7.7 Environmental and biopsychosocial factors that influence quitting

Last updated: August 2020 Suggested citation:  Greenhalgh, EM., Jenkins S., Stillman, S., & Ford, C. 7.7 Environmental and biopsychosocial factors that influence quitting. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2022. Available from http://www.tobaccoinaustralia.org.au/7-7-personal-factors-associated-with-quitting

 

There are many factors that can influence the success or failure of quit attempts ^1-5 including ^{1, 2}  

• physiological (e.g. level of nicotine dependence, withdrawal symptoms)
• behavioural (e.g. slip-ups, pattern of smoking)
• environmental (e.g. living or working with smokers, having smoking friends, home or workplace subject to smokefree policies or seeing tobacco products displayed)
• psychological or emotional/affective (e.g. stress, depression, anxiety, psychiatric disorders) 
• cognitive (e.g. knowledge, self-exempting beliefs, perceived disadvantages, motivation, self-efficacy) 
• barriers to access to interventions (e.g. affordable quitting medications, treatment programs) 
• social context or life circumstances that may result in the smoker giving quitting a low priority (e.g. poverty, social isolation, lack of perceived safety, social norms).

Adult population-level studies from a number of countries suggest that, of all these factors, greater nicotine dependence (quantified through measures such as time to first cigarette and numbers of cigarettes smoked per day) is the factor most consistently predictive of failure in quitting ^,7 Social smoking cues and a recently failed quit attempt are also important predictors. ^8,9 A systematic review found little association between gender, marital status, age, evaluations of smoking and quitting and success in quit attempts, and inconsistent evidence regarding the relationship between successful quitting and income, education level, smoking restrictions at home, quitting history, desire to quit, and confidence. ⁷

For young women, there is evidence that lifestyle and life-stage factors are determinants of smoking behaviour. For this group, recent illicit drug use and high-risk drinking appear to be related to relapse, while marriage or being in a successful relationship and moderate to high physical activity levels are associated with successful quitting. ¹⁰ Some of these factors are examined in more detail below.

7.7.1 Individual differences that predict success or failure in quit attempts

While factors associated with quitting vary between studies and individuals, there are some reasonably consistent findings. The focus of most studies has been on individual psychological and demographic factors associated with success or failure in quitting. Some of these factors can also influence how satisfied a person feels with quitting. ¹¹ There are large changes in a person’s beliefs, experiences and expectations in the days and weeks after quitting. ^12,13 Lower abstinence self-efficacy and higher frequency of urges to smoke can predict subsequent relapse, ^14,15 as can deficits in impulse control. ¹³ Quitting on a date coinciding with a particular phase of a woman’s menstrual cycle can also reduce success. ^16,17 Some particular characteristics are outlined below.

7.7.1.1 Duration of smoking

Evidence on the relationship between age and cessation is inconsistent. ^{1, 6,7, 18} Several international studies indicate a trend for smokers who start smoking at a later age to be more likely to quit. ^18-24 Based on these findings, interventions that at least delay the onset of smoking by adolescents may increase their likelihood of later quitting, ²¹ however there is no longitudinal evidence to show that such an approach is effective.

While younger smokers may be more likely to make a quit attempt, ⁶ older people may be more likely to succeed. However, many older smokers are unwilling to try to quit because of mistaken beliefs that it is too late to quit as damage has already been done, that they have the genetic make-up to protect them from the harm of smoking, and/or that they will not benefit much from quitting. ²⁵

