Testimony before the Rhode Island Senate Committee on Judiciary Regarding Banning the Sale or Regulating Electronic Cigarettes and Vapor Products

Chairwoman Coyne, Vice-Chairman Archambault, 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 the Director of the Consumer Center at 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 of March, 2020, flavored vapor products have been banned for sale in Rhode Island. Today, the Rhode Island Senate Committee on Judiciary has two pieces of competing legislation. One would ban the sale of flavored e-cigarettes; the other would allow for the sale of flavored vapor products, and provide regulatory oversight. E-cigarettes have been an effective tool at reducing smoking rates among adults. While addressing youth use, lawmakers should refrain from policies that restrict adult access.

Tobacco Economics 101: Rhode Island

In 2019, 13.3 percent of adults in the Ocean State were current smokers, amounting to 113,697 smokers in 2019.[i]. Further, 8.9 percent of Rhode Island adults (76,083) were daily smokers in 2019. When figuring a pack-per-day habit, over 555.4 million cigarettes were smoked by Rhode Islander adults, or 1.5 million cigarettes per day.

In 2019, Rhode Island imposed a $4.25 excise tax on a pack of cigarettes.[ii] In 2019, Rhode Island collected $118 million in cigarette excise taxes, when figuring for a pack-a-day habit among adults. This amounts $1,551.25 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 one 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.

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.[iii] 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.[iv] (See Supplemental Graph 1)

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

In 1995, 24.7 percent[vi] of Rhode Island adults smoked combustible cigarettes, amounting to approximately 191,783 adults.[vii] 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.

Vapor Product Emergence Correlates with Lower Young Adult Smoking

Electronic cigarettes and vapor products were first introduced to the U.S. in 2007 “and between 2009 and 2012, retail sales of e-cigarettes expanded to all major markets in the United States.”[viii] Examining data from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance Survey finds that e-cigarettes’ market emergence has just as effective as MSA payments in reducing smoking rates among young adults in Rhode Island.

In 1998, among current adult smokers in Rhode Island, 29.8 percent were 18 to 24 years old. In 2008, this had decreased by 27.9 percent to 21.5 percent of adult smokers in Rhode Island being between 18 to 24 years old. And, 10 years after e-cigarette’s market emergence in 2009, smoking rates among current smokers aged 18 to 24 years old decreased by 58.2 percent. Indeed, in 2009, among current smokers in Rhode Island, 17 percent were between 18 to 24 years old. In 2019, only 7.1 percent of current smokers were 18 to 24 years old.

Further e-cigarettes’ market emergence was associated with a larger decline in average annual percent decreases among all current smokers. Between 1998 and 2009, the percentage of current smokers aged 18 to 24 years old increased on average 2.3 percent each year. Between 2009 and 2019, annual percentage decreases average at 6.2 percent. (See Supplemental Graph 2)

Tobacco and Vapor Product Use Among Rhode Island Youth

In 2019, according to the Centers for Disease Control and Prevention’s Youth Risk Behavior Survey (YRBS), 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. (See Supplemental Graph 3)

Flavors and 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.

In 2017, among Hawaiian high school students that had ever used e-cigarettes, 26.4 percent cited flavors as a reason for e-cigarette use, compared to 38.9 percent that reported “other.”[xii]

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.[xiii] 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.

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.”[xiv] Further, 25.9 percent of Montana high school students reported using vapor products for “some other reason.”

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.”[xv]

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.”[xvi]

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.[xvii]

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.[xviii] 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.[xix] (See Supplemental Graph 4)

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.[xx]

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.[xxi] 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.[xxii] 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.[xxiii] 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.^[xxiv] There are an estimated 600 ingredients in each tobacco cigarette, and “when burned, [they] create more than 7,000 chemicals.”^[xxv] 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.^[xxvi]

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.[xxvii] 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.^[xxviii] 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.”^[xxix] 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).^[xxx] 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.”[xxxi] In 2018, the agency reiterated their findings, finding vaping to be “at least 95% less harmful than smoking.”[xxxii]

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.”[xxxiii] 

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.”[xxxiv] 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.”[xxxv]

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.”[xxxvi] 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.”

Sensible Regulations Would Address Youth Use, Not Restrict Adult Access

In 2016, FDA issued deeming regulations that extended the agency’s regulatory authority to include electronic cigarettes and other THR products.[xxxvii] All companies “engaged in the preparation, manufacture, compounding, repackaging, relabeling or processing of finished tobacco products” now must register with FDA.[xxxviii]

FDA’s regulations require e-cigarette manufacturers to comply with regulations governing tobacco, including completing a lengthy and expensive study process called the “premarket tobacco application” (PMTA). Beginning on August 8, 2016, no new e-cigarette product, including flavors and nicotine products, can be sold in the United States without first receiving premarket tobacco application approval from FDA. This one requirement alone will have a devastating effect on the industry. FDA estimates each PMTA will cost $330,000.[xxxix]

FDA also restricted sales of e-cigarettes to individuals aged 18 or older, and the agency has banned e-cigarette distribution in vending machines. FDA further requires child-resistant packaging for every e-cigarette product. In November 2019, President Donald Trump issued an executive order, which raised the age to purchase tobacco and vapor products, form 18 years to 21. Prior to this, many states had already raised tobacco and vapor product sales age to 21.

