Have there been sustained impacts of the Covid-19 pandemic on trends in smoking prevalence, uptake, quitting, use of treatment, and relapse? A monthly population study in England, 2017-2022 (preprint)

Background: This study aimed to examine whether there have been sustained impacts of the Covid-19 pandemic on smoking patterns in England. Methods: Data were from 101,960 adults ([≥]18y) participating in a monthly representative household survey between June-2017 and August-2022. Interview were conducted face-to-face until March 2020 and via telephone thereafter. Generalised additive models estimated associations of the pandemic onset (March-2020) with current smoking, uptake, cessation, quit attempts, medium-term abstinence, and use of support. Models adjusted for seasonality, sociodemographic characteristics, and (where relevant) dependence and tobacco control mass-media expenditure. Findings: Before the Covid-19 pandemic, smoking prevalence fell by 5.2% per year; this rate of decline slowed to 0.3% per year during the pandemic (RR{Delta}trend=1.06, 95%CI=1.02-1.09). This slowing was evident in more but not less advantaged social grades (RR{Delta}trend=1.15, 1.08-1.21; RR{Delta}trend=1.00, 0.96-1.05). There were sustained step-level changes in different age groups: a 34.9% (95%CI=17.7-54.7%) increase in smoking prevalence among 18-24-year-olds, indicating a potential rise in uptake, in contrast to a 13.6% (95%CI=4.4-21.9%) decrease among 45-65-year-olds. There were sustained increases in quitting among past-year smokers, with a 120.4% (95%CI=79.4-170.9%) step-level increase in cessation and a 41.7% (95%CI=29.7-54.7%) increase in quit attempts. Interpretation: In England, the rate of decline in adult smoking prevalence stagnated during the Covid-19 pandemic. Potential reductions in smoking prevalence among middle-aged adults and sustained increases in quitting among smokers may have been offset by a sustained rise in uptake among young adults. The slowing in the rate of decline was pronounced in more advantaged social grades.

Moderators of changes in smoking, drinking, and quitting behaviour associated with the first Covid-19 lockdown in England (preprint)

Aim: To estimate changes in smoking, drinking, and quitting behaviour from before to during the first Covid-19 lockdown in England, and whether changes differed by age, sex, or social grade. Design: Representative cross-sectional surveys of adults, collected monthly between August 2018 and July 2020. Setting: England. Participants: 36,980 adults ([≥]18y). Measurements: Independent variables were survey month (pre-lockdown: August-February vs. lockdown months: April-July) and year (pandemic: 2019/20 vs. comparator: 2018/19). Smoking outcomes were smoking prevalence, cessation, quit attempts, quit success, and use of evidence-based or remote cessation support. Drinking outcomes were high-risk drinking prevalence, alcohol reduction attempts, and use of evidence-based or remote support. Moderators were age, sex, and occupational social grade (ABC1=more advantaged/C2DE=less advantaged). Findings: Relative to changes over the same time period in 2018/19, lockdown was associated with significant increases in smoking prevalence (+24.7% in 2019/20 vs. 0.0% in 2018/19, ORadj=1.35[95%CI=1.12-1.63]) and quit attempts (+39.9% vs. -22.2%, ORadj=2.48[1.76-3.50]) among 18-34 year-olds, but not older groups. Increases in cessation (+156.4% vs. -12.5%, ORadj=3.08[1.86-5.09]) and the success rate of quit attempts (+99.2% vs. +0.8%, ORadj=2.29[1.31-3.98]) were also observed, and did not differ significantly by age, sex, or social grade. Lockdown was associated with a significant increase in high-risk drinking prevalence across all sociodemographic groups (+39.5% vs. -7.8%, ORadj=1.80[1.64-1.98]), with particularly high increases among women (ORadj=2.17[1.87-2.53]) and social grades C2DE (ORadj=2.34[2.00-2.74]). Alcohol reduction attempts increased significantly among high-risk drinkers from social grades ABC1 (ORadj=2.31[1.78-3.00]) but not C2DE (ORadj=1.25[0.83-1.88]), with larger increases among those aged 18-34 (ORadj=2.56[1.72-3.81]) and [≥]60 (ORadj=1.43[1.05-1.95]) than 35-59 (ORadj=2.51[1.51-4.18]). There were few significant changes in use of support for smoking cessation or alcohol reduction, although samples were small. Conclusions: In England, the first Covid-19 lockdown was associated with increased smoking prevalence among younger adults, and increased high-risk drinking prevalence among all adults. Smoking cessation activity also increased: more younger smokers made quit attempts during lockdown and more smokers quit successfully. Socioeconomic disparities in drinking behaviour were evident: high-risk drinking increased by more among women and those from less advantaged social grades (C2DE) but the rate of reduction attempts increased only among the more advantaged social grades (ABC1).

