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. Author manuscript; available in PMC: 2025 Oct 1.
Published in final edited form as: J Ethn Subst Abuse. 2022 Oct 13;23(4):764–787. doi: 10.1080/15332640.2022.2128960

Racial and Ethnic Differences in Distress, Discrimination, Substance Use Coping, and Nicotine Use among Parents during COVID-19

Ashley H Clawson 1, Ashley B Cole 2, Christine S Kurien 3, Alexandra L Blair 1
PMCID: PMC10097833  NIHMSID: NIHMS1846352  PMID: 36227608

Abstract

This study identified contributing factors for tobacco-related inequities among parents (N=331) during COVID-19. Compared to non-Hispanic White parents, Asian, Black, and multiracial parents experienced greater discrimination. Parents with a nicotine use history experienced greater discrimination and substance use coping relative to tobacco abstainers. Among parents who used nicotine during the pandemic (n=45), experiencing financial loss, having COVID-19, and greater worries were positively associated with nicotine reductions during COVID-19. Being female, increased family members with COVID-19, discrimination, and substance use coping were negatively associated with nicotine reductions. Tobacco interventions that reduce substance use coping and increase alternative coping are needed.

Keywords: Tobacco, substance use coping, COVID-19, parent, social determinants of health

Introduction

Parental nicotine use may be contributing to poor coronavirus (COVID-19) disease outcomes: Smoking is associated with poor coronavirus (COVID-19) disease outcomes among adults (Patanavanich & Glantz, 2020; Reddy et al., 2021) and. sStatewide vaping rates are associated with state-level COVID-19 cases and mortality rates (D. Li, Croft, Ossip, & Xie, 2020). Yet, there is a paucity of research specifically focused on parental nicotine use during the pandemic, though it is warranted given the aforementioned individual health risks and because pParental nicotine use confers individual and familial health risks due to greater potential child environmental exposure to smoke/vapor and child nicotine use initiation (U.S. Department of Health and Human Services, 2006; Vuolo & Staff, 2013). Unfortunately, Furthermore, parental nicotine use may pose even greater health risks to children during the pandemic given increased time at home (Woolf, Pingali, & Hauptman, 2020). Unfortunatelyin one of the few studies focused on parents, 67% of parents with nicotine use history, and of children with a respiratory illness, reported sustained or increased nicotine use during the COVID-19 pandemic (Osinibi, Gupta, Harman, & Bossley, 2021).

Disproportionate tobacco-related burdens experienced by marginalized populations before the pandemic may be further exacerbated during the COVID-19 pandemic (Melamed, Zawertailo, Schwartz, Buckley, & Selby, 2021; National Cancer Institute, 2017). Black, Indigenous, and other People of Color (BIPOC) individuals have continued to disproportionately experience high risks for contracting COVID-19, poorer COVID-19 health outcomes, and greater resource losses (e.g., income, employment, and food insecurity) during the pandemic compared to non-Hispanic White (NHW) populations (Abedi et al., 2020; Karpman, Gonzalez, & Kenney, 2020; Laurencin & McClinton, 2020). Relative to NHW populations, identified factors that increase COVID-19 risks among BIPOC populations include: higher rates of discrimination; higher rates of existing chronic health conditions; lower healthcare access and utilization; lower education, income, and wealth; crowded housing conditions (e.g., multigenerational households); and overrepresentation as essential workers interacting with the public (e.g., healthcare, farm, factory, grocery store, and public transportation employees) (Abrams & Szefler, 2020; Brangin, 2020; Centers for Disease Control and Prevention (CDC), 2020; Dutko, Ver Ploeg, & Farrigan, 2013; Khunti, Singh, Pareek, & Hanif, 2020; Laurencin & McClinton, 2020; Tai, Shah, Doubeni, Sia, & Wieland, 2021; U.S. Department of Labor, 2020; Webb Hooper, Nápoles, & Pérez-Stable, 2020). Research specifically with parents has demonstrated greater discrimination and resources losses during COVID-19 among BIPOC parents relative to NHW parents (Clawson et al., 2021). Consistent with the social-ecological model on tobacco-related health disparities (National Cancer Institute, 2017), many of these same processes/conditions that contribute to COVID-19 inequities contributed to preexisting tobacco-related inequities, and these factors may widen tobacco-related inequities among parents during and after the pandemic. Thus, further investigation of differential exposure to deleterious processes/conditions (e.g., discrimination, psychological distress, financial loss, substance use coping) among BIPOC parents and parents who use tobacco, and how these processes/conditions contribute to parental tobacco use during the pandemic, is warranted.

Perceived Discrimination and Tobacco Use during the Pandemic

Extensive literature supports has identified greater experiences of perceived discrimination among BIPOC individuals relative to NHW individuals (National Cancer Institute, 2017), including among BIPOC parents during the pandemic (Clawson et al., 2021).. Clawson and colleagues (2021) documented greater perceived discrimination among BIPOC parents relative to NHW parents with healthy children during the pandemic. However, they did not investigate differences in perceived discrimination across racial and ethnic groups, and did not investigate how perceived discrimination is related to tobacco use. This is aPn important gap in the literature given that perceived racial discrimination is linked to greater tobacco use and less tobacco cessation among BIPOC adults (Hooper et al., 2020; National Cancer Institute, 2017; Pearson et al., 2021), and the limited extant literature focused on parents has demonstrated that. There is limited research focused specifically on the associations between perceived discrimination and tobacco use among parents; however, previous research has indicated that perceived parental parental perceived racial discrimination is associated with greater substance use and mental health difficulties for both parents and their children (Gibbons, Gerrard, Cleveland, Wills, & Brody, 2004; Williams, 2018).