7.7.1.2 Level of dependence (heaviness, time to first cigarette)

Smokers with a higher level of nicotine dependence are less likely to make an attempt to quit and also to find it more difficult, ^{6-8, 18, 26-29} particularly in the early stages of a quit attempt. ³⁰ This may reflect more severe withdrawal symptoms, more pronounced neuro-adaptation (changes to the brain from nicotine exposure), a greater constitutional need for nicotine, a more highly learned and deeply ingrained habit, or possibly a physical or social environment that discourages staying quit (i.e. one with more cues and opportunities to smoke). ^{3, 6, 31,32} There is also evidence that more dependent smokers experience greater negative affect and craving pre- and post-quit regardless of their cessation status and that these factors are associated with relapse. ^33,34 Getting out of bed to smoke during the night is an indicator of nicotine dependence, and there is some evidence that night smokers who report significant sleep disturbance are at particular risk of relapse when they try to quit. ^35,36 More research is needed to substantiate this relationship. ³⁷ A longitudinal study in California found that higher nicotine dependence smokers started smoking earlier in life, highlighting the importance of preventing nicotine use among young people. ²⁴ Data from the Californian Quitline shows that dependent smokers often make numerous attempts to quit before they are successful, suggesting that those who are unsuccessful on any one attempt should be encouraged to try again. ³⁸

See  Chapter 6 for further information on addiction to tobacco and measures of nicotine dependence.

7.7.1.3 Severity of withdrawal symptoms

One of the main motives for continued smoking is to relieve nicotine withdrawal syndrome ³ (discussed more fully in  Chapter 6). The major symptoms of nicotine withdrawal syndrome include mood changes such as irritability, aggression, anxiety and depression; restlessness; poor concentration; increased appetite; cravings/urges to smoke; disturbed sleep; decreased heart rate; and decreased levels of adrenaline and cortisol. ³⁹ Withdrawal symptoms are generally most intense in the first week after quitting, and last a further two to four weeks. ³⁹ However, withdrawal symptoms can be highly variable, both across persons and over time. ⁴⁰ In some people symptoms can be chaotic; they may fall and rise, or they may not decline for a number of weeks. ^{31, 39, 41} In one study tracking withdrawal symptoms in real time, reports of recent smoking, exposure to someone smoking, and stress were all associated with worse cravings, negative affect, and greater experiences of other withdrawal symptoms in the weeks after quitting, but individual responses varied greatly. ⁴² Although withdrawal can last several weeks or more, prolonged withdrawal states beyond six months do not appear to occur with cigarette cessation. ³⁹ Relapse is often related to greater severity of symptoms, greater day-to-day symptom volatility, increases in symptoms over time, and a greater degree of symptom relief associated with re-uptake of smoking. ^41,43

Urges to smoke/cravings are a core component of withdrawal and a powerful predictor of relapse. ^{3, 14, 18, 34, 44,45} They are strongly related to nicotine dependence, and are typically most intense within the first two days after quitting. Nicotine replacement products can help reduce their severity. ^{3, 31, 46} Cravings appear to be related to negative affect. ³³ However, urges to smoke can also be triggered by cues associated with smoking, even, in some cases, months or years after quitting. ^47-49

7.7.1.4 Genetic influences

Building on earlier observations that concordance rates are higher in monozygotic compared to dizygotic twins for both persistent smoking and for successful quitting, ⁵⁰ modern research has identified robust genetic influences on nicotine dependence. ^51,52 Multiple large-scale meta-analyses have supported the relationship between certain genetic variants and smoking heaviness (defined by cigarettes per day). ^53-56 Carrying a high-risk genetic variant seems to be an important predictor of how heavily a person will smoke, his or her level of addiction, and the probability of relapse after attempting to quit. ⁵⁷

