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 unexplained vapingassociated pulmonary disease to us at the department of Public Health. We immediately started to hear about cases, ten cases or more a day as we begin to ask for this reporting. We are now looking at 66 reported cases to us and have already reported to the cdc three confirmed cases and two probable ones. What this tells me, and what im afraid of is that this is just the tip of the iceberg in what we will see related to these ecigarettes. We dont know what is causing these illnesses yet but we want to act now to protect our children. And yesterday in massachusetts, we took a landmark step. Our governor, governor charlie breaker, declared a Public Health emergency in the commonwealth and put in place an immediate fourmonth ban on the sale of all vaping products, both nicotine and thc, both in retail and online. This ban on vaping Product Sales will enable our state to take a muchneeded pause, to take a pause and gather more information and data to inform our next steps, to protect our publics health. We cant stand by and watch the industry hook another generation on these deadly products. Its up to us to confront the facts, sound the alarm and protect Public Health, particularly in our youth. Our goal is simple. We do not want another generation of children to become addicted to nicotine. Thank you for commitment to your issue and i look forward to working with you. Thank you. Thank you so much, doctor. Thanks tore the entire panel. Chair will now recognize herself for five minutes for questioning. Last year, the Surgeon General declared the use of ecigarettes as an epidemic. Now youre from all around the country. I would guess you probably would agree thwith the surgeon genera. Dr. Khaldun . Yes, i would agree. Dr. Tilson . Yes maam. Dr. Norman . Agreed. Dr. Bhasm rel . Agreed. Dr. Norman, you said in your written testimony, our youth were poised to be the generation that ended smoking. That legacy is now in jeopardy. What do you think needs to be done to reverse this tide and the epidemic . Was that a question . Dr. Norman. Number one, we are focusing today mostly on youth use of ecigarettes. One of the things that i think we cannot lose sight of is that these are so addictive, we have to also think about smoking in general, because this is an onramp to the use of combustible cigarettes. Thats exactly right. Thats right. Now i so you might have heard me say to the previous panel, ive sponsored legislation to increase the age to 21 for all of these products. And ive been i was telling mr. Guthrie that ive been its a bipartisan bill. We have bipartisan sponsorship. The Senate Majority leader mr. Mcconnell has a companion bill. Nonetheless, as ive been talking to people on both sides of the aisle and trying to get cosponsorship for my bill, people are reticent to cosponsor my bill because they say if somebody is serving in the military, they should be able to smoke and people over 18 can serve in the military. When i was listening to your testimony, dr. Norman, i thought you would be the perfect person to give the answer to that. So whats the answer to that . I dont think we should allow smoking anywhere, but thats a Public Health expert talking. Right. The military has a long history of even supporting smoking, to be honest, way back into the days when it was in c rations. And theyre available, nicotine and all products are available at very low cost. I think we need to accelerate the Smoking Cessation. Do you think thats a good idea that were making that available to the military . No, i dont theres nothing that would support that from a Public Health perspective. You said you think its a good idea to raise the smoking age to 21. Yes. Do you think that includes the military . Yes, maam. Thats because of the risk to Public Health, is that right . Yes. Now, so i want to ask each of you, i guess starting with you dr. Khaldun, what do you think the federal government could be doing more to protect children from ecigarettes . I think we need to make sure we dont allow this fraudulent marketing, this marketing to children, saying that these products are safe. I think we need more evidence and data that theyre actually, one, safe and, two, effective for Smoking Cessation. Thats not scientifically proven. Thank you. Thats what i believe. Thats important. Dr. Tilson . Yes, maam, as i mentioned in my comments, we need to think about a comprehensive approach to Tobacco Control, same way we did with combustibles, combination of policy around marketing, around regulation, around limiting access to youth, around price policies as well as we need to increase resources for states to be able to implement cdcs best practices for implementation and cessation. Dr. Norman . It hovers a lot around marketing. We need to make it less appealing and regulate availability to an older population and i think we need to control whats the labeling of the products so people know whats actual in there. Dr. Bharel . When we passed tobacco 21 last year it was based on the science of the developing brain. Whether someone can serve in the military at age 18 is a different question than whether or not someone should be using a tobacco product because the brain continues to develop up to age 25, and we know that there can be damage to that, and thats how we support tobacco