Nicotine Dependence among College Students Uninterested in Smoking Cessation during the COVID-19 Pandemic: A Cross-Sectional Survey

This study investigated nicotine dependence among Japanese university students who had reached the smoking age (20 years or older) by the time of the coronavirus disease 2019 (COVID-19) pandemic and examined factors that encourage early smoking cessation. Social dependence on nicotine was evaluated using the Kano Total Social Nicotine Dependence Level (KTSND), and physiological dependence was evaluated using the Fagerström Nicotine Dependence Index (FTND). Of the 356 college students who smoked (4.4% of the total), 182 (51.1%) stated that they were not interested in quitting. Furthermore, 124 (68.1%) of those with no interest in quitting smoking were aware that smoking is a high-risk factor for COVID-19, and 58 (31.9%) were unaware. The group not aware of this risk had significantly higher KTSND scores than the group aware of it. The examination of cigarette type that indicated the users of non-conventional cigarette products and dual-user groups scored significantly higher than the cigarette group on FTND items. Overall, the smokers scored above the normal range for social nicotine dependence, suggesting the need to reduce nicotine dependence to encourage college students who continue to smoke to quit smoking.


Introduction
Smoking increases and exacerbates the risk of contracting various diseases, including malignancies, heart diseases, and cerebrovascular diseases. Smoking cessation is essential to reduce the risk of diseases caused by smoking. A 95% reduction in smoking reduces the risk of cardiovascular disease by only 50% [1]; however, long-term quitters have a reduced risk of malignancy [2], and smoking cessation after a stroke reduces recurrence and death after 5 years [3].
The novel coronavirus disease 2019 , caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a respiratory disease that was first reported in Wuhan, China in December 2019 and is responsible for a global pandemic [4]. As of 13 January 2023, the World Health Organization reported approximately 660 million confirmed cases and more than 6.7 million deaths worldwide. Smoking is a risk factor for dependence level of university students who have just started smoking. We believe that this study is novel in that it examines nicotine dependence from social and physical aspects in college students who were less willing to quit smoking during the COVID-19 pandemic, and also assesses nicotine dependence according to risk perceptions of COVID-19 and smokers' smoking devices.

Participants
We conducted a cross-sectional survey with 8547 undergraduate and graduate students affiliated with a single university in the Aichi Prefecture from March to April 2021. The university has many faculties, including humanities, social sciences, natural sciences, health sciences, and engineering. In total, 8117 students (95%) responded to the survey. All respondents met the analysis criteria because there were no missing responses required for the analyses. The flowchart of the participants is presented in Figure 1. Of the 8117 respondents, 356 were current smokers and 182 (51.1%) were not interested in quitting smoking [24]. A total of 182 respondents who indicated that they were not interested in quitting smoking were included in the analyses. The results of the analyses showed that the statistical power in this study was 0.62. The survey was conducted during the third and fourth waves of the COVID-19 pandemic in Japan. During this period, the Japanese government lifted the state of emergency that restricted the movement of its citizens. Figure 1. Flowchart of the participants, between March and April 2021, who were undergraduate and graduate students affiliated with a single university in Aichi Prefecture and participated in the questionnaire survey. Conventional cigarettes, cigarettes smokers; non-conventional cigarettes, smokers of heated tobacco products or e-cigarettes; dual users, smokers who use both conventional cigarettes and non-conventional cigarette products.

Items Related to Attributes and Smoking
The participants were asked about their age, gender, and smoking device. Smokers were categorized as conventional cigarette smokers, users of non-conventional cigarette products, or dual users. In this study, "conventional cigarettes" were defined as cigarettes, and "non-conventional cigarette products" were defined as heated tobacco products or ecigarettes. Dual users were defined as those using both conventional cigarettes and nonconventional cigarette products. Respondents were asked about their interest in smoking and whether they were aware that smoking is a high-risk factor for COVID-19. The respondents were also asked to select their interest in quitting smoking from one of the Figure 1. Flowchart of the participants, between March and April 2021, who were undergraduate and graduate students affiliated with a single university in Aichi Prefecture and participated in the questionnaire survey. Conventional cigarettes, cigarettes smokers; non-conventional cigarettes, smokers of heated tobacco products or e-cigarettes; dual users, smokers who use both conventional cigarettes and non-conventional cigarette products.