Other regulatory requirements in the deeming rules include submitting to FDA ingredient listings, harmful and potentially harmful constituents, and substantial equivalency applications. In addition to the regulations imposed by the federal government, many states regulate electronic cigarettes.

In September 2020, per a court order, all vapor product manufacturers were required to submit a PMTA to the FDA. These PMTAs included listings of all products manufactured – including all ingredients and/or components, manufacturing processes and standard operating procedures, comprehensive literature reviews, and individual surveys of customers.

Product manufacturers were ordered to prove that their product had been on the market prior to the August 8, 2016 deadline. Further, they had to also provide evidence that their products would not be used by nonsmokers and/or minors.

FDA is prioritizing enforcement of products that are more appealing to youth. For example, the agency cited new data “from the 2020 National Youth Tobacco Survey (NYTS), will also inform the FDA’s enforcement and other actions, and flavored disposable [e-cigarettes] will now be an enforcement priority for the agency.”[xl]

The task of regulating all vapor products in the United States will be a daunting one, as the agency has received over 6 million PMTAs.[xli]

Further, many American and foreign manufacturers are members of trade associations which require strict adherence to age restrictions and marketing targeted to minors.

For example, the Smoke-Free Alternatives Trade Association provides “Age to Vape” signage to vape shops endorsing local laws “to show that [the] industry supports sensible age restrictions.”[xlii] More than 1,300 companies participated in the program in 2015. [xliii]The Consumer Advocates for Smoke Free Alternatives Association “supports laws that prohibit underaged sales and urges strict enforcement of laws” that ban access to e-cigarettes for young people.[xliv]

Associations representing vaping manufacturers also support banning sales and marketing to minors. The American E-Liquid Manufacturing Association (AEMSA) “advocates electronic cigarette products for adult use only.”[xlv] AEMSA supports a “ban on sales to minors.” The Vapor Technology Association requires members to “refrain from knowingly marketing Vapor Products to Minors, which is strictly prohibited.”[xlvi]

On June 28, 2021, e-cigarette manufacturer JUUL agreed to a consent order with the state of North Carolina.[xlvii] Including paying North Carolina $40 million to help fund youth prevention programs, JUUL is also required to adhere to particular marketing standards. These include:

• A ban on marketing that appeals to persons 21 years and younger
• No social media advertising or advertising near schools
• No health claims comparing their product to combustible cigarettes
• Online sales are only permitted with use of an independent age verification system
• Retail sales must be sold behind the counter and require a barcode scanner for age verification
• Maintain a retail compliance program through the use of secret shoppers
• No new additional flavors without FDA approval.

It should be noted that JUUL had already implemented many of these provisions prior to the consent order. For example, since October, 2019, JUUL has only offered e-cigarettes in its menthol and Virginia tobacco flavors.[xlviii] This came prior to the federal ban on flavored pod cartridges. The company has also only submitted PMTAs for those two flavors, and thus, per the FDA, is not allowed to market any additional flavors.

Since 2019, JUUL has implemented and maintained an age verification program in place that uses barcodes to scan government-issued IDs.[xlix] Further, their program automatically locks the sale of their devices until the ID is approved, as well as limits the amount of JUUL products an of age person can purchase.

Sensible regulations such as the ones described can help reduce youth use of age-restricted products, while simultaneously allow adult smokers access to tobacco harm reduction products.

Wasted Tobacco Dollars

Between 2000 and 2019, Rhode Island collected an estimated $2.326 billion in cigarette taxes.[l] During the same 19-year period, the Ocean State increased the cigarette tax eight times; in 2001, 2002, 2003, 2004, 2009, 2012, 2015 and 2017.

In the mid-1990s, Rhode Island sued tobacco companies to reimburse Medicaid for the costs of treating smoking-related health issues. And, in 1998 with 45 other states, Rhode Island reached “the largest civil litigation settlement in U.S. history” through the Master Settlement Agreement (MSA).[li]

Under the MSA, states receive annual payments – in perpetuity – from the tobacco companies, while relinquishing future claims against the participating companies. Between 1998 and 2020, Rhode Island collected $1.043 billion in MSA payments.[lii]

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.[liii] 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 5)

Conclusion & Policy Recommendations:

Allowing for the sale and regulation of flavored tobacco harm reduction products is a positive step towards tobacco harm reduction.

