Original Article
Pubblicato: 2022-05-20

Tobacco smoking during the coronavirus pandemic in the older adults from Lombardy region. Implications on psychological well-being

Dipartimento di Ambiente e Salute, Istituto di Ricerche Farmacologiche “Mario Negri” IRCCS
Istituto di Ricerche Farmacologiche “Mario Negri” IRCCS, Milano (Silvano Gallus, Cristina Bosetti, Carlotta Micaela Jarach, Alessandra Lugo, Chiara Stival). Università degli Studi di Genova, Genova (Gianluca Serafini, Andrea Amerio, Mario Amore). Università Bocconi, Milano (David Stuckler, Roberto De Sena, Simone Ghislandi, Yuxi Wang). Università degli Studi dell’Insubria, Varese (Francesco Gianfagna, Anwal Ghulam). Università degli Studi dell’Insubria, Varese e Istituto Neurologico Mediterraneo Neuromed IRCCS, Pozzilli (Licia Iacoviello, Marialaura Bonaccio). Università degli Studi di Pavia, Pavia e Università Vita-Salute San Raffaele, Milano (Anna Odone, Carlo Signorelli, Paola Bertuccio, Giansanto Mosconi, Giacomo Pietro Vigezzi). Agenzia per la Tutela della Salute della Brianza, Monza (Luca Cavalieri d’Oro, Magda Rognoni, Marco Sala). Agenzia per la Tutela della Salute di Bergamo, Bergamo (Alberto Zucchi, Roberta Ciampichini, Elvira Beato, Giacomo Crotti).
tobacco elderly mental health COVID-19

Abstract

Introduction Given the strong impact of the pandemic on smoking habits and psychological well-being in the Italian general population, it is important to analyze those effects also in the older adults, as they represent the demographic segment most affected by the pandemic. However, to date, the scientific evidence on the issue is still limited.

Methods In November 2020, a telephone based cross-sectional survey was conducted on a representative sample of 4,400 older adults (aged 65 and over) from Lombardy region, northern Italy. Compared to the previous year, we evaluated changes in smoking habits and psychological well-being, through validated scales. Through unconditional multiple logistic models, we also assessed whether smoking was a determinant of poor psychological well-being and its deterioration during the pandemic.

Results No changes in smoking prevalence were observed in the older adults. Compared to never smokers, smoking resulted a determinant of poor sleep quality (odds ratio, OR = 1.45; 95% confidence interval, CI: 1.10-1.92), of presence of depressive symptoms (OR = 1.89; 95% CI: 1.36-2.62), of anxiety (OR = 1.45; 95% CI: 1.10-1.92), and hopelessness (OR = 1.50; 95% CI: 1.14-1.96). During the pandemic, being a smoker resulted a determinant of reducing sleep quantity (OR = 1.36; 95% CI: 1.02-1.83) and increasing (or starting) using psychotropic drugs (OR = 1.85; 95% CI: 1.16-2.96).

Conclusions In the older adult population from Lombardy region, smoking habits did not change substantially during the pandemic, but tobacco smoking deteriorated psychological well-being. During emergency periods, the safeguard of psychological well-being is an additional reason to encourage smoking cessation.

Introduction

Italy was one the first European countries to disclose a case of SARS-CoV-2 infection in January 2020 [1] and the first to implement a nationwide lockdown in March 2020 [2]. Lombardy, in particular, was the most afflicted Italian region by the pandemic, reporting the highest number of infections and hospital congestion [3,4]. Despite the effectiveness of confinement measures to contain the spread of COVID-19, the restrictions imposed had substantial repercussions on lifestyles [5-7] in particular on smoking habits [5] and psychological well-being [8] of the general population. In fact, in Italy, during the pandemic, there was a sharp increase in the number of cigarettes smoked per day among smokers, which caused a general increase in consumption of about 9% [5]. In terms of psychological well-being, there was a strong intensification of depressive and anxiety symptoms, sleep disorders, and increased consumption of psychotropic drugs [8].

