Factors associated with increased cigarette consumption in the Brazilian population during the COVID-19 pandemic

Deborah Carvalho Malta Crizian Saar Gomes Paulo Roberto Borges de Souza Júnior Celia Landmann Szwarcwald Marilisa Berti de Azevedo Barros Ísis Eloah Machado Dalia Elena Romero Margareth Guimarães Lima Alanna Gomes da Silva Elton Junio Sady Prates Laís Santos de Magalhães Cardoso Giseli Nogueira Damacena André Oliveira Werneck Danilo Rodrigues Pereira da Silva Luiz Otávio Azevedo About the authors

Abstracts

Medidas de distanciamento social adotadas em diversos países para mitigar o impacto da pandemia de COVID-19 podem acarretar efeitos indesejáveis sobre a saúde e o comportamento das populações. Este estudo objetivou investigar o comportamento de fumar na população adulta brasileira durante a pandemia de COVID-19 e analisar os fatores associados ao aumento do consumo de cigarro. Foi realizado um inquérito virtual e a amostra final correspondeu a 45.160 indivíduos. Foram utilizados pesos de pós-estratificação e calculadas as razões de prevalência (RP) brutas e ajustadas por sexo, idade e escolaridade, e os respectivos intervalos de 95% de confiança (IC95%). Modelos de regressão de Poisson com variância robusta foram aplicados para a análise de associação entre o aumento do consumo de cigarros e as variáveis sociodemográficas e as relativas à adesão ao distanciamento social, qualidade do sono, estado de ânimo, alteração no trabalho e nos rendimentos. A prevalência de fumantes foi de 12% (IC95%: 11,1-12,9), dos quais 34% relataram aumento no consumo de cigarros. Esse aumento foi maior entre as mulheres (RP = 1,27; IC95%: 1,01-1,59) e entre indivíduos com o Ensino Médio incompleto (RP = 1,35; IC95%: 1,02-1,79). O aumento do consumo de cigarros esteve associado à piora da qualidade do sono, sentir-se isolado dos familiares, triste ou deprimido, ansioso, ficar sem rendimentos e pior avaliação do estado de saúde. Estratégias de promoção da saúde, de prevenção do uso e de incentivo à cessação do consumo de cigarros, bem como intervenções em saúde mental, devem ser continuadas e reforçadas no contexto de distanciamento social durante a pandemia de COVID-19.

Palavras-chave:
COVID-19; Quarentena; Comportamento de Risco; Tabagismo; Fatores de Risco


Las medidas de distanciamiento social adoptadas en diversos países para mitigar el impacto de la pandemia de COVID-19 pueden acarrear efectos indeseables sobre la salud y el comportamiento de las poblaciones. Este estudio tuvo como objetivo investigar el comportamiento de fumar en la población adulta brasileña, durante la pandemia de COVID-19, y analizar los factores asociados al aumento del consumo de tabaco. Se realizó una encuesta virtual y la muestra final correspondió a 45.160 individuos. Se utilizaron pesos de pos-estratificación y se calcularon las razones de prevalencia (RP) brutas y ajustadas por sexo, edad y escolaridad, así como los respectivos intervalos de 95% de confianza (IC95%). Se aplicaron modelos de regresión de Poisson con variancia robusta para el análisis de asociación entre el aumento del consumo de tabaco y las variables sociodemográficas, así como las relativas a la adhesión al distanciamiento social, calidad del sueño, estado de ánimo, cambios en el trabajo e ingresos. La prevalencia de fumadores fue de un 12% (IC95%: 11,1-12,9), de los cuales un 34% relataron un aumento en el consumo de cigarrillos. Este aumento fue mayor entre las mujeres (RP = 1,27; IC95%: 1,01-1,59) y entre individuos con la enseñanza media incompleta (RP = 1,35; IC95%: 1,02-1,79). El aumento del consumo de tabaco estuvo asociado con un empeoramiento de la calidad del sueño, sentirse aislado de los familiares, triste o deprimido, ansioso, quedarse sin ingresos, al igual que con una peor evaluación del estado de salud. Las estrategias de promoción de salud, prevención del consumo y de alicientes para dejar el hábito de fumar, así como intervenciones en salud mental, deben ser continuas y estar reforzadas en el contexto de distanciamiento social durante la pandemia de COVID-19.

Palabras-clave:
COVID-19; Cuarentena; Conductas de Riesgo para la Salud; Tabaquismo; Factores de Riesgo


Social distancing measures adopted in various countries to mitigate the impact of the COVID-19 pandemic can lead to unwanted effects on their populations’ health and behaviors. This study aimed to investigate smoking behavior in the Brazilian adult population during the COVID-19 pandemic and analyze factors associated with the increase in cigarette consumption. An online survey was performed, and the final sample included 45,160 individuals. The study used post-stratification weights and calculated crude prevalence ratios (PR) and adjusted by sex, age, and schooling, and respective 95% confidence intervals (95%CI). Poisson regression models with robust variance were applied to analyze associations between increased cigarette consumption and sociodemographic variables and adherence to social distancing, quality of sleep, state of mind, and changes in work and earnings. Prevalence of smokers was 12% (95%CI: 11.1-12.9), 34% of whom reported an increase in cigarette consumption. The increase was greater among women (PR = 1.27; 95%CI: 1.01-1.59) and individuals with incomplete secondary schooling (PR = 1.35; 95%CI: 1.02-1.79). The increase in cigarette consumption was associated with worse quality of sleep, feeling isolated from family members or sad, depressed, or anxious, loss of earnings, and worse self-rated health. Health promotion strategies, smoking prevention, and encouragement for smoking cessation, as well as mental health interventions, should be continued and reinforced in the context of social distancing during the COVID-19 pandemic.

