Im now delighted to introduce our second panel of witnesses for todays hear iing chief Deputy Director for health and chief medical executive Michigan Department of health and Human Services, dr. Elizabeth cuervo tillson, chief medical officer of North Carolina department of health and Human Services, dr. Lee norman, secretary of the Kansas Department of health and environment and dr. Monica berell. Dr. Berell is the commissioner of Massachusetts Department of Public Health. I want to thank all of you for appearing before the committee today. Now youre aware the committee is holding an investigative hearing and when we do so, we have the practice of taking our testimony under oath. Do you have any objections to testifying under oath today . Let the record reflect the witnesses have responded no. The chair then advises you that under the rules of the house and under the rules of the committee youre entitled to be accompanied by counsel. Do any of you request to be accompanied by counsel today . Let the record roeflt that the witnesses have stated no. If you would, then, please rise and raise your right hand so you may be sworn in. Do you swear the testimony that youre about to give is the truth, the whole truth and nothing but the truth . Let the record reflect the witnesses have responded in the affirmative and are already seated. Youre now under oath and subject to the penalties. Written statement. In front of you is the microphone and a series of lights. The light will turn yellow when you have a minute left and red to indicate when your time has come to an end. So, let me please start with you, dr. Calduhn. Chair degette and Ranking Members of the committee, thank you for letting me speak today. As the mother of three children, a practicing emergency medicine physician and a state Public Health official theres nothing more astounding than the fact that we have let an entire new generation of youth start using Nicotine Products. As a society we let these ecigarettes sneak on to the market without proper oversight or impact of their Health Effects. We can no longer stand idly by as this Public Health crisis ravages our communities. Ecigarettes nationwide increased 900 between 2011 and 2015, the total number of children currently using ecigarettes rose to an astonishing 3. 6 million in 2018, 1. 5 million more than the previous year. In some counties in michigan, more than a third of High School Students are using ecigarettes. This epidemic can be attributed in large part to the appeal of flavored vapor products to youth as well as the advertising and promotional activities by companies that glamorize the use of Nicotine Products nationwide. Flavors such as strawberry milk, banana split, cotton candy and gummy bear clearly target children and advertisements are often visually appealing to children with pictures of candy on the packaging. Studies show flavors roadway major reason youth start vaping and even scarier, many young people use these products without understanding their contents or the fact that they have nicotine in them. I recently spoke with the parent of one of my childrens friends who was devastated they found these products in their childs bedroom and is now desperately trying to find resources for support for their childs addiction. Earlier this month under the leadership of governor witmer, michigan became the first state to announce a ban on the flavor of ecigarettes. Our rules ban fraudulent or misleading advertising and disaallow marketing of these products at the point of sale. Strong leadership is necessary, given the significant toll this epidemic has taken on our society and particularly our youth. Im pleased other states are taking similar action. In addition to this Public Health crisis of youth ecigarette use as of september 20th, we had 530 confirmed or probable cases of Vaping Associated long injury across the country and nine deaths. In michigan we know of 15 confirmed or probable cases of this illness and are investigating several more. During our investigation into these vaping illnesses its been heartbreaking to speak to families of young people who are otherwise healthy and are now barely clinging to life. There are key things we must do to fight this epidemic. First, we need strong, Regulatory Oversight over ecigarettes. Ecigarettes should not be allowed on the market unless theyre proven to be safe and Companies Selling these products should not be allowed to market to youth or fraudulently market their products as safe. Second, more research is needed to understand the longterm Health Effects of ecigarette use. Assertions that ecigarette use are effective for smoking cess aegs are not scientifically proven and ecigarettes have not been proven as a cigarette cessation program. We need to make sure we allow the full impacts of these products before we allow them on the market. Sustained and increased funding for tobacco prevention education as well as funding for Tobacco Cessation efforts for youth and adults. Thats a critical part to putting an end to this epidemic. The data around youth vap something clear and we must do more to properly regulate these products so no one, youth or adult, is harmed. Thank you for allowing me to participate and i look forward to hearing from you. Dr. Tillson, youre now recognized for five minutes. Thank you for the opportunity to testify today on the Public Health threats that ecigarettes pose to our youth. Dr. Elizabeth cuervo tilson. I serve as the North Carolina department of health and Human Services state health director. As a Public Health official, pediatrician and medical physician i see this epidemic playing out in our schools in North Carolina. Youth Tobacco Survey found combustible cigarette smoking was at the lowest ever recorded at 8. 