Items Related to Attributes and Smoking
The participants were asked about their age, gender, and smoking device. Smokers were categorized as conventional cigarette smokers, users of non-conventional cigarette products, or dual users. In this study, "conventional cigarettes" were defined as cigarettes, and "non-conventional cigarette products" were defined as heated tobacco products or e-cigarettes. Dual users were defined as those using both conventional cigarettes and non-conventional cigarette products. Respondents were asked about their interest in smoking and whether they were aware that smoking is a high-risk factor for COVID-19. The respondents were also asked to select their interest in quitting smoking from one of the following options: "I will quit smoking soon", "I am not interested in quitting smoking at all", and "I will quit smoking eventually".

KTSND
The KTSND is used to quantify social nicotine dependence by assessing the psychological aspects of smoking [27] and is a useful measure for selecting cessation methods and predicting the outcome of smoking cessation treatment [28]. Originally, the KTSND was a scale used by physicians who were active in promoting smoking cessation, and it consists of beliefs about smoking extracted from conversations with smokers as well as words and actions related to beliefs that prevent smoking cessation [27]. Higher scores indicate a greater tendency to justify smoking and deny its harmfulness, and the scale can be used to ascertain perceptions and psychological acceptance of smoking [27]. Table 1 presents the questions and the distribution of scores. The 10 statements in the KTSND questionnaire are as follows: (1) "smoking is a disease in itself", (2) "smoking is a part of culture", (3) "smoking is one of life's pleasures", (4) "a smoking lifestyle should be respected", (5) "some people's lives are enriched by smoking", (6) "smoking has physical or mental benefits", (7) "a cigarette is a stress reliever", (8) "cigarettes enhance the function of smokers' brains", (9) "doctors exaggerate the harm of smoking", and (10) "a place with an ashtray is a place where one can smoke". The response options are "definitely no", "probably no", "probably yes", and "definitely yes", with scores of 0, 1, 2, and 3, respectively, for a total score of 30 (reverse scoring was applied for Question 1). A score of 0-9 is within the normal range. In a previous study, the Cronbach's alpha coefficient for this scale was 0.82, validating its reliability and generalizability [29]. In the present study, the Cronbach's alpha was 0.89, indicating a good degree of reliability.

Questions
Choices and Scores

FTND
The FTND was adapted from the Fagerström Tolerance Questionnaire [30] and is highly correlated with physiological dependence on cigarettes. Table 2 presents the questions and the distribution of the scores. The questions are (1) "How many cigarettes per day do you smoke?" (2) "How soon after you wake up do you smoke your first cigarette?" (3) "Do you find it difficult to refrain from smoking in places where it is forbidden?" (4) "Which cigarette would you hate most to give up?" (5) "Do you smoke more frequently during the first hours after waking than during the rest of the day?" and (6) "Do you smoke when you are so ill that you are in bed most of the day?" A score of 0-3 indicates low dependence, 4-6 indicates moderate dependence, and 7-10 indicates high dependence [31]. In a previous study, the Cronbach's alpha coefficient for this scale ranged from 0.56-0.92, validating its reliability and generalizability [32]. The Cronbach's alpha coefficient in the present study was 0.80, indicating a good degree of reliability.

Statistical Analyses
A t-test was used to compare the KTSND and FTND scores after dividing the respondents into two groups: "aware" and "unaware" that smoking is a risk factor for COVID-19 and its severity. A one-way analysis of variance was used to compare KTSND and FTND scores among the three groups according to the smoking device. Bonferroni's method was used for multiple comparisons. SPSS statistics version 28 (IBM Corp., Armonk, NY, USA) was used for all analyses, and statistical significance was set at less than 5% (p < 0.05).

Basic Attributes
The basic attributes of the participants (n = 182) are listed in Table 3. Regarding the type of smoking device used, 61 (33.5%) participants used conventional cigarettes, 30 (16.5%) used non-conventional cigarettes, and 91 (50.0%) dual-used cigarettes. The mean (standard deviation) age was 20.8 (±1.51) years. Of the 182 participants, 124 (68.1%) were aware that smoking was a COVID-19 high-risk factor and 58 (31.9%) were not. Conventional cigarettes, cigarettes smokers; non-conventional cigarettes, smokers of heated tobacco products or e-cigarettes; dual users, smokers who use both conventional cigarettes and non-conventional cigarette products. Figure 2 shows the KTSND and FTND scores according to participants' awareness of smoking as a risk factor for COVID-19 infection and disease severity. The KTSND scores were significantly higher in the unaware group than in the aware group (p = 0.005). However, the mean scores for both groups were above the normal range, suggesting high social dependence on nicotine.

