Testimony before the Minnesota House Committee on Taxes
Regarding Increasing the Tax on Tobacco and Vapor Products

Chairwoman Marquat and Members of the Committee,

Thank you for your time today to discuss the issue of increasing the state excise tax on tobacco 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 the nation continues to deal with the economic impact of COVID-19, many lawmakers are considering increasing excise taxes on tobacco and vapor products. Although, excise tax increases on such products do result in an immediate surge in revenue, sin taxes are unreliable and decrease over time. Further, lawmakers should refrain from increasing taxes on tobacco harm reduction products – including heat-not-burn and electronic cigarettes and vapor products – as such products are significantly less harmful than combustible cigarettes and have helped millions of American adults quit smoking.

Tobacco and Vapor Product Use Among Minnesota Youth

The most recent data on youth e-cigarette use in Minnesota comes from the 2019 Minnesota Student Survey (MSS).[i] In 2019, according to the MSS, 89 percent of 8th graders, 84 percent of 9th graders and 74 percent of 11^th graders reported not using an e-cigarette or vapor product in the 30 days prior to the survey. Further, only 7 percent of 11th graders, 2 percent of 9th graders, and 1 percent of 8th graders reported daily e-cigarette use.

It is worthy to note that Minnesota combustible cigarette use is at all-time lows. According to the MSS, in 2019, 98 percent, 97 percent, and 95 percent of 8th, 9th, and 11th graders reported not smoking a cigarette in the 30 days prior to the survey. Further, only 1 percent of 11th graders and 0 percent of 8th and 9th graders, reported daily cigarette use. This is a significant decline from 1992, when 31.3 percent of 12th graders, 19.3 percent of 9th graders and 5 percent of 8th graders reported using combustible cigarettes in the 30 days before the survey.

Tobacco Economics 101: Minnesota

In 2019, 14.6 percent of adults in Minnesota smoked tobacco cigarettes, amounting to 633,125 smokers in 2019.[ii] When figuring a pack-per-day, over 4.6 billion cigarettes were smoked in 2019 by Minnesota, or about 12.7 million per day.[iii]

In 2019, Minnesota imposed a $3.04 state excise tax on a pack of cigarettes.[iv] In 2019, the Gopher State collected $702.5 million in cigarette excise taxes, when figuring for a pack-a-day habit. This amounts to $1,109.60 per smoker per year.

Minnesota spent $17.3 million in state funding on tobacco control programs, including education, cessation, and prevention. This amounts to $27.32 per-smoker, and $13.28 per resident under age 18.

Low Income Minnesotans More Impacted by Tobacco and Vapor Taxes

An increase on tobacco and vapor products would unfairly burden lower income Minnesotans. Excise taxes are inherently regressive and tend to burden lower income persons. For example, a Cato Journal article found from 2010 to 2011, “smokers earning less than $30,000 per year spent 14.2 percent of their household income on cigarettes, compared to 4.3 percent for smokers earning between $30,000 and $59,999 and 2 percent for smokers earning more than $60,000.”[v]

In Minnesota, among current adult smokers, 27.3 percent reported annual incomes of less than $15,000 and 23.5 percent of current smokers reported earning between $15,000 and $24,999 per year.[vi] Despite four different tax increases, the percentage of smokers earning incomes of $24,999 or less has remained relatively stable.

Indeed, among adult Minnesotan smokers with incomes of less than $15,000 per year, smoking actually increased by 2.2 percent from 1995, when 26.7 percent of current smokers earning less than $15,000. Indeed, higher incomes were associated with greater declines in smoking rates. For example, smoking rates among Minnesotan adults earning $50,000 or more decreased by 34.8 percent, from 16.1 percent of smokers in 1995 to 10.5 percent in 2019.

Vapor Economics 101: Minnesota

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

IN 2018, according to the Vapor Technology Association, the industry created 1,152 direct vaping-related jobs, including manufacturing, retail, and wholesale jobs in Minnesota, which generated $44 million in wages alone.[vii] Moreover, the industry has created hundreds of secondary jobs in the Gopher State, bringing the total economic impact in 2018 to $336,366,200. In the same year, Minnesota received more than $20 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 $2.6 million.[viii]

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.”[ix] WalletHub estimated the true cost for smoker in Minnesota to be $59,336 per-smoker per-year. 

In 1995, 20.5 percent of Minnesota adults smoked combustible cigarettes, amounting to approximately 699,921 adults.[x] Among all adults, 17.4 percent (594,079 adults) reported smoking every day in 1995. In 2019, 14.6 percent of adults in the Gopher State were current smokers, amounting to 633,125 smokers. Further, 10.5 percent of Minnesota adults (455,330 adults) were daily smokers in 2019.

