affirmative. Thank you very much and please be seated. The microphones are sensitive, so please speak directly into them. Without objection, your written statement will be made part of the record. With that, youre now recognized for five minutes. Thank you. Good morning, chairman, Ranking Member cloud, and members of the subcommittee. Thank you for the opportunity to testify today about cdcs investigation into lung injury associated with using e cigarettes or vaping products. Today, ill discuss with you what we know and dont know and what were doing to dress this outbreak of lung injury. Ill also discuss our efforts to address the epidemic of youth e cigarette use or vaping. I want to make four key points. First, as soon as we learned about the initial cases of lung injury, cdc has been working 24 7 hand in hand with the fda and our state and local Public Health partners to find the cause. Secondly, our ability to do this type of investigation relies on a critical underlying Public Health infrastructure, including data systems that need modernization and a trained Public Health workforce. Third, the cdc has made important recommendations public, including the following. While this investigation is ongoing, people who are concerned about lung disease associated with e cigarette use or vaping should consider refraining from using e cigarette products or vaping. People should not buy these products off the street and should not modify them further. Adults who use e cigarettes or vaping products because they have quit cigarette smoking should not return to smoking cigarettes. We have a need to address the epidemic of youth use of e cigarettes. And this current outbreak we enforces the need to address the broader youth e cigarette epidemic. So what do we know so far . As youve heard, several hundred cases have been reported from nearly all states. Weve had a number of deaths. The cases are occurring in young people. One half of all cases are less than 25 years old. People present with cough, shortness of breath, chest pain, and sometimes with systems like nausea and vomiting, fatigue or fever. Most of the cases with information so far have reported use of thc or thc and nicotine containing products. Some have reported nicotine only. There may be some challenges with the histories of exposure in some subset of the patients. What do we not know so far . Probably the most important thing, we dont know the cause. No single product, brand, substance or additive has been linked tod linked to all cases. This investigation is ongoing and its very dynamic. What are we doing to respond . Cdc is working closely with state and local Public Health with the fda and Clinical Community to get to the bottom of this. Weve deployed staff to help states with their investigations. Weve provided technical assistance, developed a Case Definition, standardized clinical guidance, and a reporting system and are working every day on coordinating the parts of the investigation in response. We set up a system and activated our Emergency Operation center as we do in other Public Health urgent situations. Weve convened the Public Health clinical and media numerous times to share what we know and dont know and how they can be part of the solution. One such example is a clinical outreach and communication activity call we held in the past few days that had 2,500 lines and clinicians around the country listening to the latest information. Were working very closely with the fda on the Laboratory Aspects of trying 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 report using illicit products. The marketplace for e cigarettes is wide and diverse with a multitude of products and it might be complicated to tease out the problematic exposures. And our Public Health Data Collection systems are in need of an upgrade. In terms of youth e cigarette use were seeing an epidemic and in the questions id be happy goog the details about that. The most recent debaata is to bg to be concerning. Cdc is dedicating to working around the clock together with fda and the state and local Health Officials to identify the cause or causes of the outbreak and will continue to update you during the course of the investigation. Thank you very much, doctor. I now recognize myself for five minutes of questioning. Doctor, thank you for the work youre doing. The cdc has been clear its not yet possible to determine the cause of the vaping related lung disease outbreak. The cdc has recommended that people consider not using any e cigarettes from that wee gather that nothing is off the table as a possible cause. Lets first describe the general types of e cigarettes out there. From what i understand theres two major categories. First there are nicotine e cigarettes, which have been the focus of this subcommittees hearings up to this point. Second, there are thce cigarettes that represelicate t effects of marijuana. You are examining both of those products as factors in the current outbreak of lung illness. Is it correct to say you cannot rule out either as contributing to the outbreak . Thats correct at this point. Were getting new information in every day. We think its very important until we know that our recommendations be broad. Separate from this outbreak, were concerned about the rise in nicotine containing e cigarette use among youth which is an epidemic. We dont know yet what the product or products are or whether theyre components of the products that might be contained in both nicotine and thc containing devices. I want to focus on the nicotine e cigarettes for a second. In the illinois and wisconsin published analysis, almost 20 of the victims that were using only nicotine e cigarettes and overall 61 of the victims were using among other e cigarettes nicotine e cigarettes as well. So, doctor, there may be people out there for this to be a thc only problem so they can go back to vaping nicotine e cigarettes. If 20 are using nicotine only cigarettes, do we need to be concerned buabout all e cigarets at this point . At this point, i think caution for all products is recommended. It may not even be the thc or nicotine part. It may be additives. It may be material thats not labelled appropriately. We really do think consumers need to be cautious right now. Got it. You cant rule out any brand at this point, right . No single brand, product or additive has been ruled out as of today. Id like to better understand the possible contributing factors to the outbreak youre considering. First of all, on august 22nd, the cdc said, even though the cases seem similar, its not clear if these cases have a common cause or if theyre different diseases with similar presentations. Does it mean it could be multiple different problems that are causing different results . Thats right. The respiratory systems are nonspecific and the xray finding are diverse. We have cases in nearly all states at this point, whether the products in one state are the same as the problematic products in another. If so many vaping products are causing the same result, could the common link be the process of vaping itself . Inhaling liquid particles into our lungs . We dont know enough about the aerosol that vaping produces or that e cigarettes produces in terms of the short and longer Term Health Impacts and products may it may be that the process itself is risky. All ecigarettes include solvents. While theyre considered safe in food, a recent study found those solvents when inhaled reduced the lungs ability to fight infection, increases the chances of getting fl u and dying from t t. These supplements are in all e cigarettes. Can the cdc rule them out as a factor in the current outbreak . We have not ruled out any substance yet. Many of the victims were using flavored products to. To add flavor to an e cigarette requires additional chemicals on top of the solvents we just tau talked about. Can the cdc rule out the flavors . No we cant. Doctor, i want the cdc advis public not the use any e cigarettes at this point. They also advice that those who do not vape not to start. That children and pregnant women never use e cigarettes. For those trying to quit smoking to use an fda approved cessation device. E cigarettes are not approved for smoking secession. With that, thank you. Now i recognize mr. Cloud for five minutes. Thank you. Doctor, previously the cdc has said that the illnesses that were seeing arent a result of do you maintain that the distinction or is it possible that the Chemical Exposure is leading to reduced immune system, therefore, leading to infection . Part of the Case Definition is to rule out infections as a cause. Certainly people presenting with cough, shortness of breath and abnormal xraies often have an infection. In this episodes, we dont believe infection is causing the problem. We think its one or more Chemical Exposure. Okay. Do the patients have systems immediately after vaping, or is it after do they appear later . We understand from the early reports that theres a progression between day and weeks of worsening symptoms until the difficulties are severe enough to present for hospitalization. Nearly all the cases have required hospitalizations. Many of them have required intensive care units and in some cases have passed away. Have you been able to investigate supply lines . What ive read, it seems like its been very difficult to backtrack where a number of these products are coming from. This is a very active investigation. The fda is leading the product trace backs. They are also working with the dea in that effort. Were certainly trying to gather information on the products that is right that the individuals have used. They may have gotten them from retail, other sources or on the street. Do you have a sense of where teens are acquiring products . I dont have that data right now. But we do see a significant rise in the use of e cigarettes among teenagers. Both middle school and High School Students. And one of the things we see in common there is the role of flavors. Flavors are a big attractor for teenagers. Usually the first product people are using is flavored. But in terms of where theyre getting them, i dont have the data. Sometimes its really just a friend or a peer who is providing something to them. And to influential follow up states its already illegal for teens to acquire the vaping products, right . Thats right in terms of e cigarette use is not supposed to be for anyone under 18. That is since the 2016 legislation. Is there any effort underway really in the realm of enforcement and prosecution for those who are getting products to teens . That would be the realm of the fda in terms of the federal legislation for the e cigarettes. So the issue of access to products is a key barrier to use of e cigarettes among youth and the stricter it is, the better. Were very much in support of making it extremely difficult for young people to get products theyre not supposed to have. What are some of the recommendations you have when it comes to that . There are a variety of Population Based strategies that are shown to be effective to limit access for youth to cigarettes or e cigarettes at this point. One of the issues is the advertising thats particularly appealing to youth. Thats a problem we saw with cigarettes decades ago. We have been seeing it again with e cigarettes more recently. Another is the retail sites requiring proof of age. There are a number of other efforts were doing in terms of raising we dont do. The States Select strategies like raising the price as well as using efforts to educate the schools, toolkits for schools and so forth. All right. Do you have an we were talking about product lines and supply chains. Do you have any sense of how much is coming from counterfeiting places or china . Theres a lot of loopholds whes it comes to freight . Do we have a sense of where the illicit products are coming from . This is an extremely dynamic market. Th the in the past couple of years and i believe theres likely to be an elicit market thats mirroring the rise were see in in the legal market. Thank you. I recognize the congressman for five minutes of questioning. Thank you, mr. Chairman, for having this hearing and doctor, thank you for the work you do in being here. On september 6th, the cdc issue ed a following statement during a press conference. I quote while the investigation is ongoing, cdc advises that individuals considered not using e cigarettes because as of now, this is the primary means of preventing this type of disease and that the use is never safe for youth, young adults or pregnant women. During the same press conference, you announce you were setting up your emergency center. Could you describe what fakctor led cdc to that decision and what kind of expertise will result from that and giving the life threat benning emergency were faced in, how do we make sure we dont lose anyone else . You know this is a fast moving