Overall, multilevel tobacco control strategies, and the associated denormalization of tobacco use, have been successful at reducing tobacco use at the population level; however, some individuals, including caregivers (Evans-Polce, Castaldelli-Maia, Schomerus, & Evans-Lacko, 2015; Greaves, Oliffe, Ponic, Kelly, & Bottorff, 2010; Triandafilidis, Ussher, Perz, & Huppatz, 2017), who use tobacco experience smoking-related stigma and perceived discrimination (Stuber, Galea, & Link, 2008). Greater smoking-related stigma may facilitate smoking reductions for some, but may lead to unintentional consequences for others (e.g., concealment of smoking, more affiliation with other individuals who smoke, or distress) (Evans-Polce et al., 2015; Stuber et al., 2008; Stuber, Galea, & Link, 2009); these unintended consequences may intersect with other pandemic-related harms to contribute to the marginalization of parents who use substances during the pandemic (Melamed, Hauck, Buckley, Selby, & Mulsant, 2020). Qualitative data have highlighted that individuals who experience smoking-related stigma and discrimination also experience other discrimination and marginalization based on other identities (e.g., gender, race/ethnicity, class position), resulting in more negative outcomes for multiply marginalized individuals (Antin, Annechino, Hunt, Lipperman-Kreda, & Young, 2017; Triandafilidis et al., 2017); this research emphasizes the importance of examining the intersectional experiences of racially marginalized parents who use tobacco.

Thus, perceived discrimination, both racial and nonracial discrimination (e.g., tobacco-related), may contribute to continued tobacco use among parents during COVID-19. Perceived racial and nonracial discrimination (e.g., gender, socioeconomic status, age, sexual orientation) has been linked to greater tobacco use among adults prior to the pandemic (Unger, 2018). Parents who experience discrimination (racial and nonracial discrimination) may be more at risk for continuing to use tobacco during the pandemic, including racially marginalized parents and parents who use tobacco. Consistent with intersectional theoretical frameworks and research (Bauer, 2014; Crenshaw, 1989; Lopez & Gadsden, 2016; Potter, Lam, Cinciripini, & Wetter, 2021), parents who experience both racial discrimination and smoking-related discrimination may be most at risk for sustained or escalated tobacco use during the pandemic.

Thus, perceived discrimination, both racial and nonracial discrimination, may be an important process that contributes to continued tobacco use among parents during COVID-19. Research is needed to better understand differences in parental perceived discrimination experiences across diverse parents, and to understand how perceived discrimination (a process linked to health disparities) relates to nicotine use among parents during COVID-19 (Bauer, 2014; Pearson et al., 2021).

Notably, it can be difficult for individuals to reflect on their experiences of discrimination and then identify the perceived reasons for discrimination, especially as there may be more than one source of discrimination (e.g., race/ethnicity, gender, appearance, disability, religion, smoking). One quantitative approach to identifying different experiences of discrimination is to investigate differences in perceived discrimination across those with various identities (Bauer, 2014). The current study will expand on the limited quantitative research in this area by identifying how experiences of perceived discrimination during the pandemic differ between three categories: racially marginalized parents, parents with a history of tobacco use, and parents with the intersecting identities of being racially marginalized and using tobacco (Pearson et al., 2021; Potter et al., 2021). Furthermore, this study will investigate how perceived discrimination, as well as other predictors, relates to parental nicotine use during the pandemic.

Psychological Distress, Substance Use Coping, and Tobacco Use during the Pandemic

The psychosocial toll of COVID-19 has been burdensome for parents (Patrick et al., 2020), particularly parents of children with pre-existing medical conditions (e.g., asthma (Clawson et al., 2021)) and BIPOC parents (Abrams & Szefler, 2020; Clawson et al., 2021; Fortuna, Tolou-Shams, Robles-Ramamurthy, & Porche, 2020). Among adults, psychological distress and COVID-19-specific worry have been associated with both increases and decreases in nicotine use during COVID-19 (Bommelé et al., 2020; Gold et al., 2021; Rigotti et al., 2021; Wade et al., 2021). For example, greater fear of COVID-19 was associated with smoking reductions and greater motivations to quit (Gold et al., 2021). However, separate studies demonstrated that greater COVID-19 worry was associated with smoking initiation and greater smoking coping motives, perceived barriers to quitting, and negative quitting outcome expectancies among adults (Rogers, Shepherd, Garey, & Zvolensky, 2020; Shepherd, Fogle, Garey, Viana, & Zvolensky, 2021). The scant literature with parents documented that anxiety and COVID-19-specific stress were associated with increased parental substance use during COVID-19 (Saddik et al., 2021; Wade et al., 2021).

Some parents may be using tobacco to cope with pandemic-related distress (Martínez-Cao et al., 2021; Shepherd et al., 2021) or to cope with discrimination (Gerrard et al., 2012), a process often referred to as substance use coping or coping motives (Carver, 1997; Cooper, Kuntsche, Levitt, Barber, & Wolf, 2015). Approximately 13% of adults have initiated or increased their substance use during COVID-19 to cope with distress, with increased substance use coping seen among Latinx and Black adults relative to White adults (Czeisler et al., 2020). Furthermore, adults who use nicotine may be more likely to engage in substance use coping relative to adults who do not use nicotine (Acar, Şaşman Kaylı, & Yararbaş, 2019); empirical investigation on greater substance use coping among individuals who use tobacco is limited, with no available data on parents.

Greater substance use coping may contribute to greater substance use directly (i.e., demonstrating a main effect on substance use) and/or by moderating the associations between risk factors and substance use. For example, Gerrard and colleagues (2012) found that substance use coping exhibited a main effect on substance use and also modified the association between perceived discrimination and substance use (i.e.,. More specifically, perceived discrimination was related to greater willingness to use substances and greater substance use among those with high, but not low, substance use coping). Data on substance coping among parents is limited; however, one study that focused on parents of a child who had cancer identified that men with lower education used greater substance use coping relative to women and men with higher education (Gage-Bouchard, Devine, & Heckler, 2013), emphasizing the importance of investigating how caregivers may be using substances to cope with situations associated with child health risks, such as the pandemic. The current study extends the limited research on COVID-19 worry and substance use coping among parents by identifying how these constructs differ between racially marginalized parents and parents with a tobacco use history (Pearson et al., 2021; Potter et al., 2021), and by identifying how COVID-19 worry and substance use coping relate to parental nicotine use reductions during the pandemic.