Genetic influences have been estimated to account for about half of the variance in risk for failed smoking cessation, ⁵⁸ and along with level of dependence, genetic variants can also influence the effectiveness of pharmacologic cessation therapies. A 2012 randomised controlled trial found that smokers with high-risk genetic variants were three times more likely than smokers with a low-risk variant to respond to nicotine patches, nicotine lozenges, or bupropion alone, or combinations of patches and lozenges or lozenges and bupropion. ⁵⁹ A 2015 meta-analysis revealed a significant association between genetic variation in the dopamine pathway (which is widely implicated in nicotine addiction) and smoking cessation, ⁶⁰ and several candidate genes within this pathway have been reported to be associated with the efficacy of bupropion and NRT. ⁶¹ Variants in another gene have been shown to affect the rate of nicotine metabolism, and one study found that NRT is effective among individuals with fast, but not slow, nicotine metabolism. Fast metabolisers may be at greater risk of relapse because when their nicotine levels drop rapidly, they experience more cravings; NRT seems to help alleviate this. ⁶² Taken together, these findings have prompted suggestions that developing personalised smoking cessation interventions based on a person’s genetic risk factors could lead to greater success in smoking cessation interventions. ^{59, 62} A cohort study of smokers in the UK found that attributing smoking to genetic factors is associated with lower levels of perceived control over smoking but not lower quit rates, suggesting that learning of one's genetic predisposition to smoking as part of a personalised smoking cessation intervention may not deter quitting. ⁶³

7.7.1.5 History of previous failed quit attempts

Research indicates that previous attempts at quitting, and the recency and duration of quit attempts predicts making another quit attempt. ^{6, 20} Smokers who have made recent attempts to quit are more likely to try again, and those whose previous attempts have lasted longer are more likely to successfully stop. ^{6, 64-66} Results from a longitudinal study of adult smokers from Canada, the US, the UK, and Australia (the ITC-4 study) showed that ever having made a quit attempt, especially within the previous year, strongly predicted subsequent quit attempts. The likelihood of subsequent attempts decreased with time since last quit attempt, suggesting that rather than being demoralised by failed attempts, smokers may instead be motivated to try again. However, findings also showed that the likelihood of achieving sustained abstinence was reduced for smokers with a failed quit attempt within the last year, and even more so for those with two or more failed attempts. Smokers who repeatedly try to quit, but fail, may therefore need tailored support in order to stay quit. ⁹ Nonetheless, even unsuccessful quit attempts can be beneficial; smokers who relapse are more likely to reduce consumption compared to those not making a quit attempt, ⁶⁷ which can be a useful step toward complete cessation. ⁶⁸

7.7.1.6 Low confidence, poor self-efficacy

Self-efficacy is the belief or confidence that one has the capacity to perform a behaviour, and that the action will achieve its desired outcome. Self-efficacy is an important tenet of social cognitive theory (see  Section 7.3), and is often thought to underpin motivation and to be a requirement for behaviour change, along with having actual skills, knowledge and opportunity. ^{69, 70} According to the theory, behaviour change comprises a number of phases, each affected by self-efficacy beliefs. ⁷⁰ In the context of smoking cessation, these can include considering quitting, motivating oneself to stop smoking, persevering with the change, being vulnerable to relapse, recovering after a setback, and adjusting to and maintaining a non-smoker lifestyle. One study has shown that self-efficacy judgements and expectations are predicted by a person’s smoking behaviour and quitting history. ⁷¹

In general, high self-efficacy is a predictor of success at smoking cessation in the short to medium term. ^{14, 72, 73} Self-efficacy is reinforced by success, ⁶⁹ but tends to decrease following relapse. ⁷⁴ Some researchers have suggested that further investigation is warranted into the notion of self-efficacy as a reflection of recent smoking behaviour change rather than solely as a cause. ⁷⁵ Evidence suggests that drops in self-efficacy are associated with progression from one lapse to the next. ⁷⁶ Some additional factors can also affect a person’s self-efficacy; in one study, self-efficacy for quitting tended to be lower in people from low socio-economic backgrounds, ⁷⁷ while in another, smokers who were experiencing pain had reduced self-efficacy for future smoking abstinence. ⁷⁸

