Changes in tobacco use at the early stage of the COVID-19 pandemic: Results of four cross-sectional surveys in Hong Kong

Cigarettes, heated tobacco products and dual use: exhaled carbon monoxide, saliva cotinine and total tobacco consumed by Hong Kong tobacco users

BACKGROUND

Independent studies on exhaled carbon monoxide (CO) and saliva cotinine levels in regular heated tobacco product (HTP) users, and how they compare with conventional cigarette (CC) smokers, are lacking.

METHODS

A total of 3294 current users of CCs, HTPs or electronic cigarettes (ECs) from a household survey and a smoking hotspot survey were classified into seven groups: exclusive users of CCs, HTPs, ECs; dual users of CCs and HTPs, CCs and ECs, HTPs and ECs; and triple users. We measured exhaled CO level using the piCo Smokerlyzer (n=780) and saliva cotinine using NicAlert cotinine test strips (n=620). Among the seven groups, the differences in (1) CO and cotinine levels were examined using Kruskal-Wallis test, and (2) the average daily tobacco consumption in the past 30 days was examined using multivariable linear regression.

RESULTS

Both exclusive and dual users of CCs had a higher CO level than exclusive HTP or EC users (p<0.05). Exhaled CO levels were similar between HTP and EC users, as were saliva cotinine levels among the seven groups. Compared with exclusive CC users, those who also used HTPs or ECs smoked fewer CCs (CCs+HTPs: adjusted coefficient -2.79, 95% CI -3.90 to -1.69; CCs+ECs: -1.34, 95% CI -2.34 to -0.34), but consumed more tobacco sticks equivalent in total (2.79 (95% CI 1.61 to 3.96); 1.95 (95% CI 0.79 to 3.12)).

CONCLUSIONS

HTP or EC use showed lower exhaled CO but similar saliva cotinine levels compared with CC use. Dual users of CCs and HTPs/ECs smoked fewer CCs than exclusive CC users, but consumed more tobacco in total.

Risk perceptions and changes in tobacco use in relation to Coronavirus Disease 2019 pandemic: A qualitative study on adolescent tobacco users in Hong Kong

INTRODUCTION

Tobacco use is associated with an increased risk of Coronavirus Disease 2019 (COVID-19) infection, severe COVID-19 outcomes requiring intensive care, and mortality. We investigated the perceived risk of and changes in cigarette, e-cigarette (EC) and heated tobacco product (HTP) use in relation to COVID-19 in Hong Kong adolescent tobacco users.

METHODS

We conducted semi-structured telephone interviews from January to April 2021 and in February 2022 on 40 adolescents (65% boys, Secondary school grades 2-6) who participated in our previous smoking surveys and were using cigarettes, ECs or HTPs before the first wave of the COVID-19 pandemic in January 2020.

RESULTS

Adolescents generally perceived higher risks of contracting and having more severe COVID-19 from using cigarettes than ECs/HTPs, but they had limited knowledge of COVID-19 risks from EC/HTP use, particularly. Both increased and reduced consumption were found in tobacco, with EC use being the less affected product. Changes also included switching to ECs for convenience and lower cost and shifting from smoking cigarettes outside to mainly at home or in hidden areas. COVID-related policies, fear of infection, non-COVID-related health concerns, less social opportunities and pocket money, and limited access to tobacco products were barriers to tobacco use. In contrast, greater freedom at home versus school and negative emotions due to social distancing were facilitators. Family/peer influence had mixed impacts.

CONCLUSIONS

Adolescent tobacco users perceived lower COVID risks associated with HTPs and ECs than cigarettes, and various changes in tobacco use were found amid the pandemic in Hong Kong. COVID-19 and related social changes may both facilitate or deter adolescent tobacco use.

Impact of mandatory masking amid the COVID-19 pandemic on outdoor smoking: an interrupted time-series analysis of a 33-month unobtrusive observational study

Background

Mask-wearing in outdoor public places in Hong Kong was mandated on 29 July 2020, amid the COVID-19 pandemic. We aimed to evaluate the impact of mandatory masking with no exemption for smoking on outdoor smoking.

