Associations of changes in smoking-related practices with quit attempt and smoking consumption during the COVID-19 pandemic: A mixed-methods study

Introduction How changes in smoking routine due to COVID-19 restrictions (e.g. refraining from smoking outdoors and stockpiling tobacco products) influence smoking behaviors remains understudied. We examined the associations of changes in smoking-related practices with quit attempts and smoking consumption in current smokers using a mixed-methods design. Methods In a community-based telephone survey conducted between the second and third wave of the COVID-19 pandemic in Hong Kong, 659 smokers (87.1% male; 45.2% aged 40–59 years) were asked about quit attempts and changes in cigarette consumption and five smoking-related practices since the COVID-19 outbreak. Logistic regression was used to calculate adjusted odds ratio (AOR), adjusting for sex, age, education level, chronic disease status, heaviness of smoking (HSI), psychological distress (PHQ-4) and perceived danger of COVID-19. A subsample of 34 smokers provided qualitative data through semi-structured interviews for thematic analyses. Results Favorable changes in smoking-related practices, including having avoided smoking on the street (prevalence: 58.9%) and reduced going out to buy cigarettes (33.5%), were associated with a quit attempt (AOR: 2.09 to 2.26; p<0.01) and smoking reduction (AOR: 1.76 to 4.97; p<0.05). Avoiding smoking with other smokers (50.5%) was associated with smoking reduction (AOR=1.76; p 0.05). Unfavorable changes, including having increased smoking at home (25.0%) and stockpiled tobacco products (19.6%), were associated with increased smoking (AOR: 2.84 to 6.20; p<0.05). Low HSI (0–2) was associated with favorable changes (p<0.01), while high HSI score (3–6) was associated with unfavorable changes (p<0.01). Qualitative interviews revealed a double-edged effect of staying at home on smoking consumption and that pandemic precautionary measures (e.g. mask-wearing) reduced outdoor smoking. Conclusions Amid the pandemic, favorable changes in smoking-related practices in smokers were mostly associated with quit attempts and smoking reduction, while unfavorable changes were associated with increased smoking. Smokers with higher nicotine dependence were more negatively impacted