Cognitive predictors of COVID-19 mitigation behaviors in vaccinated and unvaccinated general population members.

BACKGROUND: Given the long-term threat posed by COVID-19, predictors of mitigation behaviors are critical to identify. Prior studies have found that cognitive factors are associated with some COVID-19 mitigation behaviors, but few studies employ representative samples and no prior studies have examined cognitive predictors of vaccination status. The purpose of the present study was to examine associations between cognitive variables (executive function, delay discounting, and future orientation) and COVID-19 mitigation behaviors (mask wearing, social distancing, hand hygiene and vaccination) in a population representative sample. METHODS: A population representative sample of 2,002 adults completed validated measures of delay discounting, future orientation, and executive function. Participants also reported frequency of mitigation behaviors, vaccination status, and demographics. RESULTS: Future orientation was associated with more mask wearing (ß = 0.160, 95 % CI [0.090, 0.220], p < 0.001), social distancing (ß = 0.150, 95 % CI [0.070, 0.240], p < 0.001), hand hygiene behaviors (ß = 0.090, 95 % CI [0.000, 0.190], p = 0.054), and a higher likelihood of being fully vaccinated (OR = 0.80, 95 % CI [0.670, 0.970], p = 0.020). Lower delay discounting predicted more consistent mask wearing (ß = -0.060, 95 % CI[-0.120, -0.010], p = 0.032) and being fully vaccinated (OR = 1.28, 95 % CI [1.13, 1.44], p < 0.001), while more symptoms of executive dysfunction predicted less mask wearing (ß = -0.240, 95 % CI [-0.320, -0.150] p < 0.001) and hand hygiene (ß = -0.220, 95 % CI [-0.320, -0.130], p < 0.001), but not vaccination status (OR = 0.96, 95 % CI [0.80, 1.16], p = 0.690) or social distancing behaviors (ß = -0.080, 95 % CI [-0.180, 0.020], p = 0.097). Overall, social distancing was the least well-predicted outcome from cognitive factors, while mask wearing was most well-predicted. Vaccination status was not a significant moderator of these effects of cognitive predictors on mitigation behaviors. CONCLUSIONS: Cognitive variables predict significant variability in mitigation behaviors. regardless of vaccination status. In particular, thinking about the future and discounting it less may encourage more consistent implementation of mitigating behaviors.

Do the vaccinated perform less distancing, mask wearing and hand hygiene? A test of the risk compensation hypothesis in a representative sample during the COVID-19 pandemic.

The "risk compensation hypothesis" holds that vaccinated individuals may be less motivated to protect themselves using other COVID-19 mitigation behaviors-e.g., masking, distancing and hand hygiene-given that they may percieve thier infection risk to be lower. The current investigation provides an empirical test of the risk compensation hypothesis in the COVID-19 context using prospective data from the Canadian COVID-19 Experiences Survey (CCES). The survey comprised 1,958 unvaccinated and fully vaccinated individuals drawn from a representative sample, using quota sampling to ensure substantial representation of unvaccinated individuals. Two waves of data were collected 6 months apart. Findings revealed that vaccinated individuals performed COVID-19 mitigation behaviors significantly more frequently than their unvaccinated counterparts, and they also showed lower rates of attenuation as the pandemic continued. In summary, our findings do not support the risk compensation hypothesis; instead they support the notion that people adopt vaccination and other protective behaviors in parallel.

Social cognitive predictors of vaccination status, uptake and mitigation behaviors in the Canadian COVID-19 Experiences survey.

Emerging infectious diseases like COVID-19 will remain a concern for the foreseeable future, and determinants of vaccination and other mitigation behaviors are therefore critical to understand. Using data from the first two waves of the Canadian COVID-19 Experiences Survey (CCES; N = 1,958; 66.56 % female), we examined social cognitive predictors of vaccination status, transition to acceptance and mitigation behaviors in a population-representative sample. Findings indicated that all social cognitive variables were strong predictors of mitigation behavior performance at each wave, particularly among unvaccinated individuals. Among those who were vaccine hesitant at baseline, most social cognitive variables predicted transition to fully vaccinated status at follow-up. After controlling for demographic factors and geographic region, greater odds of transitioning from unvaccinated at CCES Wave 1 to fully vaccinated at CCES Wave 2 was predicted most strongly by a perception that one's valued peers were taking up the vaccine (e.g., dynamic norms (OR = 2.13 (CI: 1.54,2.93)), perceived effectiveness of the vaccine (OR = 3.71 (CI: 2.43,5.66)), favorable attitudes toward the vaccine (OR = 2.80 (CI: 1.99,3.95)), greater perceived severity of COVID-19 (OR = 2.02 (CI: 1.42,2.86)), and stronger behavioral intention to become vaccinated (OR = 2.99 (CI: 2.16,4.14)). As a group, social cognitive variables improved prediction of COVID-19 mitigation behaviors (masking, distancing, hand hygiene) by a factor of 5 compared to demographic factors, and improved prediction of vaccination status by a factor of nearly 20. Social cognitive processes appear to be important leverage points for health communications to encourage COVID-19 vaccination and other mitigation behaviors, particularly among initially hesitant members of the general population.

