Testimony Before the Chicago City Council Committee on Health and Human Relations Regarding Banning the Sale of Flavored Tobacco and Vapor Products
The Smoke Free Alternatives Coalition of Illinois
Tobacco Harm Reduction 101
Monday, July 6, 2020

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Chairman Sawyer and members of the Committee, thank you for taking the time today to discuss the issue of banning the sale of flavored tobacco and vapor products.

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The Smoke Free Alternatives Coalition of Illinois is a coalition of Illinois businesses that are part of the manufacturing, wholesale, retail, and supply and distribution chains for vapor products and other alternatives to combustible tobacco. The coalition educates state legislators, local public officials, and media on tobacco harm reduction alternatives. We work with our members to ensure they are informed on the most current proposals and policies, in order to protect access to vapor products for Illinois consumers.

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Tobacco Harm Reduction 101, https://thr101.org, is a website that seeks to provide policymakers with up-to-date information on tobacco and vapor products.

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Many localities and states have proposed banning flavored tobacco products altogether in an effort to combat what the media and some public health officials have declared is a “youth vaping epidemic.”

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Although addressing policies that could deter youth consumption of tobacco products are laudable, policymakers should refrain from proposals that would restrict adult access to tobacco harm reduction products.

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E-Cigarettes & Tobacco Harm Reduction

The evidence of harm associated with combustible cigarettes has been understood since the 1964 U.S. Surgeon General’s Report 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.[1] There are an estimated 600 ingredients in each tobacco cigarette, and “when burned, [they] create more than 7,000 chemicals.”[2] 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.[3]

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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” appeals.

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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.

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E-cigarettes were first introduced in the United States in 2007 by Ruyan, a Chinese manufacturer.[4] 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.

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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.”[5] 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 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.

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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).[6] 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.

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It should be noted that flavored pod systems are currently banned under federal regulations due to their appeal among younger users. Lawmakers should refrain from enacting their separate bans to understand the effects of the federal ban.

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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:

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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.”[7] In 2018, the agency reiterated their findings, finding vaping to be “at least 95% less harmful than smoking.”[8]

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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.”[9] 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. 

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The National Academies of Sciences, Engineering, and Medicine: In January 2018, the academy noted “using current generation e-cigarettes is less harmful than smoking.”[10]

The American Cancer Society: Most recently, the American Cancer Society noted that “e-cigarette use is likely to be significantly less harmful for adults than smoking regular cigarettes.”[11] This is attributed to the fact that “e-cigarettes do not contain or burn tobacco.”

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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.”[12] 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.”

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Youth E-Cigarette Use

In Chicago, many youths are not using electronic cigarettes. For example, according to the Illinois Youth Survey for the City of Chicago, in 2018, 94 percent of Chicago 8th graders and 88 percent of Chicago 10th and 12th graders reported not using an e-cigarette or vapor product in the 30 days prior to the survey.[13] Only 1 percent of 8th graders, 2 percent of 10th graders, and 1 percent of 12th graders reported using e-cigarettes “more than once a day” in the 30 days prior to the survey.

 

Further, many youths are not overwhelmingly using e-cigarettes and vapor products because of flavors. For example, only 23.9 percent of Connecticut high school students reported “flavors” as a reason for using e-cigarettes in 2017, compared to 41.6 percent who reported they used a vapor product because a friend and/or family member had used them.[14] Similarly, only 26.4 percent of Hawaii high school students cited flavors as a reason to use e-cigarettes in 2017.[15] In 2019, 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.[16] Only 17 percent of Vermont high school students reported flavors as a reason to use e-cigarettes in 2017, and 33 percent cited friends and family members.[17] In 2019, 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.[18] Lastly, only 6.2 percent of Virginia high school students reported using e-cigarettes because of flavors, while 11.3 percent used them because a friend and/or family member used them.[19]

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A more recent May 2020 “research letter” published in JAMA examined a survey of 1,129 respondents between 14 and 24 years old.[20] Only 4.7 percent of respondents reported “flavors” as a reason for JUUL use, compared to 62.2 percent of respondents that cited social reasons. A June 2020 study by a Yale researcher noted that flavored e-cigarette use “was no more associated with youth smoking initiation than vaping tobacco-flavors.”[21] 

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Further, Chicago vape stores and tobacco retailers are doing a good job in not selling tobacco and vapor products to minors. For example, between January 1, 2018 and October 1, 2019, the U.S. Food and Drug Administration conducted 507 tobacco product compliance inspections in Chicago tobacco and vape retailers.[22] Of these, only 99 resulted in a failed inspection that lead to the sale of a tobacco and/or vapor product.

