ABSTRACT

INTRODUCTION

Recent research shows that in many countries smokers who increased smoking
during the COVID-19 pandemic outnumbered those who decreased it, in spite of
higher exposure to COVID-19 severity and death. In this study we compared
changes in smoking behavior in the initial and latter stage of pandemic, as well as
factors associated with lower intensity of smoking.

METHODS

We conducted two rounds of survey on representative samples, the first in the

initial stage of pandemic (11-19 May 2020) and the second in the latter stage
(04-11 June 2021). A multinomial logistic regression was run to estimate
associations between smokers' characteristics and lower intensity of smoking.
Opposite to the majority of studies which assess psychological factors affecting
smoking, we focused on factual determinants of the change in smoking intensity.

RESULTS

The share of smokers who claimed to smoke more increased significantly, from
22.7% in May 2020 to 35.2% in June 2021. The share of smokers who reported a
decrease in smoking only slightly increased, from 11.7% to 13.3%. Persistence of
the pandemic considerably increased intentions to cease smoking, from 26.3% to
40%. The higher education, income fall and occasional smoking increase odds to
reduce smoking during the pandemic. Smokers who are older than 24 years,
were not infected by COVID or consume more alcohol are less likely to curb their
tobacco consumption.

CONCLUSIONS

This research highlights that the majority of smokers do not realize that they are
particularly exposed to health risks related to COVID-19, thus smoking the same
or more until they get COVID-19 infected. Therefore, tobacco control policy
needs to be more proactive in creating public campaigns which demonstrate the
severity of COVID-19 impact on smokers’ health. Such campaigns should
especially target those groups of smokers who are less able to curb their
smoking intensity.

INTRODUCTION

Outbreak of the COVID-19 pandemic posed a global threat to both physical and
mental health of the world population. Over 1.8 mil. COVID-19 deaths were
officially reported only in 2020, while the WHO assessment suggests at least 3
million deaths attributable to the COVID-19 in 2020 (WHO). The COVID-19
pandemic also severely affected mental health of the general population in terms
of psychological distress, anxiety and depression (Xiong et al. 2020). The
smokers are particularly exposed to health risks, as smoking significantly
increases the risk of COVID-19 severity and death (TID). Moreover, smoking
cessation for one month or more turns out to be beneficial to reduce the risk of
developing COVID-19 and respective complications (Eisenberg & Eisenberg,
2020). Despite higher health risks, many country-specific studies revealed that
smokers who started, relapsed or increased smoking in pandemic outnumbered
those who reduced or quit smoking (The Netherlands, Italy 2, New Zealand,
Israel, France, Poland, Serbia). This is a matter of particular concern, as the
duration of pandemic is unknown, as well as whether the end of pandemic will
contribute to the decline in smoking intensity.

The existing research on the change in smoking habits during the COVID-19
pandemic predominantly paid attention to the psychological factors associated
with change in consumption of tobacco products and intentions to quit smoking.
The studies examining worsening of the smoking habits identified range of
stress-related psychological factors to be associated with higher consumption of
tobacco products, such as deterioration of mental health (UK), loneliness and
isolation (New Zealand), increase in anxiety and depression (Italy 2) or boredom
(France, Poland, Netherlands). Overall, there is strong empirical evidence that
greater psychological distress and worsening of the psychological well-being are
to blame for higher intensity of smoking, especially in those countries which
experienced harsh lockdowns. On the other hand, health concerns almost
uniformly appear as the major factor for reduced smoking or smoking cessation
(Spain, US, Turkey, China).

Similar to other European countries, coronavirus infection and death toll have
had several highs and lows since the pandemic outbreak. We conducted the first
round of survey on changes in smoking behavior during May 2020, several days
after the Government of Serbia ended lockdown to impede the initial spreading
of the COVID-19 virus. The second round of survey was conducted during June
2021, when most of the population got used to living in pandemic conditions.
This study aims to explore (1) dynamic aspects of changes in smoking behavior
regarding the initial and the latter stage of the COVID-19 pandemic, and (2)
factors associated with overall decrease in smoking intensity during the COVID-
19 pandemic.

