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.
17 comments
eciguser says:
Jan 18, 2013
You wrote;
“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.”
But what about the millions of people who have completely freed themselves from tobacco smoking using electronic cigarettes? I, like so many others, can provide you with a personal testimony that NRT Patches, Gum and Lozenges failed to keep me away from tobacco smoking, and that I haven’t smoked a cigarette in 14 months because I find electronic cigarettes to be sufficient for my needs.
Am I, and all these e-cig users to be simply ignored?
What you are claiming here is that simply becuase there is not “clinical studies” for electronic cigarettes as smoking cessation aids, then no one should consider it as an alternative to the extremely unhealthy activity of inhaling tobacco smoke.
The whole debate is far more complex. Please see the following links about the debate over the claim that “e-cigs should be avoided” because of the lack of “clinical tests”. Smokers have the right to know that millions of people have found electronic cigarettes to be a successful smoking cessation product. I myself am one of them.
http://forums.aussievapers.com/e-cigarette-vaporization-political-media-discussion/8997-individual-testimonies-evidence.html
http://tobaccoanalysis.blogspot.com.au/2013/01/when-you-dont-like-evidence-make-up.html
http://antithrlies.com/2013/01/15/is-stanton-glantz-unable-to-figure-out-light-switches/
http://antithrlies.com/2013/01/16/glantzs-tenuous-grasp-of-science-cont/
MN says:
Jan 18, 2013
State of Maine legislation also categorizes/regulates e-cigarettes as tobacco products and therefore an individual must be 18 to purchase. Additionally they are included in all of the same laws regarding smoking in public places, indoors, etc.
JustTheFacts says:
Jan 18, 2013
“Therefore, e-cigarettes may hinder young adult smokers from quitting smoking.” We could also say that e-cigarretes may assist young adults to quit smoking. A young man I know, who had begun smoking at 15, was arrested on false charges when he was 21. He spent a month in a local jail. When he was finally released, the first thing he wanted wasn’t a steak, or even a beer, it was a cigarette. His mother is my best friend, and she hated that he smoked. I bought him an e-cigarette kit for his 22nd birthday. He used it for a few months in place of smoking tobacco. He is now smoke-free, AND no longer uses an e-cigarette or any other form of nicotine.
My story is based on actual fact, yours on supposition. I guess the fact that nicotine can be used by adults in a responsible manner that does not harm bystanders really does bother public health. After all, it is all about your funding, isn’t it?
Lou says:
Jan 18, 2013
“Second, previous chemical analyses of the e-cigarette nicotine liquid found that some samples contain tobacco-specific cancer-causing agents and anti-freeze.” Studies have shown TRACE amounts of tobacco-specific cancer causing agents….equal to or lower than those found in accepted tobacco replacement therapies. Also the reference to anti-freeze is completely bogus, and makes me wonder if you analyzed the actual research or simply read the biased summaries, which fail to mention that the so-called anti-freeze is found in many many accepted products, and was formerly used in inhalers for asthmatics for many years. Just because a product is found in anti-freeze, doesn’t mean that it is harmful.
I am also curious who is funding this research. As a Minnesotan, and a former employee of the University of Minnesota I am extremely disappointed in the shoddy research this interview represents.
I have been cigarette free for 30 months after smoking for 30 years, and trying countless “proven” “accepted” quit smoking programs, therapies and methods. I had given up on trying to quit smoking when I decided to try one more thing….because it was a replacement for the BEHAVIOR of smoking, as well as providing a nicotine replacement. I recognize that I am still using nicotine, and that there are risks associated with it, but I am personal proof that using electronic cigarettes works to quit smoking….and I am NOT SMOKING. The Public Health system needs to seriously look at harm reduction as opposed to an abstinence only policy in promoting quit smoking methods. Please have a more open mind when looking at electronic cigarettes.
gotsteam? says:
Jan 18, 2013
Dr. Choi,
Although nicotine is an addictive substance, so is caffeine. If you ask serious coffee drinkers, you’ll find that they can’t go without their coffee. In small amounts, nicotine is no more dangerous than a can of soda or a cup of coffee. You should know that being a “PhD, MPH”. The question is, is nicotine a carcinogen or hazardous to one’s health? Answer, no and not really. These you should know too. I am not a doctor but I do know that nicotine and caffeine can elevate heart rates. Is that dangerous? Maybe to some but not to most.
Now apparently you haven’t spent much time in researching your answers because if you had, you would have learned that the “anti-freeze” was found in only ONE cartridge and in an extremely small amount. There is more (1)diethylene glycol in a traditional cigarette than what was found in the nicotine liquid tested.
