Testimony before the Rhode Island House of Representatives Municipal Government and Housing Committee Regarding Regulating Electronic Cigarettes and Vapor Products

Chairman Hull, Vice Chairs, and Members of the Committee:

Thank you for your time today to discuss the issue of regulating the sale and distribution of 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.

Many states are looking into the issue of reducing youth use of e-cigarettes and vapor products and have sought to give localities control over their local tobacco ordinances. Although addressing youth use of age-restricted products is laudable and important, policies that allow for local control create a patchwork of laws that not only create confusion, but also unfairly burden retailers in localities with greater restrictions. Further, existing local policies in other states, such as flavor bans, have not reduced youth use of age-restricted products. Rather than allowing localities to impose restrictions on access to tobacco harm reduction products, lawmakers in the Ocean State should allocate existing tobacco monies towards robust tobacco control programs, including cessation, education, and youth prevention.

Tobacco Economics 101: Rhode Island

In 2019, 13.3 percent of adults in Rhode Island smoked tobacco cigarettes, amounting to 854,904 smokers in 2019.[i] When figuring a pack-per-day, over 830 million cigarettes were smoked in 2019 by Rhode Island adults, or about 2.3 million per day.[ii]

In 2019, Rhode Island imposed a $3.75 excise tax on a pack of cigarettes.[iii] In 2019, Rhode Island collected $155.6 million in cigarette excise taxes, when figuring for a pack-a-day habit among adult residents that smoked. This amounts to $1,368.75 per smoker per year.

Rhode Island spent $391,000 on tobacco control programs in 2019, or $3.44 per smoker per year. This is less than 1 percent of what the state received in excise taxes in 2019 from Rhode Island adult smokers, based off a pack-a-day habit, and even less than what the state received in total tobacco tax collections in 2019. When figuring amount spent on youth in the state, Rhode Island spent $1.91 per year for each resident under 18 years of age. (See Supplemental Graphs 1)

Vapor Economics 101: Rhode Island

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

In 2018, according to the Vapor Technology Association, the industry created 271 direct vaping-related jobs, including manufacturing, retail, and wholesale jobs in Rhode Island, which generated $8 million in wages alone.[iv] Moreover, the industry has created hundreds of secondary jobs in the Ocean State, bringing the total economic impact in 2018 to $54,082,500. In the same year, Rhode Island received more than $18 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, sales of these products in Rhode Island eclipsed $2.2 million.[v] (See Supplemental Graph 2)

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.”[vi] WalletHub estimated the true cost for smoker in Rhode Island to be $63,639 per-smoker per-year. 

In 1995, 24.7 percent[vii] of Rhode Island adults smoked combustible cigarettes, amounting to approximately 191,783 adults.[viii] In 1995, among all adults, 21.3 percent (165,384 adults) reported smoking every day. In 2019, 13.3 percent of adults in the Ocean State were current smokers, amounting to 113,697 smokers. Further, 8.9 percent of Rhode Island adults (76,083) were daily smokers in 2019.

Among Rhode Island adults, current smoking decreased by 46.2 percent between 1995 and 2019. Moreover, there are an estimated 97,455 fewer smokers in 2019, compared to 1995, and 106,003 fewer daily smokers. Using the WalletHub figures, this reduction represents an estimated $6.2 billion in yearly savings.

Tobacco and Vapor Product Use Among Rhode Island Youth

According to the Centers for Disease Control and Prevention’s Youth Risk Behavior Survey (YRBS), in 2019, 48.9 percent of Rhode Island high school students reported ever using an e-cigarette or vapor products. [ix] This far less than the national average for 2019 at 50.1 percent of high school students reported having ever tried an e-cigarette.[x] Further, in 2019, only 30.1 percent of Rhode Island high school students reported current use of e-cigarettes, or they had used an e-cigarette on at least one occasion in the 30 days prior to the survey. Only 7.3 percent of Connecticut high schoolers reported daily e-cigarette use.

In 2019, among all Rhode Island high school students, only 4.5 percent reported “flavors” as a reason for use. Conversely, 12.5 percent reported using vapor products because a “friend or family member used them,” and 15.9 percent cited “some other reason.”^[xi]

It is worthy to note that youth combustible cigarette use is at an all-time low. In 2019, 17.5 percent of Rhode Island high school students reported ever trying cigarettes, a 74.7 percent decrease from 1997 when 69.1 percent of high school students had tried cigarettes. Further, past month use of combustibles has decreased 88.1 percent from 35.4 percent in 1997 to 4.2 percent in 2019. Daily cigarette use has decreased 90 percent from 16 percent of high school students that reported daily cigarette use in 1997 to 1.6 percent in 2019.

Preemption Laws Have Minimal Impact on Reducing Youth Tobacco and Vapor Product Use

As of September 30, 2020, 23 states have preemption laws preventing localities from enacting local tobacco ordinances related to youth access.[xii] Many opponents claim that preventing cities from enacting local tobacco laws threaten localities’ public health efforts, but existing preemption laws have had minimal effect on youth use of age-restricted products.