Current Study

This study included a diverse sample of parents typically underrepresented in research (e.g., fathers; parents of color; parents of children with asthma) and examined differences in experiences of perceived discrimination, pandemic-related financial loss, pandemic-related worry, and substance use coping, and identified how these constructs related to parental nicotine use reductions during the pandemic. To achieve this overall purpose, several specific aims were examined.

Aim 1:

Among the full sample (N=331), identify group differences in parental experiences of perceived discrimination, COVID-19 worry (General COVID-19 Worry; Infection Worry; Resource Loss Worry), financial loss, and substance use coping by parental race/ethnicity and lifetime tobacco use history. To investigate the intersectional experiences of being a racially marginalized parent who uses tobacco, the interactive effect of race/ethnicity and lifetime tobacco use history on dependent variables was examined. It was hypothesized that 1) parents from racially marginalized backgrounds (compared to NHW parents) and parents with a history of tobacco (compared to parents with no history) would experience greater perceived discrimination, COVID-19 worry, financial loss, and substance use coping relative to NHW parents; and 2) parents from racially marginalized backgrounds with a lifetime history of tobacco use would experience the highest levels of perceived discrimination, COVID-19 worry, financial loss, and substance use coping.

Exploratory Aim 1Aim 2:

Investigate how perceived discrimination, COVID-19 worry, financial loss, and substance use coping relate to parental nicotine use reductions during the pandemic among a subsample of parents who had used nicotine since the start of the pandemic (n=53). For this aim (and the next exploratory aim), processes and conditions known to contribute to tobacco-related disparities (i.e., perceived discrimination, financial losses, distress, substance use coping) (Gerrard et al., 2012; National Cancer Institute, 2017) were investigated rather than using race/ethnicity as a proxy for these processes (Pearson et al., 2021). It was hypothesized that greater discrimination, financial loss, and substance use coping would be associated with lower lower odds of nicotine reductions during COVID-19. Given that COVID-19 worry has been associated with both increases and decrease in nicotine use among adults, no specific hypothesis was proffered for this relation. Both exploratory aims should be interpreted with caution given the limited sample size may have affected our ability to detect effects and/or introduced bias.

Exploratory Aim 2:

Among a subsample of parents who had used nicotine since the start of the pandemic (n=53), examine whether substance use coping would moderates associations between discrimination, financial loss, and COVID-19 worry with nicotine use. Examining moderation may help to disentangle under what coping conditions COVID-19 stressors and worry relate to parental nicotine use. This aim was exploratory given that our limited sample size may have affected our ability to detect interaction effects. It was hypothesized that the association between the independent variables and nicotine use would be stronger among parents with greater substance use coping.

Materials and Methods

Participants and Study Design

This study utilized Prolific, a crowdsourcing panel that produces data with higher reliability and validity compared to alternative platforms (Peer, Brandimarte, Samat, & Acquisti, 2017). This study obtained IRB approval and informed consent. This study recruited parents (N=331) from June 2020 to August 2020. This study purposefully recruited parents from the following groups (n=321 due to missing data on either parent race/ethnicity or child asthma): 1) NHW parents of children with asthma (n=62), 2) BIPOC parents of children with asthma (n=91,), 3) BIPOC parents of healthy children (n=100), and 4) NHW parents of healthy children (n=68). Inclusion criteria included parents aged ≥18 years, and parents as the legal guardian who lived with a child between the ages of 5–17 years. Detailed information on procedures are presented elsewhere (Clawson et al. 2021). The full sample was included for Aim 1 (N=331), and a subsample of parents who reported nicotine use since March 2020, the onset of the COVID-19 pandemic in the U.S.,(n=53; 16% of the full sample) was included for the remaining aims (n=53; 16% of the full sample).

Measures

Demographics.

Parents reported on their age, gender, educational attainment (≥ Bachelor’s degree vs. lower), and child asthma status. An overall parent race and ethnicity variable was created based on parents’ self-reported race/ethnicity and included the following categories: NHW (coded as referent), Black, American Indian/Alaska Native, Latinx/ Hispanic, Asian, or from multiracial backgrounds/from an “other background.”

Parent Nicotine Use and COVID-19 Impacts.

Parents completed portions of the Johns Hopkins University COVID-19 Community Response Survey, a PhenX measure (Mehta, 2020).

Parents self-reported on if they had a lifetime history of using any tobacco product (including combustible, smokeless, and electronic nicotine products); no history was coded as 0 and history was coded as 1. Parents were asked if the pandemic led them to smoking/vaping nicotine less than usual; response options were dichotomized to no reductions in nicotine use (0) versus reductions in nicotine use (1).

Parents were asked if they had been diagnosed with COVID-19 and how many immediate family members had been diagnosed with COVID-19. A previous exploratory factor analysis on worry/anxiety questions from the Mental Health Impacts module identified the following subscales; each demonstrated good reliability in our full sample: General COVID-19 Anxiety (α= .89); Resource Loss Concerns (e.g., fears about finances/food during COVID-19; α = .85); and COVID-19 Infection Concerns (α = .87)(Clawson et al. 2021). Acceptable to excellent reliability was demonstrated across parent racial and ethnic groups; : General COVID-19 Anxiety (α range = .88 (Black parents) to .95 (American Indian/Alaska Native parents)); Resource Loss Concerns (α range = .78 (American Indian/Alaska Native parents) to .89 (Black parents)); and COVID-19 Infection Concerns (α range= .78 (American Indian/Alaska Native parents) to .93 (NHW parents)). Importantly, the reliabilities across these groups need to be considered within the context of the small sample sizes for some groups, such as American Indian/Alaska Native parents (n=7). gGood to excellent reliability was demonstrated among parents with different lifetime histories of tobacco use.: General COVID-19 Anxiety (α range = .89 (no history) to .91 (history)); Resource Loss Concerns (α range = .88 (no history) to .85 (history)); and COVID-19 Infection Concerns (α range = .91 (no history) to .88 (history)). See Online Supplement 1 for more information on internal consistencies across groups.

Pandemic-related Financial Loss.

