Cigarette, cigar, and other combustible tobacco users appear to be at greater risk for developing serious complications from COVID-19 [1
]. At least four systematic reviews/meta-analyses have concluded that smoking is associated with adverse outcomes associated with COVID-19 and worse disease progression [1
], which aligns with research showing that smokers are at greater risk for contracting and experiencing severe respiratory infections [5
]. However, some research has suggested that there are no associations between tobacco use and severity of COVID-19 complications, or that using tobacco use may confer protective benefits, such as smokers being at lower risk for contracting COVID-19 [7
]. While there appear to be substantial limitations to this latter work [11
], more research is needed on how COVID-19 is affecting tobacco users, including how they perceive COVID-19 risks and how they are altering their intentions and behaviors in response to this new threat.
Due to the potential negative health outcomes associated with COVID-19, it is possible that many tobacco users feel more vulnerable to its health effects and are trying to quit using tobacco—which aligns with both previous research and theory on risk perception [12
]. However, it is also possible that some tobacco users are increasing their tobacco use due to stress or anxiety associated with COVID-19, which has also been documented in previous research on stress and smoking behavior [14
]. One study recently examined smoking behaviors due to COVID-19, reporting descriptive changes in smoking in a small, convenience sample [18
]. More research is needed examining how tobacco users are perceiving and reacting to COVID-19.
The goals of this study were to examine cigar smokers’ perceived risk of COVID-19, quit intentions, and behaviors during the current pandemic. In the United States (US), cigars are one of the most commonly used tobacco products with 7.2% of adults reporting smoking cigars in the past 30 days [19
]. While cigars are used less frequently than cigarettes [19
], dual use of cigarettes and cigars is high. Research shows that between 30–60% of cigar smokers also smoke cigarettes [20
], and over 30% of cigarette smokers smoke cigars [21
]. Compared to cigarette smokers, cigar smokers tend to be younger [22
], include more African Americans [22
], and use cigars on fewer days per month [23
We also examined how other correlates were associated with COVID-19 quit intentions and behaviors, including demographics, such as age and race, and tobacco use variables, such as other tobacco use and nicotine dependence. We did so because research has found several factors in the US to be associated with risk of acquiring COVID-19 and experiencing complications, including race/ethnicity, age, and other comorbidities. Specifically, African Americans in the US are dying of COVID-19 at greater rates than white people, and are experiencing more complications [25
]. Increasing age and other co-morbid conditions, like types 2 diabetes, also elevate the risk of complications, including death [26
The COVID-19 epidemic has negatively impacted millions of people around the globe, particularly those with co-morbid conditions that elevate risk of complications, including death [26
]. Combustible tobacco use appears to be a major risk factor for worse outcomes if a tobacco user contracts COVID-19 [1
]. Results from our study suggest that most tobacco users correctly perceive themselves to be at higher risk of COVID-19 complications, and this risk appears to relate to intentions to quit using tobacco and attempting to quit. This relationship appears even stronger for African Americans, who are at an even higher risk of complications and death due to COVID-19 [25
]. Yet, despite this knowledge and these intentions / behaviors, over twice as many tobacco users reported increasing rather than decreasing their tobacco use in our study.
These results have implications for practitioners, policy-makers, and public health agencies. For practitioners, out results suggest that their patients who use tobacco have a heightened interest in quitting because of COVID-19. Each year around two thirds of tobacco users want to quit and make a quit attempt [38
]. That the majority of tobacco users in our study, most of whom used multiple tobacco products and displayed multiple symptoms of nicotine dependence, intended to quit and made a quit attempt is important. To translate quit attempts into successful cessation, support for tobacco users should be made available during this time, including increased access to nicotine replacement therapy, virtual support with tobacco treatment counselors, and mental health assistance, particularly since better perceived mental health was associated with increased intentions to quit in our study. Tailoring support to sub-groups of tobacco users may also be important. For instance, tobacco users who have increased their tobacco use in response to COVID-19 may need additional help with higher dependency, as well as with coping strategies for stress and anxiety. Those who have decreased their tobacco use have an even greater chance of successfully quitting with clinician support.
Tobacco users with higher COVID-19 risk perceptions appear to have higher quit intentions and higher odds of making a quit attempt since COVID-19 started. However, not all smokers believed that they had a higher or similar risk of COVID-19 complications, compared to non-smokers. These findings indicate that clear and consistent messages about risks of COVID-19 to tobacco users are needed. Importantly, these messages may need to evolve as more data on tobacco use and COVID-19 become available.