Keywords:
COVID-19; Quarentine; Health Risk Behaviors; Tobacco Use Disorders; Risk Factores


Introduction

The COVID-19 pandemic, caused by the novel coronavirus (SARS-CoV-2) and declared by the World Health Organization (WHO) on March 11, 2020 11. World Health Organization. WHO Director-General's opening remarks at the media briefing on COVID-19 - 11 March 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020 (acessado em 20/Ago/2020).
https://www.who.int/dg/speeches/detail/w...
, altered various aspects of society, interfering in social contact, the economy, employment, increasing inequalities, and health services’ routines and dynamics 22. Cucinotta D, Vanelli M. WHO declares COVID-19 a pandemic. Acta Biomed 2020; 91:157-60.. The WHO recommended social distancing measures 11. World Health Organization. WHO Director-General's opening remarks at the media briefing on COVID-19 - 11 March 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020 (acessado em 20/Ago/2020).
https://www.who.int/dg/speeches/detail/w...
to mitigate spread of the virus, save lives, and improve health services’ response. However, such recommendations may also result in negative effects on health and living conditions in society 33. Barreto ML, Barros AJD, Carvalho MS, Codeço CT, Hallal PRC, Medronho RA, et al. O que é urgente e necessário para subsidiar as políticas de enfrentamento da pandemia de COVID-19 no Brasil? Rev Bras Epidemiol 2020; 23:e200032.,44. Holmes EA, O'Connor RC, Perry VH, Tracey I, Wessely S, Arseneault L, et al. Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. Lancet Psychiatry 2020; 7:547-60., and behavioral changes, such as the an increase in cigarette consumption 55. Alla F, Berlin I, Nguyen-Thanh V, Guignard R, Pasquereau A, Quelet S, et al. Tobacco and COVID-19: a crisis within a crisis? Can J Public Health 2020; 111:995-9.,66. Malta DC, Szwarcwald CL, Gomes CS, Machado IE, Souza Júnior PRB, Romero DE, et al. The COVID-19 Pandemic and changes in adult Brazilian lifestyles: a cross-sectional study, 2020. Epidemiol Serv Saúde 2020; 29:e2020407.,77. Stanton R, To QG, Khalesi S, Williams SL, Alley SJ, Thwaite TL, et al. Depression, anxiety and stress during COVID-19: associations with changes in physical activity, sleep, tobacco and alcohol use in Australian adults. Int J Environ Res Public Health 2020; 17:4065.,88. Chen DT. The psychosocial impact of the COVID-19 pandemic on changes in smoking behavior: Evidence from a nationwide survey in the UK. Tob Prev Cessat 2020; 6:59.,99. Yach D. Tobacco use patterns in five countries during the COVID-19 lockdown. Nicotine Tob Res 2020; 22:1671-2..

During periods of epidemics and social distancing, the separation of loved ones and friends, loss of freedom, fear of acquiring the disease, changes in routine activities, and financial losses can cause situations of distress, anxiety, depression, stress, insomnia, and irritability 1010. 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.,1111. Ornell F, Schuch JB, Sordi AO, Kessler FHP. "Pandemic fear" and COVID-19: mental health burden and strategies. Braz J Psychiatry 2020; 42:232-5.,1212. Shigemura J, Ursano RJ, Morganstein JC, Kurosawa M, Benedek DM. Public responses to the novel 2019 coronavirus (2019-nCoV) in Japan: mental health consequences and target populations. Psychiatry Clin Neurosc 2020; 74:281-2., which in turn can increase the urge to smoke 77. Stanton R, To QG, Khalesi S, Williams SL, Alley SJ, Thwaite TL, et al. Depression, anxiety and stress during COVID-19: associations with changes in physical activity, sleep, tobacco and alcohol use in Australian adults. Int J Environ Res Public Health 2020; 17:4065.,1313. van Zyl-Smit RN, Richards G, Leone FT. Tobacco smoking and COVID-19 infection. Lancet Respir Med 2020; 8:664-5.,1414. McKay D, Yang H, Elhai J, Asmundson GJG. Anxiety regarding contracting COVID-19 related to interoceptive anxiety sensations: the moderating role of disgust propensity and sensitivity. J Anxiety Disord 2020; 73:102233.,1515. Pericot-Valverde I, Elliott RJ, Miller ME, Tidey JW, Gaalema DE. Posttraumatic stress disorder and tobacco use: a systematic review and meta-analysis. Addict Behav 2018; 84:238-47.. A study in Australia during the COVID-19 pandemic identified an association between increased cigarette consumption and depression (odds ratio - adjusted OR = 1.09; 95% confidence interval - 95%CI: 1.04-1.13), anxiety (adjusted OR = 1.12; 95%CI: 1.06-1.18), and stress (adjusted OR = 1.10; 95%CI: 1.05-1.15) 77. Stanton R, To QG, Khalesi S, Williams SL, Alley SJ, Thwaite TL, et al. Depression, anxiety and stress during COVID-19: associations with changes in physical activity, sleep, tobacco and alcohol use in Australian adults. Int J Environ Res Public Health 2020; 17:4065..