and very serious outbreak of a new condition in primarily young people. Cdc established an Incident Management System to respond to the outbreak then took the additional step of activating our Emergency Operation center. We have more than 100 people responding to the outbreak now in atlanta as well as deployed to assist in states and we took the step of activation to better support the state and local and Public Health who were on the front line of this. We have hundreds of cases getting reported to us from all across the nation. In order to work efficiently and effectively with the states as well as the fda and others, the eoc activation facilitates that. Doctor, im from the San Francisco bay area. When i go home, juul is now spending up to 40 million probably more in overturning a local ordnance by the San Francisco municipal government that merely says that e cigarettes are banned until the fda comes up with the end of their investigation, whether theyre safe or not. Recently, we had an executive and founder of juul and say from my perspective, that their product is helpful to keeping people away from tobacco, particularly young people. In richmond, california, in my district, they just passed a similar ordnance. So those ordnance, well talk about this more in the second panel, seems to be a preventive, cautious approach to this. Youve got a product out there that is lead iing to deaths. Whakt we do further to make sure that doesnt happen as a congress . We have a company in my view that has no ethical boundaries. Is in the business of addicting people, particularly young people, and is willing to spend 40 million and the fdas announced their Criminal Division is investigate iing th and i hope they investigate their Political Consultants as well. Theyre shameless when it comes to the information they give. Giving your getting the Public Health officials. Give iing that this committee i actively involved, this is a daunting task to try to make sure the public understands, particularly young people, who are vulnerable as you alluded to in your opening statements, to advertising like this. You know,i appreciate the committees attention youve given to this. We know that youth should not use e cigarettes. That nicotine is one of the most addictive substances there is and that its dangerous for the developing brain that adolescents and young adults have. We know that flavors are a major attra attractant for young people and that they often are the first e cigarette type that children use and that the latest generation of e cigarettes has a higher available nicotine level that is particularly addictive and so the last few years of data raised our concerns substantially in terms of the epidemic of youth e cigarette use and i appreciate all the committees doing to address that. Do you need more Statutory Authority . Would it be helpful for the cdc if they had the authority to prohint people from using this until your gags is done . Well the cdc doesnt particularly have Regulatory Authority over this matter. The fda does and theyre taking many measures now to intensify their work in light of f this epidemic. Both the epidemic of youth vaping and outbreak of lung injury. I think one of the key things that could help this n this investigation though in terms of the outbreak is modernization of our data systems that are really outdated. Slow. That the epidemic is moving faster than our data gathering and were really losing people in the meantime. I appreciate that. The reason i asked the question is to suggest that the fda is moving too slowly and it might be in my perspective, more efficient if the cdc had the to say this product should be removed from being legally sold. Thank you, mr. Chairman. Thank you. I now recognize congressman graphman for five minutes of questioning. How long have these been on the market . There are a number of dis different products and were really on the fourth generation. How many years . In 2011, we were seeing the first of the products and by 2012, there was a doubling in their use. First ones were on the market in just 2011 . We started measuring. Excuse me, excuse me, this just in. 2007. Yeah, i thought it was before that. Okay. You said maybe 80 of the people who got sick got sick, they admitted putting thc in their e cigarettes. How do you determine whether or not they had illegal substance in there or not . The information youre citing is based on history. Individuals said what they thought they were using. There has been some testing of products that are still available. Okay. What im trying to get at here, youre the one who testified that 80 of the people who got sick may have had thc in the product because its i believe illegal in most states in the country and i assume that some people dont like to volunteer that theyve been doing something illegally, i wonder whether thats a hard number or maybe its closer to 100 because some when asked dont admit they are breaking the law. The number youre citing comes from an illinois wisconsin report in the new england journal of medicine about what a small number of patients described using. We acknowledged that individuals may be reluctant to describe use. Selfreporting. Okay. Next question. You guys report about 72 of the fiemme who got sick with were male. Could you tell me, e cigarettes overall, what percentage of people who buy legal e cigarettes are female and what percent are male . More males by them than females. 72 seems a high number. The statistics on the proportion of these lung injury cases that are male has been decreasing so well be updating those numbers but youre right that so r far, nearly three in in our cases are in boys or men how about people who buy them to prevent smoking. Ten years ago, i thought that was the whole deal. We had this new way to prevent people from smoking. 400,000 people are dying of smoking related illnesses. Ten years a aerks this was a good thing. Of f people who buy e cigarettes to stop smoking, break down male by female. We know use is much more frequent in young people than adults. I dont have the breakdown of those who are using e cigarettes for cessation. Okay. I think in most states, thc is illegal. More states are legalizing marijuana. I dont know who to blame for that. Including my neighbor to the south and illinois. Are these which legalize marijuana or not . The legal provinces and states are quite different. Its a very diverse landscape and i dont have the specifics on individual states. You dont know whether the states will make this legal . Theres no single l product just say i dont know. Theres no additive thats been linked to the cases in this outbreak. Okay, but you dont know its b possible that illinois just made this stuff legal . Which stuff . Thc in cartridges. I dont know. Id like you to look into it. Sounds like its big trouble if illinois just made these things legal. Could you explain, why is this a new thing happening now and you never heard about it eight years ago. Do you mean the youth vaping or outbreak of lung injury . People dying. Thank you. We, we dont know but we know that the use has probably increased, but we dont know if theres a risky product or a substance in the products or manipulation thats dangerous. Theres a fourth generation of e cigarette products out there that may perhaps be related in some way to this, but we dont know yet why this condition is occurring in this particular epidemic. Thank you. I now recognize congresswoman hill. Thank you so much, mr. Chairman. Doctor, on september 6th, l. A. County had its first reported vaping death. The week before, an l. A. County teenager began an antivaping campaign from her hospital bed where her lungs had failed and she had to be put on a ventilator. Dr. Davis has compared the revelation to the slow danger of cigarettes several decades ago. Across kcalifornia, there have been 57 cases with acute lung disease with a history of vaping since late june. Parents, kids and adult vapors are scared by the disease sweep ing the country. The cdc and state Health Departments have been working together to investigate the outbreak. As of a couple of days ago, cdc report td 530 confirmed and probably cases of lung disease in 38 states. Are those numbers expected to grow as states examine older cases against the current case definiti definition . We are seeing more and more cases each day. I expect the next weekly numbers will be b much higher. Thank you. How does the disease typically present itself . People have days or even weeks 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 to stet in after the last use . We dont have lots of details. May be days or weeks. For those affected by the lung disease, how long are they hospitalized and are they typically in intensive care . The average length so far is about six days. Many in intensive care require mechanical ventilation. Thats what i was going to say. How many require medical intervention to breathe . A large proportion. Whats been successful in treating them . As of now, we know antibiotics dont have an effect. Thats consistent with the idea its not an infection, but some are seeing improvement after use of corticosteroids. We dont have evidence of the benefits b and risks, but we believe they believe use them in treating patients on an individual basis. So potentially some kind of inflammation like an acute inflammation. Thats right. So the joint study by illinois and wisconsin found a median age of 19 years old and that 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 all the data, were finding more individuals who are older at risk. But we do see in our National Data half of the cases are under 25. Is there anything that weve learned in how this results in death and how we can avoid it . Were looking into it closely. Sadly, we are hearing about more deaths as you mentioned and we expect more. Thats wup of the reasons weve been trying to get our Health Recommendations out there. So until we know more, people refrain from using e cigarettes or vaping products or at least consider that. Is it possible this disease has been going on longer than we thought and its just now being linked to e cigarette use . I think its less likely that large scale, weve been seeing this and missed it. Were using syndromei krrk surveillance to look back at Emergency Department visits and we have evidence that things started to pick up in the spring and summer. There have been individual instances that we missed. So when i think about families in my district whose kids are vaping and who are deeply concerned, to me this is one of the most important questions. When specifically should someone go to the doctor and what information should they convey . You know if youve been vaping and youre having difficulty breathing or cough and the kind of symptoms weve described, you should talk to your doctor about that. We dont know exactly how rapidly people progress, but we are concerned about the very severe cases weve been seeing in young people. Weve learned that in some cases, doctors havent asked and vapors say now. We recommend that doctors not only ask do you smoke cigarettes, but ask if you use e cigarettes or vaping products. We think its really important for clinicians and parents to educate themselves about the types of products out there and to ask the right questions. Patients who have recovered and released are being told theyll need periodic lung scans. Do we know whether this will result in longterm or permanent lung damage . I fear it may, but we dont know yet and we recommend clinicians to regular follow up of individuals. The Clinical Community, the pull monoologies and so forth are studying parents and its so new that we dont have longterm follow up yet. Thank you so much. Im out of time and yield back. I want to spend my five minutes talking about cbd. I believe theres a lot of misinformation and confusion about what it is and what thc is. Cbd is cannabis oil and something that a lot of people talk. A lot of people in Congress Take cbd. Millions of americans take cbd. I take cbd. These are two of the products that i take and ill talk about that in a minute. Theres hemp and marijuana. Like broccoli and cauliflower. They have slar similarities and are very different. Thats the way it is with hemp and marijuana then theres thc. Its an acronym that pressumeas the level of sky ko active materi material, a lot of cbd that most americans are taking and theyre having really positive effects is coming from hemp not marijuana and the hemp cbd has little to no cbd. Prior to coming to congress. I was in kentucky. We were the first state. In kentucky, we became the first state to grow hemp. There are at least 15 hemp process e processors. There are at least 15 making cbd oil. These two products here that i take, ive been in those companies. Ive seen their labs. Those Companies Want the industry to be regulate. Currently, there are no regulations on cbd oil and the legitimate, credible Companies Want regulation. Let me know. Juul does not sell any cbd pods. All their pods are nicotine pods. So the sickness that happened and deaths that came from cbd from people ju, ling or using e cigarettes with cbd, these were counterfeit pods and the people that were producing these pods, they werent putting regulation ts on it. Its a good industry. Its a good product, but there needs to be regulation. Im conservative, but sometimes we need regulations. A young man was recently hospitaled from vaping with excessive amounts of cbd. They released him from the hospital. Got sick again. Hospitaledize again with a collapsed young and had to be put on life support in my district. I ask you consent this article detailing my constituents story be inserted into the record. Without objection. Associated press has tested 30 vapor product that were marketed containing cbd and found ten of the 30 contained synthetic marijuana. 