Testimony before the Hawaii Senate Committees on Health and Consumer Protection and Commerce Regarding Regulating Vapor Products

Members of the Committee,

Thank you for your time today to discuss the issue of regulating electronic cigarettes and vapor products. My name is Lindsey Stroud and I am a Policy Analyst with the Taxpayers Protection Alliance (TPA). TPA is a non-profit, non-partisan organization dedicated to educating the public through the research, analysis and dissemination of information on the government’s effects on the economy.

As lawmakers attempt to address youth use of age-restricted products, many policymakers are seeking to prohibit the sale of flavored e-cigarettes, as well as restrict online shipments. Although, addressing youth use is laudable, flavor bans are not effective in reducing youth e-cigarette use. Further such policies harm adults that rely on vapor products to quit smoking and remain smoke-free.

E-Cigarettes and Tobacco Harm Reduction

The evidence of harm associated with combustible cigarettes has been understood since the 1964 U.S. Surgeon General’s Report that smoking causes cancer. Research overwhelmingly shows the smoke created by the burning of tobacco, rather than the nicotine, produces the harmful chemicals found in combustible cigarettes.^[i] There are an estimated 600 ingredients in each tobacco cigarette, and “when burned, [they] create more than 7,000 chemicals.”^[ii] As a result of these chemicals, cigarette smoking is directly linked to cardiovascular and respiratory diseases, numerous types of cancer, and increases in other health risks among the smoking population.^[iii]

For decades, policymakers and public health officials looking to reduce smoking rates have relied on strategies such as emphasizing the possibility of death related to tobacco use and implementing tobacco-related restrictions and taxes to motivate smokers to quit using cigarettes. However, there are much more effective ways to reduce tobacco use than relying on government mandates and “quit or die” appeals.

During the past 30 years, the tobacco harm reduction (THR) approach has successfully helped millions of smokers transition to less-harmful alternatives. THRs include effective nicotine delivery systems, such as smokeless tobacco, snus, electronic cigarettes (e-cigarettes), and vaping. E-cigarettes and vaping devices have emerged as especially powerful THR tools, helping nearly three million U.S. adults quit smoking from 2007 to 2015.

Indeed, an estimated 10.8 million American adults were using electronic cigarettes and vapor products in 2016.[iv] Of the 10.8 million, only 15 percent, or 1.6 million adults, were never-smokers, indicating that e-cigarettes are overwhelmingly used by current and/or former smokers.

E-cigarettes were first introduced in the United States in 2007 by Ruyan, a Chinese manufacturer.^[v] Soon after their introduction, Ruyan and other brands began to offer the first generation of e-cigarettes, called “cigalikes.” These devices provide users with an experience that simulates smoking traditional tobacco cigarettes. Cig-alikes are typically composed of three parts: a cartridge that contains an e-liquid, with or without nicotine; an atomizer to heat the e-liquid to vapor; and a battery.

In later years, manufacturers added second-generation tank systems to e-cigarette products, followed by larger third-generation personal vaporizers, which vape users commonly call “mods.”^[vi] These devices can either be closed or open systems.

Closed systems, often referred to as “pod systems,” contain a disposable cartridge that is discarded after consumption. Open systems contain a tank that users can refill with e-liquid. Both closed and open systems utilize the same three primary parts included in cigalikes—a liquid, an atomizer with a heating element, and a battery— as well as other electronic parts. Unlike cig-alikes, “mods” allow users to manage flavorings and the amount of vapor produced by controlling the temperature that heats the e-liquid.

Mods also permit consumers to control nicotine levels. Current nicotine levels in e-liquids range from zero to greater than 50 milligrams per milliliter (mL).^[vii] Many users have reported reducing their nicotine concentration levels after using vaping devices for a prolonged period, indicating nicotine is not the only reason people choose to vape.