METHODS

Study design

This survey is an extension of a national representative survey of tobacco

products consumption in Southeastern Europe in Serbia (Lawless, 2015), which
was implemented within the regional project "Accelerating Progress on Effective
Tobacco Tax Policies in Low-and Middle-Income Countries" in cooperation with
the University of Illinois Chicago and Bloomberg Foundation. It was motivated by
the urgent need to maintain continuous records of the smoking habits under the
changed health and economic circumstances posed by the pandemic, so the
original questionnaire was adjusted to include several questions related to the
pandemic.

We conducted a telephone survey among a representative sample of the Serbian

adult population aged less than 65 years (N=1,002), including both smokers and
non-smokers. The survey was conducted from 11 to 19 May 2020, 5 days since
the Government of Serbia has declared an end of the state of emergency and
abrogated all containment measures.

Measures and variables

Statistical analysis

Descriptive statistics were used for presenting the characteristics of the current
smokers. A multinomial logistic regression was run to estimate associations
between smokers' characteristics (predictors) and change in smoking intensity
(dependent). The results of the logistic regression are presented as odds ratios
(OR) with 95% Confidence Intervals (CI). A p-value <0.05 indicates Statistical
significance is indicated if a p-value is lower than 0.05. The Stata version 16.0
was used to conduct statistical analysis.

RESULTS

Baseline characteristics of subjects

The share of current smokers in the total sample is 40.1% (n=562). The female
smokers make almost half (49.5%) of current smokers. Majority of the smokers
are aged 45-65 years (44.3%), tertiary educated (52.3%), full-time employed
(62%) and live in urban areas (60.7%). The number of unvaccinated smokers
slightly exceeds (51.1%) those who are vaccinated, whereas 29% of the total
smokers recovered from COVID-19. The vast majority of the smokers (69.9%)
live in a household wherein at least one more member is a smoker, while 42.9%
of the smokers reported that at least one household member was infected by
COVID-19. Around one third of the smokers claimed higher spending on tobacco
products since the pandemic outbreak (35.2%), more than those who reported
higher spending on alcoholic beverages (12.6%).

When compared to the 2020 survey (EA referenca), some changes in the
smoking habits are observed. The share of smokers who claimed to smoke more
increased from 22.7% to 35.2%. The lower intensity of smoking was reported by
13.3% of the smokers, which is slightly higher than 11.7% reported in 2020.
Overall, the results of the 2021 survey indicate higher intensity of smoking since
the pandemic outbreak. On the other hand, persistence of the pandemic
motivated smokers to think about quit smoking, as the intentions to cease
smoking considerably increased from 26.3% to 40%. The other positive aspect is
reflected in the decline of everyday smokers from 84.6% to 80.3%. Consumption
structure of the tobacco products has mostly remained stable.
Table 1 Characteristics of Serbian smokers (n=562)
Variables n (%)*
Socio-demographic
Gender female 278 (49.5)
male 284 (50.5)
Age 18-24 65 (11.5)
25-34 124 (22.1)
35-44 124 (22.1)
45-65 249 (44.3)
Education secondary or less 265 (47.7)
tertiary 290 (52.3)
Type of settlement rural 221 (39.3)
urban 341 (60.7)
Employment status FT employed 341 (62)
non-FT employed 55 (10)
unemployed/out of labor force 154 (28)
Financial
Income change since COVID-19 pandemic higher or same 375 (66.7)
lower 187 (33.3)
Spending on tobacco products since the less or same 364 (64.8)
COVID-19 pandemic more 198 (35.2)
Spending on alcoholic beverages since the less or same/no expenses 491 (87.4)
COVID-19 pandemic more 71 (12.6)
Tobacco consumption
Smoking frequency regular 451 (80.3)
occasional 111 (19.7)
Tobacco product consumed cigarettes 458 (81.5)
tobacco (cut) 63 (11.2)
other 41 (7.3)
At least one more household member is a no 169 (30.1)
smoker yes 393 (69.9)
The intensity of smoking since the COVID- less than before 74 (13.3)
19 pandemic same than before 336 (51.4)
more than before 152 (35.2)
Intention to cease smoking since the no 337 (60)
COVID-19 pandemic yes 225 (40)
Health
Vaccinated no 287 (51.1)
yes 275 (48.9)
Recovered from COVID-19 yes 163 (29.0)
no 399 (71.0)
At least one household member infected by yes 241 (42.9)
the COVID-19 no 321 (57.1)