Comparison of KTSND and FTND by Awareness of Smoking as a Risk Factor for COVID-19
The FTND scores did not differ between the two groups, and the mean scores for both groups were within the low-dependency range for FTND scores.  Figure 3 shows the results of the comparisons of KTSND and FTND scores among the 124 participants who were aware that smoking was a risk factor for COVID-19 infection and disease severity based on the smoking device(s) used. The KTSND scores did not differ significantly among smokers based on smoking device use. In addition, the mean KTSND scores were above the normal range for all groups of smoking participants.

Comparison of KTSND and FTND Scores by Smoking Device among Those Aware That Smoking Is a Risk Factor for COVID-19
The FTND scores for the users of non-conventional cigarette products (p = 0.001) and dual users (p = 0.012) were significantly higher than those for conventional cigarettes. All p-values were based on multiple comparisons. However, the average FTND scores for all smoking groups were within the low-dependency range. scores by smoking device among those who were aware that smoking is a risk factor for COVID-19; (B) comparison of FTND scores by smoking device among those who were aware that smoking is a risk factor for COVID-19. All p-values are based on multiple comparisons. *, p < 0.05; **, p < 0.01; KTSND, Kano Test for Social Nicotine Dependence; FTND, Fagerström Test for Nicotine Dependence; COVID-19, coronavirus disease 2019; conventional cigarettes, cigarettes smokers; non-conventional cigarettes, smokers of heated tobacco products or e-cigarettes; dual users, smokers who use both conventional cigarettes and non-conventional cigarette products. The FTND scores did not differ between the two groups, and the mean scores for both groups were within the low-dependency range for FTND scores.

Comparison of KTSND and FTND Scores by Smoking Device among Those Aware That
Smoking Is a Risk Factor for COVID-19 Figure 3 shows the results of the comparisons of KTSND and FTND scores among the 124 participants who were aware that smoking was a risk factor for COVID-19 infection and disease severity based on the smoking device(s) used. The KTSND scores did not differ significantly among smokers based on smoking device use. In addition, the mean KTSND scores were above the normal range for all groups of smoking participants. The FTND scores did not differ between the two groups, and the mean scores for both groups were within the low-dependency range for FTND scores.  Figure 3 shows the results of the comparisons of KTSND and FTND scores among the 124 participants who were aware that smoking was a risk factor for COVID-19 infection and disease severity based on the smoking device(s) used. The KTSND scores did not differ significantly among smokers based on smoking device use. In addition, the mean KTSND scores were above the normal range for all groups of smoking participants.

Comparison of KTSND and FTND Scores by Smoking Device among Those Aware That Smoking Is a Risk Factor for COVID-19
The FTND scores for the users of non-conventional cigarette products (p = 0.001) and dual users (p = 0.012) were significantly higher than those for conventional cigarettes. All p-values were based on multiple comparisons. However, the average FTND scores for all smoking groups were within the low-dependency range.  scores by smoking device among those who were aware that smoking is a risk factor for COVID-19; (B) comparison of FTND scores by smoking device among those who were aware that smoking is a risk factor for COVID-19. All p-values are based on multiple comparisons. *, p < 0.05; **, p < 0.01; KTSND, Kano Test for Social Nicotine Dependence; FTND, Fagerström Test for Nicotine Dependence; COVID-19, coronavirus disease 2019; conventional cigarettes, cigarettes smokers; non-conventional cigarettes, smokers of heated tobacco products or e-cigarettes; dual users, smokers who use both conventional cigarettes and non-conventional cigarette products.
The FTND scores for the users of non-conventional cigarette products (p = 0.001) and dual users (p = 0.012) were significantly higher than those for conventional cigarettes. All p-values were based on multiple comparisons. However, the average FTND scores for all smoking groups were within the low-dependency range. Figure 4 shows the comparison of the KTSND and FTND scores by smoking device for the 58 participants who were unaware that smoking is a risk factor for COVID-19 infection and disease severity. The total KTSND and FTND scores were not significantly different among the three groups. The mean KTSND score was above the normal range in all groups. In contrast, the mean FTND scores were within the low-dependence range of the FTND scores for all groups.  Figure 4 shows the comparison of the KTSND and FTND scores by smoking device for the 58 participants who were unaware that smoking is a risk factor for COVID-19 infection and disease severity. The total KTSND and FTND scores were not significantly different among the three groups. The mean KTSND score was above the normal range in all groups. In contrast, the mean FTND scores were within the low-dependence range of the FTND scores for all groups.