There is some evidence that self-efficacy may be less influential than previously thought, and that some studies may have overestimated its importance by failing to appropriately control for smoking behaviour at the time of self-efficacy assessment. ⁷⁹ The predictive power of people’s self-efficacy beliefs may be limited by their limited understanding of the challenges associated with quitting, or influenced by the phase of change they are in at the time of measuring self-efficacy. For example, if a person bases their self-efficacy beliefs on his or her confidence at resisting temptations to smoke immediately after quitting, but does not consider the need to adjust to a non-smoking lifestyle in the longer term, then self-efficacy may not have as much value for predicting long-term success. ^{72, 80-82} Further, self-efficacy beliefs based on past quitting experience may be better informed than pre-quitting expectations. ⁷³ Nonetheless, a number of more recent studies have affirmed self-efficacy as an important predictor of quitting behaviours and maintaining abstinence. ^83-86

7.7.1.7 Impulsivity, sensation seeking, and time perspective

Impulsivity and sensation seeking are related, individual differences that have been linked to risky behaviour, including smoking initiation, smoking status, and smoking cessation. ⁸⁷ Sensation seeking refers to a person’s tendency to seek out and engage in thrilling activities, while impulsivity is a person’s tendency to act in haste, without sufficient reflection. ⁸⁸ Several studies have found that people with higher sensation seeking and/or impulsivity scores are less likely to succeed in quitting smoking. ^89-92 The ITC-4 study found that the related construct of time perspective is also an important determinant of smoking cessation; smokers with a stronger future orientation at baseline (i.e., a tendency to consider future outcomes, and value them more highly than more immediate happenings) were more likely to have tried to quit ⁹³ and also more likely to have successfully quit at follow-up. This relationship was largely explained by consistent involvement in quit-related behaviours among future-oriented smokers. ⁸⁷

In an attempt to better understand the mechanisms underlying these relationships, one study found that higher sensation seeking predicted lower compliance with NRT and cessation strategies, which in turn reduced the odds of abstinence. ⁸⁹ Researchers have theorised that people high in sensation seeking may be less able to engage in non-automatic planned strategies (such as making plans for high risk situations, thinking about the benefits of quitting, or avoiding situations that could trigger smoking) that would help them to avoid relapse. They suggest that smokers high in sensation seeking might therefore benefit from behavioural rehearsal of cessation strategies and emphasis on compliance, in order to alleviate the effects of strategic processing deficits among such smokers. ⁸⁹ Similarly, results from the ITC-4 study suggest that encouraging smokers to adopt a future-oriented time perspective, and emphasising the importance of maintaining engagement in the quit cycle by making repeated cessation attempts over time, may be useful components of a tailored intervention. ⁸⁷

7.7.1.8 Concern about weight gain

Fear of weight gain is a significant factor in discouraging quitting and provoking relapse in smokers. ^{5, 94-102} Researchers that developed a specific measure of smoking-related weight concerns found that four factors—smoking to suppress appetite, smoking to prevent overeating, smoking to cope with body dissatisfaction, and withdrawal-related appetite increases—predicted smoking frequency, eating pathology, and body image concerns. ¹⁰³ Some evidence suggests that weight gain after quitting is of greater concern to younger women. ¹⁰⁴ Concerns about weight when trying to quit is associated with higher body mass index, intention to quit, more previous quit attempts, and less support for quitting. ¹⁰⁵ Such concerns can also attenuate the effectiveness of tobacco control policies—including cigarette price increases, smokefree laws, or anti-tobacco messaging—on quit attempts. ¹⁰⁶

(See  Section 7.1.11.3 for further information on the effects of cessation on weight. See Chapter 3,  Section 3.29 for information on the health effects of smoking in conjunction with and compared with the health effects of obesity.)