Among Minnesota adults, current smoking decreased by 28.8 percent between 1995 and 2019. Moreover, there are there are an estimated 255,852 fewer smokers in 2019, compared to 1995, and 299,217 fewer daily smokers. Using the WalletHub figures, this reduction represents nearly $15.2 billion in yearly savings.

Excise Taxes Are Unreliable Sources of Revenue

Existing excise taxes are unreliable revenue sources. Cigarette tax increases result in long-term revenue shortfalls. From 2001 to 2011, “revenue projections were met in only 29 of 101 cases where cigarette/tobacco taxes were increased,” according to the National Taxpayer Union Foundation.[xi] Moreover, a decline in cigarette consumption caused cigarette tax revenues “to drop by an average of about 1 percent across all states from 2008 to 2016,” according to a report by Pew Charitable Trusts.[xii] A 2020 report by the Tax Foundation noted that cigarette tax revenue has fallen in all states and considers cigarette tax revenue to be “so unstable.”[xiii]

In Minnesota, cigarette taxes have been increased four times since 1999. In 2005, the state increased the excise tax on pack of cigarettes by $0.75, bringing the total tax to $1.23. Although this led to an immediate 143.9 percent increase in cigarette tax revenue, cigarette tax revenue declined on average by 2.4 percent annually between 2007 and 2012. Indeed, in 2012, Minnesota collected $377.2 million in cigarette tax revenue, a 17.8 percent decline from 2008’s $408.6 million in revenue.

In 2013, the state increased the cigarette tax again, by $1.60, to $2.83 per pack. Again, this led to an immediate 53.3 percent increase in revenue. But, since 2015, cigarette tax revenue has decreased on average by 2.46 percent annually. Further, in 2019, the Gopher State collected $499.4 million in cigarette tax revenue, a 11.9 percent decrease from 2014’s $566.7 million revenue.

(See supplemental graph 1.1)

Wasted Tobacco Dollars

Deeply problematic with the proposed legislation is the fact that Minnesota spends very little on tobacco control, including education and prevention.

In 1998, Minnesota and “Blue Cross and Blue Shield of Minnesota settled their lawsuit against several companies and related organizations,” reaching Minnesota’s Tobacco Settlement (MTS). Under the settlement, Minnesota receives annual payments – in perpetuity – from tobacco companies. Between 1999 and 2019, the Gopher State has received more than $4.293 billion in MTS payments.

During the same period, Minnesota has allocated only $460.7 million in state funding on tobacco control programs. [xiv] This is only 10.7 percent of MTS payments and only 6.1 percent of what the state collected in cigarette excise payments.[xv]

(See supplemental graph 1.2)

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.^[xvi] There are an estimated 600 ingredients in each tobacco cigarette, and “when burned, [they] create more than 7,000 chemicals.”^[xvii] 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.^[xviii]

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.[xix] 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.^[xx] 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.”^[xxi] 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).^[xxii] 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.”[xxiii] In 2018, the agency reiterated their findings, finding vaping to be “at least 95% less harmful than smoking.”[xxiv]

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.”[xxv] 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.”[xxvi]

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.”[xxvii] 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.”

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.”[xxviii]

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.[xxix]

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.[xxx]

FDA Recognizes Tobacco Harm Reduction Potential of Heat-Not-Burn Products

A novel tobacco harm reduction product are heat-not-burn (HNB) tobacco products. HNB technology is a unique tobacco harm reduction tool because it has the “ability to regulate and distill flavor and nicotine at lower temperatures.”[xxxi] Several brands have been introduced and tested in various international markets, but only two brands are currently allowed to market in the United States including RJ Reynolds’ Eclipse tobacco and menthol flavored HNB products,[xxxii] and Philip Morris’ IQOS devices, available in both tobacco and menthol flavor.[xxxiii]

IQOS is an electronic device that heats a “HeatStick” – a small stick containing tobacco that a user places into the device and discards after use. The IQOS device heats the stick with no combustion, which reduces the amount of toxins a normal cigarette user would be exposed to.

In July, 2020, the FDA authorized IQOS to be marketed as a modified risk tobacco product.[xxxiv] In the agency’s order, FDA is allowing IQOS to market the specific products with:

            “AVAILABLE EVIDENCE TO DATE:

• The IQOS system heats tobacco but does not burn it.
• This significantly reduces the product of harmful and potentially harmful chemicals.
• Scientific studies have shown that switching completely from conventional cigarettes to the IQOS system significantly reduces your body’s exposure to harmful or potentially harmful chemicals.”

