Public health challenges of electronic cigarettes in South Korea.

Abstract

Electronic cigarettes (e-cigarrettes) were recently introduced and advertised as a smoking cession device in South Korea. As the social norm to quit smoking has gained hold in the country, the number of e-cigarette users is growing rapidly. This phenomenon should be urgently considered, because of the lack of research that has been conducted to examine the safety of e-cigarettes and its efficacy as a smoking cessation aid. This paper raises several public health concerns on e-cigarettes in South Korea. Uncertain regulations of the government on e-cigarettes are contributing to an increase of e-cigarette users and allowing the e-cigarette industry to circumvent existing regulations. The aggressive marketing activity of this industry is also a core factor that is responsible for the rapid increase of e-cigarette use, in particular among the youth. Following the enforcement of tobacco control, some cigarette smokers may be encouraged to purchase e-cigarettes in order to circumvent the regulations, even though the dual use of e-cigarette and cigarette may be more harmful. Until there is clear evidence of the e-cigarette's safety, it is recommended that the industry's marketing and promotional activities be banned and closely monitored, and public campaigns be initiated to educate the public regarding e-cigarettes.

Full text

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INTRODUCTION
Tobacco use is a leading cause of preventable illness
and is responsible for more than 40000 deaths annually
in South Korea [1]. In the early 1980s, it was estimated
that 8 out of 10 Korean men smoked cigarettes [2].
Additionally, cigarettes were commonly viewed as
something to be enjoyed, similar to an individual’s
preference for a “favourite food,” rather than as a
harmful product. However, along with the rapid
economic growth during the 1990s, concerns about
tobacco use and its harmful effects on health have
become hugely widespread throughout the country. This
has resulted in a rapid decrease of the overall smoking
rate, as shown in Table 1 [2]. Notably, the introduction of
the “well-being” life trend in the early 2000s placed a
high priority on achieving and maintaining one’s health,
which accelerated anti-smoking and tobacco control
activities. Intensive efforts to reduce tobacco use have
also been conducted by the government and public
health professionals, leading to the implementation of
strong and effective tobacco control policies and
measures, such as tobacco tax increases, media
campaigns, and ratification of Framework Convention
on Tobacco Control [3]. As a result, the number of
smokers who want to quit has significantly increased;
according to the 2010 National Actual Smoking Survey,
approximately 60% of Korean current smokers indicated
a desire to quit smoking [4].
If these smokers were able to quit based purely on
their desire to do so, a rapid decrease in the smoking
prevalence in Korea would certainly be observed.
However, previous studies indicate that given the
behaviours or habits driven by nicotine addiction, many
smokers who wish to quit can easily relapse and
continue their smoking habit [5,6]. This is also true for
Korean smokers. Nearly 70% of smokers in South
Korea say they are still smoking, because smoking has
become their “habit” [4]. Once an individual initiates
smoking, nicotine is absorbed into the bloodstream
within 10 to 15 seconds, and flows immediately to the
brain, where nicotine works to produce a range of
gratifying effects [7]. Through this process, smokers
experience pleasure, cognitive enhancement, relaxation,
http://dx.doi.org/10.3961/jpmph.2011.44.6.235
pISSN 1975-8375
eISSN 2233-4521
Journal of Preventive Medicine and Public Health
Novemver 2011, Vol. 44, No. 6, 235-241
This article is available at http://jpmph.org/.
Public Health Challenges of Electronic Cigarettes
in South Korea
Sungkyu Lee1, Heejin Kimm2, Ji Eun Yun2, Sun Ha Jee2
1Center for Tobacco Control Research and Education, University of California, San Francisco, USA; 2Institute for Health Promotion &
Department of Epidemiology and Health Promotion, Graduate School of Public Health, Yonsei University, Seoul, Korea
Electronic cigarettes (e-cigarrettes) were recently introduced and advertised as a smoking cession device in South
Korea. As the social norm to quit smoking has gained hold in the country, the number of e-cigarette users is growing
rapidly. This phenomenon should be urgently considered, because of the lack of research that has been conducted to
examine the safety of e-cigarettes and its efficacy as a smoking cessation aid.