9 , ecigarette use increased 894 since 2011. Ecigarettes have become the most commonly used tobacco product amongst youth in North Carolina and concerns have arisen with lung illnesses. Luca is a teenager from high point, North Carolina. As a high school freshman, luca started using juul as a way to fit in with upper classmen on football friday nights. He became addicted even to the point of selling his clothes and other items to raising the 150 a week. Once a boy scout, athlete and a student, luca let his grades fall and dropped out of extracurricular activities. Usually a wellbehaved 15yearold, luca became irritable and angry, throwing outbursts of rage. Nicotine seizure ended him up in the emergency department. That point luca and his parents knew they needed to do everything they could to get him treatment for his nicotine addiction. He participated in a 40day program twice. Thankfully he is living substance free. Luca is not alone. Weve heard similar stories across our state and our nation and we must act to protect our children. Ecigarettes are not safe. Nicotine is the major psychoactive substance found in ecigarette solutions and is highly addictive. Youth and young adults are at risk for nicotine on their developing brain. Can cause seizures, harm to developing fetus and nicotine use can increase risk of em emphysema. 36 cases have been reported in North Carolina, almost all requiring hospitalations, more than half requiring intensive care. Thankfully, weve had no deaths to date in North Carolina and currently weve not identified the exact cause of this illness in our state. Key factors identify that maybe driving ecigarette use among our youth is Marketing Strategies that appeal to youth, Delivery Systems like the usblike systems that are easy to conceal, used discreetly, attract youth to the products and highly addictive nicotine which keeps them coming back. Youth use of nicotine has challenged despite our 100 tobacco free policy, school staff are finding ecigarettes on School Grounds to report that its problematic, contribute to learning disruptions and they do not have the resources to address this new wave of Tobacco Products. Insufficient resources to do mass health and promotions to compete with the ecigarette vaping messages. Our telephone and webbased Tobacco Treatment Program is only able to serve about oneeighth and our local Health Departments are not structured or resourced to sustain a longterm response to this new outbreak. Ecigarette epidemic is a Public Health threat that will not be solved by one policy, one strategy, single policy or state. We need a comprehensive approach and utilize best practices and Lessons Learned from my success in combustible tobacco. Federal and state policies considertoconsider include limiting youth access to ecigarettes, retail and internet settings, reducing access to flavored Tobacco Products by youth, implementing price policies and smokefree indoor air policies. Increased funding should be further allocated on cdc evidence based stit and local Tobacco Cessation, community interventions, mass reach Health Communications and mass media, evidencebased treatment and intervention, infrastructure, administration and management. Thank you for the opportunity to share some of our experience with you. I applaud the subcommittees work to help address this urgent Public Health issue. Thank you, dr. Tilson. Thank you for putting a human face on this, too. Dr. Norman, you are recognized for five minutes. Good afternoon, chair degette, Ranking Member guthrie, and subcommittee members and thank you for the opportunity to speak with you today. My name is dr. Lee norman, kansas secretary of the department of health and environment. Im the state Health Official and an Army Lieutenant colonel and army state surgeon of kansas. A brief update of what were seeing in kansas. Ten hospitalizations are confirmed from vaping and ecigarette related illnesses, including two deaths in adults. Thats an increase over the numbers that were quoted by the cdc from last week. And that was just a new adult added this week to that list. We have the same vaping patterns as seen around the country with these lung diseases and illnesses from the Vaping Solutions. Some have been nicotine only. Some have been thc only and some have been a combination of both, including cbd oil. The final analysis is pending the return of the test results from the fda and what i just told you was what we took by way of history of the deceaseds family members. Twothirds are 18 to 34yearolds in kansas, 16 are under the age of 18, 17 of users are under age 35 and threefourths of the users are male. In kansas and nationwide, over onehalf of all ecigarette users also smoke combustible cigarettes. 