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Menthol Cigarette Ban Will Have Little Impact on Adult and Youth Consumption

Beyond e-cigarettes, policymakers’ fears about the role of menthol and flavorings in cigarettes and cigars are overblown and banning these products will likely lead to black markets.

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Data from the National Health Interview Survey (NHIS) finds nearly a third of all American adult smokers smoke menthol cigarettes. In a 2015 NHIS survey, “of the 36.5 million American adult smokers, about 10.7 million reported that they smoked menthol cigarettes,” and white menthol smokers “far outnumbered” the black and African American menthol smokers.[23]

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Although lawmakers believe banning menthol cigarettes will deter persons from smoking those, such a ban will likely lead to black markets. A 2012 study featured in the journal Addiction found a quarter of menthol smokers surveyed indicated they would find a way to purchase, even illegally, menthol cigarettes should a menthol ban go into place.[24] Further, there is little evidence that smokers would actually quit under a menthol ban. A 2015 study in Nicotine & Tobacco Research found only 28 percent of menthol smokers would give up cigarettes if menthol cigarettes were banned.[25]

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Further, there is no evidence to suggest that menthol cigarettes lead to youth tobacco use. Analysts at the Reason Foundation examined youth tobacco rates and menthol cigarette sales.[26] The authors of the 2020 report found that states “with more menthol cigarette consumption relative to all cigarettes have lower rates of child smoking.” Indeed, the only “predictive relationship” is between child and adult smoking rates, finding that “states with higher rates of adult use cause higher rates of youth use.”

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Finally, menthol bans would require law enforcement to enforce such bans and will likely lead to racial repercussions. Although white Americans smoke more menthol cigarettes than black or African Americans, “black smokers [are] 10-11 times more likely to smoke” menthol cigarettes than white smokers.[27]

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Given African Americans’ preference for menthol cigarettes, a ban on menthol cigarettes would force police to further scrutinize African Americans and likely lead to unintended consequences. Lawmakers in Chicago should reexamine the case of Eric Garner, a man killed while being arrested for selling single cigarettes in the city. In a recent letter to the NYC council, who are also debating a ban on menthol cigarettes, Garner’s mother, as well as Trayvon Martin’s 3 mother, implored officials to “pay very close attention to the unintended consequences of a ban on menthol cigarettes and what it would mean for communities of color.”[28] Both mothers noted that a menthol ban would “create a whole new market for loosies and re-introduce another version of stop and frisk in black, financially challenged communities.”

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Ban Will Increase Already-Thriving Black Market in the Windy City

Deeply troubling is that the legislation would require adult users of such products to find alternative ways to obtain vapor products, including utilizing black markets – something Chicago is already prone to due to high cigarette prices. Cook County, which includes Chicago, also has a Cigarette Tax Reward Program, which offers monetary awards of up to $250 to persons reporting those seeking to avoid paying cigarette taxes, including people who use unstamped or counterfeit packs or even stray cigarettes.[29] It has been reported that Chicago police issue an estimated $4 million worth of tobacco citations each year, however, only 15–20 percent are actually are paid.[30]

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In February 2020, WGN followed Chicago’s Department of Business Affairs and Consumer Protection as agents “searched for illegal cigarettes in stores through” the city.[31] In 2019, the department “issued $838,000 worth of fines for illegal tobacco sales.” Agents told WGN News that there is “a direct link between unstamped cigarettes and crime in [Chicago] neighborhoods.”