This paper raises several public health concerns on e-cigarettes in South Korea. Uncertain regulations of the
government on e-cigarettes are contributing to an increase of e-cigarette users and allowing the e-cigarette industry to
circumvent existing regulations. The aggressive marketing activity of this industry is also a core factor that is responsible
for the rapid increase of e-cigarette use, in particular among the youth. Following the enforcement of tobacco control,
some cigarette smokers may be encouraged to purchase e-cigarettes in order to circumvent the regulations, even though
the dual use of e-cigarette and cigarette may be more harmful.
Until there is clear evidence of the e-cigarette’ s safety, it is recommended that the industry’ s marketing and promotional
activities be banned and closely monitored, and public campaigns be initiated to educate the public regarding e-cigarettes.
Key words: Electronic cigarettes, Electronic nicotine delivery systems, Tobacco
J Prev Med Public Health 2011;44(6):235-241
S Sp pe ec ci ia al l A Ar rt ti ic cl le e
Corresponding author : Sun Ha Jee, PhD.
50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea.
Tel : +82-2-2228-1523, Fax: +82-2-365-5118, E-mail : jsunha@yuhs.ac
Received : 18 August 2011, Accepted : 17 September 2011
This is an Open Access article distributed under the terms of the Creative Commons
Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/)
which permits unrestricted non-commercial use, distribution, and reproduction in any
medium, provided the original work is properly cited.
cc

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and reduction in anxiety [10-12]. As an individual
continues to smoke, the amount of nicotine required to
experience these effects is increased, leading to an
increase in the number of cigarettes smoked in order to
achieve the desired effect, ultimately causing nicotine
addiction. For this reason, health professionals have
focused on counselling, education, and medicinal
nicotine replacement products (available as gum and
patches) in order to treat nicotine addiction and to
encourage cessation among smokers attempting to quit.
Recently, the electronic cigarette (Figure 1) (referred to
as e-cigarettes hereafter) was introduced and advertised
as an “incredible smoking cession device” in the South
Korean market. On advertisements, e-cigarettes are
described as “healthy cigarettes” [13]. Emphasis is also
placed on the lack of withdrawal symptoms that e-
cigarette users experience, thus making it attractive to
current smokers looking to quit [14]. Following the
context that quitting smoking may become the social
norm as more than half of current smokers want to quit
their smoking habit [4], and given that the products are
currently advertised as an effective smoking cession
device [15], it is not surprising that the amount of e-
cigarette imports is growing rapidly [16]. In addition, it
is assumed that youth and young people are more likely
to be targeted by the e-cigarette industry, and a rapid rise
in the number of youth e-cigarette users is also being
observed by mass media [16]. This phenomenon should
be urgently and intensively considered, because of the
lack of research that has been conducted to examine the
safety of e-cigarettes and its efficacy, if any, as a
smoking cessation aid.
Based on this background, this commentary paper
discusses the public health challenges of e-cigarettes in
South Korea and suggests a number of clear and important
recommendations for comprehensive control on e-
cigarettes.
E-CIGARETTES: BRIEF INTRODUCTION
AND CONTROVERSIAL ISSUES
In recent years, e-cigarettes have been introduced to
the global market. This device was invented by Ruyan
Group (Holdings) Limited, China in 2003, and the
company patented e-cigarettes in Canada in 2004 [17].
