The double-edged relationship between COVID-19 stress and
smoking: Implications for smoking cessation

Introduction:
Although recent research shows that smokers respond differently to the COVID-19 pandemic, it offers little explanation of why some have increased their smoking, while others decreased it. In this study, we examined a possible explanation for these different responses: pandemic-related stress.

Material and Methods:
We conducted an online survey among a representative sample of Dutch current smokers from 11–18 May 2020 (n=957). During that period, COVID-19 was six weeks past the (initial) peak of cases and deaths in the Netherlands. Included in the survey were measures of how the COVID-19 pandemic had changed their smoking, if at all (no change, increased smoking, decreased smoking), and a measure of stress due to COVID-19.

Results:
Overall, while 14.1% of smokers reported smoking less due to the COVID-19 pandemic, 18.9% of smokers reported smoking more. A multinomial logistic regression analysis revealed that there was a dose-response effect of stress: smokers who were somewhat stressed were more likely to have either increased (OR=2.37; 95% CI: 1.49–3.78) or reduced (OR=1.80; 95% CI: 1.07–3.05) their smoking. Severely stressed smokers were even more likely to have either increased (OR=3.75; 95% CI: 1.84–7.64) or reduced (OR=3.97; 95% CI: 1.70–9.28) their smoking. Thus, stress was associated with both increased and reduced smoking, independently from perceived difficulty of quitting and level of motivation to quit.

Conclusions:
Stress related to the COVID-19 pandemic appears to affect smokers in different ways, some smokers increase their smoking while others decrease it. While boredom and restrictions in movement might have stimulated smoking, the threat of contracting COVID-19 and becoming severely ill might have motivated others to improve their health by quitting smoking. These data highlight the importance of providing greater resources for cessation services and the importance of creating public campaigns to enhance cessation in this dramatic time.

CONFLICTS OF INTEREST

The authors have each completed and submitted an ICMJE form for disclosure of potential conflicts of interest. The authors declare that they have no competing interests, financial or otherwise, related to the current work. J. Bommelé, P. Hopman, B. Hipple Walters, E. Croes and M. Willemsen, report grants from Dutch Ministry of Public Health, Welfare, and Sport, during the conduct of the study. C. Geboers reports grants from Longfonds, Hartstichting, KWF Kankerbestrijding, Trombosestichting, Diabetesfonds, during the conduct of the study. G.T. Fong reports grants from Ontario Institute for Cancer Research, during the conduct of the study and that he has served as an expert witness on behalf of governments in litigation involving the tobacco industry. A.C.K. Quah reports grants from Canadian Institutes of Health Research, during the conduct of the study.

FUNDING

This work was supported by the Dutch Ministry of Public Health, Welfare, and Sport. G.T.F. was supported by a Senior Investigator Grant from the Ontario Institute for Cancer Research. A.C.K.Q. was supported by the Canadian Institutes of Health Research Foundation Grant (FDN- 148477). The sponsors had no role in the study design, data collection, interpretation of the data, writing of the article or the decision to submit it for publication.

AUTHORS' CONTRIBUTIONS

All authors contributed to the design of the study and its conduct. JB, PH and MW designed the questionnaire. JB analyzed the data and drafted the first manuscript. All authors actively contributed to subsequent drafts, and they all read and approved the final manuscript.

PROVENANCE AND PEER REVIEW

Not commissioned; externally peer reviewed.

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