being raised to 21 for all. Go ahead. I was just going to add i support what the other panelists said around restriction of flavors, restriction of nicotine content and ad restrictions as well. I want to ask you one more question. You said after you used your authority to require reporting, reports sky rocketed. Do you think thats going to happen in other states around the country as we get more and more reporting . Yes, i do. And i think the reason for that is several. One is that clinicians have not been asking about vaping. Teens have not been disclosing the use of these products. As we increase awareness and begin to ask and come forward, well see those cases. There seems to be something going on in this current environment. Thats why i say im worried this is the tip of the iceberg. Well see not just acute things but chronic conditions as well. Thank you very much. Im pleased to recognize the Ranking Member mr. Guthrie. Im not going to argue on the military. People in 18 should not be smoking but the principle kind of is if somebody is going to be old enough to wear the uniform, are they old enough to make other decisions . I think its debatable. Im open to looking at your bill as well. And also i mentioned i wont say i mentioned but we were talking about thc here. Theres a big move to ban nicotine, which we need to prevent nicotine. But other states all across the country that are giving more opportunities. I know theyre not focusing on young people but if you give people access to marijuana it will get in the hands of young people. Im glad, dr. Bharel, you banned all forms of vaping, including thc. You kind of answered this in your Opening Statement but you say you reported cases of vaping related to pulmonary illness. How many cases have been reported in your state . Can you provide a breakdown of how many of those cases involved nicotine, thc or both . And did it also have eacetate . Yes. We, in michigan, have had over 44 cases reported to the health department. 15 of those are confirmed or probable cases. Weve seen a mix. Again, this is family members or patients who are self reporting. So we have some questions about what the actual truth may be, but this is self reported. Its been thc, nicotine, its been both for some of them. Again, we dont know what the exact substance is. We have not in michigan we dont test the products ourselves. We send it to the fda lab for testing. At this point we do not know what other substances may be involved. Okay. Yes, sir, ill share some of the data from North Carolina. 36 cases reported so far. Were in the midst of investigating those cases. So for the 27 that we have the medical record information from, 75 of them have reported thc use, 17 prs have reported cbd, 45 have reported nicotine and flavors and 37 have reported both thc and nicotine. Of the 16 that weve had the actual interviews for, 94 have revealed use of thc and 56 reported vaping nicotine. We have been doing testing in our state lab as well as sending our samples to the fda. We dont have our fda reports back, same as other states. In the lab of the 41 we have results from 71 have had evidence of thc. Half have had evidence of vitamin e. Only half, and the other half havent. As well as we found terpines, menthol, so a mixed bag of foundings. You already talked about that, dr. Norman. Dr. Bharel . 66 cases have been reported to us. The rest are currently under investigation. We do know that so far the majority of them are under the age of 30 in terms of the suspects and we also know that it is a mix. Some are thc only. Some are nicotine only and some are both thc and nicotine. Do you know if there are other oils . Do you know if there are other oils . Were not doing our investigation of the actual materials. This is survey based from clinicians and individuals. We are doing the actual testing in our lab. Thanks a lot. Youre using the fda, waiting on fda results. How long does it take to get the results from the fda . And have they told your state about the information they will share about your states results and how do your results compare . In michigan im actually not aware how long it will take the fda to get those results back to us. We have regular communications at the cdc. Im not aware of how long it will take to get those results back. Yes, sir, i think starting to get results back, so you know how long its taken or youre still waiting . Im still waiting. Weve not gotten specific results back but have gotten communication from the fda, talking about what they have been finding. Having one specific additive, a broad range of additives, not one substance seems to be identified. Weve been getting qualitative reports back from the fda but not specific quantitative reports back. Thank you. Dr. Norman . Our first sample was sent in, in mid august, and we havent received the results back yet. Okay. Our information is qualitative as well at this point. Thanks. The question so getting back on the if you do just a search on the web, chair degett showed the cord of the hoodie as a vaping device. I dont know if thats the illicit side but obviously its marketing toward children, unless people at work want to do it without people knowing otherwise. People going from cigarettes to vaping arent hiding that because they were smoking and moving to vaping. Im out of time so ill turn it over to my friend from