Although the results are not adjusted for other factors that may affect COVID-19 progression, systematic reviews indicate that smoking is likely to be associated with worse prognosis of the disease, greater need for admission to the intensive care unit (ICU), and adverse COVID-19 outcomes 1616. Berlin I, Thomas D, Anne-Laurence LF, Cornuz J. COVID-19 and smoking. Nicotine Tob Res 2020; 22:1650-2.,1717. Vardavas CI, Nikitara K. COVID-19 and smoking: a systematic review of the evidence. Tob Induc Dis 2020; 18:20.,1818. Zhao Q, Meng M, Kumar R, Wu Y, Huang J, Lian N, et al. The impact of COPD and smoking history on the severity of Covid-19: a systemic review and meta-analysis. J Med Virol 2020; 92:1915-21.,1919. Banerjee B, Banerjee R. Role of tobacco in SARS-CoV-2 infection and COVID-19: a scoping review. Int J Non-Commun Dis 2020; 5:70-5.. Factors involved in the relationship between smoking and SARS-CoV-2 infection include the increase in type 2 angiotensin-converting enzyme (ACE2) in the population of smokers 2020. Olds JL, Kabbani N. Is nicotine exposure linked to cardiopulmonary vulnerability to COVID-19 in the general population? FEBS J 2020; 287:3651-5.,2121. Leung JM, Yang CX, Tam A, Shaipanich T, Hackett TL, Singhera GK, et al. ACE-2 expression in the small airway epithelia of smokers and COPD patients: implications for COVID-19. Eur Respir J 2020; 55:2000688., repetitive “hand-mouth” movements, the increase in viral contamination 1616. Berlin I, Thomas D, Anne-Laurence LF, Cornuz J. COVID-19 and smoking. Nicotine Tob Res 2020; 22:1650-2.,2222. Silva ALO, Moreira JC, Martins SR. COVID-19 and smoking: a high-risk association. Cad Saúde Pública 2020; 36:e00072020., and worse cardiorespiratory performance 2323. Cattaruzza MS, Zagà V, Gallus S, D'Argenio P, Gorini G. Tobacco smoking and COVID-19 pandemic: old and new issues. A summary of the evidence from the scientific literature. Acta Biomed 2020; 91:106-12.. Smoking is also one of the most important risk factors for cardiovascular and metabolic diseases 2424. World Health Organization. Global action plan for the prevention and control of NCDs 2013-2020. Geneva: World Health Organization; 2013.,2525. Malta DC, Silva AG, Machado IE, Sá ACMGN, Santos FM, Prates EJS, et al. Trends in smoking prevalence in all Brazilian capitals between 2006 and 2017. J Bras Pneumol 2019; 45:e20180384. and comorbidities which in turn magnify the risk of exacerbation of COVID-19. A study found that smokers with COVID-19 present 3.25 times higher odds of developing more severe forms of the disease when compared to non-smokers 2626. Guan W, Ni Z, Hu Y, Liang W, Ou C, He J, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020; 382:1708-20..

Considering the harmful effects of smoking on health, initiated or aggravated during epidemic processes and the additional risks of such behaviors in the COVID-19 pandemic, it is necessary to monitor the occurrence of smoking and changes in smoking behavior in order to promote and target interventions and public policies to encourage healthy behaviors during social distancing. We thus aimed to investigate smoking behavior in the Brazilian adult population during the COVID-19 pandemic and analyze factors associated with the increase in cigarette consumption.

Methods

This study used data from the research project ConVid - Behavior Survey. This is an online health survey conducted during the COVID-19 pandemic to assess changes in the lives of Brazilian adults, related to social distancing measures. The present study is a partnership between researchers from the Federal University of Minas Gerais (UFMG), Oswaldo Cruz Foundation (Fiocruz), and State University of Campinas (Unicamp). Participants provided formal consent, and all the answers were anonymized and with no type of participant’s identification. The study was approved by the Brazilian National Commission on Research Ethics (approval number 3.980.277).

Data collection took place from April 24 to May 24, 2020. Subjects were invited to participate in the study through a snowball-type sampling process. In the first stage, the 15 researchers involved in the design or development of the study chose a total of 200 other researchers from different states of Brazil and invited them to perticipate as respondents. In addition, each of 15 above-mentioned researchers chose another 20 persons from their social network, totaling 500 selected persons. These persons, called “seeds”, were then asked to send the study link to at least 12 persons from their social networks, with stratification by sex, age bracket (18-39 years; 40-59; 60 or older) and schooling (incomplete secondary or less; complete secondary or more). The persons invited by the “seeds” comprised the second wave of the recruiting chain. Each person in the second wave was asked to invite at least three other persons from their social networks, through a message at the end of the questionnaire: “Be part of the ConVid Network and share this survey with three or more contacts from your social network. You can do this by clicking here or copying and sending our link, https://convid.fiocruz.br”. Information on the study was publicized through press releases, social communiqués from the participating research institutions, state health departments, and social media. The survey’s link was also available on the websites of the research institutions’ with which the researchers were affiliated. This process led to a rapid increase in contacts, and the final sample of respondents was 45,160 adult individuals (18 years or older) 2727. Szwarcwald CL, Souza Júnior PRB, Damacena GN, Malta DC, Barros MBA, Romero DE, et al. ConVid - Pesquisa de Comportamentos pela Internet durante a pandemia de COVID-19 no Brasil: concepção e metodologia de aplicação. Cad Saúde Pública 2021; 37:e00268320..