Given the strong impact of the pandemic on smoking habits and psychological well-being in the general Italian population, it is extremely critical to examine these effects also in the older adult population; this is because not only they represent the demographic segment most affected by the pandemic [9-12], but also because, due to their different habits and lifestyles, often the results on the general population are not generalizable to older adults. To date, however, scientific evidence on the older adults is still rather limited. Most of the surveys undertaken during the pandemic in fact, in order to obviate the rules on distancing, were conducted through web-based questionnaires: this has implicitly excluded almost automatically the elderly population, who was difficult to involve through online tools [13]. Furthermore, most of the studies available today are not based on representative samples and hence did not allow generalization of results [8].

The clear association between tobacco smoking and reduced psychological well-being [14-17] and the higher prevalence of smoking among people with anxiety, depression, or other psychological disorders [15], prompted us to investigate the effects of the pandemic on the combination of the two factors.

The aim of this large telephone survey, representative of the Lombardy older adult population, is to evaluate the effects of confinement due to the COVID-19 pandemic on smoking habits, as well as possible implications on psychological well-being.

Methods

As part of the Lockdown and Lifestyles in Lombardy (LOST in Lombardy) study, we conducted a cross-sectional telephone survey, coordinated by Mario Negri Institute and other Italian Universities and research Institutes, between November 17th and 30th, 2020. With the support of Doxa, a sample of 4,400 older adults (aged 65 years and older) from Lombardy was recruited, representative in terms of gender, age, and residence. The study protocol was approved by the ethics committee (EC) of the coordinating group (EC of Fondazione IRCCS Istituto Neurologico Carlo Besta, file number 76, October 2020). All participants provided informed consent to participate in the study.

The questionnaire included sociodemographic information, such as age, sex, education level, and province of residence, and smoking habits. A specific section of the questionnaire addressed psychological well-being. Specifically, several mental health indicators were explored: quality and quantity of sleep (using 2 items of the Pittsburgh Sleep Quality Index, PSQI) [18], anxiety levels (Generalized Anxiety Disorder scale, GAD-2) [19], depressive symptoms (Patient Health Questionnaire, PHQ-2) [20], and hopelessness (using 4 items of the Beck Hopelessness Scale; BHS) [21]. The questionnaire also investigated the use of psychotropic drugs (antidepressants, anxiolytics, hypnotics, antipsychotics, and mood stabilizers). In order to quantify the impact of COVID-19 restrictions on participants’ mental health, all questions in this section of the questionnaire (except those related to the BHS scale) were asked in reference to both the previous year (baseline period: fall 2019) and at the time of the interview (fall 2020).

To investigate whether smoking is a determinant of psychological distress, or of its worsening during COVID-19 confinement, we estimated odds ratios (ORs) and 95% confidence intervals (CIs) for each mental health indicator through unconditional multiple logistic regression models, adjusting for age, sex, and education level.

Results

During the pandemic, compared with the previous year no change in smoking status was observed in the general older adult population, nor in men, neither in women, or according to different age groups (Figure 1). The prevalence of smokers increased from 13.1% before the pandemic to 12.6% during the pandemic; the proportion of former smokers from 23.7% to 24.2%, and the proportion of nonsmokers had remained stable at 63.2% in both periods.

Overall, compared with never-smoker status, smoking was found to be a determinant of poor sleep quality (OR = 1.45; 95% CI: 1.10-1.92), presence of depressive symptoms (OR = 1.89; 95% CI: 1.36-2.62), anxiety (OR = 1.45; 95% CI: 1.10-1.92), and hopelessness (OR = 1.50; 95% CI: 1.14-1.96) (Table 1). Ex-smokers, compared with never-smokers, also more frequently reported the same indicators of psychological distress.

During the pandemic, 9.9% of the elderly experienced reduced sleep quantity, 9.2% reported worsening sleep quality, 29.1% depressive symptoms, 37.7% anxiety, and 3.7% began using or increased their use of psychotropic drugs.