The association between risk perceptions, anxiety, and self-reported changes in tobacco and nicotine product use due to COVID-19 in May-June 2020 in Israel.

BACKGROUND: Early in the COVID-19 pandemic, reports about a possible protective effect of nicotine on COVID-19 conflicted with messaging by public health organizations about increased risks of COVID-19 due to smoking. The ambiguous information the public received, combined with COVID-19-induced anxiety, may have led to changes in tobacco or other nicotine product use. This study examined changes in use of combustible cigarettes (CCs), nargila (hookah/waterpipe), e-cigarettes, and IQOS and home-smoking behaviors. We also assessed COVID-19 related anxiety and perceptions regarding changes in risk of COVID-19 severity due to smoking. METHODS: We used cross-sectional data from a population telephone survey that was conducted in Israel in the early phase of the COVID-19 pandemic (May-June 2020) and included 420 adult (age 18+) individuals who reported having ever used CCs (n = 391), nargila (n = 193), and/or electronic cigarettes (e-cigarettes)/heated tobacco products (e.g., IQOS) (n = 52). Respondents were asked about the effect that COVID-19 had on their nicotine product use (quit/reduced use, no change, increased use). We assessed changes in product use, risk perceptions, and anxiety using adjusted multinomial logistic regression analyses. RESULTS: Most respondents did not change their frequency of product use (CCs: 81.0%, nargila: 88.2%, e-cigarettes/IQOS: 96.8%). A small percentage either decreased use (CCs: 7.2%, nargila: 3.2%, e-cigarettes/IQOS:2.4%) or increased use (CCs:11.8%, nargila:8.6%, e-cigarettes/IQOS:+ 0.9%). 55.6% of respondents used a product in the home prior to COVID-19; but during the first lockdown COVID-19 period, a greater percentage increased (12.6%) than decreased (4.0%) their home use. Higher levels of anxiety due to COVID-19 were associated with increased home smoking (aOR = 1.59, 95% CI:1.04-2.42, p = 0.02). Many respondents believed that increased severity of COVID-19 illness was associated with CCs (62.0%) and e-cigarettes/vaping (45.3%), with uncertainty about the association being lower for CCs (20.5%) than for vaping (41.3%). CONCLUSIONS: While many respondents believed that nicotine product use (particularly CCs and e-cigarettes) was associated with increased risk of COVID-19 disease severity, the majority of users did not change their tobacco/nicotine use. The confusion about the relationship between tobacco use and COVID-19 calls for clear evidence-based messaging from governments. The association between home smoking and increased COVID-19-related stress suggests the need for campaigns and resources to prevent smoking in the home, particularly during times of stress.

Neurocognitive and psychiatric symptoms following infection with COVID-19: Evidence from laboratory and population studies.