massachusetts but what are your states doing to move forward . But i will yield back. The acting chair, thanks. And recognizes the gentle lady from illinois. Thank you. On august 23rd of this year, we learned that illinois resident died from the current outbreak of young illness lenked to ecigarettes. The death is tragic, but the more i listen to the testimony ive heard today, it also seems to be preventable. And dr. Norman, your state has also suffered two deaths in recent weeks due to this illness. Do you believe, and anyone else can weigh in on this. Do you believe that we could have prevented these deaths in this outbreak if the fda had not delayed the Obama Administration final rule that would have started ecigarette regulation in 2018 . And thenpostponed by this current administration. Who was that directed to . You or anyone else who wants to answer as well. Weve been doing public messaging for a long time. In the state of kansas, potential users know its not healthy to vape or use ecigarettes. Its not out of lack of knowledge that people are starting and using ecigarettes. And i do believe that whatever regulations can be propulgated, thats where the holy grail is. My question was actually it could have started in 2018, would that have been effective . Regulation could have started . Anyone if anything else wanted to weigh in. Doctor . We saw a 900 increase in students who were using vaping products between 2011 and 2015, so it started a little bit earlier. I do know that there are youth in the state of michigan who dont even know whats in these products. Theyve been marketed to. So, it is a possibility that that could have potentially prevented some of this, but i dont think we would know for sure. Again we dont know the exact cause of these vapingrelated illnesses are. So, we heard from dr. Shugut that the not the accelerator. What do you call the what . The aerosol has toxic chemicals in it that we apparently know that. So do we are we aware of everything thats in these . Have we done Good Research to know even how things like the aerosol could affect the health . Anybody . Do we know . We learned last week on an fda call that the we have more information about what is in the vaping solution that goes in that end of the ecigarette than when wha comes out in the aerosol. Certainly its changed by the process of the vaping. So were you all here for the last panel . Yes. Yes. Okay. Yes . So did you hear enough in terms of what is being done . Do you feel satisfied that going forward, were going to make progress as fast as we could, as effectively as we could, from what you heard, both from the fda and the cdc . Lets start at that end. I think its a complex investigation. Im pleased that the fda and cdc are providing information to our state and local governments. Collectively as a society, we probably could have done more sooner, but i am pleased that the cdc and fda are looking at this closely. Okay. I would agree. Im pleased with the proactive approach cdc and fda is taking. We all acknowledge and the prior panel acknowledged theres a lot more we need to do. This is an urgent Public Health crisis that we need to do a lot more and do it quickly. Agree. Okay. What i know is that we are seeing an alarming increase, as you mentioned earlier, in these Vaping Associated pulmonary diseases and in massachusetts, we put the temporary ban of all vaping products in place in order to take a pause, prevent further illness and death from this lungassociated disease and be able to gather more data and information, because there is so much thats unknown. So were going to see an increase in the number of people, we are, that are addicted to nicotine right now. Is this something that is going to be alleviated even at this point . Are we going to see this increase going on as we go forward . Just yes or no. Yes, we do currently have youth who are addicted to nicotine and need to help them address their addiction. Yes, and we need a comprehensive full steam ahead approach to address this. Yes, i think well see a marked uptick. Nicotine is highly addicted to youth in the way its currently being marketed with flavors and access. Were going to see the problem continue to get worse. Thank you. I yield back. Thank you. Chair now yields. Thank you, madam chair. The information is very important to us. Thank you all for being here. Because marijuana is not legalized in your states, do you believe youth are accurately reporting their use of products containing thc when they become sick . Well, its always hard to know exactly if people are being xlelt accurate. However, in both our medical records and our interviews, people are reporting that they are using thc, up to 75 . So its hard to know that everybody is reporting accurately but a certain large percentage are reporting. Same question to you, dr. Norman. I feel pretty certain that we dont always get the straight story. Thats why we really do need to know the chemical analysis. I dont think people are always honest with their medical history. Yeah. And are there understand the chemical but are there any other alternatives you might use to increase the accuracy of the reporting . Either of you. Well, we are testing their devices and what the solution is in the devices. Its a combination of medical reports, interview and testing of the actual liquid and devices theyre