Health Effects of Electronic Cigarettes and Vapor Products

Despite recent media reports, e-cigarettes are significantly less harmful than combustible cigarettes. Public health statements on the harms of e-cigarettes include:

Public Health England: In 2015, Public Health England, a leading health agency in the United Kingdom and similar to the FDA found “that using [e-cigarettes are] around 95% safer than smoking,” and that their use “could help reducing smoking related disease, death and health inequalities.”[viii] In 2018, the agency reiterated their findings, finding vaping to be “at least 95% less harmful than smoking.”[ix]

The Royal College of Physicians: In 2016, the Royal College of Physicians found the use of e-cigarettes and vaping devices “unlikely to exceed 5% of the risk of harm from smoking tobacco.”[x] The Royal College of Physicians (RCP) is another United Kingdom-based public health organization, and the same public group the United States relied on for its 1964 Surgeon General’s report on smoking and health. 

The National Academies of Sciences, Engineering, and Medicine: In January 2018, the academy noted “using current generation e-cigarettes is less harmful than smoking.”[xi]

A 2017 study in BMJ’s peer-reviewed journal Tobacco Control examined health outcomes using “a strategy of switching cigarette smokers to e-cigarette use … in the USA to accelerate tobacco control progress.”[xii] The authors concluded that replacing e-cigarettes “for tobacco cigarettes would result in an estimated 6.6 million fewer deaths and more than 86 million fewer life-years lost.”

An October 2020 review in the Cochrane Library Database of Systematic Reviews analyzed 50 completed studies which had been published up until January 2020 and represented over 12,4000 participants.

The authors found that there was “moderate-certainty evidence, limited by imprecision, that quit rates were higher in people randomized to nicotine [e-cigarettes] than in those randomized to nicotine replacement therapy.” The authors found that e-cigarette use translated “to an additional four successful quitters per 100.” The authors also found higher quit rates in participants that had used e-cigarettes containing nicotine, compared to the participants that had not used nicotine.

Notably, the authors found that for “every 100 people using nicotine e-cigarettes to stop smoking, 10 might successfully stop, compared with only six of 100 people using nicotine replacement therapy or nicotine-free e-cigarettes.”

Tobacco Economics 101: Hawaii

In 2019, 12.3 percent of adults in Hawaii smoked tobacco cigarettes, amounting to 137,232 smokers in 2019.[xiii] When figuring a pack-per-day, more than one billion cigarettes were smoked in 2019 by Hawaiians, or about 2.7 million per day.[xiv]

In 2019, Hawaii imposed a $3.20 excise tax on a pack of cigarettes.[xv] In 2019, Hawaii collected $185.3 million in cigarette excise taxes, when figuring for a pack-a-day habit. This amounts to $1,168 per smoker per year.

Hawaii spent $4.5 million on tobacco control programs in 2019, or $32.79 per smoker per year. This is only two percent of what the state received in excise taxes in 2019 from Hawaii adult smokers, based off a pack-a-day habit. When figuring amount spent on youth in the state, Hawaii spent $15.01 per year on each resident under 18 years of age.

Vapor Economics 101: Hawaii

Electronic cigarettes and vapor products are not only a harm reduction tool for hundreds of thousands of smokers in the Aloha State, they’re also an economic boon.

According to the Vapor Technology Association, in 2018, the industry created 451 direct vaping-related jobs, including manufacturing, retail, and wholesale jobs in Hawaii, which generated $18 million in wages alone.[xvi] Moreover, the industry has created hundreds of secondary jobs in the Aloha State, bringing the total economic impact in 2018 to $100,745,600. In the same year, Hawaii received more than $9 million in state taxes attributable to the vaping industry. These figures do not include sales in convenience stores, which sell vapor products including disposables and prefilled cartridges. In 2016, average national sales of these products eclipsed $11 million.[xvii]

Switching from combustible cigarettes to electronic cigarettes and vapor products will also reduce smoking-related health issues and save persons and states money. WalletHub estimated the “true cost of smoking” including “…cost of a cigarette pack per day, health care expenditures, income losses and other costs.”[xviii] WalletHub estimated the true cost for smoker in Hawaii to be $61,139 per-smoker per-year. 

In 1995, 17.8 percent[xix] of Hawaii adults smoked combustible cigarettes, amounting to approximately 157,802 adults.[xx] Among all adults in 1995, 15.1 percent (133,866 adults) reported smoking every day. In 2019, 12.3 percent of adults in the Aloha State were current smokers, amounting to 137,268 smokers. Further, 8.1 percent of Hawaii adults (90,396 adults) were daily smokers in 2019.