The ConVid - Behavior Survey addressed such topics as adherence to social distancing, economic losses, noncommunicable diseases, lifestyle changes, and state of mind, among others. Futher details about the study procedures are available elsewhere 2727. Szwarcwald CL, Souza Júnior PRB, Damacena GN, Malta DC, Barros MBA, Romero DE, et al. ConVid - Pesquisa de Comportamentos pela Internet durante a pandemia de COVID-19 no Brasil: concepção e metodologia de aplicação. Cad Saúde Pública 2021; 37:e00268320..

The target outcome variable in this study, “increase in cigarette consumption during the pandemic”, was analyzed with the following questions: “Are you a smoker?”; “Before the pandemic, on average how many cigarettes did you smoke per day?”; and “During the pandemic, on average, how many cigarettes do you smoke per day?” The choices for the latter two questions were: “I didn’t (don´t) smoke cigarettes, only other products”; “Fewer than 1 a day”; “1 to 9 cigarettes”; “10 to 19 cigarettes”; “20 to 29 cigarettes”; “30 to 39 cigarettes”; “40 or more cigarettes”. To assess the number of cigarettes before (time 1 or t1) and during the pandemic (time 2 or t2), we used the midpoint in the response category and calculate the difference between the two moments (t2 - t1). Increase in cigarette consumption was defined as a positive difference between t2 and t1.

Explanatory variables included the following factors: adherence to social distancing measures, quality of sleep, state of mind (feeling isolated from family, feeling sad or depressed, feeling anxious or nervous), changes in work or employment, in earnings, and in self-assessed health status, besides sociodemographic variables (Box 1).

Box 1
Description of the explanatory variables.

The following sociodemographic variables were analyzed: sex (male and female), age bracket (18-39; 40-59; and 60 years or older), and schooling (complete Primary or less; complete Secondary; and complete University or more).

Considering that the sample was non-probabilistic, post-stratification weights were used, based on data from the Brazilian National Household Sample Survey (PNAD 2019) of the Brazilian Institute of Geography and Statistics (IBGE), for the sample to have the same distribution as the Brazilian population according to state, sex, age bracket, race/color, and schooling. To assess the factors associated with the increase in cigarette consumption, we calculated crude prevalence ratios (PR) and adjusted by sex, age, and schooling and respective 95%CI, using Poisson regression models with robust variance.

Data processing used Stata, version 14 (https://www.stata.com), employing the survey module, which considers the post-stratification weights.

Results

Most of the study participants were women (53.6%; 95%CI: 52.0-55.0), 18 to 39 years of age (45.7%; 95%CI: 44.3-47.1), and with complete secondary schooling (72.4%; 95%CI: 71.3-73.5).

Prevalence of smokers in the study population was 12% (95%CI: 11.1-12.9), and 34% of the smokers reported having increased their cigarette consumption (Figure 1). Of all the persons who increased their cigarette consumption, 6.4% (95%CI: 4.3-9.4) increased by up to 5 cigarettes per day, 22.5% (95%CI: 19.6-25.7) by around 10 cigarettes per day, and 5.1% (95%CI: 3.4-7.7) by 20 or more cigarettes per day.

Figure 1
Prevalence of smokers and changes in smoking habit during the COVID-19 pandemic. ConVid - Behavior Survey, Brazil, 2020.

The increase in consumption was greater among women (PR = 1.3; 95%CI: 1.1-1.6) and among individuals with incomplete secondary schooling (PR = 1.3; 95%CI: 1.1-1.8), compared to those with a bachelor’s degree or higher. There were no significant differences in relation to age bracket (Table 1).

Table 1
Prevalence and prevalence ratio for the increase in cigarette consumption during the COVID-19 pandemic, according to sociodemographic characteristics. ConVid - Behavior Survey, Brazil, 2020.