22 of the 30 contained little or not cbd. This cbd produced in my Congressional District processed in any Congressional District has no thc. Zero thc. So theres a will tlot of misinformation and confusion about cbd that i wanted to make sure everyone understood. The associated proeess also reported that the dea found 128 of the cbd products they had tested contained sin thynthetic marijuana. Three of these contained fentanyl. So mr. Chairman, i ask unanimous consent that the two articles from the Associated Press be inserted into the record. Without objection so ordered. And if i may, ill conclude by saying that i think that there is a lot of positive benefits from cannabis oil, but this Industry Needs to be regulated. Its very prevalent in my Congressional District and they want regulation to make sure there are no bad actors, no fly by night companies producing the oil with excessive amounts of thc. So thats something that im working on. Ahad chairman peterson in my Congressional District sunday visiting with some of these hemp processors. Our office is working with usda and fda to try to see that we have good regulations that product the consumers while helping the industry grow. Thank you. Thank you t. I now recognize the congressman for five minutes of questioning. Thank you, mr. Chairman, and thank you for your leadership on this issue. Is it true that 12th graders vaping at least once in the past 30 days . Those data are from the preliminary results of the 2019 National Youth Tobacco Survey. The final results arent quite available, but thats right. Is there a Statistical Analysis that found that for one smoker than successfully quits thanks to e cigarettes, 81 young e cigarette users will become traditional cigarette smokers . Are you familiar with that . I dont have that statistic, but what i can say is that e cigarette use is much more frequent among young people, youth, than it is among adults. And are you familiar with the people who use them that end up going and using regular cigarettes . Thats right. The national akcademy of medicie looked at that in terms of whether e cigarette use may lead to tobacco use and theres moderate evidence about that. The newest generation of e cigarettes isnt really covered under that study and the newest generation seems to have a number of factors that make it even more addictive or more popular among youth so we dont have a longterm follow up on them. On september 11th, 2019, President Trump announced a ban on flavored e cigarettes. Final did something i agree with. And it hasnt been implemented. The cdc came out in strong support of the flavor ban with the director stating needed to reduce the epidemic. But washington is a very political place. And now theyre saying this is going to hurt his election in battleground states because there are hundreds of people in battleground states who vape. What would you tell the president about that argument his advisers are making and whether he should stick to his original ban . Let me just say that the regulation of Tobacco Products is under the fda not the cdc. As a Public Health expert and 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 we want to avoid another generation being addicted the nicotine. So addressing flavors directly is a good idea in terms of the role they play in young people particularly middle school and High School Students. Beginning to use e cigarettes. And on a substantive level, how would you answer the trade off where people say we agri with you on children not having these flavors. Thats why i support a ban. Thats why people support ban, but what do you say adults should do who want to transition off cigarettes . Are there ways they can still use e cigarettes without the flavor, with only the tobacco flavor . Is there any evidence to suggest it would diminish their ability to reduce their addiction to cigarettes . We dont think flavors are the critical factor for adults who are trying to get off of smoking cigarettes. We think the nicotine level is the principle issue there. And Behavioral Counseling is also looked at. None of the companies have applied to fda to be arooufed as a cessation device as of yet. So would it be fair to say then that you dont think banning flavors in e cigarettes would in any way harm harm adults who seek to quit regular cigarettes by using regular cigarette products. No further questions. Would the gentleman yield . Fourth generation devices, you keep referring to this. What are those . What im trying to imply is that the juul andrylated products use nicotine salts. We believe they can cross the, the product can cross the blood brain barrier and lead to more effect on the developing brain in adolescents. And when was this fourth generation introduce d in the market . Well the juul was 2015. But the market share really ratcheted it 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. And thats based on the fourth generation device really taking off. Right and we know that juul went up to over 70 market share more recently than 2015. It had a tiny market share. Okay. Thank you so much. I now recognize congresswoman miller for five minutes of questioning. Thank you, chairman. And Ranking Member cloud and thank you for being here today. There are two key issues that we must keep in mind surrounding e cigarette usage. First, we must do everything we can to keep e cigarettes out of the hands of those who are underaged. Secondly, we must also recognize e cigarettes Critical Role in Harm Reduction. For that reason, we must not throw the baby out with the barth water. We can both prevent children from using e cigarettes while ensuring they remain available for those adults who are 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 e cigarette, pods and vape fluid by underaged individuals. This unregulated black market does not have any of the protections for those to use their products and to pose a safety risk for the public. I understand that there are companies who sell in the United States that have taken positive steps to prevent underaged individuals from procuring their products both online and in stores. Doctor, can you first discuss the dangers of buying illegal or counterfeit vape Products Online . We think its really critical to know what you are using and its 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 very diverse and vastly changing and its really one of those arrows where people have to be aware. We think that Retail Stores really need to be enforcing the rules about not selling to underage individuals. And we need to ensure that companies are theres just a lot of. Testing found by a lab in california found that cartridges contained more than 38 vitamin e acetate and some tested 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 no one would really want to have in the middle of their lungs. I think right now, what were working vigorously on is trying to understand what are the products that individuals when have come down with this lung injury use and what was in them in a will tlot of other product. So laboratories are working hard on that issue right now. So the that present in the cases of the cdc is monitoring right now . Theres a variety of different substances were hearing about. We dont have full data yet. Its important to know there may not be much remaining product from an individual, they may have used up the pod for instance and there may be differences from whats in a pod than the lungs are exposed to when that substance is heated to a very high temperature. So there are sophisticated studies going on to analyze the product and vapor and air sole so we cant see a particular substance has been linked to a majority of cases as of yet. Is there a name of this disease people are getting . Were calling it lung injury associated with e cigarettes or vaping. Its not particularly catchy, so we dont have a name thats shorter yet. Lung disease. Were saying lung injury because it really looks like an injury, not a longterm disease. Of course longterm, there may be consequences of the injury that were seeing. Isnt it true that counterfeit products sometimes design their packaging to look like legitimate manufacturers and is the cdc seeing cases of pulmonary illness coming from these counterfeit products . I dont have information about counterfeit products, but thats exactly why counterfeit products make labels to deceive the consumer. Okay. I yield back my time. Thank you. Thank you. I now recognize congresswoman pressly. I am heartened to see the bipartisan interest and commitment to address what is a fast moving outbreak and am hopeful we will show similar and eck wittable outrage when it comes to gun violence which is a Public Health crisis. Doctor, thank you for being here and thank you for your efforts in addressing this outbreak. Imtedded to just revisit the line of question iing from representative cana in talking about the trump administrations intent to ban all favored e cigarettes from the market. It states that mint and menthol will be included and i wanted to get this answer on the record. Those are of course flavors, correct . Z correct. Yes or no. To be effective, do you agree the ban needs to include mint and menthol. Yes. Thank you. Im encouraged on banning flavors especially as flavors continue to be a main driver of why youth are using these products. A special bit of acknowledgment, my home state, the commonwealth of massachusetts, our attorney general, leadership of 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 has just flavors. A dangerous misconception considering all juul products deliver nicotine and according to the companys website, a single pod is e ququivalent to smoking one pad of cigarettes. Are you familiar with term nick sick. What about nicotine poisoning. Yes. Can you describe how these syndromes might present themselves in children are high intake of nicotine . The high level is scary. The spechk specifics, ill probably neat knead to get to you, but i think we are aware of a number of poise b b b control calls related to e cigarette use and sort of overdosing, if you will, then in terms of seizures having been r reported as adverse ooents, but the specifics id have to get back to you. 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 . Yeah, the concerns about the developing brain in adolescents are that nicotine can lead to difficulty with memory. Learning and attention. It can also prime the brain and body for addiction to other sub ta tanss and thats of particular concern. Have any 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 h t hospitals as they begin to track longterm impacts . We know in small numbers, the use 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 clinic n 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. Thank you. No matter what you call it, juuling, vaping, smoking, its the same and a number of young people are becoming addicted to these flavors. We have no idea of the impacts. As a mother and law mmaker, i fd this frightening. I yield back. Thank you. Will the gentlewoman yield her time for questioning fourth squlen ration e cigarettes and the nicotine salts. What is is importance of that . You said it penetrates the blood brain barrier. Whats the import of that . You know the issue is easier of access to nicotine to the brain may have a higher risk of leading to those issues ive mentioned. The learning difficulty, the attention problems. Memory issues. And so as well as priming for addiction. So i think that the brain is pretty central in the issue of addiction as well as in cognitive functioning and were concerned that higher doses of nicotine getting into the brain may lead to larger problems. That fourth generation is not just juul, but its the other pod mod combos. And the factor i havent mentioned, the devices are ones that are very easy to conceal. You can have them in the classroom. The teacher doesnt even know youre using it. So between the very high levels of accessible nicotine and the discreet use of the products, we think that the rise in teen youth is particularly dangerous. Thank you. I know recognize Ranking Member jordan for five minutes of questioning. Thank you, mr. Chairman. Doctor, 530 cases and then is it accurate eight deaths as well have been thats associated with the lung illness and vaping . Yes, its even more than that now, but well be updating the official numbers on thursday so we believe that probably hundreds more have come in since the numbers we released last week. What about the no additional people passed away, right . 