Among Hawaiian adults, current smoking decreased by 54.5 percent between 1995 and 2019. Moreover, there are an estimated 20,534 fewer smokers in 2019, compared to 1995, and 43,470 fewer daily smokers. Using the WalletHub figures, this reduction represents an estimated $1.26 billion in yearly savings.

The substitution of e-cigarettes for combustible cigarettes could also save the state in health care costs.

It is well known that Medicaid recipients smoke at rates of twice the average of privately insured persons, according to the Centers for Disease Control and Prevention (CDC). In 2013, “smoking-related diseases cost Medicaid programs an average of $833 million per state.”[xxi]

A 2015 policy analysis by State Budget Solutions examined electronic cigarettes’ effect on Medicaid spending. The author estimated Medicaid savings could have amounted to $48 billion in 2012 if e-cigarettes had been adopted in place of combustible tobacco cigarettes by all Medicaid recipients who currently consume these products.[xxii]

A 2017 study by R Street Institute examined the financial impact to Medicaid costs that would occur should a large number of current Medicaid recipients switch from combustible cigarettes to e-cigarettes or vaping devices. The author used a sample size of “1% of smokers [within] demographic groups permanently” switching. In this analysis, the author estimates Medicaid savings “will be approximately $2.8 billion per 1 percent of enrollees,” over the next 25 years.[xxiii]

Hawaiian Youth Are Not Overwhelmingly Using Vapor Products Because of Flavors, Nor Using Internet to Purchase E-Cigarettes

Despite lawmakers’ intentions, many Hawaiian youth are not using e-cigarettes because of flavors. According to the 2017 Hawai’i Youth Tobacco Survey (HYTS), in 2017, 39.4 percent of Hawaiian high school students reported having ever used an e-cigarette or vapor product and 20.9 percent reported having used an e-cigarette in the past 30 days.[xxiv]

When asked for reasons why to use e-cigarettes, 26.4 percent of high school students responded “flavors, such as mint, candy, fruit or chocolate.” Conversely, 38 percent cited “other” and 12.7 percent responded that they used vapor products because “they are less harmful than other forms of tobacco, such as cigarettes.”

In regards to where youth purchased their vapor products, among e-cigarette users only 7.8 percent reported purchasing an e-cigarette on the internet. Alternatively, 10.8 percent of high school students reported purchasing e-cigarettes at a “vape shop or store that sells only e-cigarettes,” and whopping 60 percent reported purchasing vapor products from friends.

Flavors Are Not Main Driver of Youth E-Cigarette Use

Despite media alarmism, many American high school students are not overwhelmingly using vapor products due to flavors. Indeed, in analyses of state youth tobacco use surveys, other factors including social sources are most often cited among youth for reasons to use e-cigarettes and vapor products.

Connecticut
For example, in 2017, of Connecticut high school students that had ever used an e-cigarette, 23.9 percent reported “flavors” as a reason for use. Conversely, 41.6 percent reported using vapor products because a “friend or family member used them,” and 33 percent cited “some other reason.”[xxv] In 2019, among all Connecticut high school students, 5.2 percent reported using e-cigarettes because of “flavors,” 18.2 percent cited “other,” and 12.9 percent reported using e-cigarettes because of friends and/or family.[xxvi]

Maryland
According to results from the 2018 YRBS, Maryland high school students reported using flavored vapor products, but flavors weren’t overwhelmingly cited by e-cigarette users as a reason for use.[xxvii] When asked about the “main reason” Maryland high school users used flavors only 3.2 percent responded “flavors.” Conversely, 13 percent reported because “friend/family used them,” 11.7 percent reported “other,” and 3.8 percent reported using e-cigarettes because they were less harmful than other tobacco products.

Montana
In 2019, among all Montana high school students, only 7 percent reported using vapor products because of flavors, compared to 13.5 percent that reported using e-cigarettes because of “friend or family member used them.”[xxviii] Further, 25.9 percent of Montana high school students reported using vapor products for “some other reason.”