Objective: The objective of the current investigation was to examine associations between symptomatic COVID-19 history, neurocognitive function, and psychiatric symptoms using cognitive task performance, functional brain imaging, and a prospective population survey. Methods: Study 1 was a laboratory study conducted between 3 May 2022 and 16 Nov 2022 involving 120 fully vaccinated community dwelling adults between 18 and 84 years of age (Mage = 31.96 (SD = 20.71), 63.3% female). In this cross-sectional study we examined the association between symptomatic COVID-19 infection history and performance on three computer tasks assessing cognitive function (Flanker interference, delay discounting and simple reaction time) and measured oxygen saturation within the prefrontal cortex using functional near infrared spectroscopy (fNIRS). Study 2 was a 2-wave population survey undertaken between 28 September 2021 and 21 March 2022, examining the prospective relationship between symptomatic COVID-19 and self-reported symptoms of cognitive dysfunction, depressive symptoms, anxiety symptoms, and agitation at 6-month follow up. The sample (N = 2,002, M age = 37.0, SD = 10.4; 60.8% female) was collected using a quota process to ensure equal numbers of vaccinated and unvaccinated individuals. Structural equation modelling with latent variables was performed on the population-level data, evaluating the fit of the proposed mediational model of symptomatic COVID-19 to psychiatric symptoms through cognitive dysfunction. Results: Findings from Study 1 revealed significant effects of symptomatic COVID-19 history on Flanker interference and delay discounting. Effects on flanker performance were significantly stronger among older adult women (effect: 9.603, SE = 4.452, t = 2.157, p = .033), and were accompanied by task-related changes cerebral oxygenation at the right superior frontal gyrus (F (1, 143.1) = 4.729, p = .031). Additionally, those with a symptomatic COVID-19 infection history showed evidence of amplified delay discounting (coefficient = 0.4554, SE = 0.2208, t = 2.0629, p = .041). In Study 2, baseline symptomatic COVID-19 history was associated with self-reported cognitive dysfunction and a latent variable reflecting psychiatric symptoms of anxiety, depression and agitation at follow-up. Mediational analyses revealed evidence of cognitive mediation of clinically significant psychiatric outcomes: depression (indirect effect = 0.077, SE = 0.026, p = .003) and generalized anxiety (indirect effect = 0.060, SE = 0.021, p = .004). Conclusions: Converging findings from laboratory and population survey data support the conclusion that symptomatic COVID-19 infection is associated with task-related, functional imaging and self-reported indices of cognitive dysfunction as well as psychiatric symptoms. In some cases, these findings appear to be more amplified among women than men, and among older women than younger.

Cognitive function following SARS-CoV-2 infection in a population-representative Canadian sample.

Background: SARS-CoV-2 infection is believed to adversely affect the brain, but the degree of impact on socially relevant cognitive functioning and decision-making is not well-studied, particularly among those less vulnerable to age-related mortality. The current study sought to determine whether infection status and COVID-19 symptom severity are associated with cognitive dysfunction among young and middled-aged adults in the general population, using self-reported lapses in executive control and a standardized decision-making task. Method: The survey sample comprised 1958 adults with a mean age of 37 years (SD â€‹= â€‹10.4); 60.8% were female. Participants reported SARS-CoV-2 infection history and, among those reporting a prior infection, COVID-19 symptom severity. Primary outcomes were self-reported symptoms of cognitive dysfunction assessed via an abbreviated form of the Barkley Deficits in Executive Functioning Scale (BDEFS) and performance on a validated delay-discounting task. Results: Young and middle-aged adults with a positive SARS-CoV-2 infection history reported a significantly higher number of cognitive dysfunction symptoms (M adj  â€‹= â€‹1.89, SE â€‹= â€‹0.08, CI: 1.74, 2.04; n â€‹= â€‹175) than their non-infected counterparts (M adj  â€‹= â€‹1.63, SE â€‹= â€‹0.08, CI: 1.47,1.80; n â€‹= â€‹1599; ߠ​= â€‹0.26, p â€‹= â€‹.001). Among those infected, there was a dose-response relationship between COVID-19 symptom severity and level of cognitive dysfunction reported, with moderate (ߠ​= â€‹0.23, CI: 0.003-0.46) and very/extremely severe (ߠ​= â€‹0.69, CI: 0.22-1.16) COVID-19 symptoms being associated with significantly greater cognitive dysfunction. These effects remained reliable and of similar magnitude after controlling for demographics, vaccination status, mitigation behavior frequency, and geographic region, and after removal of those who had been intubated during hospitalization. Very similar-and comparatively larger-effects were found for the delay-discounting task, and when using only PCR confirmed SARS-CoV-2 cases. Conclusions: Positive SARS-CoV-2 infection history and moderate or higher COVID-19 symptom severity are associated with significant symptoms of cognitive dysfunction and amplified delay discounting among young and middle-aged adults with no history of medically induced coma.

Brain and behavior in health communication: The Canadian COVID-19 Experiences Project.