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. Lets stick with the numbers 530 and eight. You said this about the 530 c e cases. T most patients have reported history of using e cigarette products containing thc. Many have reported using thc and nicotine. Some have reported the use of e cigarette products containing nicotine. Most, many and some. If i get it right. Can you give me percentages on those . Most of the 530 have used e cigarette products with thc. What percentage is that . Actually, those terms are related to the very small number that had been described in the illinois wisconsin series. This is really about less than 50 cases and this, most was about 80 . Many was about 60 . And some was less than 20 . But well be updating the numbers you dont have the percentages on the 530 . Just on the smaller population sample in illinois and wiscon n wisconsin. Any guess at the 530 . Would you think it would be similar . 80 have used, do you think it would be similar and 80 of f the 530 cases were using the thc . The trend continues in the preliminary look it. Larger number, but i dont have f the precise final numbers yet. So i do believe that the majority report use of thc or thc and nicotine products. Then of course theres the issue that the gentleman from wisconsin raised that the people who say they only used e cigarette products using only nicotine may not be totally forthcomi forthcoming. May be fudging a little bit on that. Absolutely. 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 day on those . Were they using thc or not . I dont have that data, but really important point is it may not be the thc or the nicotine, but it may be something associated with those products that people are using. You just dont know yet. Right. Okay. Now you also said you talked about the epidemic at the youth level particularly high school level. What was the, what was the numbers and i agree, this is, i dont want any kids using this product. Bunch of other things either, but what was the number for high schools students who were using the product . 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 was a big jump from about 20 the year before. That is. What is do you know the numbers for High School Students who have used marijuana . Its less common, but i dont have the numbers right in front of me. My understanding its over 20 as well. Is that right . I think you need to differentiate numbers used in the past year versus the past month and the numbers i was giving you for e cigarettes was use d in the past month so i dont have those numbers for marijuana. Would you, is it over 20 as well . I dont know. Im sorry. Okay. Okay. I mean, i figured it was. Okay. I was just 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. That i yield back, mr. Chairman. Thank you. Actually, i sorry, i did find the number. I knew i had seen it, but the number that i have r for adolescents use of marijuana is 12. 5 in the past year. Okay. So not the past month, but the past year so a bit less than the 28 in the past month for e cigarettes. Miss jordan, would you yield your remaining 14 seconds for questioning. Okay. Of the 530 cases, how many of them were related to fourth generation devices . I dont have that data yet. Okay. Thank you. I now recognize congresswoman talib for five minutes of question iing. Thank you, mr. Chairman. Earlier this month, my home state of michigan became the first to ban flavored e cigarettes. This came after news of the smokers showing up in Emergency Rooms with shortness of breath, chest pain, coughing, vomiting. Nationally, we have seen as weve repeated, at least 530 cases of lung disease in e cigarette users and 38 states. And it exposes just how little we know about these products. Advertises safer alternative. In practice, i believe that weve become testing ground to the American Public. Most disturbingly, our american youth. And right now, theres so much about the longterm impact of e cigarettes, but what we know now currently is pretty alarming. Why do you believe they have not been approved at cessation methods . Because theyre advertised that way. To my knowledge, the companies havent submitted the data. Why . 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. Thats right. And yes or no. Is it ever safe for kids or young adults to use e cigarettes . No. What about traditional cigarettes . No. Cdc has stated that e cigarettes 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 . Theres a lot going on in adolescents, but it may be part of that. We have also heard from many people who believe e cigarettes were safe and its easy to see why as weve continually see the misleading and lies to the American Public, but 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. Those tin collude d testimony a our july hearing that juul went into schools and told ninth graders its products were quote totally safe. They used the word totally safe. We were ploezed to see the fda answer our call by declaring that juul broke the law and issuing a warning letter, they gave them until september 30th to respond. To those listening, please Pay Attention to that response and what we hope will be prompt action by fda to hold juul accountable. So the cdc has asked the public to consider not using e cigarettes. Has the industrys false safety narrative made it more difficult to get your message out . We know theres a will the of noise out there and weve been repeating our messages. We hope the seriousness of disease and including death is getting attention. But theres a lot of competing messages. As much as e Cigarette Companies imply they are a sm e Smoking Cessation products, none are approved by the fda. Cdc has recommended adult smokers to quit smoking should use quote evidence based 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. Not to my knowledge. Thank you so much and i yield the rest of my time. Thank you, congresswoman talib. Without objection, miss wa wasserman shults. You have five minutes. Thank you, i thank the committees indulgence for including me. Doctor, welcome and thank you so much. Ive had the honor of working with with cdc 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 lustytive ones. Is there evidence that nicotine addiction is harmful to an individuals health . Yes. Could you elaborate . Were particularly concerned about nicotine use in youth. In pregnant women. Or women who are pregnant 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. 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 executive that sat where you are sitting actually had the audacity to say they didnt market their product as a smo Smoking Cessation product. Splitting hairs between the idea they are an al teternative, a sr alternative to smoking versus marketing it specifically as a smoking se. Seth sags product. Thats a distinction without a difference and so having an expert, a Public Health expert actually say 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 e cigarettes because she likeded the taste of the flavors and became addicted. She initially thought she had the flu, but within days, she had to be rusheded to the emergency room and put in a coma and there are now countless people who have had to be put into medically induced comas due u to the impacts of vaping and she spent nearly a month in the hospital. She was a nonsmoker drawn to e cigarettes by their flavors. Is there evidence that you found that other nonsmokers are being drawn in by the attraction to flavors . Yes, thats right. Among youth right now, were seeing that e cigarettes are more common than cigarettes and that flavors are pretty much always what brings the youth in. 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 to the flavors to fwin vaping or if they were no longer available have people cease to vape . We know flavors are a attr t attractant so i hope if flavors were not there, fewer people would take the product up in their teen years. Okay. And e cigarette use is still relatively new. I support Harm Reduction Public Health activities, advocates often describe e cigarettes as a harmry duction for smokers, but im concerned that we dont actually know enough to say with confidence that e cigarettes reduce harm and in fact, there have been, juulfederal ly prosecuted because of their criminal deceptive practices. Can you talk to us about the challenges of being able to accurately assess the safety of e cigarettes . The products have been changing quite a bit over the past several years so shortterm effects might have been lookeded at but the longterm effects we dont know yet and the aerosol they produce has a lot of substances in it. The longterm effect we just dont know. Its not just the nicotine thats the Public Health problem and the threat. So i mean, hyper focusing 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. Thank you. Thank you for your indulgence f. Mr. Chairman, i yield back. Thank you and now i recognize congressman cox for five minutes of questioning. Want to thank chairman murphy, 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. In one of the most recent death and the beauty queens was from one of my communities. Im troubled to hear that we have another crisis on our hands and this was one a special threat to tour families. We need to know why that has happened. We need to understand what your agency is doing to combat this and we need solutions to prevent this from happening again to not one more american dies needlessly. We called to see what happened to this individual, and they didnt have much information. Im concerned about the collection efforts were employing to stop this outbreak from worsening. Earlier, you pointed out one of the actions that your office your cdc is doing is to consider refraining quote, consider refraining from using the product. No disrespect, but to me, that sounds like pretty weak tea. Would it be more accurate to state simply that use of the product could cause death . Were trying to be careful when we dont know what the substance at risk is and were trying to sustain credibility against those who may think were exaggerating. We know that people are dying right now in this outbreak of lung injury and we want people to protect themselves and not take risks unnecessarily. Sorry, doctor, but im really looking for a yes or no. Would it be accurate to state use of this product could cause death . This product part is hard to say. One of these vaping products. Right, so our recommendations are very broad. Because something that is in e cigarettes or other vaping product ss leading to death so use of whatever that substance or brand or product or additive is can cause death. Yes, i think your comment is right, but when we dont have a specific product, consumers may not take action. So were trying to make them take this seriously in a way that theyll believe us. Yeah. I think the admonition that it could cause death could be a warning that they should take it seriously. More in the broader sense is that regular laces in my mind are really protections so when this administration boasts of regulating things, which really happening is that protections are being eliminated and these deaths could be prevented if we enforce preventative Public Health measures. The value of evaluating the products before they hit the market. Especially markets with known harm like nicotine. And so the question is really why is the default procedure for letting products on to 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 my product delivered through inhalation should be rigorously evaluated before marketing . Yes. I can tell you the cdc in this regard needs to find its voice again and we in congress are committed to helping you do just that. Further, some specifics about what the cdc is currently doing, id like to know a little bit more about the individuals that have got the confirmed lung illnesses from e cigarettes and although very little is known about the longterm Health Consequences of using these products, whats the cdc going to do about tracking the consequences . The individuals who have the condition right now, majority are male. Half are under 25. Many are previously healthy. Were just gathering data now in more detail, but were working with a clinical communities including lung specialists to try