Rhode Island
In 2019, among all students, only 4.5 percent of Rhode Island high school students claimed to have used e-cigarettes because they were available in flavors, while 12.5 cited the influence of a friend and/or family member who used them and 15.9 percent reported using e-cigarettes “for some other reason.”[xxix]

Vermont
In 2017, among current e-cigarette users, only 17 percent of Vermont high school students reported flavors as a reason to use e-cigarettes. Comparatively, 35 percent cited friends and/or family members and 33 percent cited “other.”[xxx]

In 2019, among high school students that were current e-cigarette users, only 10 percent of Vermont youth that used e-cigarettes cited flavors as a primary reason for using e-cigarettes, while 17 percent of Vermont high school students reported using e-cigarettes because their family and/or friends used them.[xxxi]

Virginia
Lastly, in 2017, among all Virginia high school students, only 6.2 percent reported using e-cigarettes because of flavors, while 11.3 percent used them because a friend and/or family member used them.[xxxii] In 2019, among all Virginia high school students, only 3.9 percent reported using e-cigarettes because of flavors, 12.1 used for some other reason, and 9.6 used them because of friends and/or family members.[xxxiii]

Effects of Flavor Bans

Flavor bans have had little effect on reducing youth e-cigarette use and may lead to increased combustible cigarette rates, as evidenced in San Francisco, California.[xxxiv]

In April 2018, a ban on the sale of flavored e-cigarettes and vapor products went into effect in San Francisco and in January, 2020, the city implemented a full ban on any electronic vapor product. Unfortunately, these measures have failed to lower youth tobacco and vapor product use.

Data from an analysis of the 2019 Youth Risk Behavior Survey show that 16 percent of San Francisco high school students had used a vapor product on at least one occasion in 2019 – a 125 percent increase from 2017 when 7.1 percent of San Francisco high school students reported using an e-cigarette.[xxxv] Daily use more than doubled, from 0.7 percent of high school students in 2017, to 1.9 percent of San Francisco high school students reporting using an e-cigarette or vapor product every day in 2019.

Worse, despite nearly a decade of significant declines, youth use of combustible cigarettes seems to be on the rise in Frisco. In 2009, 35.6 percent of San Francisco high school students reported ever trying combustible cigarettes. This figure continued to decline to 16.7 percent in 2017.  In 2019, the declining trend reversed and 18.6 percent of high school students reported ever trying a combustible cigarette. Similarly, current cigarette use increased from 4.7 percent of San Francisco high school students in 2017 to 6.5 percent in 2019.

An April 2020 study in Addictive Behavior Reports examined the impact of San Francisco’s flavor ban on young adults by surveying a sample of San Francisco residents aged 18 to 34 years.[xxxvi] Although the ban did have an effect in decreasing vaping rates, the authors noted “a significant increase in cigarette smoking” among participants aged 18 to 24 years old.

Other municipal flavor bans have also had no effect on youth e-cigarette use.[xxxvii] For example, Santa Clara County, California, banned flavored tobacco products to age-restricted stores in 2014. Despite this, youth e-cigarette use increased. In the 2015-16 California Youth Tobacco Survey (CYTS), 7.5 percent of Santa Clara high school students reported current use of e-cigarettes. In the 2017-18 CYTS, this increased to 10.7 percent.

Youths Are Not Relying On Internet for E-Cigarette Products

Despite many claims, most youth are not purchasing tobacco and vapor products online. Indeed, in analysis of state Youth Risk Behavior Surveys, youth are relying on social sources – including friends and family members – to obtain vapor products.

Arkansas
In 2019, among all Arkansas high school students, only 1.1 percent of reported using the internet to get their own vapor product.[xxxviii] Alternatively, 7.3 percent of Arkansas high school students reported borrowing them and 5.1 percent reported that someone else bought them.

Maryland
In 2018, among all Maryland high school students, only 1.3 percent reported using the internet to get their own electronic cigarette or vapor product.[xxxix] Further, 9.7 percent of Maryland high school students reported borrowing vapor products, and 4.3 percent reported that someone else bought them.

Montana
In 2019, among all Montana high school students, 0.7 percent reported using the internet to get their own electronic cigarette or vapor product.[xl] Moreover, 10.6 precent of Montana high school students reported borrowing vapor products and 6.9 percent reported giving “someone else money to buy them for me.”

