Kelvin Choi, PhD, MPH, featured in the March 2013 issue of AJPH, focuses his research on tobacco marketing and tobacco control.

Kelvin Choi, PhD, MPH, is a research associate at the University of Minnesota Division of Epidemiology and Community Health. His research focuses on health risk behavior marketing and counter marketing with a particular interest in tobacco marketing and tobacco control. Choi and collaborator Jean Forster, PhD, MPH, have been researching adolescent and young adult tobacco use, including cigarettes and new tobacco products such as e-cigarettes and snus. They also investigate the need for and the effects of tobacco control policies. Featured in the March 2013 issue of the American Journal of Public Health, one of their latest studies analyzes the perceptions of electronic cigarettes among young adults. Public Health Newswire asked Choi about e-cigarettes and the results of their work.

Q: What are e-cigarettes and why are they considered unhealthy?
E-cigarettes, also known as electronic cigarettes or electronic nicotine delivery systems, are cigarette-shaped electronic devices that deliver nicotine vapor to the users. The structure of an e-cigarette consists of three parts: a battery, a vaporizer that vaporizes nicotine liquid through heat or agitation and a nicotine cartridge embedded in a mouthpiece. When users puff through the mouthpiece the negative pressure activates the vaporizer. The vaporizer then vaporizes the nicotine liquid contained in the nicotine cartridge and delivers a visual nicotine vapor to users.

There are a variety of reasons why e-cigarettes are unhealthy. First, they contain nicotine, which is a known addictive chemical. A recent study conducted by Vansickel and Eissenberg found that experienced e-cigarette users can obtain a significant amount of nicotine through e-cigarettes, which may be comparable to smoking cigarettes. Second, previous chemical analyses of the e-cigarette nicotine liquid found that some samples contain tobacco-specific cancer-causing agents and anti-freeze. Since the manufacturing and the ingredients of e-cigarettes and nicotine liquid are unregulated, we cannot be sure that e-cigarettes do not deliver toxic chemicals to users. Third, with the product being promoted as a cigarette alternative at places where smoking is not allowed, smokers may use these products to sustain their nicotine addiction, and may therefore be less likely to quit smoking

Q: As your research indicates, there are varying understandings of e-cigarettes and their uses. Many perceive them to be effective cessation tools and less harmful and addictive than cigarettes despite a lack of evidence to support these views. What perceptions of e-cigarettes do you think are of the greatest concern for the public?
Our research shows that many young adults in our sample perceived that e-cigarettes can help people quit smoking and are less harmful and less addictive than cigarettes. I think the perception of e-cigarettes as cessation aids is of the greatest concern. First, this perception may drive young adults to use e-cigarettes when trying to quit smoking instead of proven-effective cessation treatments. To date, no studies have shown that e-cigarettes are more effective than proven-effective cessation treatments such as nicotine replacement therapy and counseling. Therefore, e-cigarettes may hinder young adult smokers from quitting smoking.  Second, as many non-smokers also hold this belief, they may suggest for or even support their friends who smoke to use e-cigarettes to quit smoking. This, in turn, may reduce the use of proven-effective cessation treatments among young adult smokers, which is already very low at about 16 percent, according to 2010 National Health Interview Survey data.

Q: Your research focuses on young adult awareness and perceptions of e-cigarettes. What do you think forms young adults’ views of e-cigarettes? And what do you think is the greatest challenge to upend those perceptions and set the record straight on the risks associated with e-cigarettes?
What forms one’s view of an issue or product is a complicated question. I believe young adults form their views of e-cigarettes through the information, and misinformation, they receive through multiple channels, including peers, their community and the media. Young adults may also seek out information about e-cigarettes because of their curiosity.

One source I find to be important and also a challenge is the marketing and advertising of e-cigarettes. To date, e-cigarette marketing is not regulated. Advertisements for e-cigarettes appear on TV, magazines, the Internet and even in social media. Cigarette advertising has been known to have a strong influence on the perceptions and the use of cigarettes. Therefore, it is similarly possible that e-cigarette advertising is one of the sources of influence on young adults’ views about e-cigarettes.

The challenge is whether we should swiftly regulate e-cigarette advertising before the issue gets out of hand. The second challenge lies in developing a better understanding of the effective communication channels to reach specific populations and how to best use these channels. For example, we know that a lot of young adults use Facebook, but we do not know how to effectively use Facebook to communicate the correct information about e-cigarettes to young adults. I think we still have a lot to learn in that regard.

Q: A New York state law recently took effect that bans the sale of e-cigarettes to minors. What other states are working on similar legislation and what other next steps do you think are necessary to address e-cigarettes with public health in mind?
Protecting the minors from developing a nicotine addiction is very important. Therefore, I think it is essential to ban the sale of e-cigarettes to minors in all states. Minnesota, through its Tobacco Modernization and Compliance Act 2010, prohibited the sale of e-cigarettes to minors and Colorado has a similar policy. Public health advocates across the country should consider advocating for such policies in every state. Other important steps include expanding smoke-free legislation to include e-cigarettes and other tobacco products and promote use of proven-effective cessation treatments. Through these steps, we will be able to construct a supportive environment to help smokers quit smoking.

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