E-cigarettes look like real cigarettes, but do not burn and
combust tobacco leaves; thus, the e-cigarette
manufacturers and distributors insist that it is safer than
other tobacco products. The device consists of a plastic
tube, an electronic heating element, a liquid nicotine
cartridge, a lithium battery, and atomization chamber
with a membrane to suspend ingredients [18]. It also has
an LED-generated red light to simulate the burning end
236 Sungkyu Lee et al.
J Prev Med Public Health 2011;44(5):235-241
Table 1. Smoking prevalence of Korea’s adult over 20 years old, 1980-2008 (%)
Gender Age (y) 1980 1985 1990 1992 1994 1996 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Male
Female
20 - 29
30 - 39
40 - 49
50 - 59
60 +
Adjusted rate
20 - 29
30 - 39
40 - 49
50 - 59
60 +
Adjusted rate
76.5
78.4
81.6
83.3
79.5
79.3
1.4
2.7
9.2
28.4
47.2
12.6
71.6
74.0
71.2
69.2
66.3
71.2
1.3
1.6
4.1
16.4
32.5
8.0
77.7
79.1
72.9
73.2
68.9
75.3
1.5
1.4
3.3
11.3
29.5
7.7
82.1
75.4
73.1
62.7
72.0
75.1
3.8
3.9
3.7
6.0
12.1
5.1
76.9
76.1
73.4
70.9
51.4
72.9
3.3
0.7
0.8
8.2
7.1
3.5
79.2
77.5
60.0
55.8
54.2
69.8
7.2
5.2
1.8
2.8
10.4
5.3
70.5
71.3
65.2
51.9
44.4
64.9
4.8
3.2
2.8
4.8
10.4
4.4
67.3
71.3
67.8
64.1
55.6
67.6
5.7
2.0
1.1
2.4
0.0
3.0
77.3
78.6
69.5
62.1
43.7
69.9
5.3
2.1
2.6
1.7
3.4
3.1
71.1
66.5
60.8
44.8
42.2
60.5
8.1
2.6
3.1
7.6
10.5
6.0
66.2
61.4
55.7
47.7
41.5
56.7
4.5
0.8
4.5
4.1
4.5
3.5
66.1
61.1
58.3
50.0
45.3
57.8
5.0
1.9
2.5
3.7
7.6
4.0
59.4
57.2
50.4
43.7
31.1
50.3
4.9
1.9
3.0
1.0
4.3
3.1
50.8
51.0
44.4
39.1
27.1
44.1
3.5
1.2
2.3
2.3
2.7
2.3
44.3
54.9
43.7
36.4
21.7
42.0
5.4
3.6
5.4
2.8
5.6
4.6
43.1
52.1
42.5
32.5
23.8
40.4
4.8
2.3
4.0
2.8
4.6
3.7
Korean Association of Smoking and Health. Actual smoking rate among adults over 19 years old in South Korea [8].
Figure 1. E-cigarette component diagram.

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Public Health Challenges of Electronic Cigarettes 237
J Prev Med Public Health 2011;44(6):235-241
of a cigarette. Because of the lack of combustion
involved in an e-cigarette, the device does not deliver tar
or chemical elements that are present in regular
cigarettes that are known to cause and increase the risk
of developing cardiovascular and pulmonary diseases.
Instead, there is a replaceable cartridge containing
nicotine (with the ability of the user to adjust the nicotine
concentration), chemical additives, and flavours (e.g.
chocolate, coffee, mint, fruits). As the user exhales, some
visible vapour is released, but no tobacco smoke. With
these features, the e-cigarette industry insists that the
device is safe, can be used in non-smoking areas, and is
free from second-hand smoke concerns.
Are e-cigarettes truly safe? Can they be used as a
smoking cessation aid as the industry advertises? There
is a lack of scientific evidence offering clear answers to
these questions. There are a few short-term studies that
have investigated e-cigarettes [19,20], but the evidence
is not sufficient to conclusively end the controversial
debates on the safety of e-cigarettes. Despite the lack of
scientific evidence to confirm the e-cigarette industry’ s
claims of safety, e-cigarettes are being sold and
distributed throughout South Korea and worldwide. The
World Health Organisation (WHO) and the US Food
and Drug Administration (US FDA) have warned
against the widespread use of e-cigarettes as a nicotine
replacement product. Both bodies have recognised that
e-cigarettes may be less harmful than tobacco smoking,
given the lack of tar in e-cigarettes, but they emphasise
that e-cigarettes are almost certainly more dangerous
than medicinal nicotine replacement products [19,20].