7.7.1.9 Disturbances of mood

Negative affect is a core component of withdrawal, and an important predictor of craving, ^{33, 107} urge to smoke, and relapse. ^{34, 108, 109} Compared to sustained quitters, those who relapse are more likely to report symptoms of emotional distress ²⁶ and negative mood. ¹⁵ There is evidence that smoking may decrease happiness and stopping may increase it. ¹¹⁰ Research also suggests that anhedonia (an affective dimension related to the inability to experience pleasure) is associated with poor smoking cessation outcomes. ¹¹¹ For those who have quit smoking, positive experiences—such as the capacity to enjoy life’s simple pleasures, ability to calm down when stressed or upset, and ability to control negative emotions—increase over time. ¹³

Stress and negative affect

Smokers frequently perceive smoking to be a way of managing stress. However, individual smokers’ understanding of how smoking relates to stress can vary. ¹¹²  Smoking is commonly perceived to promote relaxation, calmness or ease. ^{3, 112} It is sometimes used as a distraction from problems, or in an attempt to convey to others that the smoker is under stress. ¹¹²

Findings on the relationship between negative affect, stress and smoking have been mixed and suggest a complex association. ^{113, 114} Smokers report more stress and negative affect relative to non-smokers. ^{113, 115-117} In Australia in 2019, daily smokers were twice as likely to have high/very high levels of psychological distress compared with people who had never smoked (see NDSHS 2019, Table 2.60) and were also twice as likely to have been diagnosed or treated for a mental health condition.  ¹¹⁸ It is possible that smoking itself, withdrawal symptoms, or a combination of the two create higher stress levels among smokers. However, smokers also smoke in response to negative life events and laboratory stressors, suggesting that smoking may play some role in stress relief. ¹¹³

Researchers have tried to determine whether nicotine genuinely improves mood or merely relieves withdrawal symptoms. The strongest evidence suggests that the interplay between stress, negative affect, and smoking can be explained by withdrawal escape (i.e., the relief of withdrawal symptoms). ¹¹³ The daily mood changes of smokers show a normal pattern during smoking, but a worsening mood pattern between cigarettes. ^{3, 119} Withdrawal symptoms include irritability, anger, frustration, anxiety and depressive symptoms, ^{39, 120} which are generally experienced within two hours of last smoking, ^{42, 114, 121} and are relieved by smoking. After repeated experiences of alleviating these withdrawal mood symptoms, negative affect may become a cue for smoking even when it occurs independently of nicotine withdrawal. ¹¹³

Despite smokers commonly citing relief from negative affect as a motive for smoking, real-time studies have found little correlation between affect and smoking behaviour during regular smoking. ⁴¹ However, during smoking cessation there appears a strong connection between stress, negative affect and lapses to smoking, particularly first lapses. ^{13, 41, 113} One study found that negative affect and concentration difficulty during early withdrawal, most notably anxiety, predicted poorer quit attempt outcomes. ¹²² Conversely, smokers with a positive outlook are more likely to succeed in quitting and have less desire to smoke again. ¹¹⁷ Further, lapses appear to mostly result in increases in negative affect, particularly guilt and discouragement and a decrease in self-efficacy. ^{113, 116} One study found that compared with relapsed smokers, abstinent smokers reported lower withdrawal symptoms, craving, and negative affect. ¹²³ Evidence also suggests that smokers with more financial stress are less likely to quit ¹²⁴ and more likely to relapse. ^{125, 126} Individuals who are high in personality traits such as hostility and anger also seem to experience greater negative affect and severe symptoms during quit attempts. ^127-129

Quitting generally results in lower stress and negative affect over time. Although smokers usually experience an increase in stress and negative affect in the weeks after they quit, these symptoms eventually diminish to levels lower than when they smoked. ^{3, 113, 130}

Depression

Smoking and depression often co-occur. Compared to non-smokers, smokers report more depressive symptoms, more frequent and severe episodes of depression and higher rates of suicidal ideation and suicide. ¹³¹

Having a history of depression, in itself, does not seem to substantially jeopardise successful quitting. ^132-134 However, depressive symptoms may increase the likelihood of relapse. ^{135, 136}

(See  Section 9A.3.5.1 for further information on how best to encourage and support smoking cessation among those with depression.)

