A Qualitative Study of the Impact of COVID-19 on Smoking Behavior for Participants in a Post-Hospitalization Smoking Cessation Trial
Abstract
:1. Introduction
2. Materials and Methods
2.1. Parent Study Participants
2.2. Baseline Survey Measures
2.3. COVID Qualitative Interview
2.4. COVID Qualitative Analysis
3. Results
3.1. Participant and Call Characteristics
3.2. Identified Impacts and Reactions to COVID-19
3.3. Stress during COVID-19
3.3.1. Coping Mechanisms
Examples
- Increased smoking: smoking as a primary coping mechanism
- ○
- “I think people stress. And if you smoke, that’s your go-to. You know what I mean? You’re not thinking about putting on a patch. You’re like, ‘I want a cigarette’… It’s detrimental to people who [are] trying to quit… and people panic. Smokers, that’s the first thing they’re picking up.”—Male, MA
- Continued smoking: physical activity as a primary coping mechanism
- ○
- “Well, like I said, the extra thoughts of stress of things going on, of getting it, of my family getting it, has not put me in the best position mentally to work my program… I do my walking and my exercises… to cope with my stress.”—Male, PA
- Decreased smoking: cognitive (prayer) and companionship (pets)
- ○
- “Because I put my faith in the good Lord… And that has helped me to keep my stress level down… I do that and pay attention to my little dog and stuff like that. And he’s a good stress breaker, too. Now, as long as I can keep my stress level down, I’m not smoking as much.”—Female, TN
- Remained quit: cognitive strategies and use of companionship
- ○
- “My poor family deals with the agitation part of my life. I feel really bad for them but it’s just who I am now, until I get over the urge of wanting to smoke. And I know it’s been seven months, but I won’t lie. I think about it every day… Normally, I take a deep breath and I count to 10 and I do the, ‘It’s going to be okay. I’m going to be okay’. And that calms me down.”—Female, PA
3.3.2. Impact of Baseline Characteristics on Stress
- Low optimism: Twelve of the 39 individuals interviewed scored between 0–13 on the LOT-R which is consistent with low optimism. Among this group, the most common mechanism for dealing with increased stress was smoking. In contrast to those with moderate-to-high optimism, those with low optimism more often referenced boredom as a smoking trigger. Nine of the 12 individuals with low optimism were actively smoking at the time of interview, and five reported increasing smoking during COVID-19.
- ○
- “I mean, really, there again, it’s just I know that I’ve increased. When I’m sitting around and not doing anything, that’s when I want to smoke and I just constantly smoke.”—Female, TN
- ○
- “My stress went through the roof. And the only way I can cope is smoking.”—Female, PA
- Low resilience: Six individuals interviewed scored a 1–2 on the BRS, classified as low resilience. Smoking as a coping mechanism for stress was also more common for this group compared to individuals with moderate to high resilience, and there was noted an increased reference to increased worry for self and others. All six individuals were actively smoking at the time of interview, five reported increasing smoking during COVID-19.
- ○
- “I live in fear now.”—Female, PA
- ○
- “It’s stressful. We have some grandchildren under eight and I worry about them. In general, with everything that’s going on. It’s nerve-wracking.”—Male, PA
- ○
- “I worry about other people having it and don’t know it, you know?”—Female, PA
- Moderate to high anxiety and depressive symptoms: Nineteen individuals were classified as having moderate to high anxiety symptoms and 21 individuals were classified as having moderate to high depressive symptoms during hospitalization at study entry. In qualitative interview, this group more often mentioned smoking as a primary coping mechanism or mentioned concern regarding the risk of contracting COVID, and reported increased financial stress, as compared to those with lower symptomatology.