The WHO defines that the e-cigarette as an electronic
nicotine delivery system (ENDS). The Organisation not
only recommends that ENDS be treated differently from
traditional tobacco products, but also recommends that
until conclusive evidence shows that e-cigarettes are
safe, they should not be marketed as a nicotine
replacement product, and that marketing activities of the
e-cigarette manufacturers and distributors must be
strictly controlled [19].
The US FDA has attempted to treat e-cigarettes as a
drug-delivery device under the Food, Drug, and
Cosmetic Act since January 2010. As a result, e-cigarette
manufacturers were required to submit an application for
evaluation and approval of their device before they could
be marketed to the public. This decision was based on
US FDA’s research showing that e-cigarettes contained
carcinogens, including nitrosamines, toxic chemicals,
such as diethylene glycol, and tobacco-specific
components suspected of being harmful to humans, such
as anabasine, myosmine, and beta-nicotyrine [20].
However, the US Court of Appeals ruled that the FDA
lacked the authority to regulate e-cigarettes as drugs or
devices on 6th December 2010. In response, the FDA
announced that e-cigarettes would be regulated as a
tobacco product [21]. Meanwhile, given the lack of
evidence regarding e-cigarettes’ safety or efficacy as a
smoking cessation aid, Australia, Canada, Singapore,
and Brazil have banned the sale of e-cigarettes [19].
There is some research to support that e-cigarettes are
effective in reducing the desire to smoke; however, this
research was funded by Ruyan Group (Holdings)
Limited. In this study, 40 participants were randomised
to use e-cigarettes containing 16 mg nicotine, placebo e-
cigarettes, or medicinal nicotine inhalators for four days.
The results indicated that there was no difference in
reducing desire to smoke between a 16 mg e-cigarette
and an inhalator, which can be interpreted to mean that
e-cigarettes probably work similarly to medicinal
nicotine replacement inhalators. In addition, the 16 mg
e-cigarettes were found to be more pleasant to use than a
nicotine inhalator [22]. Not surprisingly, these findings
support the e-cigarette industry in advertising their
device as a smoking cessation aid.
Although a few studies are available, given the
absence of evaluation of e-cigarettes for longer-term
safety, potential effects of long-term use and efficacy as
a smoking cessation aid, uncertainty on e-cigarettes still
remain. As such, more careful and comprehensive
control polices and measures on e-cigarettes are
urgently needed to prevent unexpected public health
impacts.
PUBLIC HEAL TH CONCERNS OF E-
CIGARETTES IN SOUTH KOREA
I. Uncertainty in the Regulations
E-cigarettes have been imported to South Korea since
2007, and the total volume of imports have rapidly
increased to more than three times in mid-2011,
compared to 2008 [15]. Following the recent upward
trend of e-cigarette sales, the Korean government
urgently considered how to regulate the new device and
the decision was made to place e-cigarettes under the
jurisdiction of two separate government bodies. On the
one hand, e-cigarettes which contain nicotine have been
registered by the Ministry of Finance (MOF) as same as
a cigarette product since 2010. The MOF has revised the
Tobacco Business Act (enacted in 1989), added e-

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cigarettes as a type of cigarette, and also levied health
promotion tax on e-cigarettes. However, e-cigarettes
containing no nicotine were placed under the jurisdiction
of the Korea Food and Drug Administration (KFDA) as
a health supplement, and were named “electronic
smoking desire reducers.”
Up until 2002, the MOF ran the domestic mono-polised
tobacco company, Korea Tobacco and Ginseng Corporation,
and still maintains a good relationship with the tobacco
industry to this present day. In 1989, the Tobacco Business
Act was legislated and enacted to foster tobacco business,
which gave the MOF the opportunity to encourage tobacco
business, due to the tax revenue. Because of this relationship
and potential conflict of interest, e-cigarette surveillance via
the MOF and the Tobacco Business Act may not be the
most reliable or effective.