Anxiety sensitivity

Studies have consistently shown that high anxiety sensitivity (i.e., fear of anxiety-related sensations) plays an important role in smoking maintenance and cessation failure. Smokers with high anxiety sensitivity are more likely to perceive and experience smoking as effective in reducing negative affect ^{137, 138} and anxiety. ¹³⁹ Such smokers also perceive quitting as more difficult compared with those low in anxiety sensitivity, ¹⁴⁰ experience more intense withdrawal symptoms, ¹⁴¹ and have greater odds of early smoking lapse ¹⁴² and relapse. ¹⁴³ A 2014 experimental study found that anxiety sensitivity amplified the effects of acute abstinence on nicotine withdrawal symptoms and smoking urges, which may help explain the greater likelihood of relapse among smokers who score highly on this measure. ¹⁴⁴ (See  Section 9A.3 for further information.)

7.7.1.10 Other individual factors

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7.7.2 Environmental factors that predict success or failure in quit attempts

External factors that increase the difficulty of staying quit include environmental ‘cues’ to smoke. Cue reactivity, which refers to smokers’ heightened physiological and subjective reactions to smoking-related stimuli, is increasingly being studied in relation to cessation. ^145-149 The roles of cue reactivity, social factors, and tobacco advertising and promotion in promoting cravings and undermining cessation attempts are discussed in greater detail below.

7.7.2.1 Social factors

A person’s environment plays an important role in his or her likelihood of achieving abstinence from smoking. ¹⁵⁰ Smokers whose social contexts include a greater number of smokers may be exposed to more positive norms toward smoking and more cues to smoke, ¹⁵¹ which can make quitting more difficult. ³² The smell of other people’s smoke can cause a general urge to smoke, which relates to relapse. ¹⁵² Conversely, smokers who lose smoking friends over time are more likely to intend to quit, attempt to quit, and succeed in their quit attempts. ¹⁵¹ While quitting is associated with less contact with smokers over time, overall it appears to widen a person’s social circle, rather than narrow it. ¹⁵³

Smokers often report that receiving support from close others was an integral part of achieving successful cessation. ¹⁵⁴ Among a sample of women smokers in the US, increased social support appeared to act as a buffer from the harmful effects of cessation-related withdrawal symptoms, which in turn improved cessation outcomes. ¹⁵⁵ The smoking status of a person’s partner can substantially influence smoking persistence and behaviour change, ^{156, 157} with partners of current smokers being significantly less likely to quit than those with non-smoking partners. ^{158, 159} Smokers tend to be less supportive than nonsmokers of their partner’s quit attempt. ¹⁶⁰

A person’s working environment can also affect his or her desire to quit or success in quitting. Working long hours can increase the chances that former smokers will relapse, reduce the chances that smokers will quit, and increase cigarette consumption among regular smokers, particularly for people who usually work very long hours (50 or more hours a week). ¹⁶¹ Being unemployed, or having an unemployed partner, also predict greater odds of smoking. ¹⁶²

7.7.2.2 Cue reactivity

A robust body of research shows that smokers experience increases in self-reported craving, and moderate changes in autonomic reactivity (e.g. heart rate, skin conductance, blood pressure) when they are exposed to smoking-related stimuli, which is known as cue reactivity. ¹⁶³ Cues commonly include environmental stimuli such as cigarettes, matches, ashtrays, the smell of smoke, or seeing another person smoking, but can also include feelings such as stress or negative affect. ¹⁶⁴ One study found that smokers also have an attentional bias for smoking cues in movies, such as seeing actors smoke or showing an ashtray on screen. ¹⁶⁵ Point-of-purchase cigarette displays act as cues to smoke, even among those not explicitly intending to buy cigarettes and those trying to avoid smoking. ¹⁶⁶ Smokers can also experience cravings in response to environments where cigarette cues are not present, but normally are (such as in convenience stores, even when no smoking-related stimuli is visible). ¹⁶⁷ Cue-induced cravings in turn predict smoking behaviours, such as shorter latency to smoke, as well as increased number of puffs and puff volume. ¹⁶⁸ This reactivity occurs similarly among men and women, ¹⁶⁹ and among intermittent, daily, ¹⁷⁰ and nondependent smokers. ¹⁷¹

