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Multi-level drivers of tobacco use and

purchasing behaviors during COVID-19


•lockdownŽ: A qualitative study in the
United States Daniel P. Giovenco &
Torra E. Spillane & Rachel M. Maggi &
Esther Y. Lee & Morgan M. Philbin
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International Journal of Drug Policy 94 (2021) 103175

Contents lists available at ScienceDirect

International Journal of Drug Policy


journal homepage: www.elsevier.com/locate/drugpo

Research paper

Multi-level drivers of tobacco use and purchasing behaviors during


COVID-19 “lockdown”: A qualitative study in the United States
Daniel P. Giovenco, Torra E. Spillane∗, Rachel M. Maggi, Esther Y. Lee, Morgan M. Philbin
Columbia University Mailman School of Public Health, Department of Sociomedical Sciences, 722W 168th St, New York, NY 10032, USA

a r t i c l e i n f o a b s t r a c t

Keywords: Background: The COVID-19 pandemic and associated public health prevention measures (e.g., “stay at home”
COVID-19 orders) may impact tobacco supply and demand among consumers. This qualitative study identified multi-level
Tobacco drivers of shifts in inhaled tobacco product use and access patterns during the initial COVID-19 “lockdown”
Cigarettes
period in the United States.
Electronic nicotine delivery systems
Methods: Between April and May 2020, we conducted semi-structured telephone interviews (n = 44) with adults
who use cigarettes and/or electronic nicotine delivery systems (ENDS). Transcripts were thematically analyzed
using a socioecological framework.
Results: Nearly all participants reported changes in their product use during lockdown, though patterns varied.
Increased use was most common and was predominantly driven by individual-level factors: pandemic-related
anxiety, boredom, and irregular routines. Decreased use was common among social users who cited fewer in-
terpersonal interactions and fear of sharing products. At the community level, retail access impacted cigarette
and ENDS use differently. While cigarettes were universally accessible, ENDS access was more limited, driving
some to purchase products online. Delayed deliveries led some ENDS users to compensate with readily-available
cigarettes.
Conclusion: To mitigate ways that the COVID-19 pandemic may exacerbate an existing public health crisis, multi-
level policy strategies, such as expanded virtual cessation services and implementation and enforcement of smoke-
free home rules, can better support population health during this critical period. Policies that facilitate access to
lower risk products can help minimize harm among those who cannot or do not want to quit smoking.

Introduction factor for COVID-19, and to examine whether strict policy measures im-
posed by states and cities to limit coronavirus spread (e.g., stay-at-home
COVID-19, the infectious respiratory disease caused by the SARS- orders, business closures) – hereafter referred to as “lockdown” periods –
CoV-2 coronavirus, has become a worldwide pandemic since its iden- impact the ways in which people use tobacco products. A nationally rep-
tification in Wuhan, China in December 2019. By December 2020, resentative survey in England found no significant changes in cigarette
COVID-19 infected over 70 million people worldwide and claimed more smoking prevalence pre- and post-lockdown period, despite reported in-
than 1.5 million lives (Johns Hopkins University, 2020). The United creases in smoking quit attempts (Jackson, Garnett, Shahab, Oldham, &
States (US) has been particularly hard-hit, reaching over 15 million con- Brown, 2020). Similarly, a survey of tobacco users in India, which had
firmed cases and nearly 300,000 fatalities – 20% of the global death toll a national lockdown, showed that 70% of the sample did not change
(Johns Hopkins University, 2020). their tobacco use behaviors during this time period (Gupte, Mandal, &
Clinical studies suggest that tobacco use – particularly cigarette Jagiasi, 2020). In contrast, Belgian residents who smoked reported con-
smoking – is associated with worse outcomes among COVID-19 patients suming more cigarettes on average compared to the period before na-
(Alqahtani et al., 2020; Vardavas & Nikitara, 2020). Evidence on the risk tional lockdown measures were imposed (Vanderbruggen et al., 2020).
of becoming infected with COVID-19 by tobacco use status remains in- An Italian survey indicated that changes in tobacco use varied consider-
conclusive, highlighting the need for better data collection and more rig- ably based on the type of product(s) used: whereas exclusive cigarette
orous study designs (Simons, Shahab, Brown, & Perski, 2020). Research users reported decreases in daily consumption, those who used elec-
has begun to expand beyond questions of whether tobacco use is a risk tronic nicotine delivery systems (ENDS) – such as e-cigarettes – reported
comparatively stable consumption behaviors (Caponnetto et al., 2020).


Corresponding author.
E-mail address: tes2137@cumc.columbia.edu (T.E. Spillane).

https://doi.org/10.1016/j.drugpo.2021.103175

0955-3959/© 2021 Elsevier B.V. All rights reserved.


D.P. Giovenco, T.E. Spillane, R.M. Maggi et al. International Journal of Drug Policy 94 (2021) 103175