to understand what longterm follow up should look like and how that information should be collected. Were also working with the nih in terms of some of the research questions, but the pulmonary community may help us come up with guidance for systematic ev ev evaluation and follow up. Thanks so much. We really appreciate what you and the cdc are doing on our benefit. Thank you, doctor. I think that concluded panel one and we will now commence panel two. Thank you again for your testimony. Id also like to remind efb everybody the witnesses reminded there may be additional questions for the record and the Committee Requests you answer them properly. If the second panel could please come forward. We are pleased to have you here. Thank you so much. We begin our second panel here. We have dr. Azikk, director of illinois i will. Doctor rizzo, ruby johnson, the parent of a teenager affected by the ecigarette related lung disease outbreak and i will yield to my colleague, mr mr. Grothman. I would like to take the opportunity to introduce a good fan from wisconsin, a passionate fan, whos helped countless people quit smoking by sharing her story, vicky porter. Thank you so much. If you would all please rise and raise your right hand, ill begin by swearing you in. Do you swear or affirm that the testimony youre about to give is the truth, the whole truth and nothing but the truth, so help you god . Let the record show that the witnesses answered in the affirmative. Thank you and please be seated. The microphones are sensitive, so please speak directly into them. Without objection, your written statement written statements will be made part of the record. With that, doctor, youre now recognized for five minutes. Dhachairman, Ranking Member cloud, and distinguished members of the subcommittee, thank you for inviting me to discuss this concerning situation where hundreds of people across the country, including 69 in illinois have experienced severe respiratory illness after vaping or using ecigarettes and tragically there has been one death in illinois. An additional suspected cases are being reported to the department every day. Our patients in illinois have ranged in age from 15 to 42 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 cases have required hospitalization. Threefourths have needed placement in the intensive care unit and over a third have required mechanical ventilation. While we 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. Shookit has covered the details of the outbreak and its imperative that the investigation continue as to identify the etiology of the acute illnesses, but there is another matter that needs to be addressed. In parallel to the investigation matter, and that is the youth vaping epidemic. Perhaps Public Health should have rung the bell louder. Even so, the current investigation has highlighted the creation of the next generation of nicotineaddicted americans. Ecigarette use increased 900 amongst middle and High School Students from 2011 to ar q2015. According to dr. Wangs june 2018 mmwr report. The 2019 National Youth Tobacco Survey showed 68 of youth vapors used flavored ecigarette products. In december 2018 the u. S. Surgeon general did discuss these alateraling 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 youthfocused groups and heard recurring symptoms that show nicotine withdrawal in middle to High School Students, many vaping as little as three to six months. We must permanently change the narrative around vaping and ecigarettes. Ecigarettes are harmly and highly addictive. They are so efficient of delivering nicotine directly to the brain. Nicotine has no redeeming qualities for youth and young developing brains. In 2018 traditional cigarette smoking among Illinois High 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 before they took their first hit on the ecigaret ecigarette. Contemporary product designs, attractive technology, they sync up with their iphones. The vapeware merchandise is all targeted to youth. There are ads on 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 with enticements to vape with the marketing of trendy devices, ejuice flavors like strawberry, watermelon and mango. In the state of illinois, governor pris ker supports moving forward with strong legislation to ban flavored vaping products which are exc d exceedingly popular amongst youths. We must revise curriculum among elementary and middle school to discuss the dangers of vaping. I urge congress to take up similar initiatives to protect our youth, urging all people not to vape, especially while this National Investigation is ongoing. Thank you. Thank you, doctor. Next is dr. Rizzo. You are now recognized 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 American Lung association. I still see patients in my pulmonary practice in delaware. Im here to speak about the dangers of ecigarette use. For more than a decade the American Lung association has been raising the alarm about ecigarettes. Well continue to reiterate our rent recommendation that the public not use any Tobacco Products including ecigarettes. Our nation is currently in the midst of two different ecigarette crises. First, according to the 2019 National Tobacco youth survey, 27. 5 of youth are now using ecigarettes which is 135 increase from just two years ago. According to a cdc study, one of the primary reasons teenagers use these products are because the candy and fruit flavors are so appealing. This high use of flavored ecigarette use among youth is ala alarming. The national Lung Association xhendz President Trump and his administration that they will remove all flavored ecigarettes from the marketplace. We believe this is a vital and positive step and we urge the fda and congress to act. The Second Health crisis is the current cluster of pulmonary illnesses related to vaping. As we heard today, cdc, state and local Health Departments are conducting an Ongoing Investigation of these pulmonaryrelated illnesses due to vaping. Both crises are caused by the failure of two administrations to fully implement the Tobacco Control act of 2009. The delay in the fda has left unregulated products with unknown chemicals on the market. Some chemicals found in ecigarettes are carcinogenic. Will they cause cancer . Will the inhalation cause lung diseases like copd . How do they impact people with asthma . The latest question is what will be the longterm Health Consequences of those who were hospitalized as we deal with the pulmonary ecigarette outbreak. The first report on Health Hazards of smoking including it they caused cancer. 50 years later the Surgeon Generals report added even more smokingrelated diseases. Its hard to predict the possible Health Consequences well see in another 50 years and the result of ecigarettes. Were very troubled by what we see so far. Ecigarettes contain nick even. In addition to being extremely addictive, it can increase blood pressure, heart rate, and nicotine among youth adults can alter Brain Development, cause learning and brain problems. Two chemicals can expose users to high levels of toxins that can cause[vd irreversible lung Heart Disease. Flavors attract kids which is why the American Lung association has advocated for the removal of flavored products from the market. 81 of youth who have ever used Tobacco Products initiated with a flavored product. The American Lung association believes everyone who uses Tobacco Products can quit if they use proven, safe and effective drugs by the fda. The fda has not found 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 comparing ecigarettes to nicotine replacement therapy. In this study over 90 of the smokers using nicotine replacement therapy quit smoking ending their neck teen addiction entirely. 80 of smokers given ecigarettes did not quit but switched and remained addicted to ecigarettes and, therefore, nicotine. Switching is not quitting. Quitting means ending your addiction to nicotine which can be very difficult. I have patients who have switched to ecigarettes believing they had quit. Some remain addicted to nicotine. Some have been duel users and some have returned to regular cigarettes. In conclusion, the American Lung association supports President Trumps call to end flavored ecigarettes. They have not been shown to be safe. Theyre responsible for another loss of possible generation to tobacco death and disease. Thank you for the opportunity to testify. Ill be happy to take questions later. Thank you, dr. Rizzo. Next we have mrs. Johnson. You are recognized for five minutes. Thank you so much for having me. My name is ruby johnson, im a mother of seven children ranging from an 18yearold College Freshman all the way down to a 5yearold kindergartner from new york. My 5yearold is still alive. As you will hear, that could have easily not been the case. On august 16th i loaded up my daughter and her dorm room to begin her freshman year of college. She began to cough, complain of pain in her chest when she took a deep breath and shiver like she was running a favor. She also admitted to me she was starting vaping. It turned into a neardeath experience that involved a weeklong hospital stay where my daughter went there a healthy, vibrant 18yearold to a patient who needed rapidly increasing amounts of oxygen and medications to treat her declining health. When we arrived in her college town, we went directly to the hospital. She was nauseous, tachycardic, running a high fever, couldnt take a deep breath without intense pain and keep her oxygen saturation even up to the mid80s. A ct scan showed what doctors called a diffuse pneumonia all over her lungs. Antibiotics were started immediately, her condition continued to worsen as her oxygen needs increased steadily and she was transferred to the icu in case more extreme measures needed to help her were necessary. With every doctor came the same question. Have you traveled out of the of country recently . Do you have a cold . The Million Dollar question, are you a smoker . The answer was no. Finally they asked, how about ecigarettes . Her answer to that question was, yes, but it wasnt until we got to the third doctor to see her that it seemed to be taken seriously. It was that doctor who paid attention to the fact that she said she had been vaping and she was now experiencing symptoms that matched with the newly reported cases of a mysterious lung illness popping up. He did his research by contacting doctors and hospitals that had already seen similar cases in order to determine the best course of treatment. Ill never forget watching her cry that shi she literally couldnt breathe without excruciating pain as she was pumped full of iv fluids, antibiotics, steroids, pain meds, antinausea meds and dire retic. She couldnt even get up to walk to the bathroom without her alarm screaming because her oxygen saturation was dipping so low. Her belly was purple from the nightly injections she gave her to prevent blood clots as she lay in a hospital bed. Our daughter ended up being one of the lucky ones because she got to leave the hospital and can breathe without supplemental oxygen. Per poll mondayologist feared had we waited another 24 hours for medical attention she would have been unresponsive on a ventilator. Were grateful she received the care she did, although we dont know what the future holds as far as permanent damage. We all know teenagers will inevitably make bad choices and we hope they learn from them but its scary to think theres an industry full of largely unregulated products with sfwler longterm Health Studies that are so attractive and easily accessible to youth. The ecigarette industry has actively targeted our kids through social media campaigns, on quizlit, a popular homework site and for flavors clearly made to appeal to young people. This committee knows how youth have been fooled into believing these products are safe by companies that act as if they could care less about their health and wellbeing of these kids. Consequently we have the most serious Public Health crisis our country has faced in decades. These products are designed to be hidden from parents and teachers and they accomplish that well with smells in vapors that disappear as quickly as they appear and devices that look like flash drives and apple watches. You may have read juuls ceos by saying blank happens. Well, blank happened to my family and im joining the movement of moms who as parents against vaping ecigarettes and saying enough is enough. Our kids should not be the guinea pigs. They products flooded the market without anyone knowing how they could cause damage and now were trying to clean up the mess. If this was romain lettuce, the shelves would be empty. We desperately need our legislators to help us by banning the flavors that have drawn in youth like my daughter including mint and men thol. What happened to my daughter, our kids are hooked by flavors. Kids