Testimony before the Washington House Finance Committee Regarding Regulating Tobacco and Vapor Products

Chairwoman Frame, Vice Chairs, and Members of the Committee,

Thank you for your time today to discuss the issue of regulating 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 lawmakers attempt to address youth use of age- restricted products, including electronic cigarettes and vapor products, some policymakers are seeking to impose additional 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 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 Economics 101: Washington

In 2019, 12.7 percent of adults in Washington smoked tobacco cigarettes, amounting to 756,265 smokers in 2019.[i] When figuring a pack-per-day, more than 5.5 billion cigarettes were smoked in 2019 by Washingtonian adults, or about 15.1 million per day.[ii]

In 2019, Washington imposed a $1.98 excise tax on a pack of cigarettes.[iii] In 2019, Washington collected $834 million in cigarette excise taxes, when figuring for a pack-a-day habit among adult residents that smoked. This amounts to $1,104 per smoker per year.

Washington spent $1.5 million on tobacco control programs in 2019, or $1.98 per smoker per year. This is less than 1 percent of what the state received in excise taxes in 2019 from Washington 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, Washington spent $0.90 per year for each resident under 18 years of age. (See Supplemental Graphs 1)

Vapor Economics 101: Washington

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

In 2018, according to the Vapor Technology Association, the industry created 1,995 direct vaping-related jobs, including manufacturing, retail, and wholesale jobs in Washington, which generated $68 million in wages alone.[iv] Moreover, the industry has created hundreds of secondary jobs in the Evergreen State, bringing the total economic impact in 2018 to more than $483 million. In the same year, Washington received more than $40 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 Washington eclipsed $11 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 Washington to be $56,126 per-smoker per-year. 

In 1995, 20.2 percent of Washington adults smoked combustible cigarettes, amounting to over 818,429 adults.[vii] In 1995, among all adults, 17.5 percent (709,035 adults) reported smoking every day. In 2019, 12.7 percent of adults in the Evergreen State were current smokers, amounting to 755,883 smokers. Further, 8.3 percent of Washingtonian adults (494,002 adults) were daily smokers in 2019.

Among Washington adults, current smoking decreased by 37.1 percent between 1995 and 2019. Moreover, there are 62,546 fewer smokers in 2019, compared to 1995, and 215,033 fewer daily smokers. Using the WalletHub figures, this reduction represents an estimated $3.51 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 Washington.

In 1998, among current adult smokers in Washington, 30.4 percent were 18 to 24 years old. In 2008, this had decreased by 27.3 percent to 22.1 percent of adult smokers in Washington 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 Washington, 18.4 percent were between 18 to 24 years old. In 2019, only 7.7 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 2008, the percentage of current smokers aged 18 to 24 years old decreased on average 2.7 percent each year. Between 2009 and 2019, annual percentage decreases average at 6.7 percent. (See Supplemental Graph 3)

Vapor Product Use Among Washington Youth

The most recent report on youth e-cigarette use in Washington is from the 2018 Healthy Youth Survey, which surveyed 6th, 8th, 10th, and 12th graders in Washington.[ix] Among past 30-day use, 97 percent of 8th graders and 89.5 percent of 8th graders reported not using an e-cigarette in the 30 days prior to the survey.

Among 10th and 12th graders, 21.1 percent and 29.5 percent reported using a vapor product on at least one occasion in the 30 days prior respectively. Among both 10th and 12th graders, 74.6 percent reported not using a vapor product. Only 5.2 percent of Washington 10th and 12th graders reported daily e-cigarette use.

It should be noted that many youths in Washington are not relying on the internet to obtain e-cigarettes and vapor products. In 2018, only 1 percent of 8th graders, 1.4 percent of 10th graders and 1.5 percent of 12th graders reported using the internet to purchase vapor products.

Conversely, 3.9 percent of 8th graders, 8.1 percent of 10th graders and 9.3 percent of 12th grade indicated they had borrowed vapor products from someone else in the 30 days prior to the survey.

Low Income Washingtonians More Impacted by Tobacco and Vapor Taxes

An increase on tobacco and vapor products would unfairly burden lower income Washingtonians. 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.”[x]

In Washington (in 2019) among current adult smokers, 34.2 percent reported annual incomes of less than $15,000 and 23.4 percent of current smokers reported earning between $15,000 and $24,999 per year.[xi] Indeed, 57.6 percent of all current adult smokers earned less than $24,999 per year in 2019.

Further, tax increases did not lead to significant declines in smoking rates among lower income persons. For example, in 2010, Washington increased the cigarette tax by $1.00, to $3.025-per-pack. In 2011, smoking rates among persons earning less than $24,999 per year increased by 19.7 percent from 56.8 percent of adult smokers to 68 percent of adult smokers. (See Supplemental Graph 4)

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. Such attempts are unlikely to reduce youth use as 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.[xii]

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.[xiii]

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.[xiv]

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.[xv]

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.[xvi]

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.[xvii]

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.[xviii]

In 2015, according to Pennsylvania’s YRBSS, 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.[xix]

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.[xx]

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.[xxi]

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.

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.[xxii] 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.[xxiii] 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.”[xxiv]

Between 2000 and 2019, Washington collected an estimated $7.354 billion in cigarette taxes.[xxv] During the same 19-year period, the Evergreen State increased the cigarette tax three times; in 2002, 2005, and 2010 with the last tax increase of $1.00 bringing the total tax to $3.025-per-pack.