While quantitative, survey-based studies provide valuable insight considerably less risky than traditional cigarettes (Glasser et al., 2017;
into changes in tobacco use during lockdown periods, this approach of- McNeill, Brose, Calder, Bauld, & Robson, 2020; National Academies of
ten fails to capture the complex drivers and mechanisms that may con- Sciences, 2018). Including participants who use either or both products
tribute to these shifts. Indeed, lockdown measures could impact patterns can provide insight into whether perceptions of harm reduction relate
of tobacco use through multi-level factors that influence both supply to product use behaviors during the pandemic.
(e.g., ability to access tobacco products) and demand (e.g., motivation Given the current shortcomings of existing COVID-19 treatments,
to increase or decrease use). At the community level, COVID-19-related possible delays in vaccine distribution, and the potentially cyclical na-
shifts in the tobacco retail environment may shape consumption pat- ture of outbreaks and lockdowns, results can help identify the unique
terns. While “essential businesses,” such as convenience stores, gas sta- needs of cigarette and ENDS users during these critical periods. And
tions, and grocery stores that sell tobacco, were allowed to remain open while the end of this pandemic may be on the horizon, COVID-19 has
in the initial stages of the pandemic, other retailers (e.g., vape shops, already impacted individuals and altered aspects of society in ways that
tobacconists) were deemed non-essential in some states and required to will extend beyond the pandemic and plausibly influence tobacco use
close. In one Californian study, 40% of sampled vape shops temporar- behaviors moving forward. This study can highlight ways that pub-
ily shut down during the lockdown (Medel, Meza, Galimov, Baezconde- lic health interventions and policies can better support quit attempts
Garbanati, & Sussman, 2020). Generally, tobacco specialty stores, such and/or harm reduction, both during the COVID-19 pandemic and be-
as vape shops, carry a much larger inventory of nicotine products com- yond.
pared to “traditional” tobacco retailers (e.g., convenience stores, gas sta-
tions), including advanced generation vaping products that many con- Methods
sumers prefer (Pattinson, Lewis, Bains, Britton, & Langley, 2018). More-
over, individuals’ willingness to access tobacco products in community Participant recruitment
settings may be influenced by the fear of being outside, inside a crowded
store, or by their ability to get to the store. Factors that limit people’s Participants were recruited using an advertisement campaign on
ability to access tobacco products may be most salient among those with Facebook and Instagram from April 14 to 24, 2020. During this window,
greater nicotine dependence. approximately 88% of the US population experienced some form of state
Social distancing and stay-at-home orders, key COVID-19 preven- lockdown. Forty states ordered non-essential businesses to close, 38
tion measures, substantially alter interpersonal interactions. In addi- banned group gatherings, and 32 enacted stay-at-home orders (Law At-
tion to engaging in fewer social activities, many individuals are con- las, 2020). Advertisements targeted social media users in the US over the
fined to their homes during lockdown periods, either alone, with fam- age of 18 and linked to a screener questionnaire that collected informa-
ily members, or with other housemates. As a result, the context of to- tion on tobacco use and demographic characteristics. Eligibility criteria
bacco use behaviors (i.e., where, when, and with whom people use to- included: 1) being 18 years of age or older, 2) being able to communi-
bacco) may differ from pre-COVID routines. These changes may be es- cate in English, and 3) reporting use of cigarettes and/or ENDS “every
pecially relevant for those who use tobacco socially or who live with day” or “some days” in the past month (a standard measure of “current
children or other vulnerable populations. Finally, at the individual level, use” among adults in the US) (Cornelius, 2020). Among 71 participants
pandemic-related factors may cause heightened stress and anxiety, emo- who were eligible based on critieria in the screener questionnaire and
tions known to contribute to tobacco use (Hajek, Taylor, & McRobbie, who were contacted by study team members, 44 completed a telephone
2010; Lawless, Harrison, Grandits, Eberly, & Allen, 2015). Notably, in- interview. Two participants were found to be ineligible during the tele-
creases in smoking behaviors were observed after other disasters or trau- phone interviews, and 25 did not respond to our outreach or responded
matic events in the US, such as the September 11th terrorist attacks and after the study period ended. There were no substantial differences in
Hurricane Katrina (Alexander, Ward, Forde, & Stockton, 2019). Other product use, age, or other characteristics between those who completed
individuals, however, may view a respiratory disease pandemic as an an interview and those who did not.
optimal time to reduce use or quit. In a recent survey of 366 concurrent
cigarette and ENDS users (i.e., “dual users”), approximately one-third Data collection
reported increased motivation to quit due to COVID-19 health concerns
(Klemperer, West, Peasley-Miklus, & Villanti, 2020). Interviews were conducted between April 17 and May 13, 2020
While we can speculate how store closures, social isolation, increased (range: 35–50 min ); participants provided informed verbal consent.
anxiety, fear of an infectious respiratory disease, and other factors might The open-ended, semi-structured interview questions explored product
independently impact tobacco use based on theory or historical events, use and purchasing behaviors during COVID-19 lockdown, with a fo-
the unprecedented COVID-19 pandemic led to a convergence of these cus on comparisons to pre-lockdown use (see supplemental file). We
factors for many tobacco users. Descriptive qualitative research can be first asked participants to describe their typical cigarette and/or ENDS-
a useful tool to reveal detailed information about individuals’ complex related behaviors prior to the pandemic (i.e., January-February 2020);
experiences, uncover topics not initially considered, and give context parallel questions were asked about use during the COVID-19 lockdown.
to the mixed results of existing quantitative studies. The primary aim The interview guide was primarily organized to assess: a) behavioral
of our study is to identify – via qualitative methods that foreground shifts in patterns of product use before and after COVID, b) potential
participant voices – multi-level factors that exerted particularly strong supply-side related drivers (e.g., shifts in retail availability), and c) po-
influences on participants’ product use and purchasing behaviors at the tential demand-side related drivers (e.g., perceived COVID risk to access
height of the initial lockdown period in the US. and/or use products).
To achieve this goal, we conducted semi-structured interviews in The interview questions further assessed potential drivers at multiple
April-May 2020 with US adults who use cigarettes and/or ENDS. Al- levels within a socioecological framework. Socioecological models posit
though cigarettes and ENDS differ in important ways, we included users that health behaviors and outcomes are influenced by factors at multi-
of both products for several reasons: Dual-use frequently occurs among ple levels (e.g., community, interpersonal, individual), as well as their
adults. For example, nearly 70% of current adult e-cigarette users in the interactions. Although this theory has its origins in the study of human
US also currently smoke cigarettes (Baig & Giovenco, 2020). Addition- development, (Bronfenbrenner, 1977) socioecological frameworks have
ally, ENDS are increasingly used by some cigarette users as a tool to been adopted more generally in the field of public health – including
quit smoking (Delnevo et al., 2016; Glasser et al., 2020) or as a form tobacco control (US National Cancer Institute, 2017) – to help concep-
of tobacco harm reduction. Because ENDS deliver nicotine without the tualize and measure drivers of various health-related issues. Interview
harmful byproducts of combustion, researchers believe that they are questions focused on the role of structural drivers (lockdown policies),