Parents completed the COVID-19 Adolescent Symptom and Psychological Experience Questionnaire-Parent, a PhenX measure (Ladouceur, 2020), and reported on perceived financial losses due to COVID-19 (e.g., job loss and difficulty paying bills). A binary variable was created: no financial difficulties (0) versus ≥1 difficulty (1).

Parent Discrimination.

Parents completed the Everyday Discrimination Scale (Williams, Yan Yu, Jackson, & Anderson, 1997), which assesses the frequency of experiencing discrimination in the past year. Consistent with prior research, a frequency total score was competed, reflecting the frequency of experiencing discrimination; however, the frequency total score does not delineate between specific identity attributions for experiencing discrimination (e.g., because of one’s race, age, religion, physical appearance, sexual orientation, socioeconomic level, disability, or others) (Krieger, Smith, Naishadham, Hartman, & Barbeau, 2005; Williams et al., 1997). This measure demonstrated excellent psychometric properties in prior studies (Krieger et al., 2005; Williams et al., 1997) and in the current full sample (Cronbach’s α = .92), including good to excellent reliabilities across parents with differing tobacco use histories and racial and ethnic backgrounds (. see Online Supplement 1).Good to excellent reliabilities were also demonstrated across parent racial and ethnic groups in the current sample (α range = .84 (Latinx parents) to .97 (American Indian/Alaska Native parents)) and for parents with and without a lifetime tobacco use history (α = .92 for both groups).

Parent Substance Use Coping.

Parents completed the substance use coping scale from the Brief COPE (Carver, 1997) to assess the degree that they had been using substances to cope with the pandemic. This measure demonstrated excellent reliability in prior samples (α = .90) (Carver, 1997) and acceptable reliability in our full sample (α = .79). The reliability was, with acceptable across parents with differing tobacco use histories and varying varied reliability from poor (Latinx parents: α =.55) to excellent across parent racial and ethnic groups (See Online Supplement 1 for more information on internal consistencies across groups).: NHW parents (α = .86), American Indian/Alaska Native parents (α = .82), Asian parents (α = .80), Black parents (α = .67), Latinx parents (α =.55), and parents who identified as multiracial/other background (α =.95). The reliability was acceptable for parents with a history of tobacco use (α = .79) and for parents without a history of tobacco use (α = .76).

Data Analysis

Aim 1 analyses were conducted with the full sample (N = 331) using SPSS version 26. Separate ANOVAs were conducted to examine mean differences in perceived discrimination, COVID-19 worry, financial loss, and substance use coping by investigating the main effects of the multi-categorical parent race/ethnicity variable and lifetime tobacco history use and the race/ethnicity*tobacco use history interactions. Heteroskedascity was examined using the White test; heteroskedascity was not violated across analyses. The Levene’s test of homogeneity was examined across these analyses; given the slightly skewed nature of the variables, the median was evaluated for the Levene’s test (Brown & Forsythe, 1974). Given the extremely limited research in this area, an alpha of .01 was used when interpreting the Levene’s test. The Levene’s test was only significant for the analysis that investigated substance use coping. Two separate one-way ANOVAs were conducted to investigate homogeneity associated with the main effects of parent race/ethnicity and tobacco use history, respectively, on substance use coping; the Levene’s test was only significant for the model including tobacco use history. Thus, the Welch statistic, a robust test of equality of means, was used to examine mean differences in substance use coping by tobacco use history. Logistic regression was used to examine pandemic-related financial loss. No alpha inflation procedure was used given the scant literature on parental tobacco use during the pandemic.

The analyses for Aim 2 and the exploratory aims were conducted on a subsample of 53 parents who reported nicotine use since March 2020; due to missing data, the final analysis for the subsample included 45 parents (84.9% of subsample) who had used nicotine since March 2020. Mplus version 8 and the ML estimator were used. Missing data were addressed using full information maximum likelihood approaches (Enders & Bandalos, 2001). A saturated path analysis was executed to examine: 1) main effects of discrimination, pandemic-related financial loss, COVID-19 worry, and substance use coping on parental reductions in nicotine use during COVID-19, and 2) the moderating role of substance use coping on the associations relations between discrimination, pandemic-related financial loss, and COVID-19 worrythe independent variables with nicotine use. Covariates included: parent gender, education, and COVID-19 diagnosis; family member COVID-19 diagnoses; and child asthma status. Standardized logits were presented. Continuous independent variables were mean centered. These moderation analyses were exploratory due to limited power and thus should be interpreted with caution; results are presented to inform future research. Significant interactions were probed by estimating the conditional logits of the independent variable on nicotine use reductions at varying levels of substance use coping, i.e., low (1 SD below the mean), average (0 mean centered), and high substance use coping (1 SD above the mean). Conditional logits were unstandardized.

Results

Information on participant characteristics for the full and subsample is provided in Table 1. The full sample was 50% female, over 45% had a child with asthma, approximately 59% identified as BIPOC, and over 34% endorsed lifetime tobacco use. A binary categorization of BIPOC vs. NHW parents was associated with ta obacco use history of tobacco use (x2(1, 305) = 4.74, p = .03):, with BIPOC parents reported ing higher rates of tobacco abstinence (64.4%) relative to NHW parents (35.6%); however, the multi-categorical race/ethnicity variable was not related to tobacco use history (x2(5, 305) = 7.47, p = .19). Of parents who had used nicotine since the start of the pandemic (n=53), over 60% had not reduced their nicotine use during COVID-19. Parent race/ethnicity was not associated with nicotine use reductions during the pandemic [(binary categorization of BIPOC vs. NHW (x2(1, 50) = 1.03, p = .31); the multi-categorical race/ethnicity variable was also not associated with nicotine use reductions during the pandemic (x2(4, 50) = 3.43, p = .49)].

Table 1.

Descriptive Statistics.