Although the increased tax rates have resulted in revenue increases, these increases are only seen in the short term as fewer Washington adults smoke over time. For example, in 2011, Washington collected an estimated $432.7 million in cigarette taxes, a 11.5 percent increase from 2010’s revenues of $388 million. Since 2012, average revenues have declined by 2.8 percent annually. Moreover, in 2019, Washington collected only $345 million in cigarette tax revenues, a 20.3 percent decrease from 2011’s revenue.

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

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

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.”[xxxv] 

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.”[xxxvi] 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.”[xxxvii]

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.”[xxxviii] 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.”

The substitution of e-cigarettes for combustible cigarettes could save the state in healthcare 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.”[xxxix]

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.[xl]

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.[xli]

Nicotine 101

Research overwhelmingly shows that it is the smoke created by the burning of tobacco, rather than the nicotine, that produces the harmful chemicals found in combustible cigarettes.[xlii]

Unfortunately, many Americans “incorrectly believe that nicotine causes cancer and other health risks,”[xliii] with a 2017 survey finding 53 percent of respondents believing that nicotine “causes most of the cancer related to smoking.”[xliv] Despite recent fearmongering campaigns, nicotine (while addictive) is not a harmful chemical. Nicotine is a mild stimulant and/or relaxant with many of the same properties as caffeine, another addictive substance consumed by tens of millions of Americans in a wide variety of products.[xlv]

Both nicotine and caffeine enhance concentration and mental performance, encourage a sense of well-being, and elevate mood. Both raise heart rates and blood pressure levels transiently during use, but neither is directly responsible for cancer, emphysema, or heart disease.

Wasted Tobacco Dollars

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

Between 2000 and 2020, Washington received an estimated $3.040 billion in payments attributed to the Master Settlement Agreement (MSA).[xlvi] During the same time period, the Evergreen State allocated only $279.3 million toward tobacco control programs – or about 9 percent of what the state received in MSA payments during the period.[xlvii] These figures do not include the state’s excise tax on cigarettes – which, between 2015 and 2019, Washington collected over $1.6 billion cigarette and other tobacco excises taxes. Indeed, Washington’s tobacco control spending over 20 years is only 17 percent of what the state received in tobacco taxes and settlement payments in the four years between 2015 and 2019. (See Supplemental Graph 5)

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 earmarking adequate funding for smoking education and prevention programs.

• Excise taxes on tobacco and vapor products are regressive an unfairly burden low-income persons. In 2019, 57.6 percent of adult smokers in Washington reported earning incomes of $24,999 or less. Indeed, over one-third (34.2 percent) of adult smokers in Washington earned less than $15,000 a year in 2019.
• Cigarette taxes are unreliable sources of revenue. Since 2012, cigarette tax revenue has decreased, on average, 2.8 percent annually.
• To address youth use of age-restricted products, as well as adult use of deadly combustible cigarettes, Washington must allocate additional funding from revenue generated from existing excise taxes and settlement payments. Washington woefully underfunds such programs and in 19 years has only allocated 9 percent of settlement payments towards tobacco control programs – including youth prevention.
• Washington’s education and health departments must work with tobacco and vapor product retailers to ensure there are no sales of age-restricted products to minors. Any solution to address such strategies must include all actors – not only proponents of draconian policies.

[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/WA.

[iii] Washington, Tobacco Harm Reduction 101, https://www.thr101.org/Washington.

[iv] Vapor Technology Association, “The Economic Impact of the Vapor Industry WASHINGTON,” 2019, https://vta.guerrillaeconomics.net/reports/7e62a55c-b3cc-4903-8e61-8f69d43288cc?.

[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] 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] Washington State Department of Health, “Healthy Youth Survey,” 2018, https://www.doh.wa.gov/DataandStatisticalReports/DataSystems/HealthyYouthSurvey.

[x] 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. 

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

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

[xiii] Centers for Disease Control and Prevention, “High School YRBS 2019 Results,” 2019, https://nccd.cdc.gov/Youthonline/App/Default.aspx.

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

[xv] Centers for Disease Control and Prevention, supra note 12.

[xvi] 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.

[xvii] Centers for Disease Control and Prevention, supra note 12.

[xviii] 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.

[xix] Centers for Disease Control and Prevention, supra note 12.

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

[xxi]Centers for Disease Control and Prevention, supra note 12.

[xxii] 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. 

[xxiii] 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.  

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

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

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

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

[xxviii] 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.

[xxix] 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. 

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

[xxxi] 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.

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

[xxxiii] 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.

[xxxiv] 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.

[xxxv] 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.

[xxxvi] 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.

[xxxvii] 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.

[xxxviii] 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. 

[xxxix] 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.

[xl] 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.

[xli] 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.

[xlii] Brad Rodu, For Smokers Only: How Smokeless Tobacco Can Save Your Life (Los Angeles, CA: Sumner Books, 1995), p. 103.

[xliii] Lindsey Stroud, “State Policies Help Promote Misperception that Nicotine Causes Cancer,” Research & Commentary, The Heartland Institute, March 19, 2018, https://www.heartland.org/publications-resources/publications/research–commentary-state-policies-help-promote-misperception-that-nicotine-causes-cancer.

[xliv] Richard Craver, “Study finds majority of adults erroneously link nicotine to cancer,” Winston-Salem Journal, March 4, 2018, https://www.journalnow.com/business/study-finds-majority-of-adults-erroneously-link-nicotine-to-cancer/article_d249b427-3993-5c35-a044-bc6334617f07.html.

[xlv] Brad Rodu et al., “Vaping, E-Cigarettes, and Public Policy Toward Alternatives to Smoking,” The Heartland Institute, February 20, 2017, https://www.heartland.org/publications-resources/publications/vaping-e-cigarettes-and-public-policy-toward-alternatives-to-smoking.

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

[xlvii] 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.