The associations between characteristics of smokers and change in

intensity of tobacco products consumption

Table 2 shows the results of multinomial logistic regression examining the

associations between change in intensity of tobacco products consumption and
characteristics of smokers. Two of the characteristics presented in Table 1 were
not included in the regression model: spending on tobacco products since the
COVID-19 pandemic and intention to cease smoking since the COVID-19
pandemic. The former is not included as causality is obviously running from
intensity of smoking to spending of tobacco consumption. The latter is not
included as, opposite to other variables, does not capture actual facts but
forward-looking intentions.

The results of the regression analysis indicate that six out of thirteen
characteristics included in the logistic model are associated with lower intensity
of tobacco products consumption. Among socio-demographic characteristics
gender, employment status and type of settlement does not appear associated
with intensity of smoking at all. The smokers with tertiary education are two-
time more likely to smoke less during the pandemic (OR=2.11; 95% CI: 1.08 -
4.13, p<0.05). Regarding age, odds to smoke less decline among groups of
smokers aged above 24 years relative to group of younger smokers (OR=0.37;
95% CI: 0.13 - 0.99, p<0.05).

Variables depicting change in level and structure of the income of the Serbian
smokers appear associated with lower smoking intensity, but in opposite
directions. The smokers who suffered income fall during the pandemic are two-
time as likely to smoke less (OR=2.14; 95% CI: 1.11 - 4.11, p<0.05). Increase in
spending on alcoholic beverages considerably declines the odds of lower
smoking intensity (OR=0.22; 95% CI: 0.08 - 0.59, p<0.01), indicating that
consumption of alcohol and tobacco covariates in the same direction. Amidst
health characteristics, vaccination and facing the COVID disease among
household members were not found to affect odds of change in smoking
intensity. On the other hand, those smokers who were not infected by the
coronavirus have lower odds to smoke less (OR=0.42; 95% CI: 0.22 - 0.81,
p<0.01). Regarding smoking habits, the occasional smokers are four-time more
likely to reduce smoking during the pandemic (OR=4.24; 95% CI: 2.26 - 7.96,
p<0.001). Type of tobacco product consumed and other smokers among
household members are not associated with change in smoking intensity.

Table 2 Results of logistic regression

Variables Indicator OR (95% CI)
Socio-demographic
Gender female (ref)
male 0.79 (0.44 - 1.42)
Age 18-24 (ref)
25-34 0.37* (0.13 - 0.99)
35-44 0.76 (0.28 - 2.1)
45-65 0.98 (0.38 - 2.5)
Education secondary or less (ref)
tertiary 2.11* (1.08 - 4.13)
Type of settlement rural (ref)
urban 0.83 (0.45 - 1.52)
Employment status FT employed (ref)
non-FT employed 1.24 (0.48 - 3.21)
unemployed/out of labor force 0.61 (0.27 - 1.37)
Financial
Income change since COVID-19 pandemic higher or same (ref)
lower 2.14* (1.11 - 4.11)
Spending on alcoholic beverages since the less or same/no expenses (ref)
 COVID-19 pandemic more 0.22* (0.08 - 0.59)
Tobacco consumption
Smoking frequency regular (ref)
occasional 4.24* (2.26 - 7.96)
Tobacco product consumed cigarettes (ref)
tobacco (cut) 0.79 (0.26 - 2.38)
other 0.86 (0.32 - 2.27)
At least one more household member is a no
smoker yes 1.11 (0.55 - 2.22)
Health
Vaccinated no
yes 0.94 (0.49 - 1.82)
Recovered from COVID-19 yes
no 0.42* (0.22 - 0.81)
At least one household member infected by yes
the COVID-19 no 0.91 (0.49 - 1.69)
Dependent variable: The intensity of smoking since the COVID-19 pandemic, 0 - smoke less, 1 - smoke
same or more