Full Sample (N = 331) Subsample of Parents who have Used Nicotine during the Pandemic (N =53)
Demographic and Family COVID-19 Variables M (SD))/ n (%) M (SD))/ n (%)
Age 36.71 (8.92) 37.67 (7.64)
Female 165 (49.8%) 24 (45.3)
Race and Ethnicity
 Non-Hispanic, White 136 (41.1%) 23 (43.4%)
 American Indian/ Alaska Native 7 (2.1%) 0 (0)
 Asian 34 (10.3%) 6 (11.3%)
 Black 97 (29.3%) 15 (28.3%)
 Hispanic/ Latinx 25 (7.6%) 4 (7.5%)
 Multiracial/ From another background 32 (9.7%) 5 (9.4%)
Education level (Greater than or equal to Bachelor’s Degree) 187 (56.5%) 33 (62.3%)
Caregiver diagnosed with COVID-19 18 (5.4%) 6 (11.3%)
Number of immediate family diagnosed with COVID-19 .12 (.65) .09 (.45)
Child has asthma 150 (45.3%) 20 (37.7%)
Parent Individual and Contextual Experiences
Past year experiences of discrimination (range 0–37) 8.27 (9.49) 12.02 (10.72)
Experienced pandemic-related financial loss 149 (45.0%) 33 (62.3%)
General COVID-19 anxiety (range 4–19) 9.17 (4.45) 10.04 (4.59)
Worry about COVID-19 resource loss (range 5–24) 13.36 (5.76) 14.79 (5.89)
Worry about COVID-19 infection (range 5–24) 9.16 (3.69) 9.87 (3.46)
Substance Use Coping (range 2–8) 2.79 (1.37) 3.66 (1.77)
Nicotine Use
Lifetime history of nicotine use 114 (34.4%) 100 (100.0%)
Reduced nicotine use during COVID-19 pandemic - 18 (34.0%)
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Notes: N’s ranged due to missing data; percentages presented used a denominator that included those with missing data.

Differences in Parental Perceived Discrimination, COVID-19 Worry, Financial Loss, and Substance Use Coping by Parent Race/Ethnicity and Tobacco Use History

Model results are presented in Table 2; estimated marginal means are presented in Table 3. Regarding perceived discrimination (see Figure 1), NHW parents reported lower levels of perceived discrimination compared to Asian parents (p = .02), Black parents (p = .01), and parents from multiracial/other backgrounds (p = .02). Additionally, parents with no history of tobacco use history reported lower levels of perceived discrimination relative to parents with a tobacco use history (p = .04). Differences in substance use coping were also identified (see Figure 2): Parents with no tobacco use history reported less ower levels of substance use coping relative to parents with a tobacco use history. When examining pandemic-related financial loss, the race/ethnicity main effect (Wald = 5.73, p = .33), the tobacco use history main effect (Wald = 1.46, p = .23), and the interaction (Wald = 2.48, p = .65) were each nonsignificant.

Table 2.

Differences in Parental Experiences of Perceived Discrimination, COVID-19 Worry, Financial Loss, and Substance Use Coping by Parent Race/Ethnicity and Tobacco Use History

Significant post hoc comparisons
df F ηp2 (p < .05)
Perceived Discrimination
 Race/ethnicity 5, 280 2.47* .04 NHW parents < Asian, Black, and multiracial/other background parents
 Lifetime Tobacco Use History 1, 280 5.74* .02 Parents with no history < parents with tobacco use history
 Race/ethnicity*Tobacco Use History 4, 280 .40 .006
COVID-19 General Anxiety
 Race/ethnicity 5, 287 .29 .005
 Lifetime Tobacco Use History 1, 287 .67 .002
 Race/ethnicity*Tobacco Use History 4, 287 1.22 .02
COVID-19 Resource Loss Worry
 Race/ethnicity 5, 287 .84 .01
 Lifetime Tobacco Use History 1, 287 .65 .002
 Race/ethnicity*Tobacco Use History 4, 287 .10 .001
COVID-19 Infection Concerns
 Race/ethnicity 5, 289 1.33 .02
 Lifetime Tobacco Use History 1, 289 1.91 .01
 Race/ethnicity*Tobacco Use History 4, 289 1.24 .02
Substance Use Coping
 Race/ethnicity 5, 287 .43 .01
 Lifetime Tobacco Use History a - - .05 Welch Statistic = 23.84***
Parents with no history < parents with tobacco use history
 Race/ethnicity*Tobacco Use History 4, 287 .23 .003
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*

p < .05

**

p < .01

***

p < .001.

Note:

a

The Levene’s test was significant for this model; therefore, two one-way ANOVAs were used to investigate homogeneity associated with the main effects of parent race/ethnicity and tobacco use history on substance use coping separately. The Levene’s test was only significant for the model including tobacco use history. Thus, for lifetime tobacco use history, no F test is reported, and instead the Welch statistic, a robust test of equality of means, was used to examine mean differences in substance use coping by tobacco use history.

Table 3.

