with that the subcommittee will dismiss panel one and now that the second panel has been set, we will invite our witnesses to come up. thank you for coming today. [background sounds] [background sounds] >> i'm now delighted to introduce our second panel witnesses for today's hearing.

a doctor chief deputy director for chief medical date executive officiant. doctor elizabeth, state health director and she's medical officer of north carolina formative human services. doctor lee norman, secretary of the chemists department of health and environment and doctor monica rl, the commissioner of the massachusetts department of public health. i want to thankf all of you for appearing before the committee today. you know aware that the committee is holding an investigative hearing and we do so, have a practice the taking of testimony on oath. you have any any objections to testifying on oath today? >> no. let that reflect that the witnesses have responded no. on the rules of the house, and the rules of the committee, entitled to be accompanied by counsel. through do any of you request to be accompanied by counsel today.

now let the record reflect 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 you are about to give is the truth the whole truth and nothing but the truth? let the record reflect the witnesses responded in the affirmative and you are already seated. you are now on oath and the penalty set for the top title i of the united states code. the chair will now recognize our witnesses for five minutes. for a summary of their statements. the light will turn yellow we do have a minute left in red to indicate when the time is come to anic end. let me start with you doctor calhoun, w we will and you know recognized for five minutes. >> thank you the opportunity to speak with you today regarding

the public health crisis of youth e-cigarette youth use. as a mothersi of three children, state public health official, there is nothing astounding than the fact that we have led an entire new generation help start to use nicotine products. as a society, i'm stuck onto the market that went out proper oversight. we can no longer stand idly by while this public health crisis ravages our communities. nationwide, e-cigarette use among middle and high school students in christ 900 percent between 20,112,015. the total number of children who are currently using e-cigarette rose and an astonishing 3.6 million in 2018. 1.5 million mark in the previous year. in some counties in michigan, more than a third of high school students are using e-cigarette. this epidemic can be attributed to the large part and that

appeal and marketing and advertising glamorize the nicotine products nationwide. layers such as strawberry milk, banana split, cotton candy and gummy bear. clearly is targeting children. advertising for vaping products are often visuallyar appealing. candy on the packaging. studies show that many young people use these products that went out understanding the content or the fact that they have nicotine in them. i recently spoke with the parents of one ofha my childrens friends, was devastated that they found these products in f e child's bedroom. in their nowe display try to fid resources or support for the child's addiction. earlier this month, on the leadership of governor question michiganan became the first stae to announce a ban on the sale of all flavored nicotine baby products. our emergency rules also ban fraudulent or misleading

advertising and islam marketing of these products at the point-of-sale. a strong leadership is this necessary given the significant toll of this has taken on our society and particularly our youth. in addition to this public health crisis of youth e-cigarette p use as of september 20th we've had 530 confirmed or probable cases of vaping associated lung injury across the country. in nine deaths. intr michigan, we know of 15 confirmed or probable cases of this illness and are investigating several more. during our investigation and these vaping illnesses, it's been heartbreaking to speak to families of young people who are otherwise healthy. they are now barely clinging to live. they are keeping, first we need strong leg territory oversight a recent raspberry they should not be allowed in the market unless they are proven to be safe. company selling these products should not not be allowed to market to youth.

our fraudulently market the products and safe. second, more research is need it in order to understand the long-term use. e-cigarette uses effective fruit smoking cessation are not scientifically proven and the fda has not approved e-cigarettes as part off a smoking cessation program e-cigarette also contain cancer-causing toxins and we need to make sure that we fully understand health impact of these products before we allow them to be on the market. and finally, we need to make sure there are sustained and increased funding for tobacco provision education as well as funding for the efforts for youth and adult prevention efforts are a critical part of looking into this epidemic.nd the data, are the epidemic of youth vaping is very clear. we love to do more to regular these products and no one youth or adult is harmed. thank you for h allowing me to participate in the subcommittee hearing today. i look forward to working with you.