Table 2 shows factors associated with the increase in cigarette consumption during the COVID-19 pandemic. In relation to quality of sleep, compared to persons that continued to sleep well during the pandemic, there was an increase in cigarette consumption in individuals who began to suffer sleep problems during the pandemic (adjusted PR = 2.1; 95%CI: 1.4-3.0) or those whose preexisting sleep problems became worse (adjusted PR = 2.2; 95%CI: 1.5-3.2). Meanwhile, persons who reported that their sleep problems had improved reduced their cigarette consumption (adjusted PR = 0.5; 95%CI: 0.2-0.9). As for state of mind, there was a higher prevalence of increasing cigarette consumption among persons who reported the following: feeling isolated from family members often (adjusted PR = 2.0; 95%CI: 1.2-3.4) or always (adjusted PR = 2.4; 95%CI: 1.4-4.2); feeling sad or depressed often (adjusted PR = 2.2; 95%CI: 1.4-3.7) or always (adjusted PR = 2.4; 95%CI: 1.4-4.0); and feeling anxious or nervous often (adjusted PR = 3.1; 95%CI: 1.4-6.7) or always (adjusted PR = 3.5; 95%CI: 1.6-7.8). A partial reduction in earnings did not alter cigarette consumption, while losing all of one’s earnings (zero income) increased consumption (adjusted PR = 1.5; 95%CI: 1.1-2.0). Worse self-assessed health status was also associated with increased cigarette consumption (adjusted PR = 1.5; 95%CI: 1.2-1.8). The variables adherence to social distancing and change in work/employment were not associated with increased cigarette consumption.

Table 2
Factors associated with increased cigarette consumption during the COVID-19 pandemic. ConVid - Behavior Survey, Brazil, 2020.

Discussion

The current study’s findings pointed to 12% prevalence of smokers, a third of whom reported having increased their cigarette consumption during the pandemic. Meanwhile, 12% reported smoking less, while 54% were smoking the same amount. Increased cigarette smoking was greater among women and individuals with incomplete secondary schooling. After adjusting for sex, age, and schooling, factors associated with the increase in cigarette consumption were the following: feeling isolated from family members, sad or depressed, anxious, worse quality of sleep, complete loss of earnings, and worse self-assessed health status.

A study in Australia during the COVID-19 pandemic found a similar prevalence of smokers (11%) to that in our study (12%), but the majority (89%) of the Australian smokers interviewed had not changed their smoking behavior, and the prevalence of increased cigarette smoking among smokers was only 6.9% 77. Stanton R, To QG, Khalesi S, Williams SL, Alley SJ, Thwaite TL, et al. Depression, anxiety and stress during COVID-19: associations with changes in physical activity, sleep, tobacco and alcohol use in Australian adults. Int J Environ Res Public Health 2020; 17:4065.. The same study found other negative behavior changes besides smoking more, such as a decline in physical activity (48.9%), worse sleep (40.7%), and increased alcohol intake (26.6%) 77. Stanton R, To QG, Khalesi S, Williams SL, Alley SJ, Thwaite TL, et al. Depression, anxiety and stress during COVID-19: associations with changes in physical activity, sleep, tobacco and alcohol use in Australian adults. Int J Environ Res Public Health 2020; 17:4065.. Studies in Italy and the United States indicated an increase in prevalence of smoking during the economic recessions in those countries, attributed to the assumed effect of the increase in stress caused by financial problems and unemployment 2828. Mattei G, De Vogli R, Ferrari S, Pingani L, Rigatelli M, Galeazzi GM. Impact of the economic crisis on health-related behaviors in Italy. Int J Soc Psychiatry 2017; 63:649-56.,2929. Gallus S, Ghislandi S, Muttarak R, Bosetti C. Effects of the economic crisis on smoking prevalence and number of smokers in the USA. Tob Control 2015; 24:82-8.. However, another study in Italy in 2016 and 2017 on the effect of the economic crisis on lifestyle found a reduction in smoking due to budget restrictions and lower buying power 3030. Petrelli F, Grappasonni I, Peroni A, Kracmarova L, Scuri S. Survey about the potential effects of economic downturn on alcohol consumption, smoking and quality of life in a sample of Central Italy population. Acta Biomed 2018; 89:93-8.. In this sense, paradoxically, a crisis period can either predispose to increased smoking, hinder initiation, or contribute to smoking cessation 3030. Petrelli F, Grappasonni I, Peroni A, Kracmarova L, Scuri S. Survey about the potential effects of economic downturn on alcohol consumption, smoking and quality of life in a sample of Central Italy population. Acta Biomed 2018; 89:93-8..