2
D.P. Giovenco, T.E. Spillane, R.M. Maggi et al. International Journal of Drug Policy 94 (2021) 103175

community drivers (product availability), interpersonal drivers (shifts in Table 1


peer networks under COVID), and individual drivers (anxiety and stress Participant tobacco use status and demographic characteristics (n = 44).
levels). We also ensured that question probes incorporated this frame- n (%)
work. For example, in one interview, we inquired: “You mentioned that a
Current tobacco use
you now live with your parents as a result of the pandemic. Tell me
Cigarette-only 17 (38.6)
about how this living situation impacts your vaping” (interpersonal fac- ENDSb -only 6 (13.6)
tor). Following the interview, participants received a $30 electronic gift Dual usec 21 (47.7)
card as compensation. The Institutional Review Board at Columbia Uni- Gender identity
Female 24 (54.5)
versity approved all study procedures.
Male 20 (45.5)
Age group
Data analysis 18–34 18 (40.9)
35–59 17 (38.6)
Interviews were digitally recorded and transcribed verbatim. Three 60+ 9 (20.5)
Race or ethnicity
members of the study team conducted initial line-by-line “open cod-
White 26 (59.1)
ing” on the first five interviews to develop a provisional coding scheme Black 9 (20.5)
(i.e., inductive coding). We also created initial deductive codes based Hispanic/Latinx 5 (11.4)
on multi-level factors known to influence tobacco use (e.g., stress, so- Asian 2 (4.5)
Not stated/unknown 2 (4.5)
cial influences, tobacco retail environment) (US National Cancer In-
Education
stitute, 2017). Team members then coded a random sample of 10 Less than high school 2 (4.5)
additional transcripts to refine the code dictionary and develop a High school or GED 8 (18.2)
codebook, which was reviewed and amended by all team members Some college or associate degree 16 (36.4)
(MacQueen, McLellan, & Kay, 1998). Two coders independently applied Bachelor’s degree or higher 18 (40.9)
US census region
the final coding scheme to all interview transcripts, and full-team discus-
South 16 (36.4)
sions resolved any discrepancies. Data were analyzed using the constant West 11 (25.0)
comparative method (Buetow, 2010; Glaser & Strauss, 1967) to develop Northeast 9 (20.5)
themes related to behavioral shifts and to explore potential axes of dif- Midwest 8 (18.2)
Underlying health conditiond 18 (40.9)
ference by product use status (e.g., cigarette-only, ENDS-only, dual use).
We organized major themes under their respective levels of the socioe- a
Measured as some day or daily use in the past month.
cological model to better conceptualize multilevel drivers of behavior b
ENDS: electronic nicotine delivery systems.
c
change and identify potential prevention strategies. Dedoose, a web- Reported past month use of both cigarettes and ENDS.
d
based software application for qualitative and mixed-methods analyses, Underlying health condition that has been linked to poorer COVID-19 out-
was used for coding and analysis (Dedoose, 2020). comes, including: asthma, chronic obstructive pulmonary disease, cardiovascu-
lar disease, diabetes.
Results

A total of 44 participants from 21 US states completed an interview. primary levels: community, interpersonal, and individual (Fig. 1 high-
At the time of their interviews, nearly all participants (90%) lived in lights these key findings).
a state that closed “non-essential” businesses, and approximately 70%
lived in states with school closures. Further, three-quarters of respon-
dents lived in a state with a mandated stay-at-home order: generally, Community level
these limit all travel outside the home with the exception of essential
activities, such as doctor visits, grocery shopping, or going to work Product accessibility
for essential workers. Notably, however, all participants were volun- Despite observing other product shortages in retail stores (e.g., toi-
tarily isolating at home unless required to leave the house. As shown let paper, yeast), participants shared that cigarettes seemed to be well-
in Table 1, nearly half (48%) reported past month dual use, 39% re- stocked and always available in the gas stations, convenience stores, and
ported cigarette-only use, and 14% reported ENDS-only use. The ma- grocery stores that remained open during state lockdowns. Some partic-
jority of participants self-identified as white (59%), followed by Black ipants observed a slight increase in cigarette prices, although most in-
(21%), Hispanic/Latinx (11%), Asian (5%), and not stated/unknown dividuals described no changes in prices. One individual described the
(5%). Over half identified as female gender (55%) and nearly half (41%) accessibility of cigarettes despite shortages of other essential items:
reported having an underlying health condition (e.g., asthma, chronic There are so many products out there that you cannot find, such as toilet
obstructive pulmonary disease, cardiovascular disease, or diabetes). paper - and when I went to the grocery store today the meat department
was barren. And the fruit department, barren. But they never run out of
Shifts in patterns of use during COVID-19 lockdown cigarettes. They sure have tons of smokes. It’s a product that I don’t think
they’re ever going to run out of. (Male, 60+, Cigarettes-only)
The majority of participants reported some shift in patterns of prod-
uct use during COVID-19 lockdown, including the frequency or amount In contrast, participants described greater variability in ENDS ac-
of use; however, these patterns varied considerably (Table 2). Overall, cessibility, including limited variety and lack of availability. This was
reported increases were slightly more common among cigarette-only because vape shops, smoke shops, and other tobacco specialty stores –
and dual users, with dual users often reporting increases in ENDS use. which tend to carry a larger inventory of ENDS brands, flavors, nico-
Decreases in use were common among ENDS-only users, although there tine concentrations, and device accessories – were often deemed non-
were only six people in this group. We note that nearly all ENDS users essential businesses and thus closed, or had significantly reduced hours.
referred to their product use as “vaping” in the illustrative quotes pre- Some participants noted that the businesses that remained open (e.g.,
sented throughout the manuscript. gas stations, grocery stores) had unsatisfactory ENDS product selections,
We used a socioecological framework to examine the multi-level including limited flavor options, compared to vape shops. Although a
drivers of product use and purchasing behaviors in the context of few individuals reduced the frequency of their ENDS use due to these
COVID-19 prevention policies. Common themes were nested under 3 circumstances, more shifted to online purchasing during the lockdown.

3
D.P. Giovenco, T.E. Spillane, R.M. Maggi et al. International Journal of Drug Policy 94 (2021) 103175

Fig. 1. Key findings: Ecological framework of factors that im-


pacted tobacco use and purchasing behaviors during COVID-
19 lockdown.