Estimated Marginal Means by Parent Race/Ethnicity and Tobacco Use History

Parent Race/Ethnicity
NHW American Indian/Alaska Native Asian Black Hispanic/Latinx Multiracial/Other Background
M (SE) M (SE) M (SE) M (SE) M (SE) M (SE) Total
Perceived Discrimination (range 0–37)
 No tobacco use history 3.85 (1.15) 9.00 (4.14) 9.30 (2.07) 9.08 (1.19) 5.80 (2.39) 9.88 (2.25) 7.82 (.98)
 Tobacco use history 9.14 (1.28) - 12.67 (2.67) 11.00 (1.78) 9.43 (3.50) 12.70 (2.93) 10.99 (1.15)
 Total 6.49 (.86) 9.00 (4.14)a 10.98 (1.69) 10.04 (1.07) 7.61 (2.12) 11.29 (1.84)
COVID-19 General Anxiety (range 4–19)
 No tobacco use history 8.24 (.55) 8.50 (2.22) a 8.50 (.99) 9.10 (.57) 9.20 (1.15) 9.94 (1.08) 8.91 (.50)
 Tobacco use history 10.55 (.60) - 8.83 (1.28) 8.86 (.83) 9.86 (1.68) 9.64 (1.34) 9.55 (.54)
 Total 9.39 (.41) 8.50 (2.22) a 8.67 (.81) 8.98 (.50) 9.53 (1.02) 9.79 (.86)
COVID-19 Resource Loss Worry (range 5–24)
 No tobacco use history 12.45 .72) 12.60 (2.60) a 13.00 (1.30) 13.77 (.74) 13.20 (1.50) 13.41 (1.41) 13.07 (.62)
 Tobacco use history 13.07 (.79) - 13.25 (1.68) 14.93 (1.08) 13.14 (2.20) 15.00 (1.76) 13.88 (.71)
 Total 12.76 (.53) 12.60 (2.60) a 13.13 (1.06) 14.35 (.66) 13.17 (1.33) 14.21 (1.13)
COVID-19 Infection Concerns (range 5–24)
 No tobacco use history 8.64 (.45) 7.60 (1.64) a 8.95 (.80) 8.80 (.47) 10.50 (.98) 9.21 (.84) 8.95 (.39)
 Tobacco use history 9.31 (.49) - 10.50 (1.06) 9.17 (.68) 8.86 (1.38) 12.09 (1.10) 9.99 (.45)
 Total 8.98 (.33) 7.60 (1.64) a 9.73 (.66) 8.99 (.41) 9.68 (.85) 10.65 (.69)
Substance Use Coping (range 2–8)
 No tobacco use history 2.43 (.16) 2.80 (.60) a 2.57 (.29) 2.54 (.17) 2.13 (.34) 2.67 (.34) 2.52 (.14) b
 Tobacco use history 3.32 (.18) - 3.00 (.38) 3.45 (.25) 3.14 (.50) 3.50 (.42) 3.28 (.16) b
 Total 2.87 (.12) 2.80 (.60) a 2.79 (.24) 2.99 (.15) 2.64 (.30) 3.08 (.27)
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Note. M = mean. SE = standard error.

a

Based on modified population marginal mean.

b

Due to violation of the assumption of homogeneity of variances, two follow-up one-way ANOVAs were used to investigate homogeneity associated with the main effects of parent race/ethnicity and tobacco use history on substance use coping separately; the Levene’s test was only significant for the model including tobacco use history. Thus, the Welch statistic, a robust test of equality of means, was used to examine mean differences in substance use coping by tobacco use history; the means presented above are drawn from the initial model that included both main effects and the interaction.

Figure 1.

Figure 1.

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Estimated Marginal Means for Perceived Discrimination by Parent Race/Ethnicity and Tobacco Use History

Note. Range: 0–37.

Figure 2.

Figure 2.

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Estimated Marginal Means for Substance Use Coping by Parent Race/Ethnicity and Tobacco Use History

Note. Range: 2–8.

Associations between Parental Nicotine Use Reductions during the Pandemic and Perceived Discrimination, COVID-19 Worry, Financial Loss, and Substance Use Coping

Among the subsample of parents who had used nicotine since the start of the pandemic (n=45 due to missing data in this model), the model that examined perceived discrimination, COVID-19 worry, financial loss, and substance use coping accounted for 92.9% of the variance in parental nicotine use reductions during COVID-19. COVID-19 financial loss was associated with an increased likelihood of nicotine reductions (Table 4); however, greater discrimination was associated with a lower likelihood of nicotine reductions. Of the three COVID-19 worry subscales, only general COVID-19 worry was associated with nicotine use reductions: More COVID-19 worry was associated with an increased likelihood of nicotine reductions. Greater substance use coping was related to a decreased likelihood of nicotine reductions.

Table 4.

Subsample Exploratory Analysis Predicting Parent Smoked/ Vaped Less during COVID-19 Pandemic

Standardized Estimate SE 95% CI p
LL UL
Predictors
 Caregiver Diagnosed with COVID-19 a 2.492 .556 1.402 3.581 <.001
 Number of immediate family diagnosed with COVID-19 −.318 .148 −0.607 −0.028 .03
 Child has Asthma b .330 .287 −0.233 0.893 .25
 Parent Education Level c .579 .305 −0.018 1.176 .06
 Parent Gender: Female d −.859 .201 −1.253 −0.464 <.001
 Pandemic-related Financial Loss e .558 .207 0.153 −0.015 .007
 Parent Past Year Experiences of Discrimination f −.361 .116 −0.589 −0.133 .002
 Parent General COVID-19 Anxiety g .378 .162 0.061 0.695 .02
 Parent Worry about COVID-19 Resource Loss h .050 .124 −0.193 0.002 .69
 Parent Worry about COVID-19 Infection i .212 .116 −0.015 0.440 .07
 Parent Substance Use Coping j −.391 .169 −0.721 −0.060 .02
 Parent Substance Use Coping* Discrimination −.233 .12 −0.468 0.002 .052
 Parent Substance Use Coping* Pandemic-related Financial Loss .158 0.155 −0.146 0.461 .31
 Parent Substance Use Coping* General COVID-19 Anxiety −.348 .166 −0.673 −0.022 .04
 Parent Substance Use Coping* Worry about COVID-19 Resource Loss .244 .137 −0.025 0.513 .08
 Parent Substance Use Coping* Worry about COVID-19 Infection .48 .122 0.241 0.719 <.001
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Note. Total N = 45. CI = confidence interval; LL = lower limit; UL = upper limit. Dependent Variable: 0= Parent did not smoke/vape less during the pandemic, 1 = Parent smoked/vaped less during the pandemic. ML estimator used. This analysis was exploratory due to limited power and thus should be interpreted with caution; results are presented to inform future research.

a

0 = Not diagnosed, 1 = Diagnosed.

b

0 = No asthma, 1 = Asthma.

c

0 = Less than Bachelor’s Degree, 1 = Greater than or equal to Bachelors Degree.

d

0 = Male, 1 = Female.

e

0 = no, 1 = yes.

f-j

Variables were grand centered. STDYX standardized estimates presented for all continuous variables and all interactions. STDY standardized estimates presented for all categorical variables.