State of mind (or mood) is an important factor in increased tobacco consumption. Various studies have described the relationship between tobacco use and negative affect, anguish, or sensitivity to anxiety among individuals in situations of stress 77. Stanton R, To QG, Khalesi S, Williams SL, Alley SJ, Thwaite TL, et al. Depression, anxiety and stress during COVID-19: associations with changes in physical activity, sleep, tobacco and alcohol use in Australian adults. Int J Environ Res Public Health 2020; 17:4065.,3131. Pericot-Valverde I, Elliott RJ, Miller ME, Tidey JW, Gaalema DE. Posttraumatic stress disorder and tobacco use: a systematic review and meta-analysis. Addict Behav 2018; 84:238-47.,3232. Alexander AC, Ali J, McDevitt-Murphy ME, Forde DR, Stockton M, Read M, et al. Racial differences in posttraumatic stress disorder vulnerability following hurricane Katrina among a sample of adult cigarette smokers from New Orleans. J Racial Ethn Health Disparities 2017; 4:94-103.,3333. Asnaani A, Alpert E, McLean CP, Foa EB. Resilient but addicted: the impact of resilience on the relationship between smoking withdrawal and PTSD. J Psychiatr Res 2015; 65:146-53.,3434. Asnaani A, Farris SG, Carpenter JK, Zandberg LJ, Foa EB. The relationship between anxiety sensitivity and posttraumatic stress disorder: what is the impact of nicotine withdrawal? Cogn Ther Res 2015; 39:697-708.,3535. Baggett TP, Campbell EG, Chang Y, Magid LM, Rigotti NA. Posttraumatic stress symptoms and their association with smoking outcome expectancies among homeless smokers in Boston. Nicotine Tob Res 2016; 18:1526-32.,3636. Fu SS, McFall M, Saxon AJ, Beckham JC, Carmody TP, Baker D, Joseph AM. Post-traumatic stress disorder and smoking: a systematic review. Nicotine Tob Res 2007; 9:1071-84.,3737. Beckham JC, Calhoun PS, Dennis MF, Wilson SM, Dedert EA. Predictors of lapse in first week of smoking abstinence in PTSD and non-PTSD smokers. Nicotine Tob Res 2013; 15:1122-9.. Alexander et al. 3232. Alexander AC, Ali J, McDevitt-Murphy ME, Forde DR, Stockton M, Read M, et al. Racial differences in posttraumatic stress disorder vulnerability following hurricane Katrina among a sample of adult cigarette smokers from New Orleans. J Racial Ethn Health Disparities 2017; 4:94-103. reported that feelings related to social isolation were associated with tobacco use; individuals doubled their consumption during the crisis caused by Hurricane Katrina in New Orleans, United States, which left thousands of persons stranded. By analyzing a sample of 279 smokers, the same authors found that Blacks increased their tobacco consumption twofold, and that the stressors with the greatest impact were: mental distress, lower social support, and increased social and economic vulnerability. A systematic review that examined comorbidity of posttraumatic stress disorder and tobacco use found that prevalence of tobacco use in individuals with posttraumatic stress disorder was 24%, with high levels of nicotine dependence and heavy use of tobacco products 3131. Pericot-Valverde I, Elliott RJ, Miller ME, Tidey JW, Gaalema DE. Posttraumatic stress disorder and tobacco use: a systematic review and meta-analysis. Addict Behav 2018; 84:238-47.. The increase in chain smoking among individuals with this disorder emphasizes the importance of negative emotional states such as anxiety, depression, and stress as contributing factors to tobacco use 3131. Pericot-Valverde I, Elliott RJ, Miller ME, Tidey JW, Gaalema DE. Posttraumatic stress disorder and tobacco use: a systematic review and meta-analysis. Addict Behav 2018; 84:238-47.. Neurophysiology provides evidence of nicotine’s action on the central nervous system, altering mood by producing a feeling of relief from stress, anguish, and sadness 3838. Sociedade Brasileira de Pneumologia e Tisiologia. Tabagismo - o tabaco, exercícios aeróbicos, corridas e o coração. https://pesquisa.bvsalud.org/controlecancer/resource/pt/lis-LISBR1.1-46463 (acessado em 20/Ago/2020).
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,3939. Planeta CS, Cruz FC. Bases neurofisiológicas da dependência do tabaco. Rev Psiquiatr Clín 2005; 32:251-8.. This effect of positive feedback is mediated by the mesolimbic dopaminergic system 3939. Planeta CS, Cruz FC. Bases neurofisiológicas da dependência do tabaco. Rev Psiquiatr Clín 2005; 32:251-8..

Worse sleep is a stressful and anxiogenic situation, also observed in a study in Hubei Province, China, with 939 individuals in social isolation due to the COVID-19 pandemic 4040. Yuan S, Liao Z, Huang H, Jiang B, Zhang X, Wang Y, et al. Comparison of the indicators of psychological stress in the population of Hubei Province and non-endemic Provinces in China during two weeks during the coronavirus disease 2019 (COVID-19) outbreak in February 2020. Med Sci Monit 2020; 26:e923767-1-e923767-10.. As in the current study, Altena et al. 4141. Altena E, Baglioni C, Espie CA, Ellis J, Gavriloff D, Holzinger B, et al. Dealing with sleep problems during home confinement due to the COVID-19 outbreak: practical recommendations from a task force of the European CBT-I Academy. J Sleep Res 2020; 29:e13052. identified the relevance of worse sleep for increased tobacco consumption. Sleep plays an important role in emotional regulation, and sleep disorders involve changes in emotional behavior 4141. Altena E, Baglioni C, Espie CA, Ellis J, Gavriloff D, Holzinger B, et al. Dealing with sleep problems during home confinement due to the COVID-19 outbreak: practical recommendations from a task force of the European CBT-I Academy. J Sleep Res 2020; 29:e13052. that can result in an increase in tobacco consumption.

