INTRODUCTION
Smoking, which is designated as the most important preventable health problem by the World Health Organization (WHO), has been defined as a disorder in the ICD-11 table1. Smoking cessation polyclinics occupy a key position in the treatment of addiction to tobacco products, especially cigarettes, and in the provision of counselling services2. The importance of treating smoking addiction was reemphasized with the declaration of the COVID-19 epidemic as a pandemic on 11 March 20203.
Additional risk factors in the course of COVID-19 infection, which can range from mild (fever, dry cough, myalgia) to severe (pneumonia) and life-threatening (respiratory failure, sepsis syndrome, multiple organ failure), are the forerunners of the severity of the disease4. Among the risk factors for COVID-19 associated pneumonia, the role of smoking is controversial. It has been previously suggested that high ACE-2 expression in smokers predisposes them to increased SARS-CoV-2 infection5. There are analyses confirming that the severity of COVID-19 disease is two times higher in smokers than never smokers6. Current evidence suggests that smoking is associated with increased disease severity and mortality in hospitalized COVID-19 patients7.
To reduce the risk of transmission in COVID-19 infections, which have a high mortality rate, many countries have adopted stringent measures such as physical distancing measures, restrictions on international travel, closure of schools, and postponement of meetings and demonstrations8. Despite the implementation of these non-pharmaceutical measures taken, rising infection and death rates and uncertainty about the future may induce high levels of emotional distress and avoidance behaviors in people who are very worried about contracting COVID-199.
Somatic symptoms such as insomnia, loss of appetite, and dyspeptic symptoms often occur in conjunction with anxiety in response to extreme fear or worry. Anxiety due to COVID-19 is common, and the Coronavirus Anxiety Scale (CAS) was developed by Lee et al.10 to measure anxiety. The scale assesses symptoms of anxiety and dysfunctional thinking according to DSM-5 criteria11. The Turkish validity study of the questionnaire was conducted by Ladikli et al.12. It is a brief mental health screening to identify possible dysfunctional anxiety related to the COVID-19 crisis. Each item of the CAS measures the response to a different physiologically based fear or anxiety related to thoughts or information about coronavirus. The CAS examines five different somatically based fear and anxiety symptoms, including dizziness, tonic immobility, sleep disturbance, loss of appetite, nausea, or abdominal discomfort triggered by thoughts and information about the coronavirus10. While there are studies showing that fear and anxiety triggered by the pandemic increases adherence to protective measures (hygiene rules, mask, and social distance) to protect against infection, there are also studies showing that they contribute to the development of unhealthy behaviors such as increased alcohol consumption and decreased physical activity13. The impact of the pandemic on smoking behavior, which is one of the addictive substances, varies14.
This study aims to examine the impact of the COVID-19 pandemic on smokers’ anxiety levels and the relationship between smoking behavior and COVID-19 anxiety levels.
METHODS
Study population and sample
Our study was as a descriptive cross-sectional study and was conducted in the Smoking Cessation Polyclinic, between 31 May 2021 and 1 August 2021. Since the mean number of patients presenting to the smoking cessation polyclinic within one month between March and April was 160, the sample size was calculated to be 220 with a 95% confidence interval (n=220). Patients who applied to the outpatient clinic on the dates of the study were briefed about the study. Questionnaires were administered to those who met the inclusion criteria.
Inclusion criteria
The inclusion criteria were: patients presenting to the smoking cessation polyclinic for the first time; the date of first application of patients who had previously presented to the smoking cessation polyclinic should not be before May 31; no history of using psychiatric drugs (within the last 6 months); no psychiatric illness should have been diagnosed; no memory problems and no memory-related neurological disease (Alzheimer’s disease, vascular dementia, Lewy body dementia and frontotemporal dementia, mixed dementia); the ability to speak, understand and read Turkish; not to be pregnant; and be aged >18 years.
Data collection tools
The questionnaire form used in the study was prepared by the researchers. A total of 22 questions were asked. Questions reported on the sociodemographic characteristics of the participants and the frequency of use of tobacco and tobacco products, their smoking behavior during the COVID-19 pandemic, the time to decide to quit smoking, the impact of COVID -19 pandemic on smoking cessation, the status of having a COVID-19 infection, the presence of individuals who had COVID-19 in their immediate surroundings, and information questions about the COVID-19 infection progress in smokers. Survey questions also included the questions of the Coronavirus Anxiety Scale (CAS) and the Fagerström test for nicotine dependence (FTND). The CAS is used to determine the frequency of anxiety symptoms experienced by individuals, consisting of 5 questions whose Turkish validity for measuring anxiety levels was performed10,12. Each item of the CAS was scored on a 5-point Linkert scale ranging from 0 (never) to 4 (almost every day) based on experience in the past two weeks. The minimum score for each question was 0, and the maximum score was 4. The total score ranged from 0–20, and higher scores meant that the coronavirus-related anxiety was greater.