Background: Vaccine hesitancy and inconsistent mitigation behavior performance have been significant challenges throughout the COVID-19 pandemic. In Canada, despite relatively high vaccine availability and uptake, willingness to accept booster shots and maintain mitigation behaviors in the post-acute phase of COVID-19 remain uncertain. The aim of the Canadian COVID-19 Experiences Project (CCEP) is threefold: 1) to identify social-cognitive and neurocognitive predictors of mitigation behaviors, 2) to identify optimal communication strategies to promote vaccination and mitigation behaviors, and 3) to examine brain health outcomes of SARS-CoV-2 infection and examine their longevity. Methods: The CCEP is comprised of two components: a conventional population survey (Study 1) and a functionally interconnected laboratory study (Study 2). Study 1 will involve 6 waves of data collection. Wave 1, completed between 28 September and 21 October 2021, recruited 1,958 vaccine-hesitant (49.8%) and fully vaccinated (50.2%) adults using quota sampling to ensure maximum statistical power. Measures included a variety of social cognitive (e.g., beliefs, intentions) and neurocognitive (e.g., delay discounting) measures, followed by an opportunity to view and rate a set of professionally produced COVID-19 public service announcement (PSA) videos for perceived efficacy. Study 2 employs the same survey items and PSAs but coupled with lab-based eye tracking and functional near-infrared spectroscopy (fNIRS) to directly quantify neural indicators of attention capture and self-reflection in a smaller community sample. In the final phase of the project, subjective impressions and neural indicators of PSA efficacy will be compared and used to inform recommendations for construction of COVID-19 PSAs into the post-acute phase of the pandemic. Discussion: The CCEP provides a framework for evaluating effective COVID-19 communication strategies by levering conventional population surveys and the latest eye-tracking and brain imaging metrics. The CCEP will also yield important information about the brain health impacts of SARS-CoV-2 in the general population, in relation to current and future virus variants as they emerge.

Cognitive dysfunction following SARS-CoV-2 infection in a population-representative Canadian sample: A cross sectional study

Background Prior studies have documented reliable associations between SARS-CoV-2 infection and adverse cognitive impact, at least in older adults. The current study sought to determine whether SARS-CoV-2 infection and COVID-19 symptom severity are associated with cognitive dysfunction among young and middled-aged adults in the general population. Method The Canadian COVID-19 Experiences Project (CCEP) survey involves 1958 adults with equal representation of vaccinated and vaccine hesitant adults between the ages of 18 and 54 years. The sample comprised 1958 adults with a mean age of 37 years (SD = 10.4);60.8% were female. The primary outcome was symptoms of cognitive dysfunction assessed via an abbreviated form of the Barkley Deficits in Executive Functioning Scale (BDEFS) and performance on a validated delay-discounting task. Results Young and middle-aged adults with a positive SARS-CoV-2 infection history reported a significantly higher number of symptoms of executive dysfunction (Madj = 1.89, SE = 0.08, CI: 1.74, 2.04;n = 175) than their non-infected counterparts (Madj = 1.63, SE = 0.08, CI: 1.47,1.80;n = 1599;β = 0.26, p = .001). Among those infected, there was a dose-response relationship between COVID-19 symptom severity and level of executive dysfunction, with moderate (β = 0.23, CI: 0.003–0.46) and very/extremely severe (β = 0.69, CI: 0.22–1.16) COVID-19 symptoms being associated with significantly greater dysfunction, compared to asymptomatic. These effects remained reliable and of similar magnitude after controlling for demographics, vaccination status, mitigation behavior frequency, and geographic region, and after removal of those who had been intubated during hospitalization. Very similar—and comparatively stronger—effects were found for the delay-discounting task, and when using only PCR confirmed SARS-CoV-2 cases. Conclusions Positive SARS-CoV-2 infection history and COVID-19 symptom severity are associated with executive dysfunction among young and middle-aged adults with no history of medically induced coma. These findings are evident on self-reported and task-related indicators of cognitive function.

Attitudes towards smoking and COVID-19, and changes in smoking behaviors before and after the outbreak of COVID-19: A nationwide cross-sectional survey study in China.