Environmental cues, such as embarrassment, cost of cigarettes, and messages in the media, can prompt quit attempts. ¹⁷² Former smokers often intentionally avoid smoking cues, which can help them maintain abstinence. ¹⁷³ There are a number of promising cessation interventions that are informed by cue reactivity research, such as training smokers to preferentially attend to non-smoking related cues, ¹⁷⁴ and using behavioural techniques to extinguish the learned responses between smoking-related stimuli and cravings. ¹⁷⁵

7.7.2.3 Tobacco marketing

Exposure to tobacco advertising can reduce current smokers’ motivation to quit and increase former smokers’ likelihood of relapse. (See  Chapter 11, Section 11.1.) For example, displays of tobacco products at the point-of-sale (now banned in Australia) can create temptation and lead to impulse purchases, increase a person’s chances of relapse, ^176-179 and make quitting more difficult. ¹⁷⁷ (See  Chapter 11, Section 9). A recent ITC study shows that implementing POS tobacco display bans does result in lower exposure to tobacco marketing and less frequent impulse purchasing of cigarettes. ¹⁸⁰

7.7.3 The impact of the COVID-19 pandemic on smoking behaviours (updated July 2022)

The outbreak of the SARS-CoV-2 virus, first detected in China in December 2019, caused a global pandemic of coronavirus disease 2019 (COVID-19). The pandemic created unprecedented social and economic disruption globally, as lockdowns, isolation, social distancing measures and closures of schools, workplaces and other venues were imposed to stop the spread of COVID-19. ¹⁸¹ It is anticipated that a global event that had significant effects on the mental health, general health and lifestyles of people, may also affect smoking behaviours. 

Early evidence suggests that the COVID-19 pandemic may have had mixed effects on smoking behaviour. A meta-analysis of articles from different countries published during the pre-vaccination period of the pandemic (January−November 2020) indicated that overall, smoking prevalence modestly declined during this period. Among people who smoked, 4% reported quitting, 21% smoked less, 27% smoked more and 50% had unchanged smoking. Among people who didn’t smoke 2% started smoking during this period. There was high heterogeneity in these findings. Many studies from the pandemic period are at a high risk of bias due to the use of non-representative samples, non-response bias and use of non-validated questions due to the restrictions of the pandemic, therefore findings should be interpreted with caution. ¹⁸² At the time of writing, the research available on the impact of COVID-19 on smoking is also limited to the early period of the pandemic.

As COVID-19 adversely affects the respiratory systems, there is concern that people who smoke may be at greater risk of severe COVID-19 infection and illness. Section 3.9.12 details the research on the relationship between smoking and COVID-19 risk. Research indicates that the perception of greater disease risk among smokers can motivate quitting, though the perception of greater risk is also associated with increased stress which can reduce the likelihood of quitting. See Section 7.5.1 to find more about how personalised risk to diseases, in general, can affect smoking behaviour. In regards to COVID-19 risk perception among smokers, a representative study examining smoking behaviour in the early phases of the COVID-19 pandemic (April−June 2020) in England, Canada, the US and Australia found that 46.7% of smokers reported thinking about quitting because of COVID-19, including 37.6% of Australian smokers. Thinking about quitting because of COVID-19 was more common among smokers who had a greater perception of general and personal COVID-19 susceptibility. Despite many smokers thinking about quitting because of COVID-19, only 1.1% of smokers reported making a quit attempt and 14.2% reduced smoking in response to COVID-19. Smokers in most states in Australia (where, at that time, COVID-19 had been largely contained) were less likely to be worried about getting COVID-19 and were less likely to quit or reduce their smoking compared to smokers in the other high-income countries. The survey found that 0.1% of Australian smokers made a quit attempt, 9.6% reduced their smoking and 13.1% increased their smoking. ¹⁸³ A US survey found that the perception that smoking increased COVID-19 severity was associated with both increased smoking and feeling ready to quit smoking. ¹⁸⁴ In a survey of people in China who had quit or reduced smoking during the pandemic, 93.3% indicated they had done so due to COVID-19 related health concerns. ¹⁸⁵

