Characterising changes in smoking behaviour among people with and without COVID-19 infection: Representative cross-sectional surveys in England
Creators: name: Cox, Sharon
Publisher: name: Open Science Framework
Year: 2021
Subjects: subject: Social and Behavioral Sciences
subject: COVID-19; Smoking; Tobacco

description: Early in the COVID-19 pandemic, there was a strong a priori assumption that smoking was an increased risk factor for disease severity owing to a high incidence of respiratory illness and pre-existing poor lung function in long-term smokers (1,2). However, results of a living systematic meta-analysis indicate that current smokers appear to be at reduced risk of COVID-19 infection relative to non-smokers, and there is inconclusive evidence that smokers who are infected are at increased risk of more severe disease (3). Former smokers appear to be at increased risk of severe disease and mortality from COVID-19 (3). Nonetheless, the pandemic has triggered some smokers to consider improving their health; we found that rates of smoking cessation were higher post March 2020 lockdown compared with the pre-pandemic period in England (4). Evidence from the UK also shows that concern around infection is more common in current compared with never smokers, and smokers report being less able to enact personal protective behaviours (5). In the UK, several health agencies recognised this as a ‘tobacco teachable moment’, and there was a well a publicised ‘Quit for Covid’ public health campaign (6). Even within the context of the pandemic, smoking continues to be a public health priority. This is salient in England, where there is less than a decade to achieve the public health goal of being smoke free by 2030 (defined as a smoking prevalence of &lt;5%) (7). Therefore, understanding how smoking has changed because of the pandemic is important for assessing the wider impact of the pandemic upon public health goals. Further, in developing theories of behaviour change, it is also important to assess whether the context of the pandemic, and specifically having COVID-19, is associated with changes in smoking. It is plausible that living through the pandemic without being infected by the virus would trigger quitting smoking. The risks of combustible tobacco to respiratory health are well known, and the impact of lockdown restrictions on daily routines (e.g., working from home, reduced social contact) may have helped smokers to avoid their usual environmental and social triggers and provided an opportune moment to break the habit. However, the added experience of being infected may be especially motivating. Symptoms associated with COVID-19 (e.g., cough, trouble breathing), or an extended period of sickness, may make inhaling smoke more unpleasant. If illness has been particularly severe, this may have led to hospitalisation and lack of opportunity to smoke. On the other hand, having recovered from COVID-19 might be associated with reduced motivation to quit if any threat associated with smoking in relation to COVID-19 is perceived to have passed. To date, large population surveys show changes in quitting behaviour, including increased quit attempts, quit success, and uptake of smoking cessation support (4,8). However, little is known as to how COVID-19 infection status has influenced these changes. Evidence is still accumulating and samples early on were too small for such analyses. In an earlier analysis, we found that among smokers in England, a minority (12.2%) of quit attempts were reportedly motivated by COVID‐19 (5). We also reported changes in smoking behaviour, reducing smoking during lockdown was associated with being a light smoker (&lt;10 cigarettes per day) and increasing smoking with being a heavy smoker (&gt;10 cigarettes per day). Since the data presented above (5,9) were collected, there have been several important developments. Firstly, England has experienced two more lockdowns. Second, the absolute death and population infection rate has risen. These longer-term effects of the pandemic may have continued to impact people’s decisions to change their behaviour, especially modifying behaviours like smoking. Third, there has been an increase in access to and uptake of COVID-19 testing in England, and thus, the accuracy of whether people have had COVID-19 in self-reports is now likely to be greater than early in the history of the pandemic. Assessing the association of COVID-19 infection status on current and future changes to smoking with greater accuracy is now possible.