Being a smoker was a determinant of reduced sleep quantity (OR = 1.36; 95% CI: 1.02-1.83) and increased (or initiated) psychotropic drug use (OR = 1.85; 95% CI: 1.16-2.96). Former smokers, compared with never smokers, also more frequently reported worsening of these same conditions.

Discussion

The study showed that, in the older adult population of Lombardy, smoking habits did not change during the pandemic period. Smoking was generally found to be a predictor of poor sleep quality, depressive symptoms, anxiety and hopelessness. During the pandemic, smokers experienced more reduction in the amount of sleep and increased use of psychotropic drugs.

Unlike what has been observed in the general Italian population [5], in the older adults the prevalence of smoking did not change during the pandemic. In fact, it is likely that the lockdown had a more pronounced effect in young people, compelling them to stay at home with family members and impacting more on their social life [22], thus drastically reducing their opportunities to smoke.

In agreement with current literature, smoking has been found to be associated with several indicators of poor psychological well-being [14-17]. Although many smokers regard smoking as a strategy for reducing or controlling stress, symptoms of anxiety, depression, or other psychological conditions are all conditions that occur more often in smokers than in nonsmokers [15].

The study also showed that, during the pandemic, a high proportion of older adults reported a worsening in psychological well-being. Fear of becoming infected, coupled with the knowledge that they were the most at risk group for greater severity of COVID-19, may have accentuated this deterioration. In smokers in particular, a reduction in the amount of their sleep and an increase in the use of psychotropic drugs were found more frequently. The growing evidence of a direct relationship between smoking and worse prognosis in COVID-19 [23-25] may have exacerbated symptoms of psychological distress in this group.

Past epidemics have already shown that emergency periods require special attention because they can have strong negative effects on fragile people, causing depression, anxiety, sleep disturbances, mental illness, and can even lead to suicide in severe cases [10]. During the SARS outbreak in 2003, for example, a huge increase in suicide rates in the elderly was observed [10]. Identifying at-risk subgroups is therefore a critical tool in order to target specific support campaigns, including those at smoke-free centers. Therefore, efforts to physically prevent and treat COVID-19 are just as important as those to protect the mental health, especially for the older adults, the highest risk group.

Conclusions

During the COVID-19 pandemic, the smoking habits of the older adult population from Lombardy did not change. However, being a smoker was associated with poor psychological well-being and with mental health deterioration during the pandemic period. During emergency periods, characterized by high levels of stress and consequent deterioration of mental health, smoking cessation should be encouraged, in order to safeguard psychological well-being.

Figures and tables

Figura 1.Distribuzione degli anziani lombardi per stato di fumo, in base a sesso e classe di età, prima (novembre 2019) e durante (novembre 2020) la pandemia di COVID-19. LOST in Lombardia, 2020.