who never would have picked up a cigarette instead started using flavored ecigarettes and it becomes a gateway to other substances. The fda has allowed these to flourish. This probably would have been easier to keep private but im here today to share our story with the hope that no other family will have to live the same nightmare. Im a mom whos in her teen ijarys business constantly and i did all of the right things and this still happened because our youth are being actively targeted by manufacturers with appealing flavors and theyre able to satisfy their nicotine addiction using devices designed to be secretive. Its time we do something about it. This goes beyond party lines because this is all of our children. Thank you, mrs. Johnson. Miss porter, you have five minutes for your opening statement. Thank you. Thank you very much. My name is vicky porter. Im from lake mills, wisconsin. Im 51 years old. I started smoking cigarettes in college. I even remember the evening i started smoking. I just got dressed to go out and i was listening to jazz records drinking irish coffee. I spotted a pack of benson hedges ultralights a friend left behind in my dorm room. I took out one of those cigarettes and lit it because what goes better than whiskey and jazz, a 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 realized, 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 tried two fdaapproved drugs. Even tried one of those drugs twice. I tried hypnosis twice. I tried some hoke cuss poke cuss called laser acupuncture. All failures. By now i was around 40 years old and i figured i would live to be content dying from smoking, gasping for air like my mother and grandmother died from lung cancer. A coworker showed me an ad for ecigarettes. The promise was smoking without the harm or smell. So i ordered one because i thought, 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 havent done since before my lungs became overwhelmed with the filth and deadly toxicity of cigarettes. Vaping is a health miracle to me. Without it id 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, but less harmful nicotine dose similar to smoking. Without the deadly toxins caused by burning tobacco. Second, and this is critically important, flavors. Flavors matter to me, an adult e exsmoker. Flavors are not an industrydriven innovation. They are a userdriven innovation. Big tobacco didnt come up with the idea of flavors. Consumers, adult smokers like me came up with the idea of flavors. We demanded it. The tobacco flavors that everybody seems to think are so wonderful of the early ecigarettes were awful. They mimic the taste of a cigarette and were poor imitations of the cigarettes we actually like to smoke. We dont want our vapor to taste like cigarettes. Were trying to quit them. We want something that tastes good, that makes us want to keep vaping. Flavors keep us vaping. Flavors keep us not smoking. I took a survey on my facebook pang of exsmokers turned vapors. About 150 people left comments. I admit this is not scientific but at last count approximately 90 use flavors other than tobacco. Those are middle age and exsmokers. These flavors are demanded by adults, consumed by adults. According to a recent survey of more than 69,000 vapors, 92 preferred nontobacco flavors. Much as been made of the illness of the vaping. Its dishonest to blame ecigarettes and liquid vaping. Those lung diseases being diagnosed have everything to do with adult rated street drugs or products, notably oilbased thc. Ive been vaping now for nine years and ive never been healthier and none of the ne nicotine vapor products i use contain oil. America is about to squander based on disinformation and misinformation. The fda and local agencies, communities and parents absolutely need to do a better job of enforcing existing laws and obligations to see to it that kids dont use ecigarettes. You dont need to ban the product to make progress on that mission. In 2018 the uks Royal College of physicians published a comprehensive scientific report which concluded that vaping nicotine can eliminate almost all the harm from smoking cigarettes and recommended promoting the use of ecigarettes to smokers as widely as possible. The report also indicated that vaping nicotine is at least 95 less harmful than smoking. Public Health England concurs. Even the American Cancer Society is dwining to understand the promise of tobacco reduction. Quoting ecigarettes are likely to be less harmful for adults smoking cigarettes and they encourage adults who have failed other fdaapproved medicine to switch to ecigarettes. This product probably saved my life. Vaping has helped more than 8 million adult smokers quit completely when all other options failed for them. I think thats incredible. 8 Million People quit smoking. On whafl of former smokers, i hope youll reject the general war on vaping and i encourage you to proceed with these comments in mind. Thank you very much for your consideration. Thank you, miss porter. I need to correct the record on a couple things that were just said. There is no evidence to suggest ecigarettes are safe or even safer than cigarettes. Thats why the fda just released their regulations directed at juul. The cdc came in and presented evidence they dont know the cause of the current outbreak and did not rule out nicotine ecigarettes. May i respond . No. Were about to start questioning and you can respond then. Okay. I will recognize myself for five minutes im sorry, ms. Wasserman schultz for five minutes. To all the panelists, thank you for joining us. Specifically my initial question is directed at the two experts in Public Health. Is there any evidence, im asking you the same question i asked doctor shookit, is there any evidence ecigarettes are dangerous to a Persons Health . Are there any Health Benefits at all, including the reduction of the likelihood of smoking cigarettes to inhaling nicotine on a shortterm or longterm basis . There is no evidence that nicotine is helpful at all to young kids or their developing brains. Dr. Rizzo . I agree with that. What was the second part of your question . Is there any evidence that nicotine addiction is harmful to an individuals health . It is harmful, yes. Individuals of any age . Yes. Nicotine by itself affects the vascular system, blood pressure, heart rate and can cause heart and lung disease by itself, especially in the elderly. And do we have evidence that that is further complicated by the other chemicals that combined with nicotine that are utilized in a vaping product . I was referring mainly to nicotine by itself, but certainly when its combined with other ingredients in a vaping product the accelerants, the chemicals. Yes. Its not just nicotine thats inhaled. Correct. Are there health negative Health Impacts, including the potential for death, to the combination of yes. Chemicals in vaping . Yes. Thank you. The cdc has identified 530 cases of illnesses with the use of ecigarettes in 38 states and one u. S. Territory. Its important 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. Illinois and wisconsin were the first states to identify the outbreak and to spearhead investigations in july when ecigarette related illnesses sprung up in your states. Can you describe the severity of those initial cases and why your states felt so compelled to act swiftly . And what steps has illinois taken to identify all possible ecigarette related lung illnesses, even prior to this summers outbreak . Thank you for that question. Unfortunately, we did find ourselves at the epicenter of this outbreak. Because of the alert that the Wisconsin Department of health had released, people were in tune to the possibility of these illnesses that were not well described but had a connection between Young Healthy people without a reason otherwise to fall so sick, who had presented with severe respiratory illnesses and had a connections with vaping. So 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 alerts out to poulmonologists, hospitals, pediatricians, Emergency Medical Services to report any suspicious cases directly through their local departments which would then come to the state department. Putting out press releases, putting out information on our social media, connecting with the state board of education. Working with our advocates in the community i want to piggyback on my question. You conducted detailed interviews of those struck by the disease. 61 of the people interviewed reported using nicotine ecigarettes and 20 were using only nicotine ecigarettes. Many also did report thc use. Is it safe to safe you cannot rule out ecigarettes as contributing to the outbreak . Thats right. Your advice to the cdc is for people not to use any ecigarette products. I assume that decision is not made lightly. Can you tell us how you decided that recommendation was necessary for the Public Health . As a role to protect the public not knowing what the actual etiology is, but knowing the only commonality of our 69 cases was vaping, we know something with the vaping activity, whether the product, the product device, the brand, something therein is the culprit. Without knowing specifically, it seems safer to give a broader warning until we could get more information out. Reports show ecigarette aerosol is not harmful. Why is it dangerous to people that vape . The chemicals within the aerosol are usually irritants to the lung. The lung then responds with different kinds of reactions were seeing in some of the patients which obviously affects the oxygenation, which is the primary function of the lung, which sometimes results in needing a breathing machine to now perform that process of oxygenation. Thank you. My times expired. I want to confirm my understanding is that the testimony of miss porter is anecdotal related specifically to her opinion and she is not a Public Health expert. Thank you. I think thats correct. I now recognize i yield back. Congressman grothman for five minutes of questioning. First of all, doctor i forgot okay. Are these i know youve recently legalized marijuana in the state of illinois. Are thc cartridges now legal under the new law in illinois or not . Thc cartridges are legal through the medical cannabis act. For patients who are on the medical cannabis program, thc cartridges are available. Was that a mistake . I beg your pardon . And that was a mistake . We have no cases of our 69 cases in illinois that are from the registry of medical cannabis patients. Im sure but once you make these things legal, theres certainly more of them out there, that sort of thing. It implies theyre okay. Again, were still waiting to identify the exact etiology. Again, you mentioned that in your study, 80 of the people with Health Problem selfreported they had some thc in there. As i asked the last panel, i assume people dont usually admit theyre doing something illegally. If 80 admitted that they were using a product with thc in it, is it possible the numbers could be higher . They could be higher. We interviewed and reinterviewed patients. There were persistent conversations with these patients and so people have reported more use. Miss porter, you wanted to respond to some of the other congressmen. I want to give you an opportunity to say what you want to say. What i wanted to say is 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 actually a scientific report. Also, and im not sure how many people had a chance to see this on cbs this morning last week, dr. David abrams from the nyu college of global Public Health indicated that 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 is the particular mechanism that vegetable glycerine or appropria proply in. E gli coal could cause disease . I dont think youre supposed to ask question. Could you respond . We dont know anything about these devices because they havent been studied in any manner. When you heat the temperature up that ecigarettes do, you no longer have the same properties of the compound we knew before. A compound that could have been ingested safely is now being vaporized and inhaled into the lungs which is a much different part of the body than the stomach. In short, we dont know what the toxins are doing. We know toxins are created. Even if we say toxins are less than cigarettes, thats a low bar to beat. 7,000 chemicals in tobacco still means theres 350 in 5 of ecigarettes. Miss porter, if we banned ecigarettes, youre no longer able to get them, its obviously important for you not to smoke, what would you do . What would be your fallback position . The 7,000 chemicals the doctor were talking about is the chemicals aga chemicals generated when tobacco is burnt. A cigarette does not have 7,000 chemicals in 5 of eliquid. Thats when you light something on fire, the various carcinogens in your lungs. I know this because i smoked and i decided to learn about it. What would i do . I would i would probably just find a way to get my ecigarettes. Thats what i would do. Thats me, though. Im a very knowledgeable user and im a very knowledgeable navigator of this marketplace. Id probably order from china. Most people, anecdotally again, most people ive spoken to who vape would simply go back to smoking. The reason were vaping instead of smoking is because all of the fdaapproved 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. Im going to recognize myself for five minutes of questioning. Dr. Rizzo, could you compare to respond to the claim that ecigarettes are safer than combustible cigarettes . Yes. The quote about the United Kingdoms decision that 95 are safer than tobacco, if you read the articles about how that decision was made, a group of experts got together for two days in europe. Several of those experts admitted to be working for the vaping industry. And the european respiratory society, 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 different aspect of ecigarettes. Theyre controlled and regulated much more strictly than in country. The tobacco flavors are not there. You cant compare what happens in england to this country and it is faulty science it was based on. So that was a bogus study. What are the nicotine levels for nicotine allowed in uk versus america . I can get the exact number. I think 18 to 20 milligram is whats recommended in ecigarettes in england. Here its 59 . I believe, correct. Roughly three times the amount of nicotine here in the u. S. In any ecigarette pod compared to in britain. Now, mrs. Johnson, i want to ask you a couple of questions. How old is your daughter now . 