For example, in 2019, of the top ten states with the highest rates of daily combustible cigarette use among high school students, six were states with preemption laws, including Arkansas, Kentucky, North Carolina, Oklahoma, South Carolina and South Dakota. West Virginia, a state with no preemption laws on any tobacco regulation including smoke-free ordinances and/or local youth restrictions, had the highest rates of current combustible cigarette use, with 13.5 percent of high school students reporting having smoked a cigarette in the 30 days prior to the survey. Further, among the states with the lowest rates of daily combustible cigarette use, five (Massachusetts, Michigan, Nevada, Utah and Wisconsin), had youth tobacco access preemption laws.

The data similar to rates of daily vapor product use among high school students. For example, in 2019, among the top 10 states with the highest rates of daily e-cigarette use, five had preemption laws restricting youth access including Arkansas, Kentucky, Massachusetts, Montana and North Carolina. Conversely, among the 10 states with the lowest daily e-cigarette use among high school students four (California, Mississippi, Nevada, and Utah) had youth tobacco access preemption laws.

Wasted Tobacco Dollars at State Level

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

Tobacco taxes and tobacco settlement payments are justified to help offset the costs of smoking, as well as prevent youth initiation. Like most states, Rhode Island spends very little of existing tobacco moneys on tobacco control programs – including education and prevention. Between 2000 and 2019, Rhode Island allocated only $25.9 million in state funds towards tobacco control programs.[xiii] This is 1.1 percent of what Rhode Island collected in cigarette taxes in the same 19-year time span and only 2.7 percent of MSA payments. In total, in 19 years, Rhode Island allocated approximately 0.008 percent of what the state received in tobacco taxes and settlement payments towards tobacco education and prevention efforts. (See Supplemental Graph 3)

Local Flavor Bans Did Not Reduce Youth E-Cig Use, Increased Youth Combustible Use

Local 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.[xiv]

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.[xv] 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.[xvi] 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.[xvii] 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.

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

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” approaches.

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.

In fact, an estimated 10.8 million American adults were using electronic cigarettes and vapor products in 2016.[xxi] 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 and Vapor Products 101

E-cigarettes were first introduced in the United States in 2007 by a company called Ruyan.^[xxii] 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.”^[xxiii] 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).^[xxiv] 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.”[xxv] In 2018, the agency reiterated their findings, finding vaping to be “at least 95% less harmful than smoking.”[xxvi]

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.”[xxvii] 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. 

As recent as February 2021, PHE provided the latest update to their ongoing report on the effects of vapor products in adults in the UK. The authors found that in the UK, e-cigarettes were the “most popular aid used by people to quit smoking [and] … vaping is positively associated with quitting smoking successfully.”[xxviii] 

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

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.”[xxx] 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 more than 12,400 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.”  

Studies have also noted that substitution of e-cigarettes for combustible cigarettes could save the state in health care costs.

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

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.[xxxii]

A 2017 study by the 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.[xxxiii]

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 tobacco products, lawmakers should encourage the use of e-cigarettes and work towards providing adequate funding for smoking education and prevention programs.

• Preemption laws have had a minimal impact on youth use of age-restricted products, including cigarettes and e-cigarettes.
• To address youth use of age-restricted products, as well as adult use of deadly combustible cigarettes, Rhode Island must allocate additional funding from revenue generated from existing excise taxes and settlement payments.
• Between 2000 and 2019, Rhode Island allocated only $25.9 million in state funds towards tobacco control programs. This is 1.1 percent of what Rhode Island collected in cigarette taxes in the same 19-year time span and only 2.7 percent of MSA payments.
• Rhode Island education and health departments must work with tobacco and vapor product retailers to ensure there are no sales of age-restricted products to minors and propose statewide solutions.

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

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

[iii] Rhode Island, Tobacco Harm Reduction 101, https://www.thr101.org/rhode-island.  

[iv] Vapor Technology Association, “The Economic Impact of the Vapor Industry RHODE ISLAND,” 2019, https://vta.guerrillaeconomics.net/reports/8d469ccd-8cd7-49cc-811e-e54b50bc1762?.

[v] 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.

[vi] 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.

[vii] Centers for Disease Control and Prevention, supra note 1.

[viii] 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.

[ix] 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.

[x] Centers for Disease Control and Prevention, supra note 1.

[xi] 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. 

[xii] Centers for Disease Control and Prevention, “Map of Preemption on Youth Access,” September 30, 2020, https://www.cdc.gov/statesystem/factsheets/Preemption/preemptionyouthaccess.html.

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

[xiv] 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.

[xv] 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.

[xvi] 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.

[xvii] 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.

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

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

[xx] 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.

[xxi] 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. 

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

[xxiii] 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.

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

[xxv] 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.

[xxvi] 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.

[xxvii] 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.

[xxviii] A. McNeill et al., “Vaping in England: an evidence update including vaping for smoking cessation, February 2021,” Public Health England, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/962221/Vaping_in_England_evidence_update_February_2021.pdf.

[xxix] 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.

[xxx] 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. 

[xxxi] 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.

[xxxii] 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.

[xxxiii] 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.