New Hampshire
In 2019, among all New Hampshire high school student, 0.5 percent reported using the internet to get their own electronic cigarette or vapor product.[xli] Further, 13.9 percent of New Hampshire high school students reported borrowing vapor products, and 5.8 percent reported that someone else bought them.

Vermont
In 2019, among Vermont high school students that reported current e-cigarette use and were under the age of 18, only 3 percent reported using the internet to get obtain vapor products. Further, 52 percent of Vermont high school students that were current e-cigarette users reported borrowing them and 26 percent reported giving “someone else money to buy them.”[xlii]

Menthol Bans Have Little Effect on Smoking Rates, Lead to Black Markets, Lost Revenue and Will Create Racial Tension

Beyond e-cigarettes, policymakers’ fears about the role of menthol and flavorings in cigarettes and cigars are overblown and banning these products will likely lead to black markets.

Data from the National Health Interview Survey (NHIS) finds nearly a third of all American adult smokers smoke menthol cigarettes. In a 2015 NHIS survey, “of the 36.5 million American adult smokers, about 10.7 million reported that they smoked menthol cigarettes,” and white menthol smokers “far outnumbered” the black and African American menthol smokers.[xliii]

Although lawmakers believe banning menthol cigarettes will deter persons from smoking those, such a ban will likely lead to black markets. A 2012 study featured in the journal Addiction found a quarter of menthol smokers surveyed indicated they would find a way to purchase, even illegally, menthol cigarettes should a menthol ban go into place.[xliv] Further, there is little evidence that smokers would actually quit under a menthol ban. A 2015 study in Nicotine & Tobacco Research found only 28 percent of menthol smokers would give up cigarettes if menthol cigarettes were banned.[xlv]

Moreover, there is no evidence to suggest that menthol cigarettes lead to youth tobacco use. Analysts at the Reason Foundation examined youth tobacco rates and menthol cigarette sales.[xlvi] The authors of the 2020 report found that states “with more menthol cigarette consumption relative to all cigarettes have lower rates of child smoking.” Indeed, the only “predictive relationship” is between child and adult smoking rates, finding that “states with higher rates of adult use cause higher rates of youth use.”

Lawmakers should take note that menthol sales bans will strain minority communities. Although white Americans smoke more menthol cigarettes than black or African Americans, “black smokers [are] 10-11 times more likely to smoke” menthol cigarettes than white smokers.[xlvii]

Given African Americans’ preference for menthol cigarettes, a ban on menthol cigarettes would force police to further scrutinize African Americans and likely lead to unintended consequences. 

A 2015 analysis from the National Research Council examined characteristics in the illicit tobacco market.[xlviii] The researchers found that although lower income persons were less likely to travel to purchase lower-taxed cigarettes, “having a higher share of non-white households was associated with a lower probability of finding a local tax stamp” and “neighborhoods with higher proportions of minorities are more likely to have formal or informal networks that allow circumvention of the cigarette taxes.”

Lawmakers in New Hampshire should reexamine the case of Eric Garner, a man killed in 2014 while being arrested for selling single cigarettes in the city. In a 2019 letter to the New York City council, Garner’s mother, as well as Trayvon Martin’s mother, implored officials to “pay very close attention to the unintended consequences of a ban on menthol cigarettes and what it would mean for communities of color.”[xlix] Both mothers noted that a menthol ban would “create a whole new market for loosies and re-introduce another version of stop and frisk in black, financially challenged communities.”  

Conclusion & Policy Recommendations:

It is disingenuous that lawmakers would purport to protect public health yet restrict access to safer products. Rather than restricting access to tobacco harm reduction products and flavored vapor products, lawmakers should encourage the use of e-cigarettes and work towards earmarking adequate funding for smoking education and prevention programs.

• To address youth use of age-restricted products, as well as adult use of deadly combustible cigarettes, Hawaii must allocate additional funding from revenue generated from existing excise taxes and settlement payments.
• Hawaii’s education and health departments must work with tobacco and vapor product retailers to ensure there are no sales of age-restricted products to minors. Any solution to address such strategies must include all actors – not only proponents of draconian prohibitionist policies.