Follow-up analyses of the significant interaction between substance use coping and COVID-19 infection concerns demonstrated that COVID-19 infection concerns were marginally related to an increased likelihood of nicotine reductions among parents with high substance use coping (Est: 1.34, p = .057); COVID-19 infection concerns were not associated with nicotine reductions among those with low (Est: −.52, p = .11) or with average substance use coping (Est: .41, p = .18).

There was a significant interaction between substance use coping and general COVID-19 worry. Greater general COVID-19 worry was marginally related to an increased likelihood of reducing nicotine use at low levels of substance use coping (Est: 1.04, p = .07); there were nonsignificant associations between general COVID-19 worry and nicotine reductions at average (Est: .54, p = .10) and high levels of substance use coping (Est: .04, p = .90).

Follow-up analyses of the marginally significant interaction between substance use coping and discrimination demonstrated negative associations between discrimination and nicotine reductions as levels of substance use coping increased (Low: −.08, p = .46; Average: −.25, p = .04; High: −.42, p = .04).

Discussion

Approximately 67% of parents in the current sample who had used nicotine since March 2020 had not reduced their nicotine use during COVID-19 by summer 2020, which is consistent with prior research (Osinibi et al., 2021). Consistent with the social-ecological model on tobacco-related health disparities (National Cancer Institute, 2017), it was hypothesized that many some of the same processes/conditions contributing to COVID-19 and racial disparities may also be contributing to tobacco-related disparities inequities among parents during the pandemic. Thus, tThe current study examined the independent and intersectional experiences of being a racially marginalized parent, along with being a parent with tobacco use history during the pandemic, and identified by examining differences in past year parental experiences of perceived discrimination based on race/ethnicity and tobacco use history and differences in, COVID-19 worry, pandemic-related financial loss, and substance use coping by tobacco use history. Results indicated that Asian parents, Black parents, and parents from multiracial/other backgrounds experienced more past year discrimination compared to NHW parents. Parents with a tobacco use history experienced more discrimination relative to those without a tobacco use history. Differences in substance use coping were also identified: Parents with a tobacco use history reported greater levels of substance use coping relative to parents with no history. Furthermore, findings from exploratory aims focused among on a subsample of parents who had used nicotine during the pandemic, this study identified that experiencing financial loss, having COVID-19, and having greater COVID-19 worries were positively associated with nicotine reductions during COVID-19; being female and having increased family members with COVID-19, discrimination, and substance use coping were negatively associated with nicotine reductions.

For Aim 1, it was hypothesized that parents from racially marginalized backgrounds and parents with a history of tobacco use would experience greater perceived discrimination, COVID-19 worry, financial loss, and substance use coping, with racially marginalized parents with a history of tobacco use experiencing the highest levels. oOur hypotheses were partially supported, and findings indicated that Asian parents, Black parents, and parents from multiracial/other backgrounds experienced greater discrimination compared to NHW parents. Parents without a tobacco use history reported lower levels of perceived discrimination relative to parents with a tobacco use history. Parents without a tobacco use history also reported lower levels of substance use coping relative to parents with a tobacco use history. These results extend prior literature documenting greater experiences of discrimination among BIPOC adults (National Cancer Institute, 2017) and among BIPOC parents during the pandemic (Clawson et al., 2021) by identifying that this greater exposure to discrimination is evident across parents from numerous racially marginalized backgrounds. Furthermore, our study findings contribute to the extant qualitative research that documented smoking-related stigma/discrimination among parents prior to the pandemic (Evans-Polce et al., 2015; Greaves et al., 2010; Triandafilidis et al., 2017). Our hypothesis that racially marginalized parents with a tobacco use history would experience the greatest perceived discrimination was not supported (i.e., interaction term was non-significant). Our sample size and small cell sizes for some intersectional identities, especially for American Indian/Alaska Native parents, likely limited our ability to detect a significant interaction. Examination of the marginal means suggest that parents with the some of the highest experiences of perceived discrimination were parents with a tobacco use history and who were Asian, Black, or multiracial/from another background. Taken together, results support the need for additional research in this area and the need for interventions that help parents manage experiences of discrimination related to racial marginalization and tobacco use.

To our knowledge, this is the first study that identifiesto identify increased substance use coping among parents with a tobacco use history (relative to those with no history); this finding is consistent with an earlier study focused on adults prior to the COVID-19 onset in the U.S. (Acar et al., 2019). The current results indicated that there were no differences in substance use coping based on racial marginalization or the intersectional position of being racially marginalized and having a tobacco use history. This finding is inconsistent with prior research that demonstrated increased substance use coping among racially marginalized adults during the pandemic (Czeisler et al., 2020). Additional, larger scale research is needed to investigate substance use coping using an intersectional approach and to capture variability across larger samples of parents from marginalized backgrounds.

The remaining exploratory aims utilized included a subsample of parents who had used nicotine since the start of the pandemic to capture nicotine use reductions that occurred during the pandemic. These findings contribute to the limited data on parental nicotine use during the pandemic, however, these findings should also be interpreted with caution given the limited sample size. In these aims, race and ethnicity was not included a covariate, as this approach would have focused on race/ethnicity as a proxy for exposure to racism (Pearson et al., 2021). Instead, processes and conditions known to contribute to tobacco-related disparities (i.e., perceived discrimination, financial losses, distress, substance use coping) (Gerrard et al., 2012; National Cancer Institute, 2017; Pearson et al., 2021) were investigated. Processes and conditions known to contribute to tobacco-related inequities (Gerrard et al., 2012; National Cancer Institute, 2017; Pearson et al., 2021) were related to parental nicotine use during the pandemic. Experiencing financial loss during the pandemic, having COVID-19, and experiencing greater general COVID-19 worries were associated with an increased likelihood of nicotine reductions. Alternatively, being a female caregiver, having more family members with COVID-19, experiencing greater discrimination, and using greater substance coping were associated with a decreased likelihood of reducing nicotine use. Current results highlight areas for future research, including informing parent-directed tobacco interventions that may reduce parent and child risks during the pandemic (Patanavanich & Glantz, 2020; Reddy et al., 2021; Woolf, Pingali, & Hauptman, 2020).