• 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.
• Sensible regulations include: aggressive media campaigns urging against tobacco use, age verification mandates, and retail compliance checks.

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

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

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

[iv] 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.

[v] 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.

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

[vii] 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.

[viii] National Center for Chronic Disease Prevention and Health Promotion, “E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General,” 2016, https://www.ncbi.nlm.nih.gov/books/NBK538679/.

[ix] Centers for Disease Control and Prevention, “1991-2019 High School Youth Risk Behavior Survey Data,” 2019, https://nccd.cdc.gov/Youthonline/App/Default.aspx.

[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] 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.

[xiii] 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.

[xiv] 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.

[xv] 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. 

[xvi] 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.

[xvii] 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.

[xviii] 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.

[xix] 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.

[xx] 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.

[xxi] 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.

[xxii] 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.

[xxiii] 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.

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

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

[xxvi] 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.

[xxvii] 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. 

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

[xxix] 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.

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

[xxxi] 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.

[xxxii] 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.

[xxxiii] 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.

[xxxiv] 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.

[xxxv] 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.

[xxxvi] 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. 

[xxxvii] U.S. Food and Drug Administration, “Deeming Tobacco Products To Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Restrictions on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products,” Federal Register, May 10, 2016, http://bit.ly/2x90ef.

[xxxviii] Keller and Heckman LLP, “FDA’s Establishment Registration and Product Listing Deadline is Fast Approaching – Are You Prepared?” December 15, 2016, https://www.khlaw.com/FDAs-Establishment-Registration-and-Product-Listing-Deadline-is-Fast-Approaching—Are-You-Prepared.

[xxxix] 6 Susan Adams, “E-Cigarette Manufacturers Say New Regulations Will Devastate The Industry,” Forbes, May 5, 2016, https://www.forbes.com/sites/ susanadams/2016/05/05/e-cigarette-manufacturers-say-new-regulations-will-devastate-the-industry/#6aa5124a66d4.

[xl] U.S. Food and Drug Administration, “Submit Tobacco Product Applications for Deemed Tobacco Products,” September 10, 2020, https://www.fda.gov/tobacco-products/manufacturing/submit-tobacco-product-applications-deemed-tobacco-products.

[xli] U.S. Food and Drug Administration, “Update on FDA’s Application Review: PMTA List Posted, Progress Metrics Updated,” May 20, 2021, https://www.fda.gov/tobacco-products/ctp-newsroom/update-fdas-application-review-pmta-list-posted-progress-metrics-updated.

[xlii] Alyssa Stahr, “Support SFATA Today By Signing Up For Age To Vape Program,” Vape News, December 21, 2015, https://vapenews.com/vape-news/support-sfata-today-by-signing-up-for-age-to-vape-program/.

[xliii] Cynthia Cabrera, “Perception Vs. Reality,” Vape News, August 22, 2015, https://vapenews.com/august-2015/perception-vs-reality/.

[xliv] Consumer Advocates for Smoke Free Alternatives Association, “About Electronic Cigarettes,” 2012-2019, http://www.casaa.org/electronic-cigarettes/.

[xlv] American E-Liquid Manufacturing Standards Association, “E-Liquid Manufacturing Standards,” March 8, 2017, https://www.aemsa.org/standards/.

[xlvi] Vapor Technology Association, “Marketing Standards for Membership,” January 2018, https://vaportechnology.org/wp-content/uploads/2016/08/VTA-Marketing-Standards-for-Membership-FINAL-January-2018.pdf.   

[xlvii] North Carolina Attorney General Josh Stein, “Attorney General Stien Reaches Agreement with JUUL for $40 Million and Drastic Business Changes,” June 28, 2021, https://ncdoj.gov/attorney-general-stein-reaches-agreement-with-juul-for-40-million-and-drastic-business-changes/.

[xlviii] Juul Labs, “Juul Labs Suspends Sale of Non-Tobacco, Non-Menthol-Based Flavors in the U.S.,” October 17, 2019, https://www.juullabs.com/juul-labs-suspends-sale-of-non-tobacco-non-menthol-based-flavors-in-the-u-s/.

[xlix] Juul Labs, “Juul Labs Continues to Build on National Program to Reduce Underage Use,” Underage Use Prevention, August 29, 2019, https://www.juullabs.com/youth-prevention/.

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

[li] Tobacco Control Legal Consortium, “The Master Settlement Agreement: An Overview,” August 2015, p. 1, http://publichealthlawcenter.org/sites/default/files/resources/tclc-fs-msa-overview-2015.pdf.

[lii] Campaign for Tobacco-Free Kids, “Actual Annual Tobacco Settlement Payments Received by the States, 1998 – 2000,” August 13, 2020, https://www.tobaccofreekids.org/assets/factsheets/0365.pdf.

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