I can’t find any at Walmart or different little convenience stores where described a subsequent increase in overall product use due to the avail-
I would get them. I just think people are buying a lot of them in bulk so ability of these products at home.
they’re really hard to find. So I had to look online on the website to buy
Since I’m not going out so much, I’ll buy a carton. That’ll last me a while
them. Which is really annoying because I have to wait to get them. (Male,
and I don’t have to go back out there. I only want to go out once a week
18–34, Dual use)
and that’s it. (Female, 60+, Cigarettes-only)
Participants who resorted to purchasing their products online de-
scribed barriers to ordering, such as longer wait times due to shipping Furthermore, several participants resorted to rationing their
delays, or product backorder due to high demand. Participants discussed cigarettes and ENDS to save money and mitigate health risks of store
being more mindful of their supply and ordering products in advance to visits. In doing so, they would smoke old cigarette butts, roll or re-roll
avoid the stress of being without an ENDS product. cigarettes, or combine “juice” from old ENDS cartridges for longer use.

The ordering process is definitely different. You have to completely plan


it. This isn’t like cigarettes, where you can go to any corner store and get Interpersonal level
them. Every vape store is closed… We’re low right now and I’m going to
have to place another order even though I have five bottles on the way. Shifts in household dynamics
But I don’t know when they’ll be here. (Female, 18–34, Dual use) Many participants experienced shifts in household composition and
dynamics during quarantine. Some were newly cohabitating with par-
Some dual users noted that waiting longer for ENDS products caused ents, grandparents, siblings, and other relatives, while others now had
them to smoke cigarettes more, as cigarettes were readily available. full-time childcare responsibilities. Though this did not always affect the
[Online delivery] takes like 2–3 business days which isn’t a long time, frequency or intensity of product use, it often altered use context. For
but if you want to vape, you want it right then and there. So it can be example, participants expressed heightened cognizance of those present
a little annoying sometimes. Which has caused me to smoke [cigarettes] while they used cigarettes or ENDS. Several participants used their prod-
more because I have them on hand. (Male, 18–34, Dual use) uct(s) in private spaces or outside to avoid family members observing
their habits. One participant noted:
Participants described other accessibility-related changes in purchas-
ing patterns, such as buying products in bulk to avoid repeated online I have a room for [smoking and vaping] now…I don’t do it in public. I
purchases (and therefore more waiting) and for greater security about don’t do it with the kids. I just lock myself in the room and do it. I don’t
the duration of their supply. want my kids to do that. (Male, 35–59, Dual use).

Another participant preferred using ENDS over cigarettes when


Health risks of in-store purchasing spending time with his children.
Many participants who continued to purchase products in-store
shifted purchasing patterns based on their desire to reduce COVID- I haven’t really been smoking conventional cigarettes, it’s been more va-
related health risks. Participants sometimes traveled to stores that were ping. When we go outside it’s like a family thing, so it’s not like I’ve been
less crowded, visited during non-peak hours, or reduced the number of smoking a cigarette while walking outside with my kids. I don’t want to
visits to grocery stores, gas stations, or convenience stores to avoid po- do that with them. I don’t know why but it’s not good to have that look
tential contact with other people. so I usually vape. When I come in I go straight to the bathroom or garage
or wherever and I vape for a long time. (Male, 18–34, Dual use)
I strive not to go out as often anywhere and do anything outside just to
avoid potential contact. So that has probably played a little bit into how Other dual users who reported increased ENDS use and decreased
much I smoke. If I look into a pack and I’m down to 4–5 and that’s, let’s cigarette use attributed this shift to spending more time indoors and not
say, at 8′clock at night, I make a very conscious effort to squirrel away wanting to expose others living in the house to smoke. One participant,
what I got until the next day. Instead of running out that night. (Male, now confined to being indoors, justified her shift to greater ENDS use:
60+, Cigarettes-only)
In my mind, the vape was like less pollution in the house. It’s not as bad
Some participants resorted to stockpiling patterns such as purchas- as the cigarette. We still stayed in the bathroom because the kids were in
ing cigarette cartons (each containing 10 packs) or buying more packs the house. I’m still kind of funny about that. Like I said, I didn’t like the
per trip instead of a single pack. A majority of those who stockpiled pollution from the cigarettes as much in the house. So when I was really

4
D.P. Giovenco, T.E. Spillane, R.M. Maggi et al. International Journal of Drug Policy 94 (2021) 103175

stressed out and I needed a quick [inhalation noise] on the vape I could

“I was smoking cigarettes more [before COVID], but now I’m vaping more if that makes sense. Now that I’m inside, I’m smoking less and vaping more because I want to be healthy
complex, so you’ll run into people. And, you know, I don’t want to upset anyone with the smoke itself. [Smoking] was easier to do when I was commuting into the city.” (Female,
do that. (Female, 35–59, Dual use)
“I smoked much less [before COVID] because I was doing things. You know, I was getting out of the house. So if you go to a restaurant and bar, it’s no smoking. I can sit there and

“So yeah, I’ve been thinking about should I even bother ordering, then there’s like, well you better, because of what’s going on. I really don’t need any because I’m not vaping as

“Before [COVID] I was smoking and vaping every day. Now it has been cut down just because, you know, that’s more times that I have to go to the gas station or to the store to
“But without a doubt, the first isolation I was smoking more. It was something to do, something to do with my hands, something to do just to have another sense of normalcy.”

“Well, I’m not working right now so I’m at home more. And now I think I tend to smoke cigarettes a lot more and vape a lot more because I have a lot more time on my hands. I
“Honestly, I feel much better now. Probably after the COVID, I’m going to continue smoking just the half pack per day. I don’t want to smoke that many cigarettes anymore. If I
“But yeah, since I have been doing the 100% telecommute, I typically only smoke one [cigarette] a day at this point. Just because not wanting to be outside. It’s an apartment
These behavioral shifts reflected a perception that using ENDS in-

“I guess I do vape a little bit more. I want to say I probably smoke, like I said, about the same. Maybe a tiny bit less. But I don’t think it’s changed my habits too much on
doors and around others are less risky than smoking indoors.

Reduced social activities

and smoke the vape instead of cigarettes. If I were to smoke cigarettes the same amount as how much I vape now, I would’ve been dead by now.” (Male, 18–34)
Four participants described their product use pre-COVID as an ac-
tivity that primarily occurred with friends, sometimes in bars or other

“Vaping right now is more like an occasional thing…It’s more of a thing that I do like here and there rather than on a consistent basis.” (Female, 35–59)
nightlife venues, or while attending sporting events or concerts (i.e. “so-
cial smoking/vaping”). Thus, the absence of social activities during lock-
down generally decreased their cigarette and ENDS use. In addition to
shifts as a result of limited social activities due to the lockdown, percep-
tions of risk related to being near others while using products, or even
“I find that I am vaping a bit more because I have more free time…I think now I’m vaping because I have nothing to do.” (Male, 18–34)

sharing products, affected patterns of use.