>> thank you for the opportunity to testify today on the public health threats the cigarettes post to the youth. i surf as a state health director and chief medical director. as you know the surgeon general called this an ebony. pediatrician and preventive medicine physician, i see this epidemic playing out across schools and communities in north carolina. our most recent north carolina youth tobacco survey found that off of combustible cigarette smoking was at the lowest ever recorded amongst high school students 8.9 percent, e-cigarette use increased 894 percent since 2011, e-cigarette have become the most commonly used tobacco product amongst youth in north carolina. further concerns of numbers and with the investigation of severe lung illness. before i go on, let me put a

face on this of you. look as a teenager for my.north carolina high school freshman, started to use joule as a weight to f fit in. he quickly became addicted to the nicotine in the product even to the point n of selling his close and other items in order to support his nicotine addiction. he let his grades fall and dropped out of extra curricular activities. usually a well behaved 15iv -year-old, became irritable and angry even throwing violently outbursts of rage. finally nicotine related seizure, and it him up in the emergency department. at that., they knew they had to do everything they could to get he the treatment for the nicotine addiction. he participated in a treatment program in california twice. thankfully is now living substance free but he's not alone with her 70 stories from across the street the state and

our nation. we must protect our children. e-cigarette his are not safe. nicotine is the major substance found and is highly addictive. there particularly effects on their brain. and because harm to venus, and nicotine use can increase emphysema. further illness associated with e-cigarettene products, and six cases have been reported north carolina almost all requiring hospitalization. more than half requiring into the care. thankfully we've had no deaths today. we have not identified exactly the cause of illness in the state. key factors may be driving out among our youth, marketing strategies, the delivery systems, they're easy to conceal. but do notcr recognize the use f

flavors that attract the youth to the products in a highly addictive nicotine which keeps them coming back. they have challenge the resources of our state to address. despite her 100 percent tobacco spfree school policy, or finding e-cigarette on school grounds. as problematic contributing to learning disruptions. and they do not have the resources to address this. the insufficient resources to do evidence-based map health promotions and campaigns with e-cigarette and meant basic messages. our quick line, is only resource to about one eighth as recommended by best practices. our local health departments cannot sustain a long-term response to this new health break. as a public health wreck one policy or we need a comprehensive approach.

best practices. policy consider include curbing advertising and marketing to youth, limiting access, reducing access to flavored tobacco flavors a implementing price policies and adding e-cigarette smoke-free indoor air policies. increase funding should be allocated to further adopt and expand the cdclo recommended bad state and local tobacco use prevention. community intervention, mass re- cath mass media. evidence based, infrastructure management. thank you for the opportunity to testimony. >> thank you for putting a human face on the supreme.

>> good afternoon tear. ranking member guthrie, and some committee members and thank you for the opportunity to speak with you today. my name is doctor leif norman. i'm against secretary of the department of health and environment. most of the state health official and i am an army lieutenant colonel. on first give you a brief update as to what we are seeing in kansas. we now have ten hospitalizations confirmed. this is from vaping and e-cigarette illnesses. including two deaths in adults. that's an increase of the numbers of the recorded by the cdc from last week. just a new adult list. we have the same baking paving patterns. from the vaping solutions. some have been thc only. some a combination of both. including cbd oil. the final analysis is pending the return of thein test results from the fda. and what i just told you was of what we took in my way of

history from the deceased. on their family members. similar demographics, two thirds are an 18 to 34 -year-olds, 16 percent are on the age of 18. 17 percent are on the age of 35 in three force of the users are male. in kansas, the nationwide, over one half of all e-cigarette users also smoke combustible cigarettes.ar 80 percent of use first contact with nicotine is through vaping. what we're doing in kansas similar to my colleagues, intensive health campaign, working closely with the department of education on school programs for vape free toolkits. intensive medical professional education and alerts. we are working with the fda and cdc of course, in our local municipalities to incorporate e-cigarette his into state indoor clean air act. on a comment briefly on