Of the three COVID-19 worry subscales, only general COVID-19 worry exhibited a main effect on parental nicotine reductions, such that more worry was associated with an increased likelihood of nicotine reductions. This finding is consistent with a previous study of adult daily smokers, which demonstrated that greater COVID-19 fears were associated with greater smoking reductions (Gold et al., 2021). Future research with larger samples should investigate how different types of COVID-19 worries relate to parental nicotine use.

Substance use coping exhibited both a main effect and a moderating effect on parental nicotine use reductions during the pandemic:. Greater substance use coping was related to a decreased likelihood of nicotine reductions, and substance use coping. The exploratory aim identified the potential moderateding role of substance use coping on the relations between COVID-19 worries (general and infection worries) and nicotine reductions. Moderation These analyses were explored to provide preliminary data to help generate hypotheses for future research; thereforehowever, results should be interpreted with caution.

A differential pattern of results from the moderation analyses emerged. COVID-19 infection concerns were marginally related to an increased likelihood of nicotine reductions for parents only with high substance use coping. One potential interpretation of this pattern may be that parents with greater COVID-19 infection concerns may have reduced their smoking because of higher risks of smoking associated with COVID-19 outcomes (Patanavanich & Glantz, 2020; Reddy et al., 2021), but they may have also increased other substance use, such as alcohol use (Boschuetz, Cheng, Mei, & Loy, 2020; Schmits & Glowacz, 2021), to manage distress. This interpretation remains speculative as we do not have data on which substances parents were using to cope. Greater general COVID-19 worry was marginally related to an increased likelihood of reducing nicotine use only at low levels of substance use coping; substance use coping may wash out the role of COVID-19 worry in promoting nicotine reductions. Along with data indicating that using substances to cope with distress is associated with the poorest outcomes relative to other substance use motives (Cooper et al., 2015), current findings support the need for additional research and tobacco interventions that reduce substance use coping and increase alternative strategies for managing pandemic-related worry. Current, recommended tobacco cessation strategies during COVID-19 include access to medications and counseling, and environmental support (e.g., I COVID QUIT campaign) (University of Calinfornia San Francisco Smoking Cessation Leadership Center, 2021) and social support (Jaklevic, 2021; University of Calinfornia San Francisco Smoking Cessation Leadership Center, 2021).

Parents who experienced greater discrimination were less likely to reduce their nicotine use, and BIPOC parents and those with a tobacco use history reported greater discrimination to their NHW parents and tobacco abstinent counterparts. Taken together, Tthese findings support the need for multilevel interventions to address the deleterious processes contributing to increased tobacco-related burdens among marginalized populations during COVID-19, including parents who use tobacco (Melamed et al., 2020) and parents from racially marginalized backgrounds (Melamed et al., 2021). Current results demonstrated strong negative associations between discrimination and nicotine reductions as substance use coping increased; BIPOC parents and parents who use tobacco may be using substances to cope with racial and smoking-related discrimination (Gerrard et al., 2012), among other stressors (Martínez-Cao et al., 2021; Shepherd et al., 2021). Substance use coping may be magnifying the detrimental effects of racism on tobacco-related disparities (Czeisler et al., 2020; Pearson et al., 2021). Systemic changes are needed to address racism and to destigmatize substance use problems among parents, which may in turn, positively impact cessation (Jaklevic, 2021; Melamed et al., 2021).

Contrary to out hypothesis, fFinancial loss during the pandemic was related to increased nicotine reductions among parents. Our hypothesis was based on the idea that increased financial loss would lead to increased stress, thereby serving as a barrier to nicotine reductions. The results may indicateIt may also be the case that financial loss prohibited tobacco purchases.

Despite the study strengths, there are several limitations. The cross-sectional design and lack of information on pre-pandemic nicotine use and distress limited our ability to determine causal relations. While crowdsourcing methods have demonstrated comparable results to in-lab methods (Edgar, Murphy, & Keating, 2016) and allowed for nationwide recruitment of a diverse sample, our sample had high levels of education, thereby limiting the generalizability of findings. The use of self-report allowed for the safe collection of this important preliminary data during the summer of 2020 before there was clear knowledge about COVID-19 and before vaccines; however, self-reports may be subject to bias, including social desirability and recall biases. Notably, the ccurrent study utilizedd validated and/or PhenxX assessments when possible; furthermore, prior research supports the validity of parental report of child asthma status (Joesch, Kim, Kieckhefer, Greek, & Baydar, 2006) and has used similar self-report questions to assess financial losses (Di. Li, Suresh, Abbondanza, Vaidya, & Bancos, 2021) and nicotine use reductions during the pandemic (Gravely et al., 2021). Importantly, the findings documented in the current sample may be even more pronounced among a sample with greater representation of families with lower education/income and when using objective measures of nicotine use. Our sample size may have impeded our ability to detect main effects and interactions and/or introduced bias between parent race/ethnicity and tobacco use history for Aim 1across aims; additional larger scale research is needed. Our power was was moreespecially limited for the subsample analyses, with especially low power to detect simple slopes effects.; Tthus, current results were presented to support future research and should be considered preliminary and interpreted with caution; additional larger scale, representative research is needed and should include an investigation of how nicotine use modality (e.g., smoking versus vaping) may affect results. Furthermore, our results focused on substance use coping should be considered in the context of the low reliability detected for this measure among the subsample of Latinx/Hispanic parents in the current study. Despite these limitations, this study provides preliminary findings on differential exposure to health disparities contributors and predictors of parental nicotine use reductions during COVID-19 among a diverse sample of parents, including fathers, parents of color, and parents of a child with asthma. Results may inform future research on parental nicotine use during COVID-19, including the potential of parent-directed tobacco interventions that reduce substance use coping and increase alternative and healthier coping strategies for managing pandemic-related worry and discrimination.

Supplementary Material

Supp 1

Funding:

Manuscript preparation was supported through R01CA221819, R01MH126586, P20CA253255, and a grant through the Health Promotion Research Center.

Footnotes

Declaration of Interests: The authors have no conflicts of interests.

Data Availability:

The data underlying this article will be shared on reasonable request to the corresponding author.

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