Discussion
We conducted a questionnaire survey including university students affiliated with a single Japanese university during the third and fourth waves of the COVID-19 pandemic in Japan. The results of the KTSND demonstrated that the participants who were unaware that smoking is a risk factor for COVID-19 infection and severity were more socially nicotine dependent than those who were aware, indicating that the social nicotine dependence of the former was higher than the latter, although the KTSND score of the former was far above the normal range. However, the result of the FTND revealed that the low physical nicotine dependence of the participants was irrespective of the awareness of the risk. Notably, among the smokers who were aware of the risk, users of nonconventional cigarette products and dual users had higher physical nicotine dependence levels than conventional cigarette smokers. Overall, social nicotine dependence was higher among those who were unaware that smoking was a risk factor for COVID-19 and disease severity.
A previous study reported that smokers who wanted to quit smoking after the start of the COVID-19 pandemic perceived higher risk of infection [33]. Although the present study showed that those who perceived smoking as a risk factor for COVID-19 tended to have lower social nicotine dependence, no association was found with physical nicotine dependence. Overall, we suggest that smoking cessation education for smokers who perceive smoking as a low-risk factor for COVID-19 needs to focus on social nicotine dependence.
An analysis of those who were aware that smoking is a risk factor for COVID-19 indicated the users of non-conventional cigarette products and the dual-user group had higher FTND scores compared to the cigarette group. Since dual use has been reported to