The Fagerström test for nicotine dependence (FTND) is the most common test designed to assess tobacco dependence. The reliability and validity study of FTND was conducted in Turkey and found to be applicable in Smoking Cessation Clinics15. FTND has a graded scale (0–10) corresponding to the degree of nicotine dependence. Those who scored 0–2 points are considered to have a nicotine dependence that is ‘very mild’, 3–4 points ‘mild’, 5 points ‘moderate’, 6–7 points ‘severe’, and 8–10 points ‘extremely severe’.
Ethical considerations
Approval was obtained from the Ethics Committee of Başakşehir Çam and Sakura City Hospital for this study and was conducted in accordance with the principles of the Declaration of Helsinki. Participation in the study was on a voluntary basis, and informed consent was obtained from each participant. Confidentiality and anonymity of the respondents were also ensured.
Statistical analysis
All statistical analyses were performed using IBM SPSS version 25.0 (SPSS Inc., Chicago, Illinois USA). Continuous variables are presented as mean±SD, and some of the categorical variables are given as frequency (n) and percentage (%). In addition, Cronbach’s alpha internal consistency coefficients were calculated by employing the results of participants’ minimum, maximum, and mean scores on the scales. Parametric tests were used in the study because the number of participants exceeded 20016. Pearson correlation analysis was performed to determine the relationship between the total scores of the scales. Independent samples t-test and one-way ANOVA, which are parametric tests, were applied to determine if there was a significant difference between the independent variables and the total scores of the scales. In case of significant difference between the groups, the post hoc test was conducted to determine between which groups the significance was. The Sidak post hoc test was selected due to homogeneous variance distribution and unequal number of samples17. The chi-squared test was used to compare categorical variables. Multivariate linear regression analysis was performed to determine the variables predicting CAS total score. A p<0.05 was considered statistically significant.
RESULTS
Sociodemographic characteristics of the respondents
A total of 349 subjects participated in the study. The mean age of the participants was 36.8±10.7; 35.5% (n=124) were female. While the proportion of those whose tobacco use increased during the pandemic COVID-19 was 26.1% (n=91), 10% (n=35) decreased their tobacco use. The sociodemographic data are shown in Table 1.
Table 1
Sociodemographic characteristics of the participants (N=349)
| Characteristics | n or Mean (range) | % or Mean±SD |
|---|---|---|
| Gender | ||
| Female | 124 | 35.5 |
| Male | 225 | 64.5 |
| Age (years) | 36.0 (18.0–78.0) | 36.79±10.74 |
| ≤20 | 11 | 3.2 |
| 21–30 | 106 | 30.4 |
| 31–40 | 108 | 30.9 |
| 41–50 | 92 | 26.4 |
| >50 | 32 | 9.2 |
| Education level | ||
| Primary school or literate | 88 | 25.2 |
| Middle/high school | 166 | 47.6 |
| Undergraduate degree | 84 | 24.1 |
| Postgraduate degree | 11 | 3.2 |
| Profession | ||
| Officer | 41 | 11.7 |
| Employee | 139 | 39.8 |
| Self-employed | 82 | 23.5 |
| Retired | 17 | 4.9 |
| Housewife | 61 | 17.5 |
| Other | 9 | 2.6 |
| Marital status | ||
| Married | 240 | 68.8 |
| Single | 90 | 25.8 |
| Widowed/divorced | 19 | 5.4 |
| Chronic disease | ||
| Present | 83 | 23.8 |
| Absent | 266 | 76.2 |
| Regular use of medication | ||
| Present | 103 | 29.5 |
| Absent | 246 | 70.5 |
| Are there any COVID-19 positive people around you? | ||
| Yes | 161 | 46.1 |
| No | 165 | 47.3 |
| I’m not sure | 23 | 6.6 |
| If there is a COVID-19 positive person around you, where? | ||
| At home in my family | 78 | 48.4 |
| At the workplace | 42 | 26.1 |
| Other | 41 | 25.5 |
| Have you had a COVID-19 infection? | ||
| Yes | 35 | 10.0 |
| No | 295 | 84.5 |
| I’m not sure | 19 | 5.4 |
| Were you hospitalized when you contracted the COVID-19 infection? | ||
| Yes | 1 | 2.9 |
| No, I was treated at home | 34 | 97.1 |
| Which tobacco and tobacco products do you use? * (n=370) | ||
| Cigarette | 347 | 93.8 |
| Hookah | 16 | 4.3 |