18. When did she start vaping . After all this happened she said she tried it the first time when she was a sophomore in high school and 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 prior the vast majority of what she used was nicotine ecigarette. 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 adjusting to life as a College Freshman. Shes still out of breath when she has to walk quickly or far and will just kind of see what the future holds for her. Are you saying theres some kind of permanent injury associated with what happened due to the vaping . Unfortunately with this being such a new thing, the doctors cant really make any promises that there wont be permanent damage, so well just continue to follow up with repeat ct scans of her lungs and see what that reveals as time goes on. How did she first begin vaping in high school . She said that a friend offered it to her to try. Theyre passed 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. 28 of High Schoolers today are vaping and 5 of middle schoolers are vaping. What do you say to patients who are worried about their children getting hooked on e zets. Its super important to keep the conversation open. So many of us dont know what to look for, so i also feel its important 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 to educate ourselves and our kids. You said mint flavor was one of the ones that got her hooked. Yep. Shes been super honest as this has all happened because shes terrified and said ill never touch a vape again but she said mint was her favorite. You were very close to losing your daughter, correct . Thats correct. And before they collectly 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 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. I remember this night where she cried to her nurse saying, it hurt so bad, i cant take a deep breath. The nurse reached out to the doctor and she said, since he admitted her, he was trying to reach out to other hospitals and doctors. That was when, you know, they had us wearing a mask at first thinking it was pneumonia. Thats when the masks came off and said, i think this is what were dealing with. Thank you, mrs. Johnson. Thank you. Id now like to recognize Ranking Member cloud for five minutes of questions. Thank you, chairman. Dr. Rizzo, could you give us enlighten us on the distinction between Infectious Disease and Chemical Exposure as it relates to lung injury. Sure. When someone presents with the symptoms that were mentioned, it could be a bacterial or a viral pneumonia, meaning that the organism has gotten into the lung, the immune system has led to the cells of the body going to the lung to try to fight off that infection. Basically thats inflammation. When that occurs in the lung and depending on the intensity, it will fill the normal air spaces with fluid, pus, inflammatory cells. Therefore, the ability to get oxygen to the bloodstream is diminished. When its an infection, you can usually culture that media. Whether its sputum or a tube is put down the lung. You culture that, look for organisms under the microscope. Whats that ruled out, the inflammation must be caused by something else. In situations like this, the history is very important. You have to find out, what could they be exposed to . The right questioning, putting two and two together, doctors realized there was a commonality of vaping something. This has been touched on already, but could you explain specifically why its much more an issue for young people to start vaping. The young people seem to start vaping much more than adults because of the flavors. From a health perspective, what does it do to their body . Oh. Flavors inhalation into the lung occurs a couple different things. First of all, the lung doesnt reach full development until midtense. Youre dealing with a population where the lungs are still growing and developing. All of a sudden now you have an insult of inflammation, changing the immune system. Now the body has to try to compensate for that and recover from that but has lost ground with regard to what ultimately that Lung Development is going to be. In cases like youve heard about, this 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. We actually have tobacco 21. It is illegal to use products under the age of 21. Okay. Miss johnson, as a parent of seven children, kudos. I have a number of parenting questions not appropriate for this setting. And happy to hear your daughter is doing well. Do you it know where she was obtaining the product from . I do do know 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 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. Okay. 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 its a huge problem. I mean, were scared enough as parents, but our poor educators are drowning because its these products are not only accessible to the kids but theyre very discreet. And you mentioned a mix of legitimate and illegitimate product, is that correct . Thats correct. Dr. Ezike, whats being done we mentioned we have a store that was a bad actor. We have people who are getting minors product in the schools. Whats being done on the enforcement end to prosecute bad actors in illinois . So, not exactly within our realm, but we are 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 has anyone been charged . No one has been charged, as far as i know. But they are 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 investigations and that enforcement is going to be stepped up. Okay. Thank you. 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 regulatory cigarette users who are adults and obtaining these products legally. I also want to say the products ive been vaping for nine years are not 59 milligrams. They are 12 milligrams. I think that regarding the product the manufacturing of the product insisting on good manufacturing practices, gnp is something that is important and something i look for in the products i purchase, as someone who has, you know, making sure that nothing gets aadult rated, there isnt crosscon tom nation. With regard to kids, i think we dont even talk much about enforcement you know, in the state of wisconsin, police would send decoys in to see if young people could potentially buy a pack of cigarettes. Stores were fined substantially if they violated that. Same with underage drinking. That kind of regular enforcement is something that is quite important that doesnt seem to really be a priority is folks are fully neck deep in the panic about vaping. Again, i point out that if you get rid of flavors from vaping or vapor products, then you are stranding 11 well, 8 Million People who are exsmoker and 11 Million People from access to products that work so that they dont pick up a pack of cigarettes. With regard to advertising, i made a note here, hoodies . I mean, who makes this garbage . This kind of stuff, obviously, if it is marketed directly to children is appalling. There isnt a Single Person who uses a vapor product as an adult who thinks its appropriate for young people, freshmen, ninth graders or eighth graders or sixth graders to pass around vapor products. And i also think we need to really understand here that it appears from all indications, and no, we dont have evidence, but from all indications, these diseases i dont want one of these diseases, by the way. 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 very much. But i do think we can do something about the adult rated products on the streets. Congresswoman pressley, you have five minutes of questioning. Thank you, mr. Chair. In an nihfunded study 8,000 eliquids are on the market. Some include banana pudding, rainbow candy and hawaiian punch. Dr. Riz sdmrozo, do we know how of the 8,000 flavors were tested for toxicity . The one was done at Harvard School of health. They looked at 51 different flavors and 47 of those flavors did have chemicals in them they felt were toxic to the lung. I dont know about any larger studies at this point. 47 out of 51 . I believe was the number, yes. Dr. Ezike, you have collected samples of the products that were used by victims of the outbreak and those are in the process of being tested, correct . Thats correct. They are with the fda and were waiting for those results. As you search for the cause of the outbreak, you have not ruled out components of flavors as possible contributing factors to the outbreak, have you . That is correct. We have not ruled that out. Dr. Ezike, are any cigarettes approved by the fda as Smoking Cessation devices . No, they are not. ECigarette Companies have been allowed to apply for fda approval as smoking sesation devices for years but thet have not done so, have they . They have not. Getting approval to require approval getting ecigarettes working for Smoking Cessation and manufacturers havent even conducted the Clinical Trials to back up that central claim . Thats correct. Miss porter, im grateful for every adult smoker that ecigarettes are actually 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 i was just making a statement. I wasnt posing a question to you. Miss porter, please let miss pressley ask the question. Now ill get to dr. Rizzo. We have seen no evidence that ecigarettes are useful for Smoking Cessation. Dual usage is more prevalent. Is dual use safe . No. If someone cuts back on smoking and adds vaping, is that safe . No. Even if ecigarettes were useful for cessation, have you seen any evidence that adults who want to use them for that purpose would refuse to use tobaccoflavored ecigarettes . No. I yield back. Thank you, congresswoman pressley. Congresswoman miller for five minutes of questioning. Thank you, chairman krishnamoorthi. I want to thank you all for being here today. This is very important. Miss johnson, thank you for sharing your story. And i hope your daughter continues to recover, particularly after listening to dr. Rizzo say our lungs continue to form into our 20s. I think thats a positive and i hope and pray that she gets better. Thank you. Dr. Rizzo, is nicotine addictive . Yes, definitely. Is it also a depressant . It actually has two phases. It can initially be a stimulant and then be depressive. Its a chemical that acts as a neurotransmitter in our body via receptors. Theyre all affected by nicotine. People have been smoking for centuries, havent they . Yes. It wasnt until the 60s when they finally came out and established that it caused cancer. Yes. I also remember in the early 60s trucks putting out vapor with ddt driving around my neighborhood and children riding bicycle behind the truck because they thought that was really neat. Were there any studies done to see if ddt caused cancer . I would have to look but i suspect it was looked at at an inhaled toxin. I dont know the details on that. I can get back to you. That was another vapor that they put out. I just i vividly remember that happening. Miss porter, you said you smoked for 20some years. 