Lawmakers’ must face the reality of a larger illicit market in the wake of a ban on flavored tobacco and vapor products – prohibition does not automatically translate into reduced use, just different markets.

[i] Brad Rodu, For Smokers Only: How Smokeless Tobacco Can Save Your Life, Sumner Books, 1995, p. 103.

[ii] American Lung Foundation, “What’s In a Cigarette?,” February 20, 2019, https://www.lung.org/stop-smoking/smoking-facts/whats-in-a-cigarette.html. 

[iii] Centers for Disease Control and Prevention, “Health Effects of Cigarette Smoking,” January 17, 2018, https://www.cdc.gov/tobacco/data_statistics/ fact_sheets/health_effects/effects_cig_smoking/index.htm.

[iv] Mohammadhassan Mirbolouk, MD et al., “Prevalence and Distribution of E-Cigarette Use Among U.S. Adults: Behavioral Risk Factor Surveillance System, 2016,”  Annals of Internal Medicine, October 2, 2018, https://www.acpjournals.org/doi/10.7326/M17-3440. 

[v] Consumer Advocates for Smoke-Free Alternatives Association, “A Historical Timeline of Electronic Cigarettes,” n.d., http://casaa.org/historicaltimeline-of-electronic-cigarettes.

[vi] WHO Framework Convention on Tobacco Control, “Electronic Nicotine Delivery Systems and Electronic Non-Nicotine Delivery Systems (ANDS/ ENNDS),” August 2016, http://www.who.int/fctc/cop/cop7/FCTC_ COP_7_11_EN.pdf.

[vii] Vaping 360, “Nicotine Strengths: How to Choose What’s Right for You,” February 26, 2019, https://vaping360.com/best-e-liquids/nicotine-strengthspercentages.

[viii] A. McNeill et al., “E-cigarettes: an evidence update,” Public Health England, August, 2015, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachm.

[ix] A. McNeill et al., “Evidence review of e-cigarettes and heated tobacco products 2018,” Public Health England, February 2018, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/684963/Evidence_review_of_e-cigarettes_and_heated_tobacco_products_2018.pdf.

[x] Royal College of Physicians, Nicotine without Smoke: Tobacco Harm Reduction, April, 2016, https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0.

[xi] Committee on the Review of the Health Effects of Electronic Nicotine Delivery Systems, “Public Health Consequences of E-Cigarettes,” The National Academies of Science, Engineering, and Medicine, 2018, https://www.nap.edu/catalog/24952/public-health-consequences-of-e-cigarettes.

[xii] David T. Levy et al., “Potential deaths averted in USA by replacing cigarettes with e-cigarettes,” Tobacco Control, October 2, 2017, http://tobaccocontrol.bmj.com/content/early/2017/08/30/tobaccocontrol-2017-053759.info. 

[xiii] “BRFSS Prevalence & Trends Data,” Centers for Disease Control and Prevention, 2019, https://www.cdc.gov/brfss/brfssprevalence/.

[xiv] “Quick Facts,” United States Census Bureau, 2020, https://www.census.gov/quickfacts/ND.

[xv] North Dakota, Tobacco Harm Reduction 101, https://www.thr101.org/north-dakota.

[xvi] Vapor Technology Association, “The Economic Impact of the Vapor Industry HAWAII,” 2019, https://vta.guerrillaeconomics.net/reports/9aa96bb8-b7c8-4100-9611-f0acc6612e31?.

[xvii] Teresa W. Wang et al., “National and State-Specific Unit Sales and Prices for Electronic Cigarettes, United States, 2012-2016,” Preventing Chronic Disease, Centers for Disease Control and Prevention, August 2, 2018, https://www.cdc.gov/pcd/issues/2018/17_0555.htm.

[xviii] Adam McCann, “The Real Cost of Smoking by State,” WalletHub, January 15, 2020, https://wallethub.com/edu/the-financial-cost-of-smoking-by-state/9520.

[xix] Centers for Disease Control and Prevention, “BRFSS Prevalence & Trends Data,” 2019, https://www.cdc.gov/brfss/brfssprevalence/.