The next fact you obviously need to be made aware of is that the amounts of actual TSNAs (carcinogens) that are detectable in nicotine liquid are TRACE amounts. In fact they are the same amounts or less than that found in nicotine PATCHES. Don’t believe me? (2)LOOK IT UP!
The FDA report on e-cigarette liquids has been invalidated numerous times now and has not been retracted and is also over 3 years old and outdated. Ill informed individuals, such as your self that recite old, outdated data without doing any real research for yourself do MORE harm to the general public by attempting to steer cigarette users away from a much more effective harm reduction method than large pharmaceutical companies can provide. When was the last time you read the warning label on a bottle of chantix or wellbutrin? This stuff CAN KILL YOU. HELLO! To date, no e-cigarette user has been hospitalized for e-cigarette vapor inhalation.
Also, to date, hundreds of thousands of former cigarette users have QUIT smoking traditional cigarettes using e-cigarettes. Now do you want to be responsible for their reverting back to traditional cigarette use because of the mis-information you are providing?
Please do your self a favor and do some research on this subject before you throw your letters around attached to e-cigarette hit pieces. E-cigarettes can SAVE Thousands and thousands and thousands of lives. Get behind a movement that can make tobacco cigarettes obsolete in our lifetimes. Imagine that Kelvin, because patches and gums and harmful mind altering drugs aren’t going to do it.
(1) http://www.tricountycessation.org/tobaccofacts/Cigarette-Ingredients.html
(2) http://www.palgrave-journals.com/jphp/journal/v32/n1/fig_tab/jphp201041t1.html
Luv2Vap says:
Jan 19, 2013
Did you even consider the difference between using an ecig and smoking a tobacco cigarettes? It’s about harm reduction not harm elimination. Nicotine is a very small part of the equation and most of the harm is related to the combustion of tobacco.
castello says:
Jan 19, 2013
Yes, it should be kept away from minors but for the rest of us it is way better than smoking!
Jay R says:
Jan 19, 2013
“proven-effective cessation treatments”
In clinical studies that have proven NRT effective, participants are generally cherry picked (too many ‘chippers”). and funded by the makers (and suporters) of pharmaceutical NRT.
However, even with the availability of governemt funded “Free” NRT, longitudinal population studies show tobacco use is stagnent. NO, NRT does _not_ work in the present population of those who smoke heavily.
Kristin says:
Jan 20, 2013
“…may use these products to sustain their nicotine addiction, and may therefore be less likely to quit smoking.”
This makes no sense. Since when is sustained nicotine addiction a certain precursor to smoking? Millions use smoke-free tobacco products and never smoke in their lives or permanently switch to nicotine gums, patches and lozenges and never smoke again. It’s illogical to believe that someone who finds a SATISFYING nicotine substitute for smoking will go back to smoking again. The short-term effectiveness of gums, patches and lozenges is obviously the result of two main factors: 1) in spite of the nicotine content, the products are not a SATISFYING replacement for the experience of smoking; and 2) the requirement to become nicotine abstinent after a short term is too much for most smokers to handle. Those two factors are absent with quality e-cigarettes, so they cannot be compared to the short-term quit rates.
What Mr. Choi really means is “unlikely to quit NICOTINE,” because hundreds of thousands of e-cigarette users are reportedly leaving smoking behind. Eventually, anti-nicotine zealots will not be able to ignore the huge number of former smokers attributing their success to e-cigarettes and the science already shows that sustained nicotine use is orders of magnitudes less hazardous to their health than continued smoking.
But being smoke-free for life while still addicted to nicotine is unacceptable to people like Mr. Choi, even though all of those 443,000 deaths attributed to “tobacco use” and “nicotine addiction” are really caused by SMOKE. They continue to force nicotine abstinence on former smokers or those who cannot or will not quit, even though they know that 93.5% of those who attempt nicotine abstinence are likely to start smoking again. So, smokers who use Mr. Choi’s “proven-effective cessation treatments” (with a very low 6.5% quit rate after 12 months) will keep smoking and quitting and smoking again (usually with more smoking than quitting,) rather than find a permanent, smoke-free alternative.
What is honestly worse, Mr. Choi? Life-long addiction to a low-risk nicotine product or continuing to smoke with occasional quit attempts using your “proven-effective cessation treatments” offer them?
Mike says:
Jan 21, 2013
“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. ”
In as much as nicotine and caffeine are both addictive chemicals, I don’t see anyone trying to ban tea and coffee. Secondly, if smokers were to find e-cigs an acceptable alternative to smoking, the nicotine dose is vital to satisfy the nicotine craving.
“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.”