For the most part, I’ve avoided using vapes just to avoid sharing stuff. I
never really cared about sharing drinks or sharing vapes or bumming a
not smoke for 2 or 3 h. So I would say maybe half a pack a day then. And now perhaps I’m up to a pack.” (Female, 60+)

much. I’m not vaping outside the house anymore. My entire vaping life has changed because of this virus.” (Female, 60+)

cigarette or anything. But now I haven’t really been doing it. The friend
whose house we’d go to, he got a job at a grocery store. So I was just like,
‘Nah, I’m not going to hit his vapes or anything.’ So I actually haven’t
vaped at all since this started. I’m trying to avoid sharing things. You
know, mouth-to-mouth contact on objects. (Male, 18–34, Dual use)
Importantly, these social product users were probably less nico-
tine dependent, given that they used cigarettes or ENDS less fre-
think part of it is stress and part of it is availability with my time, my free time.” (Male, 18–34)

quently/intensely compared to other participants.

Individual level

Emotional distress
smoking. I probably just vape a little bit more than I used to.” (Male, 18–34)

Nearly all participants reported increased stress related to COVID-


19, and described it as the primary driver of increased cigarette and/or
can do it right now, there’s no reason not to after that.” (Male, 35–59)

ENDS use. Participants attributed their stress and anxiety to factors such
as fears about the virus, job uncertainty, isolation, and changes in house-
hold dynamics in the wake of stay-at-home orders. As one woman noted:
get products…So, it’s definitely changed.” (Female, 18–34)

I just pile on stress from every direction. I got the normal kind of household
stress. Then taking away all the time I had outside the house to just reset
a little bit, it just kind of keeps the baseline pretty high. I know it probably
doesn’t make a lot of sense but I stress because I know that it would make
the situation worse if I were to get sick and then I get stressed over that.
Summary of participants’ tobacco use changes during COVID-19 lockdown (n = 44).

That’s more stress and then I smoke more. (Female, 18–34, Dual use)
Boredom commonly co-occurred with increased anxiety and was also
a driver of increased use. This was especially true among participants
who were unemployed or working fewer hours, and therefore spending
more free time at home. As one participant noted:
Every now and then my fiancé’s sister will come by and we’ll sit on the
patio. Since there’s not much else to do, we’ll just sit out there and smoke.
Illustrative quotes

(Male, 60+)

We actually even smoked some hookah the other day. We were just that
bored. (Male, 18–34, Dual use)
35–59)

For a number of participants, smoking and/or ENDS use were de-


scribed as stress relievers even before the pandemic; thus, many partici-
pants gravitated towards these behaviors to manage stress and boredom
during this period of uncertainty and social isolation.
Tobacco use status and reported changes

- Increase in cigarettes, no change in


- Increase in cigarettes, decrease in

- Increase in ENDS, no change in

Irregular routines
- Increase in ENDS, decrease in
- No change in either (n = 2)

Some participants reported that the daily routine disruptions due


- Decrease in both (n = 5)
- Increase in both (n = 8)

to COVID-19 affected their product use behaviors. These disruptions


were primarily attributed to employment/workplace changes, including
- No change (n = 3)

- No change (n = 2)

cigarettes (n = 3)

cigarettes (n = 1)
- Decrease (n = 6)

- Decrease (n = 3)

working from home, working reduced hours, and unemployment. Due


- Increase (n = 8)

- Increase (n = 1)

ENDS (n = 1)

ENDS (n = 1)
Cigarette-only

to these factors, some participants described their smoking and/or ENDS


use patterns as having less structure compared to pre-COVID times.
ENDS-only

Dual use
Table 2

I basically always smoked less when I worked. I’d take a smoke break
every couple of hours. But when I’m home, I smoke every hour basically.
So going without working makes me smoke more. So if I’m not out and