military. there's anonymous trend going on and e-cigarette use in the military. military and aggregate right now is at itsag lowest rate of combustible cigarette use in modern history. but in a trendline especially due to vaping shows it to be on the rise. now alarmingly, e-cigarette users outnumber combustible cigarette smokers in military service members. in my 2017, to 2018 deployment in the middle east, i saw vaping related lung injury percent. this is an emerging military health protection issue. the hard earned anti- tobacco games are being weakly swept away by vaping and e-cigarette. we need help. at the state loophole. regulating marketing and the flavors attract the youth, no question about it.ti ninetyst 696 percent of the youh who end up using tobacco started with flavored products. joe kamel and then marble man

taught us valuable lessons on marketing to youth. we must counter the track. we must regulate cells. should it sells tobacco products to those less than 21 years of age. no internet sales of nicotine products. regulating contents of vaping and e-cigarette products, is important. there is no consistent labeling of the products. there should be. weha don't know what the offendg 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 anti- smoking laws to include e-cigarette. we need to support tobacco control and prevention funding. in some right, e-cigarette his are wildly efficient nicotine delivery systems designed to expose an addict you to nicotine.

currently approved smoking cessation are not approved for those on 18. we muchnd prevent addiction to nicotine. vaping is effectively showing them to nicotine use and addiction. u.s. preventive services task force, and other professional research organizationsns say insufficient evidence to support e-cigarette as an effective tobacco cessation intervention. other proven methods of cessation do exist. given that we don't fullyst know the health effects of vaping solutions, or oftentimes even the contents, must apply consumer protection from the metals to protect our citizens much as we would malfunctioning automobile airbags. i will we will your questions of course. thank you very much for this opportunity. >> thank you very much and good afternoon.

thank you for the opportunity to provide testimony on this pressing issue today. as a massachusetts commission of public health is the come physician in a community member. i'm extremely concerned about vaping especially monarchies. i commend you for shining light in this crisis today. let's take a few minutes to share with you today what we are staying and what we are doing about this critical public health issue in massachusetts. i probably have a long history of being at the forefront of public health. with the current vaping epidemic we are continuing to be proactive in our response based on evidence tobacco cessation and education programming. last year, massachusetts raise the minimum age to purchase tobacco products including e-cigarette to 21. we also prohibited vaping was illegal to smoke and became the

first state in the nation to ban the sale of all tobacco products in pharmacy. massachusetts has made significant progress in curbing both youth and adult tobacco use over the last few decades. look back to 1996 our youth smoking rate in 1996 was 38 percent. now that rate w today is 6.4 percent. enter adult smoking rate is one of the lowest in the nation at less than 14 percent. the cornerstone of our work has always beenne prevention. we have a strong cessation and prevention infrastructure and a network of community partners and dedicated advocates to help educate 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 it's working. in massachusetts and across the country. we heard time and time again horror stories on children who are talking about vaping in the bathrooms at school with two short of breath to participate in our sports activities. children 11 and 12 years a old sweep these devices underneath the pillows because they are so addicted and their waking up in the middle of the i night to use them. we know that in t massachusetts, that 40 percent of high schoolers have tried these products and one in five, 20 percent are using them regularly. now were confronted with the emergence of the series vaping related lung disease. we are seeing this across the country. two weeks ago, exercise my authority as public health commissioner to mandate the physicians immediately began reportingmm any unexplained vapg

associated pulmonary disease to us at the public health. we immediately started here about cases. we are now looking at 66 reported cases and already reported to the cbc confirmed cases and to possible ones. what this tells me that what i am afraid of, is this is just the tip of the iceberg. and what we will see related to e-cigarette. we don't know what is causing these illnesses yet. i want to to protect our children. and yesterday massachusetts, we took a landmark step. our governor declared a public health emergency in the commonwealth. and put in place an immediate four months and on the sale of all vapingn products. both nicotine and thc. both in retail and online.

this ban on product sales will enable our states to take those much mediated need it pause. and gather more information and data to inform our next step to protect our publict health. we can't stand by and watch the industry hook another generation on these deadly products. it's up to us to confront the facts, t sound the alarms 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 this and thank you. >> the terrible now recognize or sell for five minutes for questioning. >> last year the surgeon general declared the youth of the cigarettes is an epidemic. now you from all around the country. i would guess you probably would agree the surgeon general i think and i'll answer,.