Negative vaccine attitudes and intentions to vaccinate against Covid-19 in relation to smoking status: a population survey of UK adults (preprint)

IntroductionWe examined differences in negative attitudes towards vaccines in general, and intentions to vaccinate against Covid-19 specifically, by smoking status in a large sample of adults in the UK. MethodData were from 29,148 adults participating in the Covid-19 Social Study in September-October 2020. Linear regression analyses examined associations between smoking status (current/former/never) and four types of general negative vaccine attitudes: mistrust of vaccine benefit, worries about unforeseen effects, concerns about commercial profiteering, and preference for natural immunity. Multinomial logistic regression examined associations between smoking status and uncertainty and unwillingness to be vaccinated for Covid-19. Covariates included sociodemographic characteristics and diagnosed health conditions. ResultsRelative to never and former smokers, current smokers reported significantly greater mistrust of vaccine benefit, were more worried about unforeseen future effects, had greater concerns about commercial profiteering, and had a stronger preference for natural immunity (Badjs 0.16-0.36, p<0.001). Current smokers were more likely to be uncertain (27.6% vs. 22.7% of never smokers: RRadj 1.43 [95%CI 1.31-1.56]; vs. 19.3% of former smokers: RRadj 1.55 [1.41-1.73]) or unwilling (21.5% vs. 11.6% of never smokers: RRadj 2.12 [1.91-2.34]; vs. 14.7% of former smokers: RRadj 1.53 [1.37-1.71]) to receive a Covid-19 vaccine. ConclusionsCurrent smokers hold more negative attitudes towards vaccines in general, and are more likely to be undecided or unwilling to vaccinate against Covid-19, compared with never and former smokers. With a disproportionately high number of smokers belonging to socially clustered and disadvantaged socioeconomic groups, lower vaccine uptake in this group could also exacerbate health inequalities. ImplicationsThese results suggest that without intervention, smokers will be less likely than non-smokers to take up the offer of a Covid-19 vaccine when offered. Targeted policy action may be required to ensure low uptake of Covid-19 vaccination programmes does not compound health inequalities between smokers and non-smokers.

Associations between vaping and Covid-19: cross-sectional findings from the HEBECO study (preprint)

AimsTo explore i) associations between vaping and self-reported diagnosed/suspected Covid-19; ii) changes in vaping since Covid-19 and factors associated with these changes; iii) whether Covid-19 motivated current or recent ex-vapers to quit. MethodsCross-sectional online survey of 2791 UK adults recruited 30/04/2020-14/06/2020. Participants self-reported data on sociodemographic characteristics, diagnosed/suspected Covid-19, vaping status, changes in vaping and motivation to quit vaping since Covid-19. ResultsThere were no differences in diagnosed/suspected Covid-19 between never, current and ex-vapers. Bayes factors indicated there was sufficient evidence to rule out small negative (protective) associations between vaping status and diagnosed/suspected Covid-19. Among current vapers (n=397), 9.7% (95% CI 6.8-12.6%) reported vaping less than usual since Covid-19, 42.0% (37.2-46.9%) reported vaping more, and 48.3% (43.4-53.2%) reported no change. In adjusted analyses, vaping less was associated with being female (aOR=3.40, 95% CI 1.73-6.71), not living with children (aOR=4.93, 1.15-21.08) and concurrent smoking (aOR=8.77, 3.04-25.64), while vaping more was associated with being younger (aOR=5.26, 1.37-20.0), living alone (aOR=2.08, 1.14-3.85), and diagnosed/suspected Covid-19 (aOR=4.72, 2.60-8.62). Of current vapers, 32.2% (95% CI 27.5-36.8%) were motivated to quit vaping since Covid-19, partly motivated by Covid-19, and 17.4%, (9.7-26.3%) of recent ex-vapers quit vaping due to Covid-19. ConclusionsAmong UK adults, self-reported diagnosed/suspected Covid-19 was not associated with vaping status. Half of current vapers changed their vaping consumption since Covid-19, with the majority reporting an increase, and a minority was motivated to quit due to Covid-19. RegistrationThe analysis plan was pre-registered, and it is available at https://osf.io/6j8z3/ HighlightsO_LINo difference found in diagnosed/suspected Covid-19 between never, current and ex-vapers C_LIO_LIHalf of current vapers changed their vaping consumption since Covid-19 C_LIO_LIMotivation to quit vaping was partly related to Covid-19 C_LI

Factors associated with drinking behaviour during COVID-19 social distancing and lockdown among adults in the UK (preprint)