5
D.P. Giovenco, T.E. Spillane, R.M. Maggi et al. International Journal of Drug Policy 94 (2021) 103175

about or working, I’m smoking more because I’m home. (Female, 35–59, on social smoking found that this behavioral subgroup is more primed
Cigarettes-only) to quit and has better cessation outcomes compared to other types of
cigarette users (Song & Ling, 2011). Thus, individuals who use tobacco
Several other participants described shifting from having set times
more regularly and may be more nicotine dependent represent a priority
and settings in which they would use their product (e.g., lunch breaks,
group for cessation interventions during the pandemic.
while commuting, etc.) to more constant and uninterrupted use through-
Irrespective of changes in use frequency or intensity, all participants
out the day.
noted changes in contextual patterns of use. For example, smoking and
ENDS use behaviors generally became much less structured, more soli-
Financial pressures tary, and often occurred in different settings. These contextual shifts
While several participants described serious financial challenges as may impact cessation success among those who make a quit attempt:
a result of COVID-19, most participants still continued purchasing some on the one hand, the pandemic’s interruption of daily routines may re-
form of cigarettes and/or ENDS. To mitigate financial difficulties, how- duce social smoking or ritualistic smoking triggers (e.g., while driving,
ever, a few individuals modified their product use by switching to less during work breaks), offering an opportunity to break these associa-
expensive brands or styles. tions. Conversely, irregular routines may lead to more continuous and
I used to be loyal – when I had the financial means, it was Marlboro unpredictable use, resulting in greater difficulty managing cravings and
Menthols. Now it’s whatever the cheapest menthol is. Which ranges from perhaps greater dependency. Given the likelihood that the coronavirus
$3.18 to $3.58. (Male, 35–59, Cigarettes-only) pandemic will permanently alter elements of the workplace (e.g., in-
creased remote work), education (e.g., virtual learning), consumer be-
More rarely, participants were forced to stop buying cigarettes or havior (e.g., online purchasing), and socialization for many individuals,
ENDS entirely or began to ration existing products due to severe finan- cessation treatment plans must be tailored to address these daily condi-
cial constraint and an inability to afford basic necessities. tions and their unique impacts on tobacco use behaviors.
Taken together, these findings have implications for US tobacco con-
Health concerns trol policies related to access and cessation. Most states in the US ensure
For some participants, COVID-19 created a renewed sense of aware- that state-regulated private insurance plans, insurance plans offered to
ness of their general health. A few participants mentioned reevaluating state employees, and Medicaid programs cover at least some evidence-
their product use behaviors, with some decreasing their use and others based cessation treatments (e.g., pharmacotherapy), although the scope
contemplating quitting. of coverage varies by state (US Centers for Disease Control and Preven-
[Vaping] was just something that was a habit, something that I did every tion, 2020). During this period of global turmoil, smoking and ENDS use
day and I didn’t think much about it. But after COVID, I think I did will increase among some individuals. State and local governments and
less of it because it wasn’t like a priority for me. I was more concerned public health agencies must anticipate potential surges in both use and
about other health issues, things like catching COVID, and worrying about treatment-seeking by ensuring that cessation programs are sufficiently
family and friends catching COVID. I just instinctually started reducing supported, promoted, and even expanded. This includes national and
my consumption of vaping. I didn’t find a desire to really vape as much state-based “quitline” services, remote forms of telephone cessation sup-
now than I did before the pandemic. (Female, 35–59, ENDS-only) port. Traditional treatment approaches that typically occur in-person
(e.g., individual or group counseling) must be adapted and enhanced
However, these motivations were not necessarily attributed to par- for remote delivery given the movement toward virtual medicine dur-
ticipants’ perceptions of product use as a direct COVID-19 risk factor. ing the COVID-19 pandemic and beyond. Training cessation counselors
Rather, decreasing use was perceived as a measure that would better to effectively deliver these remote sessions would be a beneficial ap-
one’s overall health, and thus make one less susceptible to a poor COVID- proach for health agencies and healthcare organizations. Indeed, inno-
19 prognosis. Additional examples of illustrative quotes from all identi- vative cessation interventions that leverage mobile and virtual technolo-
fied themes are provided in Supplemental Table 1. gies show promise as an alternative to traditional face-to-face clinical
visits (Nomura et al., 2019; Whittaker, McRobbie, Bullen, Rodgers, &
Discussion Gu, 2016).
Most participants in this study were following their state’s stay-at-
The intense shifts in day-to-day life brought about by the COVID- home order, including working remotely. As a result, many reported us-
19 pandemic and public health response measures meaningfully shaped ing cigarettes and/or ENDS inside the home more than before COVID.
product use behaviors. Virtually all participants reported changes in Establishing and enforcing tobacco-free home rules – whether voluntary
their cigarette and ENDS use behaviors during the initial lockdown pe- or mandatory, such as those implemented in some types of multi-unit
riod, though patterns varied considerably and were influenced by fac- housing – can reduce the health risks of secondhand smoke and other ex-
tors at multiple levels. Reported increases in product use were gener- posures among residents who do not use tobacco products. Importantly,
ally more common than decreases, and were most frequently described any mandatory smoke-free housing policies should be coupled with
as resulting from individual-level factors: irregular routines, boredom, strategies to support resident cessation attempts so as to minimize unin-
and heightened anxiety about the future. COVID-related distress – in- tentionally aggravating social and economic hardships experienced by
creasingly referred to as “COVID stress syndrome” (Taylor et al.,2020) – low-income and/or marginalized populations who use cigarettes and/or
was particularly pervasive and influential, often overriding factors that ENDS products.
might conceivably reduce use, such as financial insecurity and health For individuals who are unable or do not want to stop using to-
concerns. This finding is consistent with established research on smok- bacco products, harm minimization strategies (e.g., smoking outside
ing as a powerful coping mechanism, especially among those experienc- of the home, switching to non-combusted or pharmaceutical nicotine
ing emotional distress or mental illness (Krueger & Chang, 2008). products) may be an initial step to reduce health risks to those who
While less common, some participants reported decreases in product smoke and other household members. Several dual users in this study
use that were predominantly influenced by individual and interpersonal reported smoking cigarettes less and using ENDS more during the lock-
factors. At the individual level, renewed attention to health occasion- down period, citing an aversion to the smell of cigarette smoke in their
ally motivated participants to reduce consumption. For others who fre- homes and the desire to reduce smoke exposure among family members
quently engaged in social product use before the pandemic, the lack of with whom they were isolating. ENDS – though not risk free – pose less
interpersonal interactions during home isolation and uneasiness about harm to users and bystanders than combusted cigarettes (Glasser et al.,
sharing products resulted in decreased use behaviors. Previous studies 2017). Therefore, policies that enable access to products lower on the

6
D.P. Giovenco, T.E. Spillane, R.M. Maggi et al. International Journal of Drug Policy 94 (2021) 103175

tobacco risk continuum (e.g., tactfully deciding which types of tobacco Declarations of Interest
retailer are deemed “essential”) may ultimately benefit individuals who
might otherwise continue to smoke or switch to cigarettes. Conversely, The authors have no conflicts of interest.
restricting access to lower risk products may have harmful, unintended
consequences. Supplementary materials
At the community-level, we found that product access in local re-
tailers affected smoking and ENDS use behaviors in different ways. Supplementary material associated with this article can be found, in
Cigarettes were unfailingly available in “essential businesses” during the the online version, at doi:10.1016/j.drugpo.2021.103175.
lockdown period. Although participants may have altered their cigarette
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8
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The Project Gutenberg eBook of Magic words: A
tale for Christmas time
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Title: Magic words: A tale for Christmas time

Author: Emilie Maceroni

Illustrator: Edward Henry Wehnert

Release date: June 29, 2022 [eBook #68424]

Language: English

Original publication: United Kingdom: Cundall & Addey, 1851

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*** START OF THE PROJECT GUTENBERG EBOOK MAGIC


WORDS: A TALE FOR CHRISTMAS TIME ***
MAGIC WORDS.
Day & Son, lithrs to the Queen.
MAGIC WORDS;
A Tale for Christmas Time.

BY
EMILIE MACERONI.
“Oh, many a shaft at random sent,
Finds mark the archer little meant;
And many a word at random spoken
May soothe or wound a heart that’s broken.”

Scott.

WITH FOUR ILLUSTRATIONS BY E. H. WEHNERT.