using. Thats the key piece thats missing. Our medical evaluation is pretty state forward, Clinical Care being provided is well understood. Data gathering that we forward to the cdc and fda is traditional what we do in medicine and Public Health. We do need more of the analytics. Were doing polling data, we ask the same question in two or three different ways so were trying to illicit more accurate response for you. Figure out different ways to ask something similar so you can illicit a better response. Go ahead, dr. Tilson. Making sure were reporting the data analysis, consistent reporting of different elements across the state and our interviewers are pretty experienced in doing interviews with patients. So it is hard to know exactly what theyre 100 accurate but our interviewers are pretty experienced in doing interviews with people. Ill take that as a yes. Each interviewer does it with their own style. We talked about street products and so forth. Knowing that street products are contributing to the outbreak, what are your states and enforcement authorities and jurisdictions doing to crack down on the illicit street products that arent from your commercial sellers . Anybody can answer that. Yeah. So, i couple. One, within North Carolina, Tobacco Sales are not licensed. So its a little bit hard for us to really use that licensing data and to track within our license. And then with our illicit and unlicensed dealers and vendors, possession is it illegal to possession a vaping device under the age of 18 in your state . No, sir. The temporary ban we put in place yesterday is around the sale. So the temporary ban for four months is sale. Do any of you have a possession statute . Yes, in the state of michigan, in june we actually passed a law, update youth protective app, from using a tobacco or vaping nicotine product. I appreciate that. Dr. Norman, you raised an issue earlier when you were talking about the fda and their testing, whats going in. You dont know if theyre testing whats coming out. Is that correct . Thats what we heard on the fda last week. You think it would be important, and i agree, but i dont want to put words in your mouth, that we test the smoke coming out as well, because the process, while vaping is taking pla place, could actually change some of those chemicals . Yes. Im not an expert on the engineering that goes into the vaping devices. Theres many different ones, but i think theres plenty of reason to believe that the ingredients that go in are not necessarily identical to those coming out. The lung problems could be either or both, whats in it to begin with, whats coming out as the smoke or a combination of the two, is that correct . I mean i really dont know the answer to that. Its a reasonable guess, though, some combination thereof. We need to know all the answers, no the just half of them. Is that what youre saying . Yes. I appreciate it. Yield back. The chair recognizes the gentleman from massachusetts for five minutes. Thank you, madam chair. Thank you for your patience and excessive testimony today. Dr. Bharel, wonderful to see you again. Thanks for your leadership at our home in the health care of massachusetts. Grateful youre here. Governor Charlie Baker declared an immediate ban on vaping products in massachusetts. As patients sit in hospital rooms with mysterious vaping illness and businesses haver shouldered in my mind its a catastrophic regulatory failure. Dr. Bharel, what should the fda be doing immediately to support efforts to contain this outbreak . Several things that our federal partners could do. We could look at in massachusetts we went to tobacco 21, decrease access to young people. Flavor restrictions would also decrease access as well as understanding what is the content of these products, just like we do with Tobacco Products and testing the nicotine levels as well as allowing us to limit advertising and put warnings on the products as well as in stores. And i want to see if you can clarify and walk me through this, any of the witnesses here. Looking at the acting commissioners testimony, he said that, quote, no ends product is on the market legally. For someone who doesnt quite understand the term of art there it certainly seems like theres a legal market for these products, is there not . Doctor . You know, i cant speak to that specific thing. What i do understand is that there are fda nicotine replacement fda approved nicotine replacement therapies available, and as a clinician, that is what i would advise individuals to use, the fda approved, such as the patches, the gums and the lozenges. Do you think the product is aware that some of these products do not have fda approval that are on the market . I think part of our education has to be around what approved cessation tools there are and part of our temporary ban in massachusetts, were doing an effort around enhanced education and access for fdaapproved nicotine replacement products. Do you have any suggestions as to what the fda should have done . We heard acting commissioner acknowledge in rheetrospect the should a reminder, you can see all of that hearing online at cspan. Org. Well take you live to an interview with Justice Elena kagan from George Mason University in northern virginia. This year takes the form of conversation, Supreme Court Justice Elena
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