AimTo assess what factors were associated with reported changes to usual alcohol drinking behaviour during the start of lockdown in the UK. DesignOnline cross-sectional survey from 21st March to 4th April 2020. SettingUK. Participants30,375 adults aged [≥] 18y. MeasurementsChanges in drinking over the past week, sociodemographic characteristics, diagnosed or suspected COVID-19, adherence to COVID-19 protective behaviours, stress about COVID-19, finances or boredom, recent drop in household income, key worker status, and health conditions. FindingsOf 22,113 drinkers (65.7% of analytic sample), 48.1% (95% CI=47.0-49.1%) reported drinking about the same as usual, 25.7% (24.8-26.6%) reported drinking less than usual, and 26.2% (25.4-27.1%) reported drinking more than usual over the past week. Drinking less than usual was independently associated with being younger (OR=0.88 [95% CI=0.83-0.93]), male (OR=0.76 [0.68-0.84]), of an ethnic minority (OR=0.76 [0.61-0.97]), low annual household income (OR=0.74 [0.66-0.83]), having diagnosed or suspected COVID-19 (OR=2.04 [1.72-2.41]), adhering to COVID-19 protective behaviours (OR=1.58 [1.08-2.32]), being significantly stressed about becoming seriously ill from COVID-19 (OR=1.26 [1.08-1.48]) and not being a key worker (OR=0.87 [0.76-0.99]). Drinking more than usual was independently associated with being younger (OR=0.73 [0.69-0.78]), female (OR=1.36 [1.22-1.51]), post-16 qualifications (OR=1.21 [1.04-1.40]), high annual household income (OR=1.43 [1.27-1.61]), being significantly stressed about catching (OR=1.22 [1.03-1.45]) or becoming seriously ill from COVID-19 (OR=1.28 [1.10-1.48]), being significantly stressed about finances (OR=1.43 [1.24-1.66]), and having a diagnosed anxiety disorder (OR=1.24 [1.05-1.46]). ConclusionsIn a representative sample of adults in the UK, about half of drinkers reported drinking the same amount of alcohol as usual during the start of the COVID-19 related lockdown, with a quarter drinking more and a quarter drinking less than usual. Drinking more than usual was associated with being younger, female, high socioeconomic position, having an anxiety disorder, and being stressed about finances or COVID-19. These groups may benefit targeted alcohol reduction support if there are further periods of lockdown. RegistrationThe analysis plan was pre-registered on Open Science Framework (https://osf.io/pnrhq/).

COVID-19, smoking, vaping and quitting: A representative population survey in England (preprint)

AimsTo explore 1) associations between suspected SARS-CoV-2 infection, hand washing, smoking status, e-cigarette use, and nicotine replacement therapy (NRT) use and 2) whether COVID-19 has prompted smoking and vaping quit attempts, and more smoking inside the home. DesignCross-sectional household surveys of a representative sample of the population in England from April-May 2020. ParticipantsThe sample included 3,285 adults aged [≥]18 years. MeasurementsParticipants who reported they definitely or think they had coronavirus were classified as having a suspected SARS-CoV-2 infection. Participants were asked how often they wash their hands after returning home, before eating, before preparing foods or before touching their face. They were also asked whether, due to COVID-19, they had i) attempted to quit smoking, ii) attempted to quit vaping, and iii) changed the amount they smoke inside the home. FindingsOdds of suspected SARS-CoV-2 infection were significantly greater among current smokers (20.9%, adjusted odds ratio [ORadj]=1.34, 95% confidence interval [CI]=1.04-1.73) and long-term (>1-year) ex-smokers (16.1%, ORadj=1.33, 95%CI=1.05-1.68) than never smokers (14.5%). Recent (<1-year) ex-smokers had non-significantly greater odds of suspected infection (22.2%, ORadj=1.50, 95%CI=0.85-2.53, Bayes factor= 0.55-1.17). Bayes factors indicated there was sufficient evidence to rule out large differences in suspected SARS-CoV-2 infection by NRT use and medium differences by e-cigarette use. With the exception of hand washing before face touching, engagement in hand washing behaviours was high (>85%) regardless of nicotine use. A minority (12.2%) of past-year smokers who made a quit attempt in the past three months were triggered by COVID-19, and approximately one-in-ten current e-cigarette users reported attempting to quit vaping because of COVID-19. Most people reported smoking the same amount inside the home. ConclusionsIn a representative sample of the adult population in England, current smokers and long-term ex-smokers had higher odds of suspected SARS-CoV-2 infection than never smokers, but there were no large differences by NRT or e-cigarette use. In general, engagement in hand washing was high regardless of nicotine or tobacco use. A minority of past-year smokers and current e-cigarette users, respectively, attempted to quit smoking/vaping due to COVID-19.

