The association of psychological distress and economic and health worries with tobacco smoking behavior during the COVID-19 pandemic: a two-year longitudinal cohort study

Abstract

Background: The COVID-19 pandemic and other life events may trigger worries and psychological distress. These impacts may lead to unhealthy behaviors, such as tobacco smoking, but the degree of such associations is unclear. The current three-wave longitudinal study examines changes in tobacco smoking in Norway between 2020 and 2022 and their associations with psychological distress as well as health- and economy-related worries.

Methods: Data were collected in April 2020 (baseline), January 2021, and January 2022 in Bergen, Norway, from an online longitudinal population-based survey. Smoking tobacco (the outcome variable) was dichotomized based on the responses to the question of whether participants smoked cigarettes or not. Tobacco smoking and its associations with psychological distress were assessed among 24,914 participants (response rate 36%) in a mixed model regression presented with coefficients and 95% confidence intervals (CI), adjusting for COVID-19-related worries, home office/study, occupational situation, age, gender, education, having children below 18 years living at home, living alone, and alcohol consumption.

Results: A total of 10% of the study sample were current smokers at baseline. At baseline, smoking tobacco was associated with high levels of psychological distress (absolute difference 13%, 95% CI 10%; 15%), advanced age (50-59 years: 11%, CI 10%; 13%), and hazardous alcohol use (4%, CI 3%; 5%) compared to their counterparts. Higher education (-5%, CI -6%; -4%), working from home (-4%, CI -5%; -4%), and higher physical activity levels (-4%, CI -5%; -3%) were associated with non-smoking. The prevalence of smoking among individuals experiencing severe psychological distress decreased slightly over time (-2% per year, CI -3%; -1%).

Conclusions: Smoking was associated with severe psychological distress, advanced age, and hazardous alcohol use at baseline; non-smoking was associated with high education, working from home, and high physical activity. Nevertheless, the smoking rate among individuals experiencing severe psychological distress slightly decreased over the course of the COVID-19 pandemic.

Keywords: COVID-19; Pandemic; Psychological distress; Risk factors; Smoking; Tobacco; Worries.

Fig. 1

Flow chart of the study design and cohort overview. Flow chart of the longitudinal study design, including wave 1, which consisted of a two-week baseline assessment (T0), wave 2 after nine months, covering four weeks of data collection (T1), and wave 3 after an additional 12 months, covering four weeks of data collection (T2)

Fig. 2

Sankey diagram of change in smoking behavior. The diagram shows smoking behavior broken down into two categories (smoking and non-smoking) at three time points (T0, T1, and T2). The paths show the proportion of individuals changing or not changing smoking behavior across the time points. The width of each path represents the proportion of individuals who change categories. The colors highlight the different categories of smoking: orange (T0/T1) and red (T2) are used to represent smoking and green non-smoking, respectively. At both follow-up points, more people had stopped smoking than started smoking. Non-smoking increased from T0 to T1 (7,582 to 7,614) and from T1 to T2 (7,614 to 7,644). Smoking decreased accordingly, from T0 to T1 (699 to 667) and from T1 to T2 (667 to 637)