23. When you started, did you just think that that was really cool . Sure did. Thought it was the coolest thing. I thought, im listening to jazz and drinking whiskey and smoking a cigarette. Yeah. I remember, you know, movies about world war ii and everybody had a cigarette hanging out of their mouth and the message was just that that was a cool thing to happen in the 50s and 60s. My movie was house of games request the. That was my movie. I dont know that one. It was a good one. Okay. And you are concerned about youth using ecigarettes . Absolutely. Im concerned about youth using ecigarettes, im 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 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. Well, i remember our next door neighbor had a kabalba tree and kids thought it would be cool to light those long sgra cigarlooking things that smelled terrible. When you went to ecigarettes did you notice how bad your hair or house or clothes smelled . Oh, sure. Within two weeks of switching to ecigarettes, i couldnt tolerate the smell of smoking. I couldnt tolerate 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. Yeah, its very obvious. The more obvious change, though, came about three months after i had 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 wanted to know if i was going to be sick and die. Potentially of lung cancer if i had the beginnings of copd. I mean, in three months did you think your lungs were going to change . Becauyeah, because i felt so better. My doc said, your lungs are pretty clear. I said, good, because i quit smoking. Shell said, i can tell. You mentioned a much lesser amount of nicotine in the ecigarettes. Is there like a stepdown that if you were a smoker to theres a lot of 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. Sfe depending on the device. I can use as little as three milligrams of nicotine and eliquid. Yes, you can absolutely there are multiple different variations and concentration of the liquid itself. So, it would be possible you could step down and totally get off people do it all the time. On my Facebook Page when i asked for some stories, multiple people said, i began at 18. I stepped down to 12. I went down to 9. Then i was at zero. Some team people are still vaping zero. Some people just decided to use that 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 questions. Thank you, mr. Chairman. Thank you all so much for being here and for contributing to this important conversation. As a mother, thank you, miss johnson, for coming here. I know its not easy. Even for me speaking publicly to this day, my stomach turns. So, i know how hard it is, especially something so personal. So i really do appreciate you being here. Ecigarettes were allowed onto the market without fully understanding the longterm effects and without regulation, as you all know. Their safety wasnt tested, yet Big Tobacco Companies like juul tauted their products as safe and certainly safer than cigarettes. They sent representatives into schools to tell students this is, quote, i continue to repeat it because its obviously theyre tailoring it towards our kids, quote, totally safe. The result is that ecigarette use took off. Now 27. 5 of High School Kids use ecigarettes and those kids are used as guinea pigs. We are just now beginning to find out the health risks they pose. Risks like those who we those that are suffering right now from it and the outbreak of lung disease and so forth. In fact, most ecigarettes hold and produce many other toxic substances such as formaldehyde and a compound named benzene, which is found in car exhaust systems. Dr. Rizzo, yes or no, is it safe to inhale these liquids contained inside ecigarettes into your lungs . No. What are the outcomes of inhaling such toxic substances . Are there 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 for nine to ten years. Yes. Likewise, cigarette smoking process requires the user to inhale ultrafine particles that could possibly irritate their throat, eyes and airways. Dr. Rizzo, could these particles exacerbate respiratory alignments . Particularly the ultrafine particles are similar to the particles in air pollution. They get into the lung, the bloodstream and can affect the cardiovascular system in the lungs. Very little is known about the longterm Health Effects of ecigarettes but there is longterm studies on longterm effects of nik teen. Can you explain how nicotine affects Brain Development in adolescence . The brain is developing until age 26. And with nicotine, the receptors in pediatrics, they are more susceptible to being addicted. So, they get addicted quicker and the addictions predisposed to future aaddictions down the road. Weve seen people with worse addictions usually started at earlier ages. This is very scary. As a mom, you know, i hope ecigarette users are aware of this fact and are not waiting for government to declare this kind of a National Crisis right now, right . That we already know from just a mere hospitalization cases like in your daughters case and so forth that its unsafe. Unsafe. We have heard that vaporing exposes you the harmful chemi l chemicals and so forth. You know, goi in to speak to the kids all of the time and the second and the third grade reading and they always ask, what do you do. I tell them that i work at the capitol and show them the picture and where it is geography wise and i tell them when i was your age i used to go to restaurants with your parents and now they say how many in your group and when i was young it was smoking or nonsmoking section and the kids are like, what . And smoking or nonsmoking, because they smoked the cigarettes in Public Places like restaurants and hospitals and schools and planes and the kids eyes are wide like what . That is unbelievable. And i said, yes, even though the scientists and the people were saying that the secondhand smoking was worse, was worse than directly smoking cigarettes, and even though Health Experts and others were coming forward, you had the big industry and the corporate greed misleading information out there to the public what the real impact was on health. And so it is so important that you all continue to speak truth about this. Because, the long term effects is dangerous, especially because they have been targeted toward the youth. And ms. Porter, i was reading, because i wanted to know more about you and we all have different abilities, but you call yourself a converted conservative and reformed marxist, and are you my politics are irrelevant. And why were you winking at my colleague . I know him. He is i didnt know why you were winking, because of the winking. You think that there is a conspiracy in this hearing . May i address the truth . Well, the truth is very different for the majority of you and the people in this room. And the difference is that i have quit smoking and you are lying. I am not lying under oath. Order, please. I would like to recognize congressman connolly for a five minutes for questioning. Thank you. Welcome to the panel. It seems to me that this is a new crisis that came upon us real fast and unawares, 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. And is that a fair summation of where you think that the state of illinois finds itself, dr. Ezike . I believe that there is 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 the information faster around these kinds of the epidemics as they merge. But if the federal government is not regulating the product, and hasnt done the research and analysis of pros and cons and dangers, and benefits, it kind of leaves you either to do nothing and wait or to try to take some action to protect the citizens is of your state. Isnt that fair . Yes, that is correct, sir. So we have a vacuum at the federal level. Fair enough, dr. Rizzo . Fair enough. And so this is reminding me a little bit of marijuana where we have not done enough at the federal level to classify marijuana and we have essentially limited the kind of studies we sponsor at the federal level and who gets to do them with the clear bias towards its dangers and as a result, we have lost control. So we have 27, 28 states moving to legalization in some form, and some full legalization for Recreational Purposes and some for medical purposes, but meanwhile, the federal control is gone. In this case, it is the federal government has not even really acted yet. I just wonder what would be helpful from your point of view for the federal government to undertake so that we deal with obviously in the expeditious way, because if you are looking at smoking, it can take 30, 40, 50 years for somebody to have the negative Health Impacts of chronic smoking. What has shocked us about this crisis is that, the time line has collapsed. And we are looking at young people who have engaged in vaping and according to some medical reports at least anecdotally, their lungs look like a chronic smoker of 40 years, and 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 an efficacious way and not take ten years to do it . Dr. Rizzo . I think that the first step with regard of the recent crisis of the vaping illness is that everything is going to be done and continue to be done by the cdc and the ada and we hope they come up with answers. But the Bigger Picture is if there should have been as we saw at the Lung Association, a review of the products that come out in the marketplace to deem whether or not they are appropriate for public protection. I think that the lack of that authority by the fda for multiple reasons has been slow inp going. In developing. Dr. Ezike, anything . I concur with that. Ms. Johnson, would that have made a difference from your perspective . I think so. The fact that nobody really knows how these products are going to use the products, but young people who shouldnt be using them, but have super easy access to them, and it is kind of russian roulette, and you dont know what is going to happen and with the developing lung, it is worse. I was handed a note, and sometimes we have mindless debate about regulation and all of it is bad. I bring attention to the fact that my colleague mr. Coaler, conservative republican, stated earlier, but sometimes we need it. It aint all bad. And sometimes we need it to protect the public. As you all said, frankly absent the vacuum that we created which was not deliberate, and nobody did it with mall las has cost lives. And will cost more. So we need to see this issue, and make sure that meaningful regulation can save lives and this is a great example of where that is needed. Thank you for being here today. We appreciate it. My time sup. Thank you so much. Id like to thank our witnesses for their testimony today. Without objection, all members have five legislative days in which to submit additional written questions for the witnesses to the chair which will be forwarded to the witnesses for responses. I ask our witnesses to please respond as promptly as you are able. This hearing is adjourned. Coming up this afternoon we will be hearing from House Speaker nancy pelosi who is expected to talk about the legislative agenda at an event in washington, d. C. It is possible she will be facing questions about renewed calls to impeach President Trump involving a recent whistleblower complaint involving the leader of ukraine that included talk about former Vice President joe biden and his son. A discussion with Speaker Pelosi at the atlantic festival gets under way at 2 00 p. M. Eastern live here on cspan3. Later this week, the acting director of National Intelligence Joseph Mcguire testifies before the House Intelligence Committee about the handling of the whistleblower complaint involving the president. You can watch the hearing live thursday at 9 00 a. M. Eastern, and also here on cspan3. A student chem experience is valuable to me. It had a huge effect on us as people going into the college years. For the past winners of the cspan student cam documentary competition, the experience sparked their interest in documentary production. Yes, i am going to attend a university in des moines, iowa and the fun part is that i get to be there in the middle of the caucus season, and i have been able to meet so many candidates, and because of cspan, i have had experience in the equipment and the knowledge to be able to actually film some of them. This year, we are asking middle school and High School Students to produce a Short Documentary addressing which issue you would like to see the president ial candidates address. Including cspan video and differing points of view. We are awarding 100,000 in cash prizes, including a 5,000 grand prize. Be passionate about what you are discussing to express the view no matter how large or small you think that the audience will perceive it to be. And i know that in the greatest country in the history of the earth, your view does matter. For more information to help you get started go to our website. Student cam. Org. Campaign 2020. Watch our live coverage of the president ial candidates on the campaign trail, and make up your own mind. Cspans campaign 2020. Your unfiltered view of politics politics. Over the weekend, 2020 democratic president ial candidate Pete Buttigieg was speaking in iowa at a town hall meeting in webster city. The south bend, indiana