Association of the Covid-19 lockdown with smoking, drinking, and attempts to quit in England: an analysis of 2019-2020 data (preprint)

AimTo examine changes in smoking, drinking, and quitting/reduction behaviour following the Covid-19 lockdown in England. Design/settingMonthly cross-sectional surveys representative of the adult population in England, aggregated before (April 2019 through February 2020) versus after (April 2020) the lockdown. Participants20,558 adults ([≥]16y). MeasurementsThe independent variable was the timing of the Covid-19 lockdown in England (before vs. after March 2020). Dependent variables were: prevalence of smoking and high-risk drinking; past-year cessation and quit attempts (among past-year smokers); past-year attempts to reduce alcohol consumption (among high-risk drinkers); and use of evidence-based (e.g., prescription medication/face-to-face behavioural support) and remote support (telephone support/websites/apps) for smoking cessation and alcohol reduction (among smokers/high-risk drinkers who made a quit/reduction attempt). Covariates included age, sex, social grade, region, and level of nicotine and alcohol dependence (as relevant). FindingsThe Covid-19 lockdown was not associated with a significant change in smoking prevalence (17.0% (after) vs. 15.9% (before), C)R=1.09[95%CI 0.95-1.24]), but was associated with increases in the rate of quit attempts (39.6% vs. 29.1%, ORadj=1.56[l.23-1.98]) and cessation (8.8% vs. 4.1%, ORadj=2.63[1.69-4.09]) among past-year smokers. Among smokers who tried to quit, there was no significant change in use of evidence-based support (50.0% vs. 51.5%, ORadj=1.10[0.72-1.68]) but use of remote support increased (10.9% vs. 2.7%, ORadj=3.59[1.56-8.23]). Lockdown was associated with increases in the prevalence of high-risk drinking (38.3% vs. 25.1%, OR=1.85[1.67-2.06]) but also alcohol reduction attempts by high-risk drinkers (28.5% vs. 15.3%, ORadr2.16[1.77-2.64]). Among high-risk drinkers who made a reduction attempt, use of evidence-based support decreased (1.2% vs. 4.0%, ORadj=0.23[0.05-0.97]) and there was no significant change in use of remote support (6.9% vs. 6.1%, ORadj=1.32[0.64-2.75]). ConclusionsIn England, prevalence of high-risk drinking but not smoking has increased since the Covid-19 lockdown. Smokers and high-risk drinkers are more likely than before lockdown to report trying to quit smoking or reduce their alcohol consumption, and rates of smoking cessation are higher. Smokers are no less likely than before lockdown to use cessation support, with increased uptake of remote support. However, use of evidence-based support for alcohol reduction by high-risk drinkers has decreased, with no compensatory increase in use of remote support.

COVID-19, smoking, and inequalities: a cross-sectional survey of adults in the UK (preprint)

Objectives: To examine associations between smoking and COVID-19 relevant outcomes, taking into account the influence of inequalities and adjusting for potential confounding variables. Design: Online cross-sectional survey. Setting: UK. Participants: 53,002 men and women aged [≥]18y. Main outcome measures: Confirmed and suspected COVID-19, worry about catching and becoming seriously ill from COVID-19, and adherence to protective behaviours. Socioeconomic position was defined according to highest level of education (post-16 qualifications: yes/no). Results: Compared with never smokers (0.3% [95%CI 0.2-0.3%]), prevalence of confirmed COVID-19 was higher among current (0.6% [0.4-0.8%]) but not ex-smokers (0.2% [0.2-0.3%]). The associations were similar before (current: OR 2.14 [1.49-3.08]; ex-smokers: OR 0.73 [0.47-1.14]) and after (current: OR 1.79 [1.22-2.62]; ex-smokers: OR 0.85 [0.54-1.33]) adjustment for potential confounders. For current smokers, this was moderated by socioeconomic position, with higher rates relative to never smokers only seen in those without post-16 qualifications (OR 3.53 [2.04-6.10]). After including suspected cases, prevalence was higher among current smokers (11.2% [10.6-11.9%], OR 1.11 [1.03-1.20]) and ex-smokers (10.9% [10.4-11.5%], OR 1.07 [1.01-1.15]) than never smokers (10.2% [9.9-10.6%]), but remained higher only among ex-smokers after adjustment (OR 1.21 [1.13-1.29]). Current and ex-smokers had higher odds than never smokers of reporting significant stress about catching (current: OR 1.43 [1.35-1.52]; ex-smokers: OR 1.15 [1.09-1.22]) or becoming seriously ill from COVID-19 (current: OR 1.34 [1.27-1.43]; ex-smokers: OR 1.22 [1.16-1.28]). Adherence to recommendations to prevent the spread of COVID-19 was generally high (96.3% [96.1-96.4%]), but lower among current than never smokers (OR 0.70 [0.62-0.78]). Conclusions: When assessed by self-report in a population sample, current smoking was independently associated with confirmed COVID-19 infection. There were socioeconomic disparities, with the association only apparent among those without post-16 qualifications. Smokers reported lower adherence to guidelines despite being more worried than non-smokers about catching or becoming seriously ill from COVID-19.