- ○
- “I’ve tried to quit several times. I know that I need to quit smoking because of my health issues but, however, it’s not that easy. It’s not, especially at a time like this. Somebody could have been stopped smoking, and with this going on they’ll light up. Nerves. Worry. We don’t know what this stuff is. It’s killing people.”—Male, PA
- ○
- “It’s something I really don’t want to do anymore but it’s just like there’s so much stress in my house because everybody’s home, nobody’s working. It’s just like it calms me down.”—Female, TN
- ○
- “I’m on disability so I only get so much. And by the time I pay my bills, I’m totally dead broke. And when I got to the hospital, I needed a lot of things that my insurance didn’t pay for… And it’s just crazy. So yes, I’m not doing well money-wise.”—Female, MA
3.4. Stress during COVID-19
- Primary appraisal as defined by this model refers to an individual’s assessment of a stressor, including their perceived susceptibility to and severity of the threat, taking into account their current motivation and to what extent they believe themselves responsible. Most individuals reported heightened susceptibility and increased likelihood of severe illness and reported heightened motivation to quit. Some specifically mentioned themselves as responsible for their current increased risk.
- ○
- Perceived susceptibility and severity: “What changed for me… I’m just afraid that somebody in my family is going to get it and die or me because I have COPD really bad. And I’m supposed to be on oxygen, so my lungs are already really bad for my age. So if I get [COVID-19], the chances are I probably won’t make it out of it.”—Female, PA
- ○
- Causal focus: “If I’m constantly smoking and doing everything that I’m not supposed to be doing, I don’t know. I just think that people that are doing that on purpose, not that they deserve to die or anything like that, God forbid, I don’t mean that at all. But it’s like, ‘You weren’t helping yourself.’—Male, MA
- Secondary appraisal as defined by this model refers to an individual’s assessment of perceived control over outcomes and emotions in response to a threat and includes the construct of self-efficacy. Specific to COVID-19, participants noted varying levels of perceived ability to stay safe from contracting disease, adhere to a quit attempt and manage changes in boredom, cravings, triggers, and stress.
- Coping effort as highlighted above, we observed a distinction in the efficacy of coping methods relating to smoking trajectory between individuals who utilized companionship and cognitive distraction as opposed to exercise, physical components, and/or reverting to smoking. Mapping onto the Transactional Model of Stress aligns this with the distinction between problem management (active/physical strategies) and emotional regulation (i.e., cognitive distraction, stress management).
- Moderators refers to the effects of an individual’s dispositional coping style and available supports on the stress response. As highlighted above, we observed differences in coping efforts and outcomes among individuals with differing levels of optimism, resilience, anxiety, and depression on self-report at baseline hospitalization.
- Meaning-based coping refers to an individual’s ability to view a situation in a positive light and/or utilize coping strategies reflecting core values. Some individuals mentioned an ability to view the various impacts of COVID-19 as facilitators of positive health behavior change, i.e., not being able to smoke in the house or around family, financial limitations preventing spending money on cigarettes.
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Conflicts of Interest
References
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COVID-19 Impacts | Experience | Tobacco Behavior |
---|---|---|
Change in routine | “So, my everything is upside down now. I’m not going to work, the kids aren’t going to school. They’re doing everything online, so we’re all home all the time. So, yeah, basically everything about my schedule and routine is completely different.”
| “It just gives me a lot more downtime. It definitely gives me time in my own mind and my own thoughts. So, I mean, just again, stresses that come on, and you start contemplating these other problems and don’t have this, can’t have that, can’t afford this… then you start smoking.”
|
Isolation—social | “It makes me feel isolated a lot of times. When I do wish I had someone that could come over and spend some time with me but I don’t want them to come over because I don’t want to get exposed because I don’t know what they’re doing outside of my house and stuff. My parents haven’t been able to come over like they used to because they’re in their 70s.”
| “I used to always be outside and in public and I’m a people person. I’m a hugger, you know what I mean? That has killed me. That personal human touch. That stresses me out and makes me want to go smoke.”
|
Isolation—environment | “Staying pretty much at home has bothered me… The way you got to stay in. Nothing’s moving. I’m losing a lot of work over it.”
| Quit smoking “I don’t go outside that much, to store to buy cigarettes or anything. So that’s one of the reasons I quit, because I’d rather stay at home than go outside and buy a pack.”