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The black market is so lucrative that in 2016 city council hearing, Alderman Roderick Sawyer “said he knows one man who makes $800 a day selling” loose cigarettes.[32]

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Massachusetts recently banned the sale of flavored e-cigarettes and tobacco products and is already experiencing an increased black market. Indeed, a former employee of the U.S. Bureau of Alcohol, Tobacco, Firearms and Explosives told the Massachusetts Department of Revenue’s Illegal Tobacco Task Force that “the illegal tobacco trade along Interstate 95 on the East Coast is a $10 billion industry that is already working to fill the void created by Massachusetts’ new law.”[33]

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E-Cigarette Economics

According to the Vapor Technology Association, in 2018, the industry created 3,770 direct vaping-related jobs, including manufacturing, retail, and wholesale jobs in Illinois, which generated $152 million in wages alone.[34] Moreover, the industry has created hundreds of secondary jobs in the Prairie State, bringing the total economic impact in 2018 to $1.1 billion. In the same year, Illinois received more than $69 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 Illinois eclipsed $30.8 million.[35]

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Further, the use of e-cigarettes can help reduce health care costs. It is well known that Medicaid recipients smoke at rates of twice the average of privately insured persons, according to the Centers for Disease Control and Prevention (CDC). In 2013, “smoking-related diseases cost Medicaid programs an average of $833 million per state.”[36]

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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.[37]

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A 2017 study by 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.[38]

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Deeply problematic is that Illinois spends very little in helping smokers quit. In 2019, Illinois received an estimated $1.0688 billion in tobacco taxes and tobacco settlement payments. In the same year, the state spent only $9.1 million, or less than 1 percent, on funding tobacco control programs, including education and prevention.[39] The lack of funding is notable in the state’s telephone quit line, of which Illinois invests only $2.11 per smoker, slightly lower than the national average of $2.21.

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Many Chicago youth are not using electronic cigarettes and vapor products, as evidenced in the 2018 Illinois Youth Survey. It is disingenuous that lawmakers would seek to prohibit adult access to tobacco harm reduction tools, especially as Illinois invests very little of existing tobacco monies on programs that help adults quit smoking combustible cigarettes.

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The ban on flavored tobacco and vapor products is unlikely to reduce youth e-cigarette use and will lead to black markets. Further, it will eliminate jobs and revenue, at a time when Chicago needs as much revenue as possible.

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Electronic cigarettes and vapor products have helped millions of American adults quit smoking and their use should be promoted. Chicago lawmakers ought to work with retailers and public health groups to limit youth purchases.

 

 

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

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

[3] 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.

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

[5] 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.

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

[7] 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.

[8] 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.

[9] 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.

[10] 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.

[11] The American Cancer Society, “What Do We Know About E-cigarettes? June 19, 2019, https://web.archive.org/web/20190929053909/https://www.cancer.org/healthy/stay-away-from-tobacco/e-cigarette-position-statement.html, accessed September 29, 2019.

[12] 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. 

[13] Center for Prevention Research and Development, “Illinois Youth Survey 2018 Frequency Report: City of Chicago,” School of Social Work, University of Illinois, 2018, https://iys.cprd.illinois.edu/UserFiles/Servers/Server_178052/File/state-reports/2018/Freq18_IYS_Chicago.pdf.

[14] Connecticut Department of Public Health, “Connecticut Youth Tobacco Survey Results,” 2017, https://portal.ct.gov/-/media/Departments-and-Agencies/DPH/dph/hems/tobacco/PDF/2017-CT-Youth-Tobacco-Survey-Results.pdf?la=en.

[15] 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.

[16] Rhode Island Department of Health, “2019 Youth Risk Behavior Survey Results, Rhode Island High School Survey,” 2019, https://health.ri.gov/materialbyothers/yrbs/2019HighSchoolDetailTables.pdf. 

[17] Vermont Department of Health, “2017 Vermont Youth Risk Behavior Survey Statewide Report,” May, 2018, https://www.healthvermont.gov/sites/default/files/documents/pdf/CHS_YRBS_statewide_report.pdf.

[18] Vermont Department of Health, “2019 Vermont Youth Risk Behavior Survey Statewide Report,” January, 2020, https://www.healthvermont.gov/sites/default/files/documents/pdf/HSVR_YRBS_2019_HSReport.pdf.

[19] Virginia Department of Health, “Virginia High School Survey,” 2017 Youth Risk Behavior Survey Results, April, 2017, http://www.vdh.virginia.gov/content/uploads/sites/69/2018/04/2017VAH-Detail-Tables.pdf.