| Electronic cigarette | 7 | 1.9 |
| How long have you been smoking? (years) | 17.0 (1.0–65.0) | 18.26±10.31 |
| 0–10 | 110 | 31.5 |
| 11–20 | 123 | 35.2 |
| 21–30 | 75 | 21.5 |
| >30 | 41 | 11.7 |
| The amount of smoking during the pandemic | ||
| Increased | 91 | 26.1 |
| Decreased | 35 | 10.0 |
| Unchanged | 223 | 63.9 |
| When did you decide to quit smoking? | ||
| Before the epidemic began | 182 | 52.1 |
| When the epidemic began | 23 | 6.6 |
| After the epidemic | 144 | 41.3 |
| Do you think the COVID-19 pandemic has an impact on smoking cessation? | ||
| Yes | 131 | 37.5 |
| No | 218 | 62.5 |
| Smokers are heavily infected with COVID-19 | ||
| Wrong/no answer | 142 | 40.7 |
| Right | 207 | 59.3 |
| The rate of intensive care unit (ICU) admissions due to COVID-19 infection is higher in smokers | ||
| Wrong/no answer | 137 | 39.3 |
| Right | 212 | 60.7 |
| The mortality rate due to COVID-19 infection is higher among smokers | ||
| Wrong/no answer | 135 | 38.7 |
| Right | 214 | 61.3 |
| Nicotine dependence according to FTND | ||
| Very mild | 32 | 9.2 |
| Mild | 48 | 13.8 |
| Moderate | 41 | 11.7 |
| Severe | 99 | 28.4 |
| Extremely severe | 129 | 37.0 |
Comparison of the CAS and FTND for the different variables
The internal consistency coefficients of Cronbach’s alpha for the scales used in the questionnaire ranged from 0.66–0.80. Since these values were between or above the recommended limits of 0.50–0.70 in the literature, the internal consistency of the scales in this study was adequate18-20.
The mean CAS total score was 0.89±2.13 (range: 0–20) and FTND total score obtained in the questionnaire was 6.3±2.5 (range: 0–10), while no statistically significant correlation was found between the FTND total score and the CAS total score (r=0.046, p=0.389).
Table 2 presents the analysis of results regarding the comparison of CAS and FTND total scores with different variables. The CAS was higher in women than in men (1.4±2.8 vs 0.6±1.6, p=0.005). CAS total mean scores were higher in widowed/divorced (7.16±2.09) than in married (6.06±2.57) or single (6.94±2.40) (p=0.006). The Coronavirus Anxiety Scale total score and the change in the amount of smoking during the pandemic were compared. The mean score of CAS was higher in those who reported that the amount of smoking decreased (20.88±13.27) than in those who reported that it increased (13.00±10.68) or did not change (17.64±10.64) (p=0.011). Finally, the mean score of the CAS was higher among those who thought the pandemic had an impact (1.60±2.96) than among those who said it had no impact on their thinking about quitting smoking (0.46±1.27) (p<0.001). According to this analysis, a statistically significant difference was found between the FTND total score and age (p=0.037) and changes in the amount of smoking during the pandemic (p<0.001).
Table 2
Comparison of the CAS and FTND scores for the different variables (N=349)
Results of linear regression analysis between CAS total score and some variables
Table 3 shows the results of the multiple linear regression analysis performed to determine the variables predicting the total score of CAS. The results of the established model were statistically significant [F (5;343)=8.89, p<0.001]. The total score of CAS was 0.70 points higher in females than in males (β=0.70; 95% CI: 0.25–1.15, p=0.002). The total CAS score was 1.04 points higher among those who said that the COVID-19 pandemic had an impact on quitting smoking than among those who said it did not [β=1.04; 95% CI: 0.59–1.48, p<0.001]. The total score of CAS was 0.55 points higher among those who said the amount of smoking increased during the pandemic than among those who said it had decreased (β=0.55; 95% CI: 0.59–1.05, p=0.028). The variables ‘How did your smoking amount change during the pandemic?’ (β=0.71; p=0.054) and ‘Are there any COVID-19 positive people around the participants?’ (β=-0.21, p=0.236) had no significant effect on the total score of CAS. It was found that the 11% variance in CAS score could be explained by gender and the variables ‘Does the COVID-19 pandemic have an effect on quitting smoking?’ and ‘The amount of smoking in the epidemic’ (R2=0.11).