INTRODUCTION: China has more than 300 million current smokers. There is a controversy over smokers' risk of COVID-19 infection. Smoking is a risk factor for COVID-19 disease progression, and the outbreak of COVID-19 may change people's smoking behaviors. This study assessed people's attitudes towards 'smoking and COVID-19' and changes of smoking behaviors before and after the outbreak of COVID-19. METHODS: A cross-sectional web survey of 11009 adults in China was conducted between 7 May and 3 August 2020. Attitudes towards 'smoking and COVID-19' were compared among non-smokers (n=8837), ex-smokers (n=399) and current smokers (n=1773), and changes in smoking behaviors before and after the outbreak of COVID-19 were assessed among current smokers. RESULTS: Fewer current smokers (26.2%) agreed with the statement that 'Current smokers are more likely than ex-smokers or non-smokers to contract COVID-19' compared with non-smokers (53%) or ex-smokers (41.4%); fewer current smokers (55.9%) agreed with the statement 'If contracted, current smokers are more likely than ex-smokers or non-smokers to risk disease progression' compared with non-smokers (75.5%) or ex-smokers (68.7%). There were no changes in cigarettes smoked per day (mean ± SD: 13.3 ± 9.55 vs 13.4 ± 9.69, p=0.414), percentage of daily smokers (70.8% vs 71.1%, p=0.882) and percentage of smokers with motivation to quit (intend to quit within the next 6 months, 9.4% vs 10.9%, p=0.148) before and after the outbreak of COVID-19. CONCLUSIONS: The survey found that fewer current smokers agreed that smoking is a risk-factor for COVID-19 compared with non-smokers or ex-smokers. Among current smokers, there were no changes in their cigarette consumption and motivation to quit before and after the outbreak of COVID-19. More efforts are needed to educate smokers about the health risks of smoking, as well as efforts to promote their motivation to quit.

Was COVID-19 associated with increased cigarette purchasing, consumption, and smoking at home among US smokers in early 2020? Findings from the US arm of the International Tobacco Control (ITC) Four Country Smoking and Vaping Survey.

Evidence of the impact of COVID-19 and mandatory stay-at-home orders on cigarette smoking is mixed. In the United States, household tobacco purchases increased in early 2020, but it is unclear whether this was associated with increased smoking. Using individual-level, longitudinal data from a representative cohort of US smokers (n = 3046), this study tested whether (1) carton purchases of cigarettes increased in early 2020 relative to the same calendar period in 2018, (2) more smokers permitted smoking inside their homes, and (3) smokers increased the number of cigarettes they smoked per day. Weighted multivariable logistic regression tested whether trends in carton purchasing and smoke-free homes differed in 2020 compared to 2018 while weighted multivariable linear regression tested whether trends in cigarette consumption differed in 2020 compared to 2018. Overall, 24.0% of US smokers last purchased cigarettes by the carton in early 2018; this increased to 28.8% in early 2020 (p = 0.007). Average daily cigarette consumption and the percentage of smokers reporting that smoking was not allowed inside their homes did not differ between 2018 and 2020 (p = 0.92 and p = 0.054, respectively). Overall, these findings suggest that COVID-19 mitigation measures implemented in the spring of 2020 had limited impact on the smoking behavior of US adult smokers.

Smokers' cognitive and behavioural reactions during the early phase of the COVID-19 pandemic: Findings from the 2020 ITC Four Country Smoking and Vaping Survey.

INTRODUCTION: COVID-19 is primarily a respiratory illness, and smoking adversely impacts the respiratory and immune systems; this confluence may therefore incentivize smokers to quit. The present study, conducted in four high-income countries during the first global wave of COVID-19, examined the association between COVID-19 and: (1) thoughts about quitting smoking; (2) changes in smoking (quit attempt, reduced or increased smoking, or no change); and (3) factors related to a positive change (making a quit attempt or reducing smoking) based on an adapted framework of the Health Belief Model. METHODS: This cross-sectional study included 6870 adult smokers participating in the Wave 3 (2020) ITC Four Country Smoking and Vaping Survey conducted in Australia, Canada, England, and United States (US). These four countries had varying responses to the pandemic by governments and public health, ranging from advising voluntary social distancing to implementing national and subnational staged lockdowns. Considering these varying responses, and the differences in the number of confirmed cases and deaths (greatest in England and the US and lowest in Australia), smoking behaviours related to COVID-19 may have differed between countries. Other factors that may be related to changes in smoking because of COVID-19 were also explored (e.g., sociodemographics, nicotine dependence, perceptions about personal and general risks of smoking on COVID-19). Regression analyses were conducted on weighted data. RESULTS: Overall, 46.7% of smokers reported thinking about quitting because of COVID-19, which differed by country (p<0.001): England highest (50.9%) and Australia lowest (37.6%). Thinking about quitting smoking because of COVID-19 was more frequent among: females, ethnic minorities, those with financial stress, current vapers, less dependent smokers (non-daily and fewer cigarettes smoked/day), those with greater concern about personal susceptibility of infection, and those who believe COVID-19 is more severe for smokers. Smoking behaviour changes due to COVID-19 were: 1.1% attempted to quit, 14.2% reduced smoking, and 14.6% increased smoking (70.2% reported no change). Positive behaviour change (tried to quit/reduced smoking) was reported by 15.5% of smokers, which differed by country (p = 0.02), where Australia had significantly lower rates than the other three countries. A positive behavioural smoking change was more likely among smokers with: lower dependence, greater concern about personal susceptibility to infection, and believing that COVID-19 is more severe for smokers. CONCLUSIONS: Though nearly half of smokers reported thinking about quitting because of COVID-19, the vast majority did not change their smoking behaviour. Smokers were more likely to try and quit or reduce their smoking if they had greater concern about susceptibility and severity of COVID-19 related to smoking. Smokers in Australia were least likely to reduce or try to quit smoking, which could be related to the significantly lower impact of COVID-19 during the early phase of the pandemic relative to the other countries.