The association between the loss of earnings and increased cigarette smoking was also identified, possibly because the pandemic amplifies families’ social vulnerability and consequently the presence of negative emotional states. The influence of loss of work and earnings on psychosocial disorders has also been well documented in the international literature 4242. Pikhart H, Bobak M, Siegrist J, Pajak A, Rywik S, Kyshegyi J, et al. Psychosocial work characteristics and self rated health in four post-communist countries. J Epidemiol Community Health 2001; 55:624-30.,4343. Stansfeld SA, Fuhrer R, Shipley MJ, Marmot MG. Work characteristics predict psychiatric disorder: prospective results from the Whitehall II Study. Occup Environ Med 1999; 56:302-7.. Losing one’s employment is considered one of the most stressful experiences in adulthood, leading to decreased purchasing power, family breakdown, and low self-esteem 4444. Ensminger ME, Celentano DD. Unemployment and psychiatric distress: social resources and coping. Soc Sci Med 1988; 27:239-47., in addition to being associated with changes in health status, such as depression and anxiety 4545. D'Souza RM, Strazdins L, Lim LL, Broom DH, Rodgers B. Work and health in a contemporary society: demands, control, and insecurity. J Epidemiol Community Health 2003; 57:849-54.. Prior socioeconomic status modulates the pandemic’s negative effects, and the impact of COVID-19 tends to be more severe in populations that are more vulnerable to adverse social determinants 4646. Abrams EM, Szefler SJ. COVID-19 and the impact of social determinants of health. Lancet Respir Med 2020; 8:659-61.,4747. Campos GWS. O pesadelo macabro da Covid-19 no Brasil: entre negacionismos e desvarios. Trab Educ Saúde 2020; 18:e00279111..

Given the above, it is important to promote health promotion strategies oriented to the adoption or maintenance of positive health behaviors that should be used to cope with the increase in psychological distress during the pandemic. A comprehensive, multisector, and governmental tobacco control approach is necessary, considering all the tenets and commitments of the WHO Framework Convention on Tobacco Control (WHO-FCTC) to detain the tobacco epidemic and save lives 4848. Al-Mandhari A, Hammerich A, El-Awa F, Bettcher D, Mandil A. Full implementation of the WHO Framework Convention on Tobacco Control in the Eastern Mediterranean Region is the responsibility of all. East Mediterr Health J 2020; 26:4-5.. Smoking cessation by any means should be a priority 1616. Berlin I, Thomas D, Anne-Laurence LF, Cornuz J. COVID-19 and smoking. Nicotine Tob Res 2020; 22:1650-2..

Smoking cessation can also be difficult, especially in an adverse context like the COVID-19 pandemic, given that access to health services may be compromised. In addition, during the social distancing imposed by the pandemic, face-a-face support for smokers from public healthcare workers has been hampered, with difficulty in initiating and continuing cessation treatment in the units of Brazil’s Unified National Health System (SUS) 4949. Secretaria de Atenção Primária à Saúde, Ministério da Saúde. Websérie alerta população sobre os males do tabagismo. http://aps.saude.gov.br/noticia/10258 (acessado em 25/Nov/2020).
http://aps.saude.gov.br/noticia/10258...
. Contributing factors include both the recommendation to only leave home in situations of extreme necessity and the interruption in the supply of face-to-face activities (individual and in group) in primary care, whether to avoid crowding or due to work overload.

In this scenario, strengthening health education actions via internet and telephone counseling 5050. United Nations. Responding to the challenge of non-communicable diseases. Geneva: World Health Organization; 2019. become timely and complementary strategies for the established regulatory measures at the global and national levels. A guideline based on systematic reviews and meta-analyses concluded that pharmaceutical treatment combined with counseling by trained professionals, whether individual or in group or by telephone, are highly effective methods in smoking cessation 5151. Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff. A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. Am J Prev Med 2008; 35:158-76.. The guideline also indicated that the efficacy of counseling increases with the increase in the duration and number of sessions performed. Interventions are also recommended through self-help materials (pamphlets, booklets, manuals, e-mail messages, videos, audios, computer programs, and websites), which are less effective than the previous options, but which have great potential for reaching the target public and at lower cost 5151. Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff. A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. Am J Prev Med 2008; 35:158-76..

Regulatory measures feature the initiative taken by South Africa, banning the sale of tobacco and nicotine products during the COVID-19 pandemic, designating them as nonessential goods 5252. Egbe CO, Ngobese SP. COVID-19 lockdown and the tobacco product ban in South Africa. Tob Induc Dis 2020; 18:39.. In the sphere of health education interventions, both the WHO and the Brazilian Ministry of Health, via the National Cancer Institute (INCA), have used online resources with the aim of alerting smokers and persons exposed to passive smoking to the risks associated with COVID-19, and encouraging cessation of the habit during the pandemic.

The WHO recently launched a tobacco control project 5353. World Health Organization. WHO and partners to help more than 1 billion people quit tobacco to reduce risk of COVID-19. https://www.who.int/news-room/detail/10-07-2020-who-and-partners-to-help-more-than-1-billion-people-quit-tobacco-to-reduce-risk-of-covid-19 (acessado em 20/Ago/2020).
https://www.who.int/news-room/detail/10-...
. This new Access Initiative for Quitting Tobacco (AIQT) aims to provide free access and support for adherence to nicotine replacement therapy and access to Florence, a virtual assistant that helps the interface user in the individual development of the quit-smoking plan and answers any doubts related to smoking and COVID-19 5353. World Health Organization. WHO and partners to help more than 1 billion people quit tobacco to reduce risk of COVID-19. https://www.who.int/news-room/detail/10-07-2020-who-and-partners-to-help-more-than-1-billion-people-quit-tobacco-to-reduce-risk-of-covid-19 (acessado em 20/Ago/2020).
https://www.who.int/news-room/detail/10-...
. Another key initiative is the World No Tobacco Day, promoted annually by the WHO in the month of May, in which the objective in 2020 was to raise young people’s awareness concerning the tobacco industry’s manipulation tactics 5454. World Health Organization. World no tobacco day - 31 May 2020. Protecting youth from industry manipulation and preventing them from tobacco and nicotine use. https://www.who.int/news-room/events/detail/2020/05/31/default-calendar/world-no-tobacco-day-2020-protecting-youth-from-industry-manipulation-and-preventing-them-from-tobacco-and-nicotine-use (acessado em 25/Nov/2020).
https://www.who.int/news-room/events/det...
.

