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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 59-63

Tobacco consumption patterns and coping behavior during the COVID-19 Lockdown


1 Department of Oral Medicine and Radiology, Faculty of Dental Sciences, Ramaiah University of Applied Sciences, Bengaluru, Karnataka, India
2 Department of Oral Medicine and Radiology, Swami Devi Dyal Hospital and Dental College, Panchkula, India

Date of Submission30-Nov-2020
Date of Decision05-Jan-2021
Date of Acceptance02-Feb-2021
Date of Web Publication29-Jun-2021

Correspondence Address:
S Sujatha
Department of Oral Medicine and Radiology, Faculty of Dental Sciences, Ramaiah University of Applied Sciences, New BEL Road, Bengaluru - 560 054, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhnps.jhnps_61_20

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  Abstract 


Background: During the COVID-19 pandemic, millions of Indians were self-quarantined generating exceptional challenges and stress for all people and more so among regular tobacco users. Tobacco use is known to be detrimental to lung and immune function, thus suppressing the body's ability to combat infections including the novel coronavirus, COVID-19. This study was intended at surveying the stress, tobacco consumption patterns, and the coping behavior during the COVID-19 pandemic. Methodology: Seven hundred and twenty-nine current tobacco users aged 18 years and above participated in the questionnaire study on stress due to COVID-19, tobacco consumption patterns during lockdown, years of tobacco use, prior quit attempts, thoughts of quitting currently, and means of purchasing and coping behavior. The data were subjected to statistical analysis. Results: The average Fagerström Test for Nicotine Dependence score was 6, and males had higher scores than females. 68.4% of tobacco users reported increased use, 5.07% decreased use, and 26.4% no change in tobacco use during the lockdown. Causes for increased tobacco use were stress (62.1%), being alone and restrictions in movement (21.6%), and boredom (16.3%), while the fear of contracting COVID infection and becoming severely ill has motivated few (31.6%) to decrease tobacco use. 50.9% wanted to quit, the thought of quitting tobacco was more among men (54%) as compared to women and was higher among smokers as compared to smokeless tobacco users. Conclusion: Tobacco users appear to be affected by stress related to the COVID-19 pandemic, with majority of them increasing the consumption.

Keywords: Coping behavior, COVID-19, lockdown, stress, tobacco use


How to cite this article:
Sujatha S, Shwetha V, Vaishnavi P, Sreekanth P, Nagi R. Tobacco consumption patterns and coping behavior during the COVID-19 Lockdown. J Head Neck Physicians Surg 2021;9:59-63

How to cite this URL:
Sujatha S, Shwetha V, Vaishnavi P, Sreekanth P, Nagi R. Tobacco consumption patterns and coping behavior during the COVID-19 Lockdown. J Head Neck Physicians Surg [serial online] 2021 [cited 2021 Dec 5];9:59-63. Available from: https://www.jhnps.org/text.asp?2021/9/1/59/319746




  Introduction Top


Tobacco kills more than 8 million people globally every year. Over 7 million of these deaths are from direct tobacco use, and about 1.2 million are due to nonsmokers being exposed to secondhand smoke. Tobacco is a recognized risk factor for several respiratory infections and increases the severity of respiratory diseases and is often linked with poor outcome. COVID-19 is mainly a disease of the respiratory tract that primarily attacks the lungs, and is characterized by a severe acute respiratory syndrome. Henceforth, the World Health Organization and the U.S. Food and Drug Administration have warned that smoking may increase the risk and severity of COVID-19.[1] Although everyone is susceptible to COVID-19, elderly people 60 years and above with weaker immune system, individuals with preexisting noncommunicable diseases, and individuals with adverse habits appear to be more vulnerable to becoming severely ill with the virus. Tobacco use impairs lung function and affects both innate and adaptive immunities and plays a dual role in regulating immunity by either exacerbation of pathogenic immune responses or attenuation of defensive immunity making it harder for the body to fight off coronaviruses and other diseases.[2],[3] Tobacco is also a major risk factor for noncommunicable diseases such as cardiovascular disease, cancer, respiratory disease, and diabetes making people susceptible for developing severe illness and poor outcomes when affected by COVID-19.[4]