Interestingly, we found that more people reported increasing their tobacco use (41%) than decreasing their tobacco use (18%). Only one previous study, to our knowledge, has examined how tobacco users have changed their behaviors in response to COVID-19 and reported similar results. In this study of 345 dual cigarette and e-cigarette users, 30.3% of participants reported increasing their cigarette use and 29.1% reported increasing their e-cigarette use since learning of COVID-19 [18
]. Extending these findings, we found interesting relationships between changes in tobacco use, quit intentions, and quit attempts since COVID-19 started. Specifically, quit intentions and odds of making a quit attempt were higher in people who reported decreasing their tobacco use and people with higher COVID-19 risk perceptions, which is in line with what is often called the “vulnerability hypothesis”. Indeed, both theory and research support the idea that as individuals feel more vulnerable to the health effects of smoking, they are more likely to intend to quit smoking, make quit attempts, and successfully quit [12
However, we also found that people who reported increasing their tobacco use also reported higher quit intentions and had higher odds of making a quit attempt—in line with research on the “stress hypothesis”. It is possible that these people want to quit, but are stressed or anxious, and are increasing their tobacco use despite their ‘good’ intentions. To this point, we did find that better mental health status was associated with higher intentions to quit. In addition, people may be bored or have stockpiled tobacco products before sheltering in place orders, which could have increased their tobacco use. Finally, it is also possible that people may want to quit but are not able to easily access evidence-based cessation resources like pharmacotherapy or behavioral support [40
We also found that over a fifth of participants in our sample reported calling a quitline because of COVID-19, and that those who reported calling a quitline had higher quit intentions and attempts. Although the majority of US smokers are aware of quitlines [41
], they only reach 1–2% of smokers nationally [43
]. However, states have been able to increase quitline reach through targeted efforts. For instance, by adding hours of operation and implementing a cigarette tax, Maine was able to reach over 6% of smokers [45
]. In addition, the national tobacco education campaign “Tips From Former Smokers (Tips),” which tagged many of its ads with 1-800-QUIT-NOW, led to 170,000 additional quitline calls over a three-month period [46
]. It is possible that characteristics of our study sample—which was comprised of many heavy tobacco users—meant that participants were more likely to want to quit and use available resources to do so. It is also possible that many people answered this question favorably because of a social desirability bias. Regardless, our study findings indicate that many tobacco users reported wanting to quit because of COVID-19 and reported using a quitline for help. That many participants did not quit, suggests that tobacco quitlines may need more resources and COVID-19 specific information to help smokers quit.
Finally, we identified several characteristics that were associated with COVID-19 quit intentions and attempts. For instance, Black or African American participants had higher quit intentions and attempts due to COVID-19. African Americans in the US are dying of COVID-19 at greater rates than white people and experiencing higher rates of complications [25
]. This may explain why we observed an increased desire to quit smoking among these participants. We also found that people who smoked cigarettes (in addition to cigars) had lower odds of making a quit attempt, compared to people who did not smoke cigarettes, and that people who used smokeless tobacco (in addition to smoking cigars) had higher odds of making a quit attempt, compared to people who did not use smokeless tobacco. It is possible that smokeless tobacco users had higher odds of making a quit attempt, because they do not want to put their fingers in their mouth to use these products. It is also possible that people are substituting some tobacco products with others. For instance, people could be switching to using smokeless tobacco because they are not combustible. Further research, especially longitudinal data, are needed to understand how people are changing their patterns of tobacco use in response to COVID-19. To our knowledge, we are the first to use and modify previously available measures to apply to COVID-19. As tobacco control researchers continue to collect data on tobacco use and COVID-19, the items we developed—especially those related to COVID-19 specific quit intentions, quit attempts, and perceived risk—can be used.
There are several limitations to this study. First, all data were self-reported, which introduces threats of social desirability bias. Second, this was a one-time cross-sectional study, which means that we were unable to assess temporality of associations or trends over time. Future longitudinal research is needed to understand how COVID-19 is changing participants’ smoking and quitting behaviors. Third, all participants were recruited online and are not representative of the US population or of tobacco users, which means that study findings may not apply to other countries or groups of tobacco users. Fourth, since this was a cross-sectional study and there was no possibility of randomizing participants to different exposures, we cannot make any claims of causality. We are careful throughout this article to use language like “correlates” rather than “predictors” and “associated with” rather than “causes.” Fifth, we created several measures in this study that have not been previously used (e.g., changes in tobacco use since COVID-19 started) given the novelty of COVID-19 and the rapid research needed to understand it.