>> i would agree. >> yes ma'am. >> agreed. >> agreed. >> doctor carmen you said in your testimony, interesting testimony, our youth are poised to be the generation that ended smoking. the legacy is now in jeopardy. what you think needs to be done to reverse this tide and the evidence? doctor norman: we are focusing today mostly on youth use of the cigarettes. one of the things i think we cannot lose sight of is that these are so addictive that we have to also thinknk about smokg in general because this is an on ramp to the of combustible cigarettes. to make this right. to theht've heard me say previous panel i have sponsored

legislation to increase the age to 21 or all of these products. i was telling mr. guthrie that is the bipartisan bill. we have sponsorship and in the senate, of the senate majority leader, has a companion bill but nonetheless, as i've been talking to people, on both sides of the aisle, and trying to get sponsorship for my bill, people are reticent to cosponsor my bill because they say that if somebody is surfing in the military, they should be able to smoke and people are 18 can surf in the military. when i was listening to your testimony, doctor norman, i think would be the perfectou person to give the answer to that. so what iss the answer to that. >> i don't think we should allow smoking anywhere but that is a public health expert talking. there is a military, they have a

long history of even supporting smoking to be honest. we back to the days when it was in c rations. they're available nicotine in all products is available in very low cost. i think we need to accelerate the smoking cessation. if youou think that's a good ida that we are making it available to the military. >> there is nothing that would support that from a public health perspective. >> you think it's a good idea to raise the smoking issue 21. if in the military ? >> yes ma'am. >> the risk to the public health right? >> right. >>, thanks each of you, i guess starting with you, doctor kazin, what do you think the federal government could be doing more to protect children from e-cigarettes. >> i think we really need to make sure that we don't allow this marketing to children staying that these products are safe.

i think we need more evidence and data they are actually one space and to even effective for smoking cessation because that is not scientifically i proven. >> that's important. >> as i had mentioned in my comments, i think that we need to think about a comprehensive approach. tobacco control like with combustibles. combinations of a policy around marketing and around regulation limiting access to youth and around price policies. as well as increased resources for states to be able to implement best practices recommendation for prevention and cessation. >> hovers a lot around marketing we need to make it less appealingg need to regulate the availability to an older population and i think we need to control was labeling of the products of people know what is actuallys there. >> when we passed tobacco 21 in massachusetts last year, is based on the science of the developing1 brain.

so both of somebody can surf in the military is the different question than both of or not someone should be using a tobacco product because the brain continues to develop up to age 25. we note that there can be damage to that and thatre is how we support tobacco being raised to 21 for all. and i'm just going to add the support with the other panelist said. karen restriction ofrt waivers d also restriction of nicotine content and at restriction. >> one more question. you said that after you use your authority to require recording. reports skyrocketed. do you think that's going to happen in other states around the country as we get more reporting ? >> is the do it i think the reason for that is several. one is that clinicians have not been asking about vaping and not disclosing the use of these these d products and we need to increase awareness. we need to thanks and come

forward and see these cases. there seems to be cut something coming on in this environment. this is the tip of the iceberg and we will see more not just acute things but chronic conditions as well. >> thank you very much. thank you very much. people 18 to not be smoking but the principal kind of is that someone is going to be old enough to wear a uniform, i'd love to make other decisions and about all of that. ai think i am open to looking t another bill as well. and also i was mentioning, there is talk a lot about thc but there seems like there is a big move to ban nicotine which we need to prevent nicotine but there's alter states all across the country giving more opportunities. do not focusing on young people but if you give opportunities and ecstasies to marijuana it's going to get him into the hands and our people. i'm glad youla banned banned all forms of vaping.