[xx] Kids Count Data Center, “Total population by child and adult populations in the United States,” The Annie E. Casey Foundation, September 2020, https://datacenter.kidscount.org/data/tables/99-total-population-by-child-and-adult-populations#detailed/1/any/false/1729,37,871,870,573,869,36,868,867,133/39,40,41/416,417.

[xxi] American Lung Foundation, “Approaches to Promoting Medicaid Tobacco Cessation Coverage: Promising Practices and Lessons Learned,” June 9, 2016, https://web.archive.org/web/20170623183710/https://www.lung.org/assets/documents/advocacy-archive/promoting-medicaid-tobacco-cessation.pdf. Accessed June 23, 2017.

[xxii] J. Scott Moody, “E-Cigarettes Poised to Save Medicaid Billions,” State Budget Solutions, March 31, 2015, https://www.heartland.org/_template-assets/documents/publications/20150331_sbsmediciadecigarettes033115.pdf.

[xxiii] Edward Anselm, “Tobacco Harm Reduction Potential for ‘Heat Not Burn,’” R Street Institute, February 2017, https://www.rstreet.org/wp-content/uploads/2017/02/85.

[xxiv] Lance Ching, Ph.D., et al., “Data Highlights from the 2017 Hawai’i Youth Tobacco Survey,” Hawai’i State Department of Health, June 29, 2018, http://www.hawaiihealthmatters.org/content/sites/hawaii/YTS_2017_Report.pdf.

[xxv] Connecticut Department of Public Health, “Connecticut Youth Tobacco Survey Results 2017 Surveillance Report,” 2017, https://portal.ct.gov/-/media/Departments-and-Agencies/DPH/dph/hems/tobacco/PDF/2017-CT-Youth-Tobacco-Survey-Results.pdf?la=en.

[xxvi] Connecticut Department of Public Health, “Connecticut High School Survey Codebook,” 2019 Youth Risk Behavior Survey Results, 2019, https://portal.ct.gov/-/media/Departments-and-Agencies/DPH/CSHS/2019CT_Codebook.pdf.

[xxvii] Maryland Department of Public Health, “Maryland High School Survey Detail Tables – Weighted Data,” 2018 Youth Risk Behavior Survey, 2018, https://phpa.health.maryland.gov/ccdpc/Reports/Documents/2018%20YRBS%20YTS%20Reports/Maryland/2018MDH%20Detail%20Tables.pdf.

[xxviii] Montana Office of Public Instruction, “2019 Montana Youth Risk Behavior Survey High School Results,” 2019, http://opi.mt.gov/Portals/182/Page%20Files/YRBS/2019YRBS/2019_MT_YRBS_FullReport.pdf?ver=2019-08-23-083248-820.

[xxix] State of Rhode Island Department of Health, “Rhode Island High School Survey Detail Tables – Weighted Data,” 2019 Youth Risk Behavior Survey Results, 2019, https://health.ri.gov/materialbyothers/yrbs/2019HighSchoolDetailTables.pdf. 

[xxx] Vermont Department of Health, “2017 Vermont Youth Risk Behavior Survey Report Winooski SD Report,” 2018, https://www.healthvermont.gov/sites/default/files/documents/pdf/WINOOSKI_SD_%28SU017%29.pdf.

[xxxi] Vermont Department of Health, “2019 Vermont Youth Risk Behavior Survey Statewide Results,” March, 2020, https://www.healthvermont.gov/sites/default/files/documents/pdf/CHS_YRBS_statewide_report.pdf.

[xxxii] Virginia Department of Health, “Virginia High School Survey Detail Tables – Weighted Data,” 2017 Youth Risk Behavior Survey, 2017, https://www.vdh.virginia.gov/content/uploads/sites/69/2018/04/2017VAH-Detail-Tables.pdf.

[xxxiii] Virginia Department of Health, “Virginia High School Survey Detail Tables – Weighted Data,” 2019 Youth Risk Behavior Survey Results, 2019, https://www.vdh.virginia.gov/content/uploads/sites/69/2020/06/2019VAH-Detail-Tables.pdf.