Meanwhile, the KFDA authorised the sales of e-
cigarettes containing no nicotine as an “electronic
smoking desire reducer.” Although the KFDA officially
stated that the safety of e-cigarettes and its efficacy as a
smoking cessation aid have not yet been scientifically
proven, the e-cigarette industry currently advertises their
products with a message claiming that “E-cigarettes are
authorised by the KFDA, thus it is safe” [23]. In fact, the
KFDA’s authorisation of the sales of e-cigarettes is
misleading to the public and has potential threats to
public health.
Uncertain regulations and policies of the Korean
government on e-cigarettes are contributing to an
increase of e-cigarette users in the country and also
allow the e-cigarette manufacturers and distributors to
circumvent existing regulations.
II. E-cigarette Use Among Youths
At present, no research studies have been conducted to
examine the actual e-cigarette prevalence in South
Korea, but it has already been widely assumed by the
media that the number of e-cigarette users is rapidly
increasing, particularly among youth. One such report
indicates that 20% of the total e-cigarette sales in South
Korea are contributed by youth users [16]. In addition,
the report describes youth e-cigarette users often
enjoying the device in the classroom and during class
time, and that youth users will frequently exchange
cartridges with other youth users in order to experience
and enjoy the different flavours of e-cigarettes [16]. In
the beginning of e-cigarette sales in Korea, expensive
price of the device (about US$ 200-300) took a role as a
barrier to youth access, however, following the
competitive market environment, the industry has
introduced a cheaper price range device (US$ 100-150)
to the market. Thus, price itself can no longer be relied
on as a barrier to youth access.
Evidence in the literature indicates that the most
important factors for youth smoking initiation are having
friends who smoke and being exposed to smoking offers
from close friends [24-26]. Because of the increasing
popularity of e-cigarettes among Korean youth, non-
smoking youth who have friends who use e-cigarettes
are likely to be susceptible to initiate smoking e-
cigarettes. In addition, the e-cigarette packaging may be
attractive and fashionable to youth, who may be further
tempted to try it. Compared to adult users who may
decide to use e-cigarettes for the purpose of quitting,
youth users are more likely to use e-cigarettes for the
novelty factor. Of particular concern is the ability of the
e-cigarette user to adjust the nicotine concentration, as
youth users may not be aware that they can experience
symptoms of nicotine addiction much more rapidly than
adults [27,28]. Therefore, it is important to understand
youth users’behaviours with e-cigarettes, and the
impact of e-cigarettes of e-cigarette on youth should be
carefully and quickly considered by policy makers and
public health experts.
III. Aggressive Marketing Activities
The aggressive marketing activity of e-cigarette
manufacturers and distributors is one of the core factors
that may be responsible for the rapid increase of e-
cigarette use in South Korea. The WHO and US FDA
have already addressed their concerns about the
aggressive marketing activities of e-cigarette companies
in their reports. Until conclusive scientific evidence of
safety and efficacy of e-cigarettes is released, all
marketing activities of the e-cigarette industry should be
banned [19,20]. Despite the viewpoints of the WHO and
US FDA, the industry is quick to advertise that e-
cigarettes can be an effective smoking cessation aid by
employing “above-the-line” and “below-the-line”
marketing tactics in South Korea. As previously
mentioned, given that e-cigarettes with nicotine are
regulated in the same way as a cigarette by the Tobacco
Business Act in South Korea, the e-cigarette industry’s
marketing activities should be limited as follows: (1) E-
cigarette promotions, such as free samples or the
displaying of posters, stickers, and signboards promoting
e-cigarettes, should only be available in e-cigarette retail
shops; (2) advertisements should only be permitted at
point-of-sale locations; (3) any kind of e-cigarette
advertising using broadcast media, such as TV and
238 Sungkyu Lee et al.
J Prev Med Public Health 2011;44(5):235-241

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Public Health Challenges of Electronic Cigarettes 239
J Prev Med Public Health 2011;44(6):235-241
radio, should be prohibited, but placement of 120
advertisements per e-cigarette brand family in
magazines, except magazines specifically targeted to
women or youth, would still be possible under the
Tobacco Business Act; and (4) sponsorship of social,
cultural, musical, athletic, and other specific events,
except events targeted to women or youth, would still be
possible for the e-cigarette industry.