you say you reported cases with pulmonary illness. how many cases have been recorded in your state and could you provide a breakdown of how many cases involved nicotine thc or both. an if it thc didn't also have e acetate. >> we in michigan have had over 44 cases that have been reported to the health department. fifteen of those are concerns are probable cases. we have seen a mix. this is family members are patients who are self recording. we have a question about the actual truth may be but this is self-reported. ntsc, i nicotine and both for se of them so we don't really the exact substance is. we are not in michigan, have the products ourselves, we send to the fda labs for testing. at this.we do not know what other substances may be involved. >> okay. >> will share some of the data

from north carolina. thirty-six cases reported so far. when the midst of investigating this cases. twenty-seven that we have the medical record information, 75 percent of them have reported thced use. 17 percent cv and some with nicotine nicotine flavors. in the 16 that we've had actual interviews,av 94 percent have revealed use of thc. 56 percent with nicotine. we have been doing testing in our state now in a lab as well as sending them to the fda. we don't have our fda reports back yet but we went we found in our lab of the 41 that we have results from, 71 percent have had evidence of thc and half of had evidence of vitamin e. only half and thehe other half have it. as will be found nicotine and

mental and the struggles will never get the samples as well. >> we've had in massachusetts, 66 cases that have been reported to us. we have been confirmed by the cdc definition and to probables. the rest are currently on investigation. however we doab know that so far the majority of them are on the age of 30 in terms of the age. we also know that even the mix, thc only, and somef are both. >> do you know if there are other oils which marks connect not the actual materials, this is survey based in individuals. so we aren't doing the actual testing. >> and all these being said you are using the fda and you are waiting on results. how long does it take to get the results from the fda.

as the fda told you said about the information they will share about your states results and how your results compare to the overall resorts result they had never ? >> in michigan, i'm not actually aware how long this result will get back to us. we do have regular communications withmm them and cdc, unaware about how long it will take to get those results back. >> this is the relatively new outbreak, i'm still waiting for results. we have not gotten results back but communication from the fda talking about what they have been fighting and again not one specific additive. it's a broad range of at adages. qualitative but not quantitative. >> are for was sent in mid august and we haven't received any of the results yet back yet. >> are information is quantitative as well.

>> getting back, you do surfing the web, showing a picture of a hoodie. actually shared a recording of a vaping advice. i don't know that it was an illicit site or if it was just focused towards people doing this i not wanting others to see them. moving forward, a lot of illicit products. i am out of time. as my state when your states are doing to move forward. i wheeled back. >> the acting chair, thanks. [laughter] >> thank you, on august 23rd of this year, we learned that an illinois resident died.

this was from the current outbreak of long illness linked to the cigarettes. the death is tragic the more i listen to what the testimony i've heard today, also seems to be preventable. doctor norman, your state has also severed two deaths in recent weeks due to his illness. do you believe anyone else can weigh in on this, do you believe we could have prevented these deaths and is outbreak is the fda, had not delayed the obama administration his final rule that would have started e-cigarettes regulations in 20 2018, and that was postponed by this at current administration. it was a question posed to. >> anyone who wants to answer it. >> we've been doing public

health messaging for a long time and i really feel that in the state of kansas and the potential users it's notot healy to vape. forty use e-cigarettes. it's not out of lack of knowledge the people are starting and using e-cigarettes. i do believe that whatever regulations it could be complicated to get towards restriction and regulated products, this where the holy grail is. >> so my question was actually this started in 2018, wouldn't that have been effective, regulation could've started on if anyone else wanted to weigh in. >> we saw 900 percent increase across the country. between 20,112,015. i do know that there are users who in a state of michigan do you know it's in these products.