Currently, IQOS is only available for sale in a very limited markets that includes three metropolitan areas including Atlanta, GA, Charlotte, NC, and Richmond, VA.[xxxv] In a January conference call, Philip Morris USA stated that they will be “expanding the retail distribution of HeatSticks to about 1,000 stores.”

As a novel tobacco product, many current cigarette users are unaware of the product. Nonetheless, HNB are still an important tobacco harm reduction tool and have been widely successful in other markets, specifically Japan. Indeed, around 3.1 million people in Japan currently use a specific-brand HNB product.[xxxvi]

Studies on various products have also found a reduced harm from selected HNB products.

A 2016 study published in Toxicology in Vitro provided a “comparative assessment of the biological impact of heated tobacco aerosol from the tobacco heating system … and smoke from a combustible cigarette.”[xxxvii] The study examined bronchial epithelial cultures exposed to Philip Morris International’s iQOS vapor and found significant reductions in biological markers compared to when cigarette smoke is regularly inhaled.

A 2018 literature review of HNB studies found that “HNB delivered up to 83% of nicotine and reduced levels of harmful and potentially harmful toxicants by at least 62% and particulate matter by at least 75%.”[xxxviii]

Taxes on E-Cigarettes Unlikely to Deter Youth Use

Many lawmakers have attempted to thwart youth use of electronic cigarettes and vapor products by apply sin taxes to such products. Although addressing youth use is laudable, many youths in North Dakota are not regularly using e-cigarettes. Further, data from youth surveys indicate that excise taxes don’t reduce youth use of vapor products.

In 2019, 33.1 percent of North Dakota high school students reported using a vapor product on at least one occasion in the 30 days prior and only 12.1 percent reported frequent use – or using 20 or more days.[xxxix] According to national data, between 2019 and 2020, youth use of e-cigarettes decreased by 33.3 percent.[xl]

Further, there is no data to indicate that youth use of vapor products decreased after implementing taxes on e-cigarettes and indeed, youth vaping has actually increased after other states implemented vapor taxes. Tobacco Harm Reduction 101 examined the effects of vapor taxes in six states. From 2017 to 2019, current e-cigarette use among high school students increased in five states – even with excise taxes imposed on such products.

Kansas Vapor Tax: $0.05 per milliliter
Kansas’ tax on e-cigarettes and vapor products went into effect July 1, 2017.[xli]

According to Kansas’s YRBSS, in 2017, 34.8 percent and 10.6 percent of high school students reported ever and current e-cigarette product use, respectively.[xlii]

In 2019, ever-use increased by 28.4 percent, to 48.6 percent of Kansas high school students and current e-cigarette use increased by 51.8 percent, to 22 percent of high school students using an e-cigarette on at least one occasion in the 30 days prior.

Louisiana Vapor Tax: $0.05 per milliliter
Louisiana’s tax on e-cigarettes and vapor products went into effect August 1, 2015.[xliii]

According to Louisiana’s YRBSS, in 2017, 45.1 percent and 12.2 percent of high school students reported ever and current e-cigarette product use, respectively.[xliv]

In 2019, ever-use increased by 13.3 percent, to 52 percent of Louisiana high school students and current e-cigarette use increased by 46.7 percent, to 22.9 percent of high school students using an e-cigarette at least one occasion in the 30 days prior.

North Carolina Vapor Tax: $0.05 per milliliter
North Carolina’s tax on e-cigarettes and vapor products went into effect July 1, 2015.[xlv]

According to North Carolina’s YRBSS, in 2015, 49.4 percent and 29.6 percent of high school students reported ever and current e-cigarette product use, respectively. In 2017, ever-use decreased by 12 percent, to 44.1 percent of North Carolina high school students and current e-cigarette use decreased by 33.9 percent, to 22.1 percent of high school students using an e-cigarette in the last 30 days.[xlvi]

In 2019, 52.4 percent of high school students reporting having ever used an e-cigarette, this is a 15.8 percent increase from 2017, and a 5.7 percent increase from 2015 rates. Regarding current e-cigarette use, in 2019, 35.5 percent of North Carolina high school students reported using an e-cigarette on at least one occasion in the 30 days prior, this is a 37.7 percent increase from 2017 rates, and a 16.6 percent increase from 2015 rates.