Table 3
Results of linear regression analysis between CAS total score and some variables (N=349)
Comparison of knowledge questions with different variables
As can be seen in Table 4, the impact of the COVID-19 pandemic on smoking cessation was statistically different between knowing that the rate of intensive care unit (ICU) admissions due to COVID-19 infection is higher in smokers, that smokers are heavily infected with COVID-19 and that the mortality rate due to COVID-19 infection is higher in smokers (p<0.001)
Table 4
Comparison of knowledge questions with different variables (N=349)
DISCUSSION
During epidemics, the number of people whose mental health is affected tends to be higher than the number of people affected by the infection21, with fear and stress as widespread strong emotions22. During a pandemic, fear increases anxiety levels in healthy people and exacerbates symptoms of pre-existing psychiatric disorders23. Several studies have found that anxiety levels in the general population have been high since the beginning of the COVID-19 era24. The study of more than 1200 people in China showed that 29% of participants suffered from moderate to severe anxiety during the pandemic25.
Healthcare workers, in particular, struggle with psychological problems such as predominantly fear and anxiety during a pandemic. In the study of Lu et al.26, employees of departments that have close contact with patients and are exposed to high levels of aerosols have a 2-fold higher risk of suffering from fear, anxiety, and depression than employees of departments that have relatively little contact and exposure to aerosols.
A study on stress perception of Italian athletes revealed that male athletes had lower stress perception than female athletes during the COVID-19 quarantine27. Our study also revealed that fear of COVID-19 was higher in female participants. There are many studies showing that the increased stress of a disease with high morbidity and mortality, such as COVID-19, causes an increase in negative emotions such as hopelessness, anxiety, fear of infection due to isolation and curfews, which are among the measures taken, and changes in smoking behavior28-30. It was observed that the pandemic caused some smokers to increase smoking while other smokers reduced smoking31-35.
The association between the high mortality and morbidity rates in people infected with COVID-19 and smoking can be seen as a motivating factor for people to quit smoking. Our study found that about a quarter of the participants increased their smoking amount during the pandemic. In a study conducted with 1359 smokers in the US, about half of the smokers reported that their smoking amount had not changed during the pandemic, whereas 22% reported smoking more36. However, a study from the United Kingdom showed that a quarter of smokers smoked more during the pandemic and that mental health and psychosocial well-being were strongly related to tobacco use37.
The increase in smoking amount during the pandemic among those with higher COVID-19 anxiety levels in our study supports the finding of the UK study. The literature suggests that some nicotine withdrawal symptoms may resemble the physiological stress response and contribute to an increase in stress-related smoking cravings38. It is also suggested that nicotine dependence is the initial reason for the continuation of smoking behavior and overall failure of treatment attempts39. In a study conducted by Örsel et al.40, 33% of patients presenting to the smoking cessation polyclinic were highly dependent on nicotine. More than two-thirds of the participants were considered extremely nicotine dependent in our study, which could explain the increase in smoking during the pandemic and only half of the decrease in smoking cessation and smoking amount among those who were examined.
We observed that those who had increased smoking during the pandemic were more stressed and more dependent. We can explain this result by the fact that people, especially those with high addiction potential, turn to addictive substances to relieve their negative feelings, as found in one study41. In our study, we determined that those who thought that the COVID-19 pandemic had an impact on smoking cessation and that they knew that the rate of ICU hospitalization and death was higher among smokers infected with COVID-19 had decreased the amount of cigarette or hookah smoking.
Limitations
The limitations of the study are that it only measures the level of anxiety in smokers who visited our smoking cessation outpatient clinic during the pandemic, that it measures the effect of COVID-19 on smoking behavior only with the level of anxiety, and that it does not address the frequency of smoking and anxiety level in the community during the pandemic. In addition, the small number of participants and the fact that it was conducted in a single center are other limitations of the study. On the contrary, the limited number of studies on the association between the level of anxiety due to COVID-19 and smoking can be considered as a strength of our study. Future studies will better illuminate the long-term effects of this pandemic on smoking behavior by examining the smoking status of those who quit smoking or those who never smoked during the pandemic.
CONCLUSIONS
Pandemic-related anxiety is a factor in the decision to quit smoking. It has been observed that individuals who have high levels of pandemic anxiety due to COVID-19 quit smoking and reduced the number of cigarettes they smoked at the onset of the pandemic. The level of anxiety related to COVID-19 is higher among females and individuals who smoke during the pandemic. The knowledge that COVID-19 infection is severe in smokers is one of the effective factors in the decision to quit smoking during the pandemic. We will not be able to thoroughly examine the factors that influence pandemic-related anxiety until the pandemic is over. What we need to do in the current pandemic is to intervene early in patients who develop anxiety symptoms and turn this situation into an opportunity for healthy behaviors such as eliminating harmful habits like tobacco addiction. In the time of the pandemic, we need more than ever training for health professionals, both for the fight against the pandemic and for preventive and curative healthcare.