The most common and powerful marketing tactics of
the e-cigarette industry include the use of internet
websites and blogs to sell and promote their products.
Importantly, internet blogs allow the industry to achieve
two-way communication between themselves and
existing/future consumers. These strategies of e-
cigarette companies can be seen to be contributing to the
rapid increase of e-cigarette use in South Korea. Internet
blogs are a familiar, easily accessible, and unrestricted
media for youth to learn about what e-cigarettes are,
where to buy cheaper e-cigarettes, and how to buy e-
cigarettes without national ID cards. In addition, the use
of the internet to locate information is commonplace; for
example, a simple internet search within NAVER, the
nation’s largest internet portal site, with the keyword
searching term, “electronic cigarette” indentified almost
850 legitimate retail websites (accessed at 18th July
2011), in which the majority of the websites were run by
e-cigarette manufacturers, distributors, and local
retailers. The same keyword search on NAVER’s blog
search engine identified 40 422 blog sites (access at 18th
July 2011). To date, no investigation has been conducted
to examine whether these seemingly independent
internet websites and blogs are being used by the e-
cigarette industry as one of their aggressive marketing
tactics. It should also be noted that all of the information
in the e-cigarette internet websites and blogs are open
and accessible to youth under the age of 18.
IV. Dual Use of Cigarettes and E-cigarettes:
Undermining Tobacco Control Policies and
Regulations
Dual use of e-cigarettes and traditional cigarettes
should be examined, as smokers who do not wish to quit
can easily use an e-cigarette as an alternative in non-
smoking areas. Recently, through the nationwide
enforcement of tobacco control policies and regulations
in South Korea, areas designated as non-smoking are
expanding. In Seoul, the capital city of South Korea,
some major squares (public outdoor places) are
designated as non-smoking areas. As trends are
beginning to indicate that smoking is increasingly
becoming socially unacceptable in South Korea, it is
anticipated that the next step in expanding non-smoking
areas would include prohibiting smoking in every indoor
places, including restaurants and bars. Given the
restrictions on public smoking, some cigarette smokers
may be encouraged to purchase e-cigarettes in order to
circumvent the tobacco control regulations, as the e-
cigarette industry encourages dual use by advertising
that the public use of e-cigarettes is not restricted and is
therefore legal to use in restaurants, bars, and other
indoor areas where cigarette smoking is strictly
prohibited.
V. Recommendations
Further research investigating the effects of e-
cigarettes must be conducted in order to conclusively
determine the safety of this product. In addition, these
studies should be conducted independently and should
not be sponsored or funded by the e-cigarette industry.
Descriptive studies to investigate the current prevalence
of e-cigarette use among adults and youths and to
explore current e-cigarette users’ behaviours and
attitudes should be performed. In order to determine the
safety of long-term use and efficacy as a smoking
cessation aid, longitudinal cohort studies should also be
conducted. E-cigarette initiation among non-smokers
and their behaviour changes are an important topic to be
examined. In addition, the industry’s retail websites and
internet blogs which include e-cigarette information
should be also examined and regulated in terms of what
health messages they provide and how this information
affects potential users.
Until there is clear evidence of the e-cigarette’s safety,
it is recommended that the industry’s marketing and
promotional activities be banned, in agreement with the
recommendations of the WHO and the US FDA.
However, a complete banning and regulation of these
activities may take a long length of time to enact; as
such, restrictions, particularly on youth access and
youth-centred marketing of e-cigarettes, should be in
place until such a ban can be put into effect. With no
restrictions in place concerning the e-cigarette industry’s
marketing activities, the prevalence of e-cigarette users
continues to rapidly grow in South Korea. This is cause
for concern, as the e-cigarette industry may employ
tactics used by transnational tobacco companies in order
to exert influence on government policies and for
legislation and regulations to be largely made in their
favour [29,30]. It is possible that the e-cigarette industry