In Brazil, the global campaign was addressed with the theme Smoking and Coronavirus (COVID-19, given the given the role of smoking as a potential risk factor for COVID-19 and aggravation of cases. At the national level, Brazil holds the campaign National No Smoking Day, celebrated since 1986 in the month of August. In 2020, the Brazilian campaign was aligned thematically with the global campaign and established a second action phase called Coronavirus: Another Reason for you to Quit Smoking (5555. Instituto Nacional de Câncer José Alencar Gomes da Silva. Dia Nacional de Combate ao Fumo 2020: tabagismo e coronavírus (COVID-19) - segunda fase. https://www.inca.gov.br/sites/ufu.sti.inca.local/files//media/document//nota-tecnica-dia-nacional-de-combate-ao-fumo-coronavirus.pdf (acessado em 25/Nov/2020).
https://www.inca.gov.br/sites/ufu.sti.in...
. Illustrated and text pieces were produced to support communications via websites and social media, underlining the importance of not smoking and the adoption of healthy habits, besides incentivizing cessation and discouraging smoking initiation during the pandemic. In addition, given the difficulties for initiating and continuing treatment for smokers in the units of the SUS, due to social distancing measures, the Brazilian National Cancer Institute (INCA) prepared a web-series with eight short videos featuring content addressing the harms from smoking 4949. Secretaria de Atenção Primária à Saúde, Ministério da Saúde. Websérie alerta população sobre os males do tabagismo. http://aps.saude.gov.br/noticia/10258 (acessado em 25/Nov/2020).
http://aps.saude.gov.br/noticia/10258...
. The institution also published an alert to the population on the risks of smoking for aggravating the health crisis, in which it provided a list of recommendations that can be followed individually to quit smoking 5656. Instituto Nacional de Câncer José Alencar Gomes da Silva. Alerta do INCA à população sobre tabagismo e coronavírus. https://www.inca.gov.br/publicacoes/notas-tecnicas/alerta-do-inca-populacao-sobre-tabagismo-e-coronavirus (acessado em 25/Nov/2020).
https://www.inca.gov.br/publicacoes/nota...
. A note by the National Network of Coordinators of the National Tobacco Control Program, published on the institution’s site, reinforced the importance of guaranteeing that smokers already in individual or group treatment should receive the medication for the period, besides continuing with the group or individual treatment guidelines, via telephone messages or other communication tools 5757. Instituto Nacional de Câncer José Alencar Gomes da Silva. Esclarecimento à Rede Nacional de Coordenadores do Programa Nacional de Controle do Tabagismo - Programa de Cessação do Tabagismo. https://www.inca.gov.br/publicacoes/notas-tecnicas/esclarecimento-rede-nacional-de-coordenadores-do-programa-nacional-de (acessado em 25/Nov/2020).
https://www.inca.gov.br/publicacoes/nota...
.

This is the first study to investigate smoking behavior in the Brazilian adult population during the COVID-19 pandemic and to analyze factors associated with the increase in cigarette consumption. The study’s strengths featured the inclusion of various health behaviors in a large study sample and the timing of the data collection in sync with social distancing in Brazil, with rapid responses and low cost. However, there were also some limitations that merit consideration. First, all the data are self-reported, which means that answers are subject to recall bias. Second, the data are cross-sectional, and thus causality cannot be inferred. Third, the sampling design was non-probabilistic, and the study’s participants had more schooling and better internet access on average than the general population, which required applying post-stratification weights to the data analysis. Consequently, any generalization to other populations needs to be confirmed by other studies. Longitudinal studies are also recommended to assess the impact of social distancing measures on smoking behavior changes over time.

Final remarks

The data suggest that the the worsening of mental health, quality of sleep, self-assessement of health status and the lack of earnings are factors associated with the increase in cigarette consumption by Brazilian adults during the COVID-19 pandemic. Health promotion measures targeted to the adoption or maintenance of health behaviors, such as messages via social media and orientation from healthcare workers, especially in primary healthcare, should thus be used to mitigate the pandemic’s psychological suffering and unhealthy behaviors like smoking. In addition, strategies for tobacco prevention and the promotion of smoking cessation should thus be continued and reinforced while the social distancing measures are in force, for the impacts of tobacco consumption not to further aggravate the population’s health conditions during the COVID-19 pandemic.

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Publication Dates

  • Publication in this collection
    07 Apr 2021
  • Date of issue
    2021

History

  • Received
    25 Aug 2020
  • Reviewed
    26 Nov 2020
  • Accepted
    01 Mar 2021
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