Methods

We conducted 253 unobtrusive observations at 10 outdoor smoking hotspots in 33 months from July 2019 to March 2022 and counted smokers and non-smoking pedestrians in fixed boundaries. We conducted interrupted time-series analyses on the monthly mean volume of smokers (persons per hour) using generalized linear models. The independent variables were as follows: time since the first observation, implementation of the mask regulation, time since the regulation, seasonality, and waves 1-5 outbreaks. We checked the robustness of the association using the daily mean volume of smokers as the dependent variable. Two sensitivity analyses were conducted to include the hotspot location or the number of all pedestrians as an offset.

Results

Monthly outdoor smoking decreased immediately after the regulation (incidence rate ratio [IRR]: 0.505, 95% confidence interval [CI]: 0.374 to 0.680, P < 0.001). Daily smoking analysis and the two sensitivity analyses supported the results. However, monthly outdoor smoking increased by 11% since the regulation (IRR: 1.110, 95% CI: 1.074 to 1.147, P < 0.001). An exception was observed at the most severe wave 5 outbreak when monthly outdoor smoking decreased (IRR: 0.415, 95% CI: 0.327 to 0.525, P < 0.001).

Conclusion

Outdoor smoking fell immediately after mandatory masking, rebounded to pre-pandemic levels, and decreased again at the most severe wave 5.

Smokeless Tobacco Use and Cessation Attempts during COVID-19 Lockdown: A Qualitative Study

BACKGROUND

Smokeless tobacco (SLT) use among women is widely prevalent in Manipur state accounting for 45% users as per Global Adult Tobacco Survey (GATS)-2 India. Studies from India and elsewhere indicate changes in the way people used SLT during COVID-19 lockdown. This study explores individual and economic influences on SLT consumption and cessation attempts by tribal women in Manipur during the first COVID-19 lockdown (March-June, 2020) in India.

METHODS

Twenty in-depth interviews, both in-person and telephonically, were conducted among tribal women from Imphal west, Manipur, India, who used any SLT, from April to September 2020. Objective of the study was to understand the use, factors associated with consumption, purchasing behaviors, and cessation attempts of SLT during the lockdown. Thematic content analysis was used to identify core themes and codes.

RESULTS

Study participants reported of changes in current SLT use during restrictions imposed to contain COVID-19 pandemic in India. Majority reported of reduction or quit attempts in SLT use. Reasons included inaccessibility due to travel restrictions, limited availability and price rise of SLT products, fear of COVID-19, and disposable income for purchase of SLT products. However, a few women reported of increased consumption due to bulk purchasing, or switching to other SLT products as a result of unavailability or price rise of preferred products or to cope up with social isolation caused by the lockdown.

CONCLUSION

Study findings on factors influencing quit attempts and strategies used for reducing SLT use by tribal women in Imphal, Manipur provide valuable insights for development of appropriate intervention for prevention of SLT use among women.

Perceived increased susceptibility to COVID-19 due to smoking was associated with reduced smoking at home but not on the streets amid the pandemic: A population-based cross-sectional study

INTRODUCTION

Perceived risk of COVID-19 infection is associated with smoking behaviors, but the change in smoking across different settings are uncertain. We examined the associations of perceived increased susceptibility to COVID-19 due to smoking with change in smoking at home and on the streets.

METHODS

We analyzed data of 1120 current cigarette smokers aged ≥15 years from a population-based telephone survey in Hong Kong. Perceived increased susceptibility to COVID-19 due to smoking, change in smoking, intention to quit, and tobacco dependence were measured. We used Poisson regression with robust variance to estimate adjusted risk ratio (ARR) for associations, adjusting for sociodemographic characteristics, intention to quit, and time to first cigarette after waking.

RESULTS

More current smokers reduced smoking on the streets (46.1%; 95% CI: 42.8-50.0) than at home (8.7%; 95% CI: 7.0-10.8). Perceived increased susceptibility to COVID-19 due to smoking was associated with smoking reduction at home (ARR=3.29; 95% CI: 1.80-6.00, p<0.001) but not on the streets (ARR=1.13; 95% CI: 0.98-1.30, p=0.09). More smokers with stronger quit intention and lower tobacco dependence reduced smoking at home but not on the streets in those with high perceived increased susceptibility to COVID-19 due to smoking.