Lockdown, quarantine, and outdoor restrictions were observed to contain and curb the transmission of the virus, however, essential outdoor activities such as going to a grocery store and pharmacy were permitted within regulated timings. In India, there was ban on the sales of alcohol but not tobacco and vaping products during the lockdown unlike in South Africa where it was totally banned.[5] The lockdown, one of the social isolation restrictions, is thought to be effective on human psychology and economy besides having impact on COVID-19. People are anxious about becoming ill with the virus, fear of losing jobs resulting in anxiety, stress, and depression, etc., leading to dramatic changes to daily living conditions. Negative changes in physical activity, sleep, and increased uptake of tobacco and alcohol are usually associated with depression and stress symptoms.[6] It is necessary to establish the extent to which changes in tobacco use patterns (new users, increased frequency, intensity of consumption, etc.) are taking place as a consequence of stress, or as an avoidance strategy or alternative to boredom during lockdown and the pandemic. There is no data on substance abuse disorders or studies assessing the possible increase in consumption as a consequence of lockdown in India. Current assessment of the impact on lifestyle changes associated with the pandemic is desirable. This study was intended at surveying the perceived stress levels, tobacco consumption trends, means of purchasing different tobacco products due to restricted product access, and thoughts about quitting tobacco fearing risk of developing COVID infection among the Bangalore population from an online survey during the COVID-19 lockdown.


  Methodology Top


Participants aged 18 years and above, English literate, and current tobacco users who used tobacco at least once a day were recruited from the dental hospital outpatient database of 2019 (September–December). Of 1012 eligible respondents contacted, 72% (n = 729) completed surveys. Participants consented and deemed eligible were asked to complete a 21-item questionnaire and were required to answer all questions before they could continue to the next page of the survey [Table 1]. The eligibility checks excluded respondents who made multiple entries from the same computer within a short period of time and discrepancy in data. A brief questionnaire was prepared which covered demographic data, education, employment status, perceived stress due to the pandemic, tobacco consumption patterns during lockdown, years of tobacco use, prior quit attempts (lifetime and past year), thoughts of quitting currently, and means of purchasing and coping behavior. The Fagerström Test for Nicotine Dependence (FTND) was used to assess the level of nicotine dependence. The study was approved by the Institutional Review Board. We informed participants that their answers would be anonymously stored on a computer file for statistical analyses and that they would not be transmitted to third parties. We did not request a formal consent for participation, consent was implicit.
Table 1: Characteristics of the study participants

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  Results Top


The sample of 729 current tobacco users had a mean age of 44.1 years (standard deviation [SD] = 14.4); 18.1% were women and 81.9% were men. 72.9% were smokers and 27% were smokeless tobacco (ST) users while 6.3% used e-cigarettes regularly [Table 1]. Respondents' tobacco use was an average of 14 cigarettes\ST sachets per day (SD = 9.2). The average FTND score was 6, and males had higher scores than females. 68.4% of tobacco users reported increased use, 5.07% decreased use, and 26.4% no change in tobacco use during the lockdown. Increased consumption was more among commercial ST users (75.2%) as compared to smokers, P = 0.160344, and was not statistically significant [Table 2]. The highest consumption was observed among cigarette users, P < 0.00001, and was statistically significant [Table 3]. Tobacco consumption was higher among females (73.4%) with P = 0.00473 as compared to males [Table 4]. The highest consumption was observed among individuals in the younger age group of 18–25 years and lowest among people 50 years and above, and was statistically significant, P < 0.00001 [Table 5]. Reasons for more tobacco use were increased stress (62.1%), being alone and restrictions in movement (21.6%), and boredom (16.3%), while the fear of contracting COVID infection and becoming severely ill has motivated few (31.6%) to decrease tobacco use. Further, 54.9% of current users reported being severely stressed as a result of COVID-19, 28.1% reported being somewhat stressed, and 17% reported no stress.
Table 2: Tobacco consumption pattern between the types of tobacco users (smoking and smokeless tobacco users)

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Table 3: Tobacco consumption pattern between the users of different tobacco products

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Table 4: Tobacco consumption pattern between the genders

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Table 5: Tobacco consumption pattern between the age groups