LONDON:
CUNDALL & ADDEY, 21 OLD BOND STREET.
M.DCCC.LI.
LONDON:
Printed by G. Barclay, Castle St. Leicester Sq.
TO

MRS. AUSTIN
This Little Volume

IS AFFECTIONATELY INSCRIBED.
ILLUSTRATIONS.
MARION AND HER FATHER (Frontispiece)
LITTLE MARY AND HER FRIEND TROY 11
MARION TEACHING LATIN 25
EDITH WATCHING THE DAWN 39
From Drawings by E. H. Wehnert.
MAGIC WORDS.
CHAPTER I.
It was the evening of Christmas Day. The hymn of “Peace upon
earth, good-will towards men,” had been chanted by thousands of
voices throughout the land, from the grand cathedral-choir to the
simple singers of the village church. Charity had extended her
munificent hand to the poor and needy, lighting up smiles on many a
care-worn face. Hospitality welcomed the good, the beautiful, and
the great to the lordly mansions of the rich. Love and Peace sat
enthroned in many a happy home. Poverty, shivering at the present,
was consoled by the glowing figure of Hope, pointing with radiant
eyes to the future. Memory and Sorrow lingered around the grave of
many a departed one; but of all mourners they were the saddest who
were estranged from those they still loved. Yes, amid the pain, the
sorrow, the suffering of life, their hearts were the heaviest; for (to use
the oft-quoted words of the poet) “to be wroth with those we love,
doth work like madness in the brain;” and this hallowed season
speaks strongest to our kindest feelings, and to the tenderness of
our better nature.

A train had stopped at a rough little village station about thirty miles
from town, and a few country people, on their way home, leaned
over the bridge above to admire the enormous red eyes of the
monster as it moved slowly on through a deep cutting crowned with
dark firs. They lingered yet a moment longer, to mark whom it had
borne from the great city to their quiet village. A beautiful girl of
fifteen, glowing with health and exercise, accompanied by two fine,
rough-looking dogs, rushed down to meet her playfellows and
friends. She was breathless with joy, and with her race over the
heath; but her merry laugh and warm greeting sounded pleasantly
enough as the noise of the train died away in the distance.
A lady, wrapped in a warm plaid, who had been anxiously waiting for
some time, took the arm of her husband, with a few low words of
delighted welcome, and they walked briskly away. The dogs of the
younger party barked with glee—were patted and caressed. One
look at the dear heath and at the hills beyond, with a thrill of delight
at the thoughts of a long ramble over them on the morrow, and the
ponies were mounted, the dogs whistled to, and away flew the happy
trio to the home-welcome, to the dear old hall, to all the joy of a
Christmas meeting.
Only two other passengers appeared, winding up the pathway—a
gentleman of tall and commanding aspect, and a buxom, brisk-
footed countrywoman, wrapped in her scarlet cloak, who passed him
with a low curtsey and cheerful good night. She was thinking of the
bright fireside, of the dear little faces round it anxiously awaiting her
return, and of the enormous amount of joy contained in that wicker
basket. An event of great marvel and wonderment is a poor woman’s
visit to her friends in town, and she is ever in a tearful state of
ecstasy and excitement on reaching home again; all of which
becomes a matter of grave family history in the lowly household, and
is recounted on many an occasion to eager and attentive hearers.
She quickly disappeared up a winding path cut through the furze and
heather, evidently leading to a low-roofed cottage on the skirts of a
fir-wood. Lights twinkled in the casement, and joyful voices were
soon heard approaching to meet and welcome her. The road was
now perfectly solitary. A few deep-red clouds still hung over the west,
and here and there a large bright star shone silently through the
sharp, pure air. Dogs bayed in the distance; the sound came very
pleasantly over the heather through the rough old pines.
The gentleman walked briskly on, and lights began to appear in the
valley beneath. He stopped as the merry notes of a flageolet struck
his ear, proceeding from a cottage by the road-side. The blaze of a
wood fire within illumined the little rustic porch and neat garden.
Bright branches of glistening holly shone in the tiny casement. The
tune ceased, and was followed by a light-hearted laugh and the
sound of young voices.
“How happy they seem!” said he. “It is such scenes as these which
make the country so delightful, so cheering to sense and spirit!”
And yet he sighed heavily as he walked on; and passing through an
avenue of fir and larch leading to one of the prettiest and most
picturesque cottages in the world, he paused when he reached the
garden-gate. It seemed, too, a dear, quiet, sweet-smelling home.
Lights shone from more than one of the windows; and more than one
bright young face might be seen, by the gleam of its golden hair,
flitting about in the uncertain light. A sweet young voice singing as
sweet a tune ceased, as all young voices do, suddenly, when the bell
rang out its summons, and a brisk, rosy little maid appeared, lantern
and key in hand, to admit the traveller, and guide him through the
long shadow of the firs to the house. A favourite dog bounded to
meet and gambol round him with unrepressed joy. The children
clustered into the porch to say, timidly, “How do you do?” and hold
out their little hands to shake; while their mother, advancing with a
kindly greeting, expressed her pleasure at his return. Even the maid
looked pleased and happy to see him. But yet it was not his home.
After a few minutes’ conversation, the traveller was seated in his
own room, his dog, his sole companion, looking at him with
glistening eyes, as his master fondly stroked his magnificent head.
He was a man of twenty-eight or thirty years of age, with a sad and
thoughtful cast of countenance, yet one that all who looked upon it
must instantly love and respect; it was at once so engaging and so
noble. He looked round his little room at his sketches and his gun
with evident pleasure, placed some books and papers which he had
brought on a little table before him, and drawing his arm-chair close
to the blazing pine-logs, sat watching the golden cones as they
crumbled away, one by one, at the height of their brilliancy. But every
reverie must have its end; and his was brought to a close by the
appearance of coffee, borne by a bright-eyed country maid, smirking
and smiling with pleasure, as country servants are wont to do at
every fresh arrival.
It would seem that the reverie by the bright fireside was not an idle
one, but that among many revolving thoughts, some, at least, were
considered worthy of preservation; for the coffee was soon
despatched, the table covered with books and papers, and the
stranger intently occupied with his pen.
So absorbed did he become with it, that after one or two long, wistful
glances, the fine hound lay down reproachfully on his comfortable
rug, as if despairing of any further notice that night.
The wind moaned heavily in the pine-branches round the cottage.
Presently the writer paused and listened to the sound, so like the
rushing of distant waters. He walked slowly to the window, and
gazed long and earnestly into the night. It was moonlight, yet stormy;
and large, glittering stars, looked down through the dark branches,
when the hurrying white clouds had drifted over them. The distant
clock of the old village church, slowly striking the hour, sounded
mournfully over the river; and the lonely man at that little window
thought of years that were gone, of the bright firesides in many a
happy home that night, and turned and put away his papers with a
sigh. He thought how differently he used to work years ago, when,
with all the ardour of his nature and the energy of hope, and yet with
intense fear and anxiety, he strove to render himself worthy of one
idolized, one long-sighed-for object! He thought, too, of the
bitterness, the agony of disappointment; and how long years of his
young life would have been thrown away, had he not struggled hard
to save himself from becoming a useless, melancholy being, given
up to the indulgence of selfish regrets. He had succeeded,—there
was some comfort in that reflection. He knew of what he was
capable, and dared not throw away the power he had acquired,
because it no longer availed the idol Self. So he still worked on. He
had become distinguished for his literary labours, and for his
contributions to the improvement and well-being of his fellow-
creatures; but to fame and to the praises of the great he was now
equally indifferent. His happiest hours were passed in his favourite
village, where he was greatly beloved, although he dared not wholly
give himself up to the quiet of a country life.
He had had the old Gothic church restored, with all possible
observance of its antique ornaments and its fine clustering ivy; and
took a kind of Sir Roger de Coverley delight in seeing the country
people, bettered and improved in every way, flocking to it on
Sundays to hear his good tutor’s sermons, to which he used to listen
with so much reverence in his boyish days. He had learned to
believe that the word “happiness” signifies, the being reconciled to
bear, still having courage to do, and gratitude to enjoy that which
remains. Thus, he was usually cheerful in his various occupations;
but this was Christmas time: a time when the lonely heart feels most
desolate—a time when many a tender word spoken by the absent is
remembered with sorrow—when all anger is forgotten in the feeling
of peace and love which steals over the heart. And his head lay
buried in his hands, his whole soul given up to an overwhelming
agony of regret.
Day & Son, lithrs to the Queen.