[20] Georgia C. Wood, et al., “Youth Perceptions of Juul in the United States,” JAMA Pediatrics, May 4, 2020, https://jamanetwork.com/journals/jamapediatrics/article-abstract/2765158?guestAccessKey=3969997a-4aa5-45c6-9aec-c795f1ff9827&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=050420.

[21] Abigail S. Friedman and SiQing XU, “Associations of Flavored e-Cigarette Uptake With Subsequent Smoking Initiation and Cessation,” JAMA Open Network, June 5, 2020, https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2766787?utm_source=twitter&utm_medium=social_jamapeds&utm_term=3423555898&utm_campaign=partnership&linkId=90922892.

[22] Illinois, Tobacco Harm Reduction 101, 2020, https://www.thr101.org/Illinois. 

[23] Brad Rodu, “Who Smokes Menthol Cigarettes?” Tobacco Truth, December 4, 2018, https://rodutobaccotruth.blogspot.com/2018/12/who-smokes-menthol-cigarettes.html.

[24] 0 RJ O’Connor et al., “What would menthol smokers do if menthol in cigarettes were banned?” Addiction, April 4, 2012, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3370153/.

[25] Olivia A. Wackowski, PhD, MPH, et al., “Switching to E-Cigarettes in the Event of a Menthol Cigarette Ban,” Nicotine & Tobacco Research, January 29, 2015, https://www.researchgate.net/publication/271592485_Switching_to_ECigarettes_in_the_Event_of_a_Menthol_Cigarette_Ban.

[26] Guy Bentley and J.J. Rich, “Does Menthol Cigarette Distribution Affect Child or Adult Cigarette Use?” Policy Study, Reason Foundation, January 30, 2020, https://reason.org/policy-study/does-menthol-cigarette-distributionaffect-child-or-adult-cigarette-use/.

[27] D. Lawrence et al., “National patterns and correlates of mentholated cigarette use in the United States,” Addiction, December, 2010, https://www.ncbi.nlm.nih.gov/pubmed/21059133.

[28] Carl Campanile, “Menthol cig ban will lead to more stop-and-frisk: Moms of Garner, Martin,” New York Post, October 16, 2019, https://nypost.com/2019/10/16/menthol-cig-ban-will-lead-to-more-stop-and-frisk-moms-ofgarner-martin/.

[29] Cook County Department of Revenue, “Cook County – The Cigarette Tax Reward Program,” https://apps.cookcountyil.gov/dor/index.php.

[30] “Cook County Cracking Down on Illegal Cigarette Sales,” CBS News Chicago, February 11, 2014, https://chicago.cbslocal.com/2014/02/11/cook-county-cracking-down-on-illegal-cigarette-sales/.

[31] Lourdes Duarte, “Inside Chicago’s war on illegal cigarettes,” WGN News, February 19, 2020, https://wgntv.com/news/wgn-investigates/inside-chicagos-war-on-illegal-cigarettes/.

[32] Chris Lentino, “New Cigarette Tax Will Lead to More Black Market Sales and Violence, Alderman Say,” Illinois Policy, February 9, 2016, https://www.illinoispolicy.org/chicago-aldermen-revolt-against-mayor-on-increasing-citys-cigarette-tax/.

[33] Elizabeth Sheld,” E-Cig flavor ban grows $10 billion Massachusetts black market,” The Center Square, July 2, 2020, https://www.thecentersquare.com/massachusetts/op-ed-e-cig-flavor-ban-grows-10-billion-massachusetts-black-market/article_64521da4-bc6b-11ea-8dfa-fbe26fe9e98c.html.

[34] Vapor Technology Association, “The Economic Impact of the Vapor Industry ILLINOIS,” 2019, https://vta.guerrillaeconomics.net/reports/1d54b2c1-1f61-4388-9867-6b53711733ef?.

[35] 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.

[36] 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.

[37] 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.

[38] 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.

[39]  Truth Initiative, “Tobacco use in Illinois,” June 28, 2019, https://truthinitiative.org/research-resources/smoking-region/tobacco-use-illinois-2019.