Discussion
We conducted a questionnaire survey including university students affiliated with a single Japanese university during the third and fourth waves of the COVID-19 pandemic in Japan. The results of the KTSND demonstrated that the participants who were unaware that smoking is a risk factor for COVID-19 infection and severity were more socially nicotine dependent than those who were aware, indicating that the social nicotine dependence of the former was higher than the latter, although the KTSND score of the former was far above the normal range. However, the result of the FTND revealed that the low physical nicotine dependence of the participants was irrespective of the awareness of the risk. Notably, among the smokers who were aware of the risk, users of non-conventional cigarette products and dual users had higher physical nicotine dependence levels than conventional cigarette smokers. Overall, social nicotine dependence was higher among those who were unaware that smoking was a risk factor for COVID-19 and disease severity.
A previous study reported that smokers who wanted to quit smoking after the start of the COVID-19 pandemic perceived higher risk of infection [33]. Although the present study showed that those who perceived smoking as a risk factor for COVID-19 tended to have lower social nicotine dependence, no association was found with physical nicotine dependence. Overall, we suggest that smoking cessation education for smokers who perceive smoking as a low-risk factor for COVID-19 needs to focus on social nicotine dependence.
An analysis of those who were aware that smoking is a risk factor for COVID-19 indicated the users of non-conventional cigarette products and the dual-user group had higher FTND scores compared to the cigarette group. Since dual use has been reported to be strongly associated with younger age, attempts to quit smoking, and heavy smoking [34], it is possible that, because the college students in this study were younger but old enough to legally smoke, they had less interest in quitting smoking and quitting behaviors. In our previous study, "influence from friends, classmates, and seniors" and "curiosity" were the main reasons for smoking [24]. Although this study did not examine how smokers came to dual use, youths are reported to be more attracted to the taste and appearance of nonconventional cigarettes, such as e-cigarettes, than to the motivation to quit smoking [35]. In this study, physical nicotine dependence was higher in the users of non-conventional cigarette products and dual-user groups, a result that should be noted.
In the present study, the group of smokers with less awareness of risk factors did not differ significantly in social and physical nicotine dependence, regardless of their smoking habits. The FTND, which assesses physical nicotine dependence, was lower among the college students in this study, which is consistent with smoker dependence in previous studies [26].
However, it should be noted that the mean social nicotine dependence score was above the reference value for all smoking groups. Thus, motivational incentives to increase knowledge of the risks of smoking for COVID-19 and approaches to social nicotine dependence are needed for users of all smoking devices. Although the KTSND scores were also above the normal range in previous studies, research on the negative effects of smoking and smoking cessation guidance using outpatient smoking cessation clinic data has reported significant reductions in scores [36], and youths who receive expert advice are more likely to quit smoking [37]. Therefore, it is important to provide appropriate smoking cessation education and guidance to college students who have just started smoking, reduce their nicotine dependence, and create a university environment conducive to treatment. Adjunctive nicotine therapy is a form of smoking cessation treatment that includes the use of gum and patches [38], and it was the first pharmacotherapy proven to be effective in treating tobacco dependence [39]. Nicotine administration has been shown to alleviate nicotine and tobacco withdrawal symptoms and the craving for smoking experienced by smokers for days and weeks after quitting [40]. In addition, varenicline, prescribed in smoking cessation clinics, has been found to increase the likelihood of smoking cessation in adults [41], and abstinence is maintained owing to fewer cravings and withdrawal symptoms [42]. Nicotine dependence on cigarettes is one barrier to successful smoking cessation [43]. Thus, young smokers, such as college students, are important targets in smoking cessation interventions [44] and require education about the harms of nicotine as well as guidance in transitioning to smoking cessation treatments that have been proven effective for smoking cessation. In particular, the findings of high social nicotine dependence among college students who are not interested in quitting smoking and high physical nicotine dependence among users of non-conventional cigarette products and dual users may contribute to developing smoking cessation treatment measures for college students who smoke.
Especially during the COVID-19 pandemic, college students may be more susceptible to nicotine dependence due to anxiety, increasing the necessity and importance of examining the nature of smoking cessation education [26]. During the COVID-19 pandemic, nicotine dependence may be modified due to a variety of factors, including behavioral changes, which may increase smoking dependence [25]. Therefore, along with risk education for smoking during the COVID-19 pandemic, individualized interventions may be necessary to accommodate the diversifying lifestyles of college students. It is also believed that there is a need to ensure that university education provides opportunities to convey the health hazards of smoking and the need to quit smoking.
This study had several limitations. This cross-sectional study was conducted at a single university, and the results may not be representative of the general population because different countries and regions have different attitudes, cultures, lifestyles, and social conditions regarding smoking. The participants in this study were limited to college students with a smoking history of a few months to a few years. Furthermore, this study did not distinguish between heated and e-cigarettes among non-conventional cigarettes; nicotine levels vary depending on the smoking device, which may have affected the results. Depending on the smoking device used, the inclusion of nicotine varied, which may have affected the results. In addition, in recent years, a nicotine dependence rating scale (e-FTCD) has been developed for e-cigarette and dual users [45]. Since the purpose of this study was to compare the nicotine dependence of conventional cigarettes, nonconventional cigarettes, and dual users, the same scale (FTND) was used. The FTND can be adapted to measure nicotine dependence in e-cigarette users [46,47]. However, for smokers who use heated tobacco products-as far as we know-that verification is not sufficient. Furthermore, the KTSND is a scale originally developed based on a survey of the Japanese population [27]. At the time the KTSND was developed, social nicotine dependence was noted as a social psychological tendency-common in smoking-accepting societies, including Japan-to underestimate the harms of smoking and to convince people of its positive effects [28]. Therefore, to our knowledge, with respect to the KTSND, its application to users of non-conventional cigarette products has not been clearly verified; however, the KTSND was applied in this study because it is considered a scale that reflects Japanese culture. In addition, prior studies conducted after the COVID-19 outbreak have suggested that increased mental health problems during the pandemic were also associated with increased tobacco use [48]. However, this study did not collect data on depression or anxiety. Finally, the relatively limited sample size of this study did not allow for high power. Regression analyses considering all covariates could not be employed either; however, it is possible that there are factors other than COVID-19 infection and perceived severity or smoking habits that influence nicotine dependence.
The strength of this study is that it assessed the nicotine dependence of university students using two scales: social and physical. Furthermore, the university included in this study is a comprehensive university with faculties in several academic disciplines and students from all over Japan. The results of this study can be used to implement effective smoking cessation education programs for college students who have continued to smoke. Since the COVID-19 pandemic is expected to continue, we believe that another survey should be conducted to further examine the factors that contribute to continued smoking.

Conclusions
This study found that social dependence on nicotine was higher among those who were unaware that smoking was a risk factor for COVID-19 and disease severity. In addition, while there was no difference in nicotine dependence among those who were not aware of the risk and the type of smoking device, among those who were aware of the risks, users of non-conventional cigarette products and dual users were more physically dependent on nicotine than those who used conventional cigarettes; this suggests the importance of smoking cessation education in reducing nicotine dependence. In other words, in order to enhance smoking cessation education, it is necessary to investigate nicotine dependence. The results of this study may lead to effective smoking cessation education for students who continue to smoke. No studies have investigated KTSND and FTND scores during a novel coronavirus pandemic, and further research on nicotine dependence is warranted. We believe that those involved in public health and medical care should view the COVID-19 epidemic as an opportunity to promote smoking cessation, provide knowledge about the risk of COVID-19 infection and serious illnesses caused by smoking, and administer individualized interventions according to the diversity of lifestyle behaviors and smoking habits among college students. We have also concluded that universities should ensure that students have an opportunity to learn about the health hazards of smoking and the need to quit smoking.