the possibility that that could've potentially prevented some of this but i think what we don't know for sure. we don't really know the exact cause. >> we heard what the accelerator but what is it called, the aerosol. as toxic chemicals in it. we apparently know that. so do we or are we aware of anything that's in these are everything that's in these have we done in research to know even how things like the aerosol could affect the health? >> >> we learned last week on an fda call that we have more information about what is in the vaping solution that goes in. and what comes out of the aerosol. there is certainly changed by

the process of the vaping. >> and we all hear from the last panel. did you hear enough in terms of what is being done. do you feel satisfied and going forward that we are going to make progress as fast as we could. and effectively as we on what you heard both from theha fda ad cdc. >> let's start at that. >> i think it's a complex investigation. i'm pleased they are providing support to our state and local governments. but i think that collectively as a society, we probably could've done more arid and sooner. >> i would agree. i am pleased with the proactive approach. but i think we all acknowledge in the panel acknowledges that we have a lot more that we need to do.

this is really an urgent public health crisis that we need to do a lot more. we need to do it quickly. >> agreed. >> what i know is that we are seeing an alarming increase as you mentioned s y earlier, vapig pulmonary diseases, and in massachusetts, we put the temporary ban of all vaping products in place in order to take those pause to preventer further illness and deaths from this long associated disease and be able to gather more data and information because there is so much that is unknown. students are going to see an increase in people that are addicted to nicotine right now. is this something that is going to be alleviated even at this. we going to see this increase going on as we go forward. just yes or no. >> yes we do currently have youth addicted to nicotine. we just help them address the addiction. tonight we need a comprehensive

full team approach. >> yes and uptake. spec. >> it's highly addictive to youth the way is currently marketed. we see the problem to get worse. >> i yelled back. >> thank you very much. appreciate all of you being here today information is very important to us. doctor justin and norman, marilyn it's not legalized in your states, do you believe these are accurately using and reporting what they are using. >> is always hard to know if people are being completely accurate. however, in both medical records in our interviews, people are reporting the they are using thc up to 75 percent. on no therapies reporting accurately but a large percentage are reporting. >> same question to you doctor

norman. >> i feel certain that we don't always get the straight story and asked why we really do need to know the chemical analysis. i don't think that people are always honest with her medical history. >> i understand the chemical analysis but are there any other alternatives that you might use to increase the accuracy of the recording. >> we are testing the devices and with the solution is the devices was a combination of medical reports interview and in the testing of the actual liquid in the devices that we are using. >> i think that is the key piece that is missing. herua medical advices straightforward. our data gathering is i think traditional what we do in medicine. and in public health but we do need more of the analytics. >> just curious, doing polling and data, we asked the same questions in two or three different ways so that we are

trying to elicit a more accurate response. do you all do that for this information as well. figure out different ways to thanks and to get a better response. >> we are using the cdc regarding making sure we are reporting the data so we have a consistent reporting of different elements across the state. our interviews are pretty experienced in doing areas with patientsts so it is hard to know exactly if there are 100 percent accurate but are interviewers gre pretty experienced. >> on-site that as a yes you are doing some interesting things. each does their own with their own interesting style. knowing the street products are contributing to the outbreak, what are your states enforcement authorities in jurisdictions doing to crack down the illicit street products that aren't from your commercial sellers. anybody can answer that.

>> within north carolina, tobacco sales are not licensed. since a little bit hard for us to really use our licensing data into track within our licenses and then with our illicit and unlicensed, dealers and vendors as we talked about earlier this panel, it's hard to track those down. investigation authorities they put the state bureau of investigation and art alcohol for law enforcement. we've been starting to have conversations with them. there was a complaint or a signal, it looks like it is coming from this geographic area or this place, then they can go investigate a complaint right now we don't have enough localizing data to really direct them. >> sorry it's not here earlier, do you all have a position or it is it is illegal to have a