DISCUSSION

The vast majority of the studies on the change of smoking patterns during the
COVID-19 pandemic indicates the double-edged impact of pandemic on smoking
intensity and cessation. The country-specific studies showed that the relation
between smokers who increased smoking and those who decreased is not
uniform and varies across countries. We contributed to the existing literature not
only by measuring the number of smokers who increase/decrease consumption
of tobacco products, but also by considering dynamic aspects of the change in
smoking patterns during the pandemic. Our analysis revealed two opposite
trends: the share of smokers who increased smoking intensity during the
pandemic went up from 22.7% to 35.2% in parallel with intentions to cease
smoking from 26.3% to 40%. The increase in share of smokers who smoke more
is probably related to unanticipated persistence of the pandemic over 2021 and
pandemic-related psychological distress and uncertainty about future financial
and health well-being. The positive side is that the one third of the smokers who
smoke more or same as before pandemic is aware of the smoking harmfulness
and start thinking to quit smoking.

In this study we merely focus on the factual determinants of the change in

smoking intensity rather than subjective perception of the psychological distress.
We particularly examined characteristics of the smokers associated with
improvement in smoking habits. The logistic regression analysis reveals that
most of the socio-demographic factors do not affect odds to smoke less during
the pandemic. However, more educated smokers have higher odds to reduce
smoking, similar to evidence that higher education is associated with smoking
cessation (Israel). Moreover, smokers older than 24 years are less likely to
reduce smoking, in line with finding that younger smokers have higher odds to
quit smoking (Italy 2). It is interesting that gender is not found to be a predictor
of change in smoking habits, opposite to usual findings that smoking reduction
and cessation is gender sensitive (Lawless et al, 2015; Serbia, China).
The lower smoking intensity is significantly associated with income fall during
the pandemic. This is in line with theoretical premise that smoking prevalence
declines with income fall due to the negative elasticity of demand for tobacco
products with respect to income, which is well documented in many empirical
studies (John, 2005; Peng & Ross, 2009; Tarantilis et al, 2013; Zubović et al,
2018; Jovanović et al, 2018). The increase in price of cigarettes during the
pandemic additionally reduced the affordability of tobacco products for those
smokers who suffered income fall. While increase of consumption of alcohol is
less unfavorable than increase in smoking, the strong association between those
two variables is a matter of concern for public health.

The occasional smokers are more likely to reduce smoking intensity, which is
expected since they are less addicted and usually smoke on occasions of social
events that were banned or restricted by the containment measures. Type of the
tobacco product consumed appears as an irrelevant predictor of the change in
smoking habits. This is also in line with results from our previous study that
occasional smokers are more likely to quit smoking, while type of tobacco
product do not affect smoking cessation odds (EA referenca). The consumption
of tobacco products by the other members of the household is not associated
with smoking intensity, which is somewhat opposite to finding that not living
with a smoker increases the odds of smoking cessation (Israel).

The health concerns were emphasized as the most influential determinant

contributing to smoke reduction. Instead of measuring subjective feelings, we
opt for concrete descriptors of the smokers’ concern for health induced by the
pandemic, including vaccination and facing the COVID infection either personally
or within the household. It turns out that those smokers who were not infected
by the COVID are less capable to curb consumption of tobacco products, while
other health factors do not appear as predictors of smoking intensity. We are not
aware of some other study that examines associations of smoking habits with
vaccination to compare findings.