80 of use First Contact with nicotine is through vaping. What we are doing in kansas, similar to my colleagues, intensive Public Health information campaign, working closely with the department of education, vapefree tool kits, education and alerts. Were working with the fda and cdc, of course, and our local municipalities to incorporate ecigarettes into the state indoor clean air act. I want to comment briefly on the military. Theres an ominous trend going on in smoking and ecigarette use in the military. The military in aggregate right now is at its lowest rate of combustible cigarette use in modern history. The new trend line, especially in vaping, shows it to be on the rise. Now alarmingly, ecigarette users outnumber combustible cigarette smokers in military service members. In my 2017 to 2018 deployment i saw vaping lung related injury firsthand. This is an emerging military Health Protection issue. The hardearned antitobacco gains are being quickly swept away by vaping and ecigarettes. We need help at the state level, regulating marketing, the flavors attract the youth, no question about it. 96 of the youth, you end up using tobacco started with flavored products. Joe camel and the marlboro man taught us valuable lessons about the effectiveness of marketing to youth. We must counter the industry marketing effort. We must regulate sales and not sell Tobacco Products to those less than 21 years of age. No Internet Sales of Nicotine Products. Regulating contents of vaping and ecigarette products is important. There is no consistent labeling of the products. There should be. We dont know what the offending substances are. We need to know what those are. We need time for the science to catch up with the epidemic of illnesses and death. We need to broaden the antismoking laws to include ecigarettes. We need to support Tobacco Control and prevention funding. In summary, ecigarettes are wildly efficient nicotine systems designed to expose and addict youth to nicotine. Currently approved Smoking Cessation are not approved for those under 18. We must prevent addiction to nicotine. Vaping is effectively showing them the way to nicotine use and addiction. U. S. Preventive task force and other Research Organizations say insufficient evidence to support ecigarettes as a Tobacco Cessation intervention. Other proven methods of cessation do exist. Given that we dont fully know the Health Effects of Vaping Solutions or often times even the contents, we must apply Consumer Protection fundamentals to protect our citizens, much as we would tainted meats or malfunctioning automobile air bags. I will welcome your questions, of course, later. And thank you very much for this opportunity. Thank you, dr. Norman. Now dr. Berell, im pleased to recognize you for five minutes. Thank you very much. Good afternoon chair degett, Ranking Member guthrie and members of the subcommittee. As a Community Member im extremely concerned about vaping especially among our youth. Thank you. I commend you for shining a light on this crisis today. I would like to take a few minutes to share with you today what we are seeing and doing about this critical Public Health issue in massachusetts. Im proud that massachusetts has a long history of being at the forefront of Public Health. And with the current vaping epidemic, were continuing to be proactive in our response based on evidencebased Tobacco Cessation and education programming. Last year, massachusetts raised the minimum age to purchase Tobacco Products, including ecigarettes, to 21. We also prohibited vaping where its illegal to smoke and became the first state in the nation to ban the sale of all Tobacco Products in pharmaciys. Massachusetts has made significant progress in curbing both youth and Adult Tobacco use over the last decades. Look back to 1996. Our Youth Smoking rate in 1996 was 38 . Now that rate today is 6. 4 . And our adult smoking rate is one of the lowest in the nation at less than 14 . The cornerstone of our work has always been prevention. We have a strong cessation and prevention infrastructure and a network of Community Partners and dedicated advocates to help ed kaet our communities on what we know. Unfortunately, this progress is now at risk. The industries are using the same old techniques to bring new products, cheap, sweet and attractive to youth. And its working, in massachusetts and across the country. We hear time and time again Horror Stories from children who are talking about the vaping in their bathrooms at school, who are too short of breath to participate in their sports activities and children, 11 and 12 years old, who have to sleep with these devices underneath their pillows because theyre so addicted, theyre waking up in the middle of the night to use them. We know that in massachusetts from our 2017 data that 40 of High Schoolers have tried these products and one in five, 20 , are using them regularly. And now were confronted with the emergence of the serious vaping lung disease being seen across the country. Two weeks ago, i exercised my authority as Public Health commissioner to mandate that physicians immediately begin reporting any unexpl