device in the age of 18. >> is around the sale of that band.le >> do any of you have a possession statute. >> in michigan, in june we actually passed a law and f is so it prohibits a minor from using a vapor or a vaping product. >> only thanks doctor norman, you raised an issue earlier we talked about the fda and their testing, was going on but you don't know if they are testing what is coming out. >> this we are in the last week. >> do you think it's important and i would agree with that and i don't put words in your mouth, then we test smoke that's coming out as well because the process allows vaping is taking place could actually change some of those chemicals. >> i'm not an expert on the

engineering that goes into the vaping devices and there is many different ones. but i think is probably a reason to believe that the ingredients that go in and are not necessarily identical to the previous income out. >> to the lung problems could actually be either or both what's in it to begin with and what's coming out of as the smoke or a combination of the two. is that correct. >> i really don't know the answer that. it's a reasonable guess they'll. >> we need to know all the answers, not just have them is that we are staying. >> yes. i appreciate that. >> thank you. thank you for your patience. thank you for your leadership area yesterday our governor, created an immediate ban on the selling of vaping products.

there are illnesses and the businesses are possible regulatory failure. what should the fda do immediately to support this. >> there are several things are federal partners who do. we could look at in massachusetts, went to tobaccoco 21. that would increase labor restrictions, decrease access. as well as understanding of what the content of these products, just like we dot with tobacco products. and testing the nicotine levels as well as allowing us to limit advertising and put warnings on the products as well is in stores. >> want to see if you can clarify, any of the witnesses here. looking at the commissioner his, that no ends product in united states is on the market legally.

for somebody who doesn't quite understand, it certainly seems like there is a legal market for these products is or not. >> i can't speak to that specifically. but 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 gum and the lozenges. >> do you think the public is aware that there are products that do not have actually fda approval that on the market. >> i think part of education has to be around what approved the cessation and is actually part of our temporaryry man in massachusetts. were doing after the round enhance education access. with the fda approved replacement products. >> do any of you have

suggestions of what the fda should have done. in retrospect. they should've been more active in the regulatory side. for businesses that are now shuttering, for patients who are sick, forced into a black market, there's no part of the solution that is good at the moment. had we make sure we avoid this in the next round of whatever that might be. >> >> it's important that we don't exactly know what the substance or devices that are causing these vaping illnesses but we do don't know it'sso kind of hard to say what you could've done to prevent it. but at same time i think of fraudulent marketing the fact that a lot of adults and youth think that these products are effective and they don't know what ik ey was in the products r they effective for smoking cessation is thehe problem. >> so i the fda allow these

products hit the market that went out knowing the consequences of these products. >> i think the we could've potentially a stronger regulations sooner. >> we have the problem with nicotine which we know is in there. and we have the problem what is in these substances with the vaping illness. we've known forever, nicotinee, is highly addictive. the lesson f learned, we should think about and be sure they are practically applying the approach when we are thinking about the product that has nicotine. >> about six years ago when i was a chief medical officer at kansas, i outlawed vaping our healthcare campus because we had a note tobacco policy. he got a certain of pushback for that because of the stem cell benefit for tobacco cessation. didn't believe it then and i

don't believe in now. i think looking in our rearview mirror, we would have benefited by having much tighter regulatory controls on the products may be, and the vaping solutions. we diluted ourselves early on to think that this would maybe be a flash in the pan. a fad that would pass. i nicotine doesn't act that way. it is to addictive. >> inc. you all. i yelled back. >> thank you. i would advise the panel that there are some of the numbers i would like to thanks questions. they're upstairs at the southern hearing. they can't get down.o on the committee rule, members do have ten additional business days to submit questions and i suspect several members including doctor ruby, who is the medical dr. and cares a lot about these issues they will want to thanks you questions in writing if you don't mind please respond to those because this is

an important public health issue and i so appreciate all of you coming today. your perspective from around the country, beingun on the ground d what we can do. it is really vital to our consideration. i hope you don't mind i decided to deputize all of you as our experts in assisting as we develop these policies. and with that, again, members will have ten additional days to thanks questions. i want to thank everybody and we probably will be having some more hearings. . . .