Abitudine al fumo prima della pandemia N. Scarsa quantità di sonno (≤ 6 ore/notte) prima della pandemia Riduzione della quantità del sonno durante della pandemia
% OR (95% CI) % OR (95% CI)
Totale 4.400 35,2 9,9
Abitudine al fumo
    Mai 2.781 37,2 1,00° 8,9 1,00°
    Ex 1.042 33,8 0,92 (0,79-1,08) 11,8 1,51 (1,19-1,92)
    Attuale 578 27,8 0,72 (0,59-0,88) 11,4 1,36 (1,02-1,83)
N. Scarsa qualità del sonno prima della pandemia Riduzione della qualità del sonno durante della pandemia
% OR (95% CI) % OR (95% CI)
Totale 4.400 12,3 9,2
Abitudine al fumo
    Mai 2.781 10,3 1,00° 9,3 1,00°
    Ex 1.042 17,2 1,97 (1,59-2,43) 8,4 1,00 (0,77-1,31)
    Attuale 578 12,8 1,45 (1,10-1,92) 10,1 1,08 (0,80-1,47)
N. Sintomi depressivi prima della pandemia Peggioramento dei sintomi depressivi durante la pandemia
% OR (95% CI) % OR (95% CI)
Totale 4.400 7,8 29,1
Abitudine al fumo
    Mai 2.781 6,3 1,00° 30,2 1,00°
    Ex 1.042 11,0 1,96 (1,51-2,54) 25,9 0,88 (0,75-1,04)
    Attuale 578 9,6 1,89 (1,36-2,62) 29,5 0,99 (0,81-1,21)
N. Sintomi di ansia prima della pandemia Peggioramento dei sintomi di ansia durante la pandemia
% OR (95% CI) % OR (95% CI)
Totale 4.400 11,5 37,7
Abitudine al fumo
    Mai 2.781 10,7 1,00° 37,3 1,00°
    Ex 1.042 12,9 1,38 (1,10-1,73) 38,0 1,12 (0,96-1,30)
    Attuale 578 13,0 1,45 (1,10-1,92) 39,1 1,12 (0,92-1,35)
N. Uso di almeno uno psicofarmaco prima della pandemia Aumento dell’uso di psicofarmaci durante la pandemia
% OR (95% CI) % OR (95% CI)
Totale 4.400 9,5 3,7
Abitudine al fumo
    Mai 2.781 9,8 1,00° 2,6 1,00°
    Ex 1.042 8,3 1,05 (0,81-1,37) 6,2 2,48 (1,73-3,55)
    Attuale 578 10,0 1,26 (0,92-1,71) 4,4 1,85 (1,16-2,96)
N. Perdita di speranza verso il futuro
% OR (95% CI)
Totale 4.400 13,0
Abitudine al fumo
    Mai 2.781 11,9 1,00°
    Ex 1.042 15,5 1,60 (1,29-1,98)
    Attuale 578 14,1 1,50 (1,14-1,96)
Tabella 1.Distribuzione dei 4.400 anziani lombardi in base al loro stato di fumo, a seconda di selezionati indicatori di salute mentale e a un loro peggioramento durante la pandemia (novembre 2020) rispetto all’anno precedente (novembre 2019). Odds ratio^ (OR) e intervalli di confidenza (CI) al 95%. LOST in Lombardia, 2020. Legenda: ^ Stimati tramite modelli logistici multivariati con aggiustamento per sesso, età e livello di istruzione; le stime in grassetto sono quelle significative a livello 0,05; °Categoria di riferimento.

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Affiliazioni

Chiara Stival

Dipartimento di Ambiente e Salute, Istituto di Ricerche Farmacologiche “Mario Negri” IRCCS

LOST in Lombardia Project Investigators

Istituto di Ricerche Farmacologiche “Mario Negri” IRCCS, Milano (Silvano Gallus, Cristina Bosetti, Carlotta Micaela Jarach, Alessandra Lugo, Chiara Stival). Università degli Studi di Genova, Genova (Gianluca Serafini, Andrea Amerio, Mario Amore). Università Bocconi, Milano (David Stuckler, Roberto De Sena, Simone Ghislandi, Yuxi Wang). Università degli Studi dell’Insubria, Varese (Francesco Gianfagna, Anwal Ghulam). Università degli Studi dell’Insubria, Varese e Istituto Neurologico Mediterraneo Neuromed IRCCS, Pozzilli (Licia Iacoviello, Marialaura Bonaccio). Università degli Studi di Pavia, Pavia e Università Vita-Salute San Raffaele, Milano (Anna Odone, Carlo Signorelli, Paola Bertuccio, Giansanto Mosconi, Giacomo Pietro Vigezzi). Agenzia per la Tutela della Salute della Brianza, Monza (Luca Cavalieri d’Oro, Magda Rognoni, Marco Sala). Agenzia per la Tutela della Salute di Bergamo, Bergamo (Alberto Zucchi, Roberta Ciampichini, Elvira Beato, Giacomo Crotti).

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