[xxxiv] Lindsey Stroud, “Vaping Up, Smoking Increasing Among Teens in San Francisco – Despite Bans,” Tobacco Harm Reduction 101, July 28, 2020, https://www.thr101.org/research/2020/vaping-up-smoking-increasing-among-teens-in-san-francisco-despite-bans.

[xxxv] Centers for Disease Control and Prevention, “San Francisco, CA 2017 Results,” High School Youth Risk Behavior Survey, 2017, https://nccd.cdc.gov/youthonline/App/Results.aspx?LID=SF.

[xxxvi] Yong Yang et al., “The Impact of a Comprehensive Tobacco Product Flavor Ban in San Francisco Among Young Adults,” Addictive Behavior Reports, April 1, 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7186365/#!po=0.961538.

[xxxvii] Lindsey Stroud, “Flavor Bans Do Not Reduce Youth E-Cigarette Use,” Tobacco Harm Reduction 101, 2019, https://www.thr101.org/research/2019/flavor-bans-do-not-reduce-youth-e-cigarette-use.

[xxxviii] Arkansas High School Survey, “2019 Youth Risk Behavior Survey Results,” 2019, http://dese.ade.arkansas.gov/public/userfiles/Learning_Services/School_Health_Services/YRBS/2019/2019ARH_Detail_Tables.pdf.

[xxxix] Maryland High School Survey, “2018 Youth Risk Behavior Survey Results,” 2018, https://phpa.health.maryland.gov/ccdpc/Reports/Documents/2018%20YRBS%20YTS%20Reports/Maryland/2018MDH%20Detail%20Tables.pdf.

[xl] Montana Office of Public Instruction, “2019 Montana Youth Risk Behavior Survey High School Results,” 2019, http://opi.mt.gov/Portals/182/Page%20Files/YRBS/2019YRBS/2019_MT_YRBS_FullReport.pdf?ver=2019-08-23-083248-820.

[xli] New Hampshire High School Survey, “2019 Youth Risk Behavior Survey Results,” 2019, https://www.education.nh.gov/sites/g/files/ehbemt326/files/files/inline-documents/2019nhhdetailtables.pdf.

[xlii] Vermont Department of Health, “2019 Vermont Youth Risk Behavior Survey Statewide Results,” March, 2020, https://www.healthvermont.gov/sites/default/files/documents/pdf/CHS_YRBS_statewide_report.pdf.

[xliii] Brad Rodu, “Who Smokes Menthol Cigarettes?” Tobacco Truth, December 4, 2018, https://rodutobaccotruth.blogspot.com/2018/12/who-smokes-menthol-cigarettes.html.

[xliv] RJ O’Connor et al., “What would menthol smokers do if menthol in cigarettes were banned?” Addiction, April 4, 2012, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3370153/.

[xlv] Olivia A. Wackowski, PhD, MPH, et al., “Switching to E-Cigarettes in the Event of a Menthol Cigarette Ban,” Nicotine & Tobacco Research, January 29, 2015, https://www.researchgate.net/publication/271592485_Switching_to_E-Cigarettes_in_the_Event_of_a_Menthol_Cigarette_Ban.

[xlvi] Guy Bentley and J.J. Rich, “Does Menthol Cigarette Distribution Affect Child or Adult Cigarette Use?” Policy Study, Reason Foundation, January 30, 2020, https://reason.org/policy-study/does-menthol-cigarette-distribution-affect-child-or-adult-cigarette-use/.

[xlvii] D. Lawrence et al., “National patterns and correlates of mentholated cigarette use in the United States,” Addiction, December, 2010, https://www.ncbi.nlm.nih.gov/pubmed/21059133.

[xlviii] National Research Council, “Understanding the U.S. Illicit Tobacco Market: Characteristics, Policy Context and Lessons from International Experiences,” The National Academies Press, 2015, https://www.nap.edu/download/19016.

[xlix] Carl Campanile, “Menthol cig ban will lead to more stop-and-frisk: Moms of Garner, Martin,” New York Post, October 16, 2019, https://nypost.com/2019/10/16/menthol-cig-ban-will-lead-to-more-stop-and-frisk-moms-of-garner-martin/.