Pennsylvania Vapor Tax: 40 percent of purchase price
Pennsylvania’s tax on e-cigarettes and vapor products went into effect October 1, 2016.[xlvii]

According to Pennsylvania’s YRBSS, in 2015 40.8 percent and 23.1 percent of high school students reported ever and current e-cigarette product use, respectively. In 2017, ever-use increased by 2.4 percent, to 41.8 percent of Pennsylvania high school students, and current e-cigarette use decreased by 104 percent, to 11.3 percent of high school students using an e-cigarette in the last 30 days.[xlviii]

In 2019, 52.6 percent of high school students reporting having ever used an e-cigarette, this is a 20.5 percent increase from 2017, and a 22.4 percent increase from 2015 rates. Regarding current e-cigarette use, in 2019, 24.4 percent of Pennsylvania high school students reported using an e-cigarette on at least one occasion in the 30 days prior, this is a 53.7 percent increase from 2017 rates, and a 5.3 percent increase from 2015 rates.

West Virginia Vapor Tax: $0.075 per milliliter
West Virginia’s tax on e-cigarettes and vapor products went into effect July 1, 2016.[xlix]

According to West Virginia’s YRBSS, in 2015, 49.1 percent and 31.2 percent of high school students reported ever and current e-cigarette product use, respectively. In 2017, ever-use decreased by 10.6 percent, to 44.4 percent of West Virginia high school students, and current e-cigarette use decreased by 118.2 percent, to 14.3 percent of high school students using an e-cigarette in the last 30 days.[l]

In 2019, 62.4 percent of high school students reporting having ever used an e-cigarette, this is a 28.8 percent increase from 2017, and a 21.3 percent increase from 2015 rates. Regarding current e-cigarette use, in 2019, 35.7 percent of West Virginia’s high school students reported using an e-cigarette on at least one occasion in the 30 days prior, this is a 59.9 percent increase from 2017 rates, and a 12.6 percent increase from 2015 rates.

*****

Conclusion and Policy Implications

• Excise taxes on tobacco and vapor products are regressive an unfairly burden low-income persons. In 2019, 50.8 percent of adult smokers in Minnesota reported earning incomes of $24,999 or less. Indeed, over one-quarter (27.3 percent) of adult smokers in Minnesota earned less than $15,000 a year in 2019.
• Cigarette taxes are unreliable sources of revenue. Since 2015, cigarette tax revenue has decreased, on average, by 2.46 percent annually.
• Minnesota spends very little of existing tobacco and vapor products taxes on programs to prevent youth use and help adults quit. Between 1999 and 2019, the Gopher State allocated $460.7 million toward tobacco control programs, which is only 3.9 percent of the tax revenues and tobacco tax settlement payments in the same time period.

[i] Minnesota Department of Education, “Minnesota Student Survey Reports 2013-2019,” 2019, https://public.education.mn.gov/MDEAnalytics/DataTopic.jsp?TOPICID=242.

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

[iii] 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.

[iv] Minnesota, Tobacco Harm Reduction 101, https://www.thr101.org/minnesota.

[v] 1 Kevin Callison and Robert Kaestner, “Cigarette Taxes and Smoking,” Regulation, Cato Institute, Winter 2014-15, https://object.cato.org/sites/cato.org/files/serials/files/regulation/2014/12/regulation-v37n4-7.pdf. 

[vi] BRFSS, supra note 2.

[vii] Vapor Technology Association, “The Economic Impact of the Vapor Industry MINNESOTA,” 2019, https://vta.guerrillaeconomics.net/reports/e4e2ad3b-ca91-427e-9bf3-056543b2355b?.

[viii] 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.

[ix] 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.

[x] BRFSS Prevalence & Trends Data, supra note 2.

[xi] National Taxpayers Union Foundation, “Tobacco Taxes: Problems, Not Solutions, for Taxpayers and Budgets,” Issue Brief, July 31, 2013, https://www.ntu.org/foundation/detail/tobacco-taxes-problems-not-solutions-for-taxpayers-and-budgets. 

[xii] Kil Huh et al., Are Sin Taxes Healthy for State Budgets?, The Pew Charitable Trusts and Rockefeller Institute of Government, July 2018, http://www.pewtrusts.org/-/media/assets/2018/07/sin_taxes_report.pdf. 

[xiii] Ulrik Boesen and Tom VanAntwerp, “How Stable is Cigarette Tax Revenue?” Tax Foundation, July 9, 2020, https://taxfoundation.org/cigarette-tax-revenue-tool/.

[xiv] Campaign for Tobacco-Free Kids, “Appendix A: A History of Spending for State Tobacco Prevention Programs,” 2021, https://www.tobaccofreekids.org/assets/factsheets/0209.pdf.

