**1. Introduction**

The coronavirus disease 2019 (COVID-19) pandemic is an unprecedented public health crisis [1]. Faced with an exponential rise in cases and deaths, and in an effort to avoid overwhelming health systems, countries around the globe have adopted protective measures to mitigate the spread of infection including social distancing and stay-at-home policies [2]. Although such interventions are necessary to mitigate transmission, they may

**Citation:** Zhang, X.; Oluyomi, A.; Woodard, L.; Raza, S.A.; Adel Fahmideh, M.; El-Mubasher, O.; Byun, J.; Han, Y.; Amos, C.I.; Badr, H. Individual-Level Determinants of Lifestyle Behavioral Changes during COVID-19 Lockdown in the United States: Results of an Online Survey. *Int. J. Environ. Res. Public Health* **2021**, *18*, 4364. https://doi.org/10.3390/ ijerph18084364

Academic Editors: Paolo Roma, Merylin Monaro and Cristina Mazza

Received: 23 March 2021 Accepted: 16 April 2021 Published: 20 April 2021

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**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

also modify lifestyle behaviors such as diet, physical activity (PA), smoking, and alcohol use [3,4], and have significant consequences for physical health [5].

Healthy lifestyle behaviors such as observing a healthy diet and engaging in recommended amounts of PA are consistently associated with reduced all-cause mortality, and improved health and well-being [6,7]. Increased time spent at home due to adherence with mitigation policies could present an opportunity to practice healthy lifestyle behavior (e.g., by home cooking of healthy meals and engaging in regular PA). Supporting this idea, research has documented increases in population-level interest in PA during the pandemic, although actual change in PA was not ascertained [8]. Simultaneously, increased unstructured time spent at home could contribute to people feeling lonely and distressed, eating when not hungry (i.e., emotional eating), and weight gain [9]. New telework arrangements, temporary closure of fitness facilities, and the need to stay at home could also force abrupt changes in PA, increasing the likelihood of sedentary behavior and weight gain [10,11].

Addictive lifestyle behaviors such as smoking and alcohol use are major contributors to the global burden of disease [12] and are associated with poor health outcomes [13]. Emerging evidence has suggested that slight increases in these behaviors during the pandemic [14–16] could possibly be in response to the stress, boredom, and social isolation caused by COVID-19 mitigation strategies [17–19]. In fact, a market research survey conducted by Nielsen in March 2020, during the initial lockdown period in the USA, showed that alcohol sales increased by 55% in a single week [20]. This is alarming because research has shown that individuals who started abusing substances during the SARS pandemic experienced persistent substance abuse that lasted well beyond the pandemic [21]. Meanwhile, a recent cross-sectional study of 336 U.S. adults found that 28.3% reduced tobacco smoking and 24.9% reduced vaping (e-cigarettes) during the pandemic [22].

Overall, the observed changes in lifestyle behaviors during the pandemic suggest that different people have been affected in different ways. Specifically, more leisure time at home and the threat of becoming severely ill with COVID-19 may have motivated some people to engage in more healthy lifestyle behaviors, and increased distress and changes in social patterns may have driven other people to self-medicate through substance use and abuse [23,24]. Previous studies that have focused on lifestyle behaviors during the pandemic have been largely conducted in Europe and Asia [3,11,25] and with only eating and physical activity [10,26] or smoking and drinking [22,27] as the main outcomes.

In this population-based study, we examined individual-level determinants of selfreported changes in healthy (i.e., diet and physical activity) and addictive (i.e., alcohol use, smoking, and vaping) lifestyle behaviors during the initial COVID-19 lockdown period that was observed by 42 out of 50 states in the USA. Given that healthy and addictive behaviors are not mutually exclusive, we opted to take a more comprehensive approach than previous studies and assessed both healthy behavioral changes (eating and physical activity) and addictive behavioral changes (smoking, vaping, and alcohol drinking). This study also extends the existing knowledge base by evaluating individual-level determinants of lifestyle behavioral changes during the pandemic, including sociodemographic, mental health, and behavioral (e.g., adherence to mitigation strategies) factors. By elucidating individual-level determinants, at-risk groups can be identified, and targeted lifestyle interventions can be developed.