The COVID-19 pandemic created substantial psychological stress and socio-economic challenges for many people. Research suggests that the pandemic has led to a worldwide increase in mental health conditions, particularly depression and anxiety, as well as greater stress, frustration and loneliness. ^{186, 187} In relation to smoking behaviour, anxiety and fear can motivate people to quit, though intense anxiety, fear and distress, and the maladaptive use of smoking to manage stress, can make quitting more challenging and lead to increased smoking. ¹⁸⁸ Mental health conditions also share a strong relationship with smoking (see Section 9A.3). Studies conducted in Australia, the UK and Korea found associations between increased smoking and higher symptoms of depression/low mood, anxiety and stress during the early stages of the COVID-19 pandemic. ^189-191 COVID-19-related stress and anxiety about the economic harm of the COVID-19 pandemic were also associated with increased smoking. ^{191, 192}    Increased stress, time at home and boredom were also commonly cited reasons for increased smoking during the pandemic in a US survey. ¹⁹³ A survey of Italian ever-smokers found both relapse among ex-smokers and increased smoking was more frequently reported with decreasing quality of life, decreasing sleep quality and high levels of anxiety during the early stages of the pandemic. Relapse was also associated with: fear of being infected (with COVID-19) and getting sick; fear of dying due to the virus; anxiety in listening to news of the epidemic; and a sense of powerlessness in protecting oneself from contagion. Increased smoking was associated with those stressors as well as: a sense of powerlessness in protecting loved ones from contagion; fear of losing loved ones due to the virus; and fear of infecting others. ¹⁹⁴ Boredom, removal of barriers and distractions to smoking, changes to social routines and confinement-related stress, were also reported by smokers in the UK as factors that contributed to increased smoking. ¹⁹⁵ Though, a US study observed that smokers with serious psychological distress were more likely to report intentions to quit and to seek counselling during the COVID-19 pandemic compared to other smokers. ¹⁹⁶

For smokers that quit or decreased their smoking during the pandemic, commonly cited reasons have included: spending more time around non-smokers (including children), the disruption of smoking habits, fewer opportunities to smoke, difficulty purchasing tobacco products and the distraction of time spent outdoors. ^{185, 193, 195} Surveys conducted before and during the first COVID-19 lockdown in England observed that quit attempts increased only among young adults during the lockdown. ¹⁵ Similarly, a cross-sectional study of smokers in Italy observed that both reducing smoking and quitting were associated with younger age. Quitting was also associated with being a light smoker, while smoking reduction was associated with heavy smoking, unemployment and house crowding. ¹⁶ Among smokers in China, males were less likely than females to reduce their smoking during the pandemic, as were smokers residing in urban compared to rural areas. ¹⁸⁵

The COVID-19 pandemic reduced access to in-person cessation treatment and support resources for many people. ¹⁹⁷ There is also evidence that remotely accessible cessation services, such quitlines, were less utilised during the early pandemic. US quitlines experienced a 27% decline in calls in 2020 relative to 2019, with the greatest decrease in the second quarter of 2020. ¹⁹⁸ In Australia, Quitline received 360 more calls between January and March 2020 compared to the same period in 2019, but between July and September 2020, during which metropolitan Melbourne and Mitchell Shire in Victoria were under a hard lockdown, Quitline received 992 less calls compared to the same period in 2019. ¹⁹⁹ Part of the explanation for this in Australia may be the lower spending on mass media education campaigns during a period when the Government wanted to concentrate public education on COVID-related measures.

 

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References

 

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