Biobehavioral Aspects of the COVID-19 Pandemic: A Review.

OBJECTIVE: This review highlights the scope and significance of the coronavirus disease 2019 (COVID-19) pandemic with a focus on biobehavioral aspects and critical avenues for research. METHODS: A narrative review of the published research literature was undertaken, highlighting major empirical findings emerging during the first and second waves of the COVID-19 pandemic. RESULTS: Interactions among biological, behavioral, and societal processes were prominent across all regions of the globe during the first year of the COVID-19 emergency. Affective, cognitive, behavioral, socioeconomic, and technological factors all played a significant role in the spread of infection, response precautions, and outcomes of mitigation efforts. Affective symptoms, suicidality, and cognitive dysfunction have been widely described consequences of the infection, the economic fallout, and the necessary public health mitigation measures themselves. The impact of COVID-19 may be especially serious for those living with severe mental illness and/or chronic medical diseases, given the confluence of several adverse factors in a manner that appears to have syndemic potential. CONCLUSIONS: The COVID-19 pandemic has made clear that biological and behavioral factors interact with societal processes in the infectious disease context. Empirical research examining mechanistic pathways from infection and recovery to immunological, behavioral, and emotional outcomes is critical. Examination of how emotional and behavioral factors relate to the pandemic-both as causes and as effects-can provide valuable insights that can improve management of the current pandemic and future pandemics to come.

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. 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.

Considerations for an Individual-Level Population Notification System for Pandemic Response: A Review and Prototype.

The outbreak of the coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, spread worldwide after its emergence in China. Whether rich or poor, all nations are struggling to cope with this new global health crisis. The speed of the threat's emergence and the quick response required from public health authorities and the public itself makes evident the need for a major reform in pandemic surveillance and notification systems. The development and implementation of a graded, individual-level pandemic notification system could be an effective tool to combat future threats of epidemics. This paper describes a prototype model of such a notification system and its potential advantages and challenges for implementation. Similar to other emergency alerts, this system would include a number of threat levels (level 1-5) with a higher level indicating increasing severity and intensity of safety measures (eg, level 1: general hygiene, level 2: enhanced hygiene, level 3: physical distancing, level 4: shelter in place, and level 5: lockdown). The notifications would be transmitted to cellular devices via text message (for lower threat levels) or push notification (for higher threat levels). The notification system would allow the public to be informed about the threat level in real time and act accordingly in an organized manner. New Zealand and the United Kingdom have recently launched similar alert systems designed to coordinate the ongoing COVID-19 pandemic response more efficiently. Implementing such a system, however, faces multiple challenges. Extensive preparation and coordination among all levels of government and relevant sectors are required. Additionally, such systems may be effective primarily in countries where there exists at least moderate trust in government. Advance and ongoing public education about the nature of the system and its steps would be an essential part of the system, such that all members of the public understand the meaning of each step in advance, similar to what has been established in systems for other emergency responses. This educational component is of utmost importance to minimize adverse public reaction and unintended consequences. The use of mass media and local communities could be considered where mobile phone penetration is low. The implementation of such a notification system would be more challenging in developing countries for several reasons, including inadequate technology, limited use of data plans, high population density, poverty, mistrust in government, and tendency to ignore or failure to understand the warning messages. Despite the challenges, an individual-level pandemic notification system could provide added benefits by giving an additional route for notification that would be complementary to existing platforms.