“This day last year,” he muttered, “who could have believed the
change? Oh, Edith!” he continued, taking up a miniature that lay
beside him, “who could have thought then that we should now be as
strangers to each other? Who could have thought that that bright
face, those many noble qualities, could have wrought so much
misery?” Again he looked at the lovely countenance, smiling on him
a thousand of the tenderest remembrances, and a still gentler
expression, a kindlier spirit, came over him. “Those eyes,” he said,
“how softly they have looked on me! Perhaps even now a thought
——but what folly! In the pride of beauty and prosperity, what is
there to remind her of me?”
A low tap at the door interrupted his meditations. For an instant he
could not say, “Come in!” his heart was so very full; but quickly
recovering himself, he turned with a smile to welcome a little village
child, who timidly advanced to place both her tiny hands in his.
She looked into his face with eyes beaming with love and gratitude;
but the joyful, sparkling expression soon faded away, for she saw
that he was sadder than usual; and with the quick sympathy and
natural grace of childhood she sat down quietly on the rug, and
taking the stately head of the hound on her lap, pensively stroked his
long, shaggy coat. Presently she ventured to break the silence in her
gentle way—“I am so glad you are come back, sir; I have missed you
so!”
Her companion’s countenance brightened, and he said with
animation—“Have you, though, my poor little Mary? I thought you
had forgotten me, being so long away.” And he stroked her bright
brown hair.
“You should not have thought that,” said the child, earnestly; “I
always remember you, for you taught me all I know. I was longing to
come yesterday, and all day to-day,” she continued, “to hear if you
had arrived. To-day has been so happy that I could not stay away
any longer, and so here I am,” she added, with her merry laugh,
which sounded pleasantly in that usually silent room. These simple
words, that mute caress, had restored the confidence of the two
friends. Mary was herself again, full of fun and prattle. Seated on the
extreme edge of a huge Gothic chair, she balanced her little feet on
the back of her friend Troy, who, far from resenting the liberty, fixed
his dark eyes lovingly on her sweet young face, while she talked on,
full of the details of her simple life. How she had gathered pine-
cones for several evenings, because she knew he loved their
cheerful blaze and sweet smell. How poor Turpin, who was always in
trouble, had hunted a rabbit, and been caught in a trap; of her mad
race over the hills for help; how she nursed the poor, poor foot
afterwards; and how the faithful patient cried because he could not
accompany her that night; the relation of all which very much
affected his kind little mistress. Presently she produced with great
glee her “Christmas present,”—several little bundles of bark, peeled
with great care, from the silver birch-trees, cut into slips, and tied
with red worsted. “I burnt a little bit the other day,” said she, “and the
smell was so nice I thought you would like it, so I got some to light
your taper with—do try it;” and the little creature soon held a blazing
piece in her hand.
“It is delicious, Mary; and how good of you to collect it for me!”
“I was very happy getting it,” said the child; “but I wish you had not
thought I had forgotten you. I could not forget you!” she continued,
after a pause; “you, who have been so good to me, and taught me
so much! I never looked at a book before you came. Oh, I was sadly
wild! Mother said I made more noise than the boys!” And she
laughed heartily.
The tutor laughed too, and told the often repeated story, which he
knew she loved to hear, of how, in his walks, he had frequently
listened to her little voice singing in a cornfield, while “minding” birds;
how he had been surprised at her sudden disappearance on his
nearer approach, and on making a voyage of discovery, had found
her ensconced in the body of a broken-down post-chaise, that,
singularly enough, lay between two old fir-trees at the foot of the
wood! He did not describe to her how, in imagination, he had
pictured the different and exciting scenes in which the once gay
equipage might have borne its part; but went on to say how he had
peeped in unobserved, and had seen her perched on one of the
dilapidated seats, with a little piece of board on her lap, intently
occupied in carving a morsel of meat into divers small pieces, which
she divided, with impartial care, among three ragged starlings
perched on the opposite beam, who watched her with glistening
eyes! How merrily she talked to them, and how perfectly they
seemed to love and understand each other! He reminded her of her
surprise on being discovered, and her frank invitation to the intruder

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