“It gets old after a while… I mean, it’s like being shut in and not being able to go anywhere, it’s really tough when you’re just sitting day in day out with nothing to do… I know that I’ve increased. When I’m sitting around and not doing anything, that’s when I want to smoke and I just constantly smoke.”
|
Employment | “Absolutely nothing at all [I can do] to get any kind of income to keep my business afloat. Nothing. I mean there’s nothing I can do right now. Like everybody else, I’m just sitting in the house waiting for it to pass.”
| “Well, prior to all this… I would go to work. And I worked 10 h shifts. I never once smoked at work. I’m not a person to go to lunch and have a cigarette or say I’m going to have a smoke break. I don’t do that, and that was a big part of the reason, I think, that I smoked such a small amount. And now that I’m home, I find it’s almost something to do. I work from home, but on my lunch break I’ll go outside and smoke a cigarette. And I get super mad at myself, and I do it anyway.”
|
Finances | “Well, [I have] no income because I don’t get to go to work or look for a job because there’s not many jobs open right now and [I don’t] leave the premises because we could infect other people if we leave.”
| Increased smoking “I stress about money, and so I smoke more. When I can’t do anything or help my children or anything like that that bothers me. I smoke more.”
“No, I think it changed for the good way… my health and everything... It helps with my health, [given] my financials. I don’t got $10 to spend. I used to spend $10 every two days when I used to smoke. Now, I’m saving those $10 so it changed me in a good way.”
“But now, with the virus, I need that money to pay bills because my normal way of making money completely got shut down this year. And I feel that now with the coronavirus going through that. Thank God I quit smoking because now that money can go towards bills.
|
Boredom | “Oh, I mean, we can’t do anything. We can’t go anywhere unless it is doctor-related or store-related to grab something. So I mean, with everything shut down, there’s nothing you can do. You can’t go anywhere. And it’s just so you can only sit home and do so much that you’re just extremely bored.”
| “Well, I did really good for a while. I mean, I just need a cigarette because there’s nothing else to do.”
|
Cravings/Triggers | “The other thing; my boyfriend smokes, and he smokes a lot, so it’s like… because I’m constantly around it, it’s a trigger for me.”
| Increased smoking “But it’s like, when I wake up in the morning and I’m sitting on that deck and I’m looking outside and I see nothing, nobody, nothing, I have nobody and nothing [to do]… after having a few cups of coffee… you want to have something to go with it. And what usually goes with caffeine in the morning? A cigarette.”
“Oh, I think it’s easier if you don’t see people smoking all the time to not smoke yourself.”
|
Mood/Stress | “I would say distress. I’m out of work, spending home with kids, my wife. My wife’s not working, the homeschooling. There was a long period of time with the way the weather was; you really couldn’t do anything outside, so we were doing project inside, and that gets stale… It’s a lot more stressful. I would say in even thinking and talking about it right now, [it’s] a little more stressful.”
| “It’s made me smoke more. It’s been nerve-wracking going through this… So I’ve smoked more, not knowing the end result of what’s going to become of all this.”
|
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Schnitzer, K.; Jones, S.; Kelley, J.H.K.; Tindle, H.A.; Rigotti, N.A.; Kruse, G.R. A Qualitative Study of the Impact of COVID-19 on Smoking Behavior for Participants in a Post-Hospitalization Smoking Cessation Trial. Int. J. Environ. Res. Public Health 2021, 18, 5404. https://doi.org/10.3390/ijerph18105404
Schnitzer K, Jones S, Kelley JHK, Tindle HA, Rigotti NA, Kruse GR. A Qualitative Study of the Impact of COVID-19 on Smoking Behavior for Participants in a Post-Hospitalization Smoking Cessation Trial. International Journal of Environmental Research and Public Health. 2021; 18(10):5404. https://doi.org/10.3390/ijerph18105404
Chicago/Turabian StyleSchnitzer, Kristina, Sarah Jones, Jennifer H. K. Kelley, Hilary A. Tindle, Nancy A. Rigotti, and Gina R. Kruse. 2021. "A Qualitative Study of the Impact of COVID-19 on Smoking Behavior for Participants in a Post-Hospitalization Smoking Cessation Trial" International Journal of Environmental Research and Public Health 18, no. 10: 5404. https://doi.org/10.3390/ijerph18105404