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50.9% wanted to quit, the thought of quitting tobacco was more among men (54%) as compared to women and was higher among smokers as compared to ST users. There was not much change in the way of purchasing the tobacco products during the pandemic. A multinomial logistic regression analysis revealed that there was a dose–response effect of stress: participants who were slightly stressed were likely to have marginally increased (odds ratio [OR] = 2.71; 95% confidence interval [CI]: 1.53–3.99) and those who were severely stressed had greatly increased (OR = 3.91; 95% CI: 1.80–9.99) their tobacco use [Table 6]. A small percentage reported decreased tobacco use due to stress and fear of COVID-19. Stress, therefore, seems to affect tobacco users to increase their consumption levels.
Table 6: Multinomial logistic regression for increased and reduced tobacco use. Adjusted for age, sex, education, and nicotine addiction

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  Discussion Top


COVID-19 has caused significant distress and misery to people around the world. The first COVID-19 case in India was identified in January end, and after a low phase, numbers are now rising exponentially. The nationwide lockdown to contain and curb the transmission of the virus and protect vulnerable citizens has caused not only physical but also psychological grief among people residing in India and worldwide. The fear of becoming ill with the virus and losing jobs in combination with lockdown regulations increased stress and provoked people to altercate health behavior modification, change in lifestyle, and disruption in diet which would impact the health of the populations during the pandemic.[7],[8],[9] During the lockdown, only essential goods were allowed on sale. Tobacco and other nicotine products were designated as nonessential goods and their sales were temporarily banned or restricted during lockdown making it challenging mostly for vulnerable populations (adolescents, females, and older adults). India has a substantial population of tobacco users, both smoking and ST, which could be a potential risk in community spread of COVID-19. The pandemic is predominantly problematic among individuals with comorbidities in the country, compounded by substance use problem among this susceptible group increasing the risk of developing complications from COVID-19 infection.

With liquor and tobacco not classified as essentials in India, costs of these products have shot up with several retailers vending them at black charging 5%–10% price premium over their price tag. Many tobacco users have been buying more cigarettes and other tobacco products than usual, triggered by fear that stores might run out of stock or the lockdown may be extended signifying stockpiling behavior.[10] Stress related to the COVID-19 pandemic appears to affect tobacco users in different ways, while some have increased their tobacco use, while few others have shown decrease in the use. In the present study, 68.4% of tobacco users reported increased consumption, 5.07% decreased use, and 26.4% no change in tobacco use status due to the COVID-19. A dose–response effect of stress was found, participants who were more severely stressed were more likely to have either increased tobacco consumption and vice versa. Remarkably, among e-cigarette users, no change was observed in rates of in-home vaping during the lockdown compared with pre-COVID-19 habits.[10] A US-based study during the pandemic found that among smokers who both smoked and vaped, 28% decreased while 30% increased their smoking; similarly, in a French study, it was found that 19% of smokers decreased and 27% increased their smoking. In Poland, 45.2% of smokers increased their smoking, 40% reported no change, and 14.8% were unsure if their smoking status had changed.[11],[12],[13] Consistent with other studies, in the present study, it was found that more current tobacco users reported having increased consumption rather than decreased due to COVID-19. There seems to be a double-edged relationship between COVID-19-related stress and tobacco use which seems to have affected tobacco users in different ways with increase in consumption among many users and decrease among other few. While stress, boredom, and restrictions in movement have stimulated tobacco use, the concern of contracting COVID-19 and becoming severely ill has motivated others to improve their health by reducing\quitting tobacco. A systematic review of Chinese studies found that the odds of a COVID-19 case becoming more severe and leading to death are greater among individuals with a history of tobacco use.[12],[14] Another possible explanation for decreased tobacco use could be due to fewer social activities like smoking with friends or at parties, and not because they are motivated to reduce or quit.

In the present study, increased consumption was observed more among younger individuals with ST habit (75.2%) as compared to smokers. Although the FTND scores were higher among men, it was not statistically significant, P = 0.123. The lower FTND scores among females may be due to their lower daily tobacco consumption compared to men. It was found that tobacco consumption had increased among women than men during the lockdown, perhaps because of stress and boredom. Differences based on gender have also been observed in other studies; it seems that women resort to tobacco use more frequently than men to regulate negative affect.[15] During the pandemic, smoking at home is increased in our study which could, in turn, increase secondhand smoke exposure for the nonsmoking members of the family and neighbors, especially residing in apartment complexes who share the same space.[16] Our study suggests that pandemic-related stress is associated with increasing tobacco consumption and stress generally makes quitting more difficult. Stress during adolescence has been identified as a risk factor for the initiation of tobacco use and is also considered as a mediator in the decision to start tobacco among nontobacco users.