[xv] Orzechowski and Walker, “The Tax Burden on Tobacco Historical Compilation Volume 54,” 2019. Print.

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

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

[xviii] 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.

[xix] 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. 

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

[xxi] 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.

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

[xxiii] 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.

[xxiv] 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.

[xxv] 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.

[xxvi] 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.

[xxvii] 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. 

[xxviii] 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.

[xxix] 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.

[xxx] 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.

[xxxi] 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.pdf.

[xxxii] Matthew R. Holman, Ph.D., “Substantially Equivalent Letter to R.J. Reynolds Tobacco Company,” United States Food and Drug Administration, July 19, 2018, https://www.fda.gov/media/115507/download.

[xxxiii] U.S. Food and Drug Administration, “FDA permits sale of IQOS Tobacco Hating System through premarket tobacco product application pathway,” April 30, 2019, https://www.fda.gov/news-events/press-announcements/fda-permits-sale-iqos-tobacco-heating-system-through-premarket-tobacco-product-application-pathway.

[xxxiv] U.S. Food and Drug Administration, “FDA Authorizes Marketing of IQOS Tobacco Heating System with ‘Reduced Exposure’ Information,” July 7, 2020, https://www.fda.gov/news-events/press-announcements/fda-authorizes-marketing-iqos-tobacco-heating-system-reduced-exposure-information.

[xxxv] IQOS, “Store Locator,” 2021, https://www.getiqos.com/ageaffirmed/home/where-to-find-iqos/store-locator.html.

[xxxvi] Takahiro Tabuchi et al., “Heat-not-burn tobacco product use in Japan: its prevalence, predictors and perceived symptoms from exposure to secondhand heat-not-burn tobacco aerosol,” Tobacco Control, December 16, 2017, https://tobaccocontrol.bmj.com/content/27/e1/e25.

[xxxvii] Anita R. Iskandar et al., “A Systems Toxicology Approach for Comparative Assessment: Biological Impact of an Aerosol from a Candidate Modified-Risk Tobacco Product and Cigarette Smoke on Human Organotypic Bronchial Epithelial Cultures,” Toxicology in Vitro, March 2017, http://www.sciencedirect.com/science/article/pii/S0887233316302314.

[xxxviii] Erikas Simonavicius, et al., “Heat-not-burn tobacco products: a systematic literature review,” Tobacco Control, September 4, 2018, https://tobaccocontrol.bmj.com/content/28/5/582.

[xxxix] Centers for Disease Control and Prevention, “Youth Risk Behavior Surveillance System (YRBSS),” October 27, 2020, https://www.cdc.gov/healthyyouth/data/yrbs/index.htm.

[xl] Centers for Disease Control and Prevention, “Youth e-cigarette use is down, but 3.6 million still use e-cigarettes,” September 9, 2020, https://www.cdc.gov/media/releases/2020/p0909-youth-e-cigarette-use-down.html.

[xli] Kansas Department of Revenue, “Selected Kansas Tax Rates with Statutory Citation,” 2021, https://www.ksrevenue.org/taxrates.html.

[xlii] Centers for Disease Control and Prevention, supra note 39.

[xliii] Louisiana Department of Revenue, “Retail Dealers of Vapor Products,” 2021, https://revenue.louisiana.gov/ExciseTaxes/RetailDealersOfVaporProducts.

[xliv] Centers for Disease Control and Prevention, supra note 20.

[xlv] North Carolina Department of Revenue, “Tobacco Products Tax,” December, 2019, https://files.nc.gov/ncdor/documents/files/Tobacco-Products-Tax-Bulletin_rev_12-19-Final.pdf.

[xlvi] Centers for Disease Control and Prevention, supra note 20.

[xlvii] Pennsylvania Department of Revenue, “Other Tobacco Products Tax,” 2021, https://www.revenue.pa.gov/GeneralTaxInformation/Tax%20Types%20and%20Information/OTPT/Pages/default.aspx#:~:text=E%2Dcigarettes%2FVapor%20products,the%20wholesaler%20on%20the%20following%3A&text=E%2Dcigarette%20devices%20sold%20in,liquid%20or%20substance%20contains%20nicotine.

[xlviii] Centers for Disease Control and Prevention, supra note 20.

[xlix] West Virginia State Tax Department, “E-cigarette Liquids Excise Tax FAQ,” 2021, https://tax.wv.gov/Business/ExciseTax/TobaccoTax/HowDoI/Pages/ElectronicCigaretteLiquidsExciseTaxFAQ.aspx

[l]Centers for Disease Control and Prevention, supra note 39.