CONCLUSIONS

The survey on the national representative sample showed that in Serbia smokers
who increase consumption of tobacco products outnumbered those who smoke
less with respect to their pre-COVID-19 smoking levels. The reduced intensity of
smoking during the pandemic was associated with higher education, income fall
and lower frequency of tobacco consumption, while those smokers who are
older than 24 years, were not infected by COVID or consume more alcohol are
less able to curb their tobacco consumption.
REFERENCES:

(China) Haiyang Yang, Jingjing Ma. How the COVID-19 pandemic impacts
tobacco addiction: Changes in smoking behavior and associations with well-
being. Addictive Behaviors 2021; 119(106917): 1-5.
https://doi.org/10.1016/j.addbeh.2021.106917

(New Zealand) Philip Gendall, Janet Hoek, James Stanley, Mathew Jenkins,
Susanna Every-Palmer. Changes in Tobacco Use During the 2020 COVID-19
Lockdown in New Zealand. Nicotine & Tobacco Research 2021; 23(5): 866-871,
https://doi.org/10.1093/ntr/ntaa257

(Italy 2) Giulia Carreras, Alessandra Lugo, Chiara Stival, Andrea Amerio, Anna
Odone, Roberta Pacifici, Silvano Gallus, Giuseppe Gorini. Impact of COVID-19
lockdown on smoking consumption in a large representative sample of Italian
adults. Tobacco Control 2021; 0:1-8, doi:10.1136/tobaccocontrol-2020-0564

(Israel) Yael Bar-Zeev, Michal Shauly-Aharonov, Hannah Lee and Yehuda

Neumark. Changes in Smoking Behaviour and Home-Smoking Rules during the
Initial COVID-19 Lockdown Period in Israel. International Journal of
Environmental Research and Public Health 2021; 18(1931): 1-12,
https://doi.org/10.3390/ijerph18041931

(UK) Daniel Tzu-Hsuan Chen. The psychosocial impact of the COVID-19

pandemic on changes in smoking behavior: Evidence from a nationwide survey
in the UK. Tobacco Prevention and Cessation 2020; 6(59): 1-5.
https://doi.org/10.18332/tpc/126976

(Japan) Shihoko Koyama, Takahiro Tabuchi, Sumiyo Okawa, Takayoshi

Kadobayashi, Hisaya Shirai, Takeshi Nakatani, and Isao Miyashiro. Changes in
Smoking Behavior Since the Declaration of the COVID-19 State of Emergency in
Japan: A Cross-sectional Study From the Osaka Health App. Journal of
Epidemiology 2021; ??: 1-9. https://doi.org/10.2188/jea.JE20200533

(The Netherlands) Bommelé, J., Hopman, P., Walters, B. H., Geboers, C.,
Croes, E., Fong, G., Quah, A., & Willemsen, M. (2020). The double-edged
relationship between COVID-19 stress and smoking: Implications for smoking
cessation. Tobacco Induced Diseases, 18, Article 63.
https://doi: 10.18332/tid/125580

(France) Santé Publique France (2020). Tabac, Alcool: quel impact du

confinement sur la consommation des Français? [Tobacco, Alcohol: what
impact does confinement have on French consumption?]. Retrived November
15, 2020, from https://www.santepubliquefrance.fr/presse/2020/tabac-alcool-
quel-impact-du-confinementsur-la-consommation-des-francais
(Poland) Sidor, A., & Rzymski, P. (2020). Dietary choices and habits during
COVID-19 lockdown: Experience from Poland. Nutrients, 12(6), Article 1657.
https://doi:10.3390/nu12061657

(Spain) López-Bueno, R., Calatayud, J., Casaña, J., Casajús, J. A., Smith, L.,
Tully, M., Andersen, L., & López-Sánchez, G. (2020). COVID-19 confinement
and health risk behaviors in Spain. Frontiers in Psychology, 11, Article 1426.
https://doi:10.3389/fpsyg.2020.01426

(US) Klemperer, E. M., West, J. C., Peasley-Miklus, C., & Villanti, A. C. (2020).
Change in tobacco and electronic cigarette use and motivation to quit in
response to COVID-19. Nicotine & Tobacco Research, 22(9), 1662-1663.
https://doi:10.1093/ntr/ntaa072

(Turkey) Yürekli A, Önder Z, Elibol M, Erk N, Cabuk A, Fisunoglu M, et al.

