IRP Research Investigates Tobacco-Related Health Disparities

Dr. Kelvin Choi Studies Commercial Tobacco Use in Underserved Communities

Monday, November 15, 2021

no smoking sign in a city

Research led by IRP senior investigator Kelvin Choi is uncovering the reasons why certain groups of Americans smoke more than others, as well as the consequences of those disparities and potential policy solutions.

Each year, millions of smokers in the U.S. attempt to kick the habit. Many begin their journey towards a healthier life with the annual Great American Smokeout, which falls on the third Thursday of November — November 18 this year — and marks a day when all Americans who use commercial tobacco products like cigarettes are encouraged to stop.

While smoking rates in the U.S. have dropped from a hefty 42 percent of the population in 1965 to 14 percent in 2019, it remains the main cause of preventable death globally. In the U.S., 34 million adults still smoke cigarettes, and young people are being lured in by flavored e-cigarettes, which also pose health risks and can lead to smoking cigarettes. These tobacco-related behaviors are also unevenly distributed across the population, meaning some populations suffer the consequences of smoking disproportionately compared with others. IRP senior investigator Kelvin Choi, Ph.D., is working to understand why some groups are more likely to smoke, the effects of continued smoking, and the reciprocal interplay between those factors and health.

Dr. Choi grew up in Hong Kong surrounded by many friends and family members who smoked. In graduate school, he learned about the tobacco industry’s long history of covering up risk-related information and targeting disadvantaged and vulnerable populations, like the one he grew up in. This propelled him toward a career in tobacco control.

“It just made me feel very angry that companies were knowingly selling a product that harmed my friends and family,” he explains. “That’s what pulled me toward studying the impact of tobacco use and marketing.”

The populations in which smoking is more common nowadays tend to be racial and ethnic minorities, those with less education and lower incomes, and members of the military, as well as people with behavioral health issues. Dr. Choi’s studies have shown that many factors, including personal experiences and industry activities, combine to increase the likelihood that people in these groups will use commercial tobacco products.


Dr. Choi’s research has shown that children who grow up in a household with smokers perform worse in school, potentially increasing their own risk for picking up the habit in the future.

Those influences begin at an early age. In a study published last year, Dr. Choi’s IRP team and his collaborators used data from the Population Assessment of Tobacco and Health Study to show that exposure to secondhand smoke can negatively impact children’s performance in school.1 Since less education and lower income are associated with a greater likelihood of both smoking and being exposed to secondhand smoke, these academic struggles might create a troubling intergenerational cycle in which the children of smokers are more likely to pick up the habit themselves, which could then impair their own children’s academic performance and social mobility, making them more likely to smoke as well. Interestingly, this relationship might be partially explained by sleep problems experienced by the children of smokers, since Dr. Choi and his collaborators have found that kids who live with a smoker are more likely than those who do not to suffer from sleep deprivation.2

“The effect of tobacco smoke exposure on sleep is a good place to start to understand these interactions because if you don’t sleep well, it is hard to do well in school,” Dr. Choi explains. “That could limit your educational aspirations or chances of going to college, which can affect the type of job and income you might have down the road.”

Knowing the specific factors that connect so-called ‘social determinants of health’ — things like income, housing, education, and access to food and exercise — to commercial tobacco use is key to figuring out how to break the cycle. One important target is the tobacco industry’s marketing tactics.

Tobacco companies have a long history of targeting their marketing at racial and ethnic minorities and traditionally underserved communities both in the U.S. and around the world. In one commonly used method, the companies send coupons for discounts on their products to potential or active smokers in these communities via mail or email. By making cigarettes more affordable for low-income individuals, this kind of marketing directly counters policy attempts to curb smoking through higher taxes on commercial tobacco products.3,4

“We’re doing research to better the health of the U.S. population, and some of the work we’ve done has already been translated into action,” Dr. Choi says. “For example, our studies of direct mail coupons and pricing for cigarettes showed evidence that these marketing strategies do influence cigarette smoking behavior. That’s contrary to what the tobacco industry claims.”

Dr. Kelvin Choi

Dr. Kelvin Choi

Dr. Choi’s IRP team and his colleagues on in the field have provided crucial support for policies prohibiting the marketing of tobacco with discount coupons. For example, bans were passed in Providence, Rhode Island, in 2012, and then New York City in 2013. Both municipalities were sued, and both eventually won in court. More recently, in 2020, New Jersey and New York adopted similar prohibitions statewide without any legal opposition.

These successes have come despite significant obstacles to research like Dr. Choi’s. One particularly important challenge in his field is that many surveys of smoking rates and the effects of smoking do not include enough individuals from racial and ethnic minority communities. Improving the way researchers recruit survey-takers from smaller populations that are underrepresented in tobacco-related research and designing outreach and recruitment strategies that build trust and resonate with these groups are critical to creating a foundation of data that is more representative of the actual U.S. population.

“Sending someone from the government to knock on people’s doors to do surveys may not work for everyone,” says Dr. Choi. “Engaging with groups that the community trusts and working with the community to devise ways to increase participation in surveys is important if we want to get better data and a better understanding of health disparities.”

Important elements for building this trust include taking a culturally sensitive approach, explaining the research and how it will be used, and sharing the results with the community. That is why Dr. Choi makes an effort to go out and speak about his research with different communities himself.

“It takes time away from doing research,” he says, “but I understand that if I publish a study in a journal and put it on a shelf, the people who participated in the study and the general public might never know what we learned and how it helps them.”

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[1] Secondhand smoke exposure and subsequent academic performance among U.S. youth. Choi K, Chen-Sankey JC, Merianos AL, McGruder C, Yerger V. Am J Prev Med. 2020; 58(6):776-782. doi: 10.1016/j.amepre.2019.12.020.

[2] Tobacco smoke exposure and inadequate sleep among U.S. school-aged children. Merianos AL, Mahabee-Gittens EM, Choi K. Sleep Med. 2021 Oct;86:99-105. doi: 10.1016/j.sleep.2021.08.012.

[3] Receipt of tobacco direct mail/email discount coupons and trajectories of cigarette smoking behaviors in a nationally representative longitudinal cohort of U.S. adults. Choi K, Chen JC, Tan ASL, Soneji S, Moran MB. Tob Control. 2018 Jun 19;tobaccocontrol-2018-054363. doi: 10.1136/tobaccocontrol-2018-054363.

[4] Changes in cigarette expenditure minimizing strategies before and after a cigarette tax increase. Choi K, Boyle RG. Tob Control. 2018 Jan;27(1):99-104. doi: 10.1136/tobaccocontrol-2016-053415.

Category: Science