In the present study, 50.9% of the respondents wanted to quit, the thought of quitting tobacco was more among men (54%) as compared to women and was higher among smokers as compared to ST users. Although women are more concerned about health and want to quit, many studies report they were significantly less likely to quit than men. Gender-related barriers to cessation include weight gain, level of dependency, sex hormones, and mood. Furthermore, the sensory aspects of tobacco use may have more of an effect on cessation treatment for women than for men.[17] There are apprehensions about the repercussions on mental health when people are forced to give up their addictions during the lockdown due to forced abstinence.[18] However, people should become aware that the lockdown ban provides a good opportunity to quit tobacco use. As the number of tobacco users and their level of dependency are expected to rise further with high levels of stress, this study highlights the importance of providing resources to help tobacco users quit, and\or assist them to cope with withdrawal symptoms. Furthermore, the mounting evidence that tobacco use is associated with severity of COVID-19 illness could provide a bigger drive for tobacco users to quit. Quitting would potentially help tackling not only tobacco-related chronic diseases but also the new infectious disease COVID-19. This leaves tobacco as one of the few modifiable risk factors, hence we need to prioritize tobacco cessation programs and adapt it to pandemic times. A multidisciplinary approach which includes, among others, psychologists, psychiatrists, and cessation therapists who provide psychological support and up-to-date information on the pandemic is necessary.


  Conclusion Top


Tobacco users appear to be affected by stress related to the COVID-19 pandemic, with majority of them increasing the consumption. Tobacco users been more vulnerable to infection and its associated complications, special attention should be paid to this group. Hence, there is a pressing need for providing cessation support services to adapt to current needs with emphasis on practical approaches to help people with addiction.

Acknowledgment

We would to thank all the undergraduate students who have helped in carrying out the survey.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclosure

This material has never been published and is not currently under evaluation in any other peer reviewed publication.

Ethical approval

The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.



 
  References Top

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World Health Organization. Tobacco Use and Covid-19. Bangalore, Karnataka; World Health Organization; 2020.  Back to cited text no. 1
    
2.
Qiu F, Liang CL, Liu H, Zeng YQ, Hou S, Huang S, et al. Impacts of cigarette smoking on immune responsiveness: Up and down or upside down? Oncotarget 2017;8:268-84.  Back to cited text no. 2
    
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Lang AE, Yakhkind A. Coronavirus disease 2019 and smoking: How and why we implemented a tobacco treatment campaign. Chest 2020;158:1770-6.  Back to cited text no. 3
    
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Emami A, Javanmardi F, Pirbonyeh N, Akbari A. Prevalence of underlying diseases in hospitalized patients with COVID-19: A systematic review and meta-analysis. Arch Acad Emerg Med 2020;8:e35.  Back to cited text no. 4
    
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Egbe CO, Ngobese SP. COVID-19 lockdown and the tobacco product ban in South Africa. Tob Induc Dis 2020;18:39.  Back to cited text no. 5
    
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Dubey S, Biswas P, Ghosh R, Chatterjee S, Dubey MJ, Chatterjee S, et al. Psychosocial impact of COVID-19. Diabetes Metab Syndr 2020;14:779-88.  Back to cited text no. 6
    
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Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet 2020;395:912-20.  Back to cited text no. 8
    
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Rehman U, Shahnawaz MG, Khan NH, Kharshiing KD, Khursheed M, Gupta K, et al. Depression, anxiety and stress among Indians in times of Covid 19 lockdown. Community Ment Health J 2020; 1,1 7.  Back to cited text no. 9
    
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Klemperer EM, West JC, Peasley-Miklus C, Villanti AC. Change in tobacco and electronic cigarette use and motivation to quit in response to COVID-19. Nicotine Tob Res 2020;22:1662-3.  Back to cited text no. 13
    
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Cai H. Sex difference and smoking predisposition in patients with COVID-19. Lancet Respir Med 2020;8:e20.  Back to cited text no. 15
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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