(2010) The economics of tobacco and tobacco taxation in turkey.
https://www.who.int/tobacco/en_tfi_turkey_report_feb2011.pdf. Uploaded
September 2010. Accessed December 10, 2020.

John, R. M. (2005) Price elasticity estimates for tobacco and other addictive
goods in India. Indira Gandhi Institute of Development Research, Mumbai
Working Papers 2005-003. https://ideas.repec.org/p/ind/igiwpp/2005-
003.html Uploaded January 2005. Accessed December 10, 2020.

Lawless, M. H., Harrison, K. A., Grandits, G. A., Lynn, E. E, & Allen, S. S. (2015).
Perceived stress and smoking-related behaviors and symptomatology in male
and female smokers.  Addictive Behaviors, 51, 80-83. https://doi:
10.1016/j.addbeh.2015.07.011

Zubović J, Ljumović I, Jovanović O, Bodroža D, Domazet I, Vladisavljević M,

et al. (2018) Economics of tobacco and tobacco taxation. Regional study
Albania, Bosnia-Herzegovina, Croatia, Kosovo, Macedonia, Montenegro, and
Serbia.
http://tobaccotaxation.org/cms_upload/pages/files/192_regional_study_see_201
8.pdf. Published December 2018. Accessed December 10, 2020.

Jovanović O, Zubović J, Vladisavljević M, Bodroža D, Ljumović I, Domazet I,

et al. (2018) Estimation of tobacco products price and income elasticity using
aggregate data. Economic Analysis. 2018;51(3-4), 81-94.

Tarantilis F, Athanasakis K, Zavras D, Vozikis A, Kyriopoulos I. (2013)

Estimates of price and income elasticity in Greece. Greek debt crisis
transforming cigarettes into a luxury good: an econometric approach. BMJ
Open. 2015;5:e004748. doi:10.1136/bmjopen-2013- 004748

Peng L, Ross H. (2009) The impact of cigarette taxes and advertising on the
demand for cigarettes in Ukraine. Cent Eur J of Public Health, 2009;17(2):93-
98.
Zubović J, Zdravković, A, Jovanović O. Intentions to Smoking Cessation in the
Time of COVID-19: Evidence from Serbia. Economic Analysis 2021; 54(1): 13-23,
DOI: 10.28934/ea.21.54.1.pp13-23

(TID) Umnuaypornlert A, Kanchanasurakit S, Lucero-Prisno D EI, Saokaew S.

Smoking and risk of negative outcomes among COVID-19 patients: A systematic
review and meta-analysis. Tobacco Induced Diseases. 2021;19(February):9.
doi:10.18332/tid/132411.
http://www.tobaccoinduceddiseases.org/Smoking-and-risk-of-negative-
outcomes-among-COVID-19-npatients-A-systematic-review,132411,0,2.html

Eisenberg, S. L., & Eisenberg, M. (2020) Smoking cessation during the COVID-
19 epidemic. Nicotine & Tobacco Research, 22(9), 1664-1665. https://doi:
10.1093/ntr/ntaa075

Xiong, J., Lipsitz, O., Nasri, F., Lui, L. M. W., Gill, H., Phan, L., Chen-Li, D.,
Iacobucci, M., Ho, R., Majeed, A., & McIntyre R. S. (2020). Impact of COVID-
19 pandemic on mental health in the general population: A systematic review.
Journal of Affective Disorders, 277, 55-64. https://doi:
10.1016/j.jad.2020.08.001

(WHO) https://www.who.int/data/stories/the-true-death-toll-of-covid-19-
estimating-global-excess-mortality