One sample of a Chinese e-cig detected trace amounts of diethylene glycol. The same amounts of cancer causing TSNAs are also present in nicotine replacement therapy products such as patches and gums. Hardly surprising considering that the nicotine for these products is also extracted from tobacco. Proper regulation of local producers by way of the same rules that already apply to beverages and other foodstuffs is sufficient to make sure that e-liquid does not contain poisons.
“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.”
You must surely mean, less likely to quit nicotine? As an ex-smoker who switched to e-cigs over a year ago, I have no desire to damage my health by smoking, but I wish to continue to use nicotine as it has beneficial effects, just like coffee.
James says:
Jan 22, 2013
…if i hear the contains ‘anti-freeze’ scare quote one more time i’m going to explode… how about you (meaning Dr. Choi, readers, media, the world..) look on this url:
http://www.propylene-glycol.com/index.php/faq
i dont take anything at face value or on its own… but supposedly this is from : “The members of the Propylene Oxide / Propylene Glycol sector group represent the producers of propylene glycol within Cefic, the European Chemical Industry Association.” … in my research it is the same info i have found elsewhere but this is the best citation:
see quote:
“How can a de-icer be used in food or in cosmetics?
It is not the “de-icer” that is used; the different “natural” functionalities of propylene glycol make it the preferred substance in both applications. In the de-icer it is the ability to reduce the freezing point, in cosmetics the ability to dissolve, emulsify, or carry active ingredients in substances. In the de-icer industrial propylene glycol is used, in the cosmetic it is of course propylene glycol USP/EP (pharmaceutical grade). It is the multifunctionality of propylene glycol that offers this wide variety of uses.”
The correct way to state this would be that some anti-freeze contains pg (and industrial pg iPG specifically) NOT that pg (or by way of pg, e-liquid) contains anti-freeze….
a completely predictable misrepresentation of the situation, given the bias (i personally and many others feel) exists to represent e-cigs in a negative light. i’m VERY open to proper scientific study of this, i urge it, even though i am currently passionate about the net benefit of ecigs from my own past 4 years of experience with them, i AM open to possible negative information if it is real and presented in a proper objective balanced way (if such a thing exists any more)…
but tell anyone that anything has ‘antifreeze’ in it and it tends to have a potent effect – kind of like telling people the latest soda has rat dropping as a main ingredient…. but its so over the top (and i think used before) you’d think it would raise a red-flag that something is likely not being presented accurately – or is being hyped/spun here. sadly most in the public swallow the message delivered through easy to swallow “medical” articles or press releases then media soundbites…
in fact i fully expect you may not have looked into those quotes/claims as they are presented in a scientific ‘authoritative’ source – thus are seeded to drill themselves into the narrative, through more reinforcement such as this article .
(oh, and your comment that ecigs are shown to be able to deliver plenty of nicotine… i agree – but interesting how that goes against the other studies claiming that ecigs don’t deliver nicotine at all or practically none… and the current discussion / argument against ecigs that it is some sort of placebo effect – suggesting that nicotine isn’t properly delivered through the vapor)….
see: http://tobaccoanalysis.blogspot.ca/2013/01/when-you-dont-like-evidence-make-up.html
Jonny Carter says:
Jan 23, 2013
At present, the electronic cigarettes devices are not obligatory to have printed health caution nor are these governed by any federal laws. Conversely, these could become illegal for minors to buy if a bill passed in Arizona legislature is approved. Developing such kind of addictions in minor age is not a healthy habit. And selling to or buying these devices by a minor can be charged a huge fine.
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Jan 25, 2013
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eCig News Roundup 1-25 – It’s a Small World says:
Jan 26, 2013
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MECR says:
Jan 28, 2013
Frankly, he makes some very good points. He actually provides very balanced arguments and isn’t against e-cigarettes, per se, but suggests that education and some regulation is needed. Even as a person involved in the business, I agree with him. No product or service is ever perfect or purely good – everything has drawbacks, and people should educate themselves on the issues. However, I believe he would agree that electronic cigarettes have their niche in the marketplace, but that it isn’t the solution for everyone.
E-Cig Hub says:
Mar 17, 2013
I definitely would agree, minors should not be exposed to tobacco period. If adults choose to use an e-cigarette they should be able to exercise that option the same way they can use a normal cigarette.
Ms Rose says:
Jun 16, 2013
You are not so bright,1 you don’t ask ex smokers how they feel from quitting cigarettes after 35 years, no tobacco, no smoke,no smell just the nicotine and some have ZERO nicotine. Smokers that quit smoking start from 24 mg down to ZERO. THOSE ARE THE FACTS GET IT RIGHT. Actually your getting paid to lie and deceive and instill fear for either pharmaceutical companies or tobacco industry or environmentalist. You have no clue what your talking about none zip. E-cigs are the future.