CONCLUSIONS

This is the first report showing that more cigarette smokers reduced smoking on the streets than at home, and the perceived increased susceptibility to COVID-19 due to smoking was only associated with smoking reduction at home but not on the streets. Improving smokers' awareness of the susceptibility to COVID-19 may be an effective strategy to reduce tobacco consumption and secondhand smoke exposure at home within the context of future respiratory pandemics.

Factors affecting tobacco, nicotine, and cannabis product use among California young adults during the COVID-19 pandemic: A qualitative study

The effects of COVID-19 on tobacco use and cannabis has been variable, and it is unclear the extent to which factors affecting changes in tobacco and cannabis use differ. The purpose of this study was to identify the COVID-19-related factors that affect changes in tobacco and cannabis use during the pandemic. Focus groups with 114 young adults in California in April 2021 were held to discuss tobacco and cannabis use patterns, adverse events, and the effect of COVID-19 on tobacco and cannabis product use. Factors affecting changes in use were largely similar between tobacco products and cannabis products. Drivers of increased cannabis use distinct from tobacco or nicotine product use included feeling greater freedom to disengage and perceptions of less harm. Increases in product use were a result of changing social environment, coping with emotional and psychological distress, and product related factors. Decreases in product use were a result of social isolation, COVID-19-related health concerns, disruptions in daily patterns of living, and reduced access. Improved understanding of how the pandemic has affected tobacco and cannabis use can inform tailored interventions to both support those who have decreases or quit and assist those who have increased use during the pandemic to reduce or cease their consumption.

Substance Use Among Residents of Homeless Shelters During the COVID-19 Pandemic: Findings From France

Objectives: To record the prevalence and risk factors of substance use amongst homeless persons during the COVID-19 pandemic.

Methods: The ECHO study consisted in two independent cross-sectional waves of data collection in the regions of Paris, Lyon, and Strasbourg during the Spring of 2020 (n = 530) and 2021 (n = 319). Factors associated with substance use were explored using generalised logistic regression models.

Results: The most prevalent substance used was tobacco (38%–43%), followed by alcohol (26%–34%). The use of both substances positively associated with each other, although risk factors varied depending on the substance. The only factors consistently associated with alcohol and tobacco use were being male, exposure to theft/assault and participants’ region of origin. Whilst the rate of tobacco use was relatively stable between Spring 2020 and 2021, alcohol use was more common in 2021.

Conclusion: These findings highlight a high prevalence of substance use amongst homeless persons. People experiencing homelessness face specific challenges in the context of the pandemic, alongside greater vulnerability to illness and low healthcare access, therefore the need to improve prevention and support services for substance abuse within this population is vital.

The COVID‑19 pandemic and the consumption of tobacco and nicotine-containing products: a literature review

The fight against the COVID‑19 pandemic has led to the implementation of unprecedented measures in countries, including self-isolation, which have had a significant impact on people’s behavior and could lead to a change in the consumption of tobacco and nicotine-containing products. This article provides an overview of studies evaluating smoking behavior change and its impact on the prevalence of tobacco and nicotine use in the community at the start of the pandemic.

Methods. The review included 31 published studies with data on smoking from more than 250,000 people from 24 countries that examined the following aspects of the problem: the association of smoking with COVID‑19 outcomes, identification of factors influencing smoking behavior at the beginning of the COVID‑19 pandemic, changing prevalence of tobacco and nicotine consumption at the start of the COVID‑19 pandemic, tobacco company actions during the pandemic, impact of misinformation about the association of smoking with COVID‑19 on consumers of tobacco and nicotine products, government actions to reduce the sale of tobacco and nicotine products during the pandemic time.

Findings. All researchers identified mixed responses from consumers of tobacco and nicotine-containing products early in the pandemic. In equal proportions, smokers increased their tobacco/nicotine intake or reduced their smoking intensity. To a lesser extent, consumers quit smoking, but there were respondents who reported starting smoking due to the COVID‑19 pandemic.

Conclusion. Monitoring the prevalence of consumption of tobacco and nicotine-containing products and the causes influencing it in the early periods of the COVID‑19 pandemic made it possible to identify